Journal of the New Zealand Medical Association Vol 130 | No 1459 | 21 July 2017 Do robots get burnout?

Short-term outcomes following cytoreductive surgery and heated intra- peritoneal chemotherapy at Waikato

Where to from here? Posthumous healthcare A cross-disciplinary assessment of student data, digital e(lectronic)-mortality and New loans debt, nancial support for study and Zealand’s healthcare future career preferences upon graduation Publication Information published by the New Zealand Medical Association

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NZMJ 21 July 2017, Vol 130 No 1459 ISSN 1175-8716 © NZMA 2 www.nzma.org.nz/journal CONTENTS

EDITORIAL VIEWPOINT 6 64 Do robots get burnout? Where to from here? Posthumous Frank Frizelle, Roger Mulder healthcare data, digital e(lectronic)-mortality and New ARTICLES Zealand’s healthcare future 11 Katie Hoeksema, Richman Wee, Alastair Demographic and psychological Macdonald, Parry Guilford, Jesse Wall, correlates of satisfaction with Jon Cornwall healthcare access in New Zealand CLINICAL CORRESPONDENCE Carol HJ Lee, Chris G Sibley 71 25 The thumb sign Appendicitis presenting as the Satvinder Bakshi rst manifestation of colorectal carcinoma: a 13-year retrospective 73 study A villous adenoma of bladder/ Rebecca J Shine, Abigail Zarifeh, Chris urachus origin located in the Frampton, Jeremy Rossaak perineum 33 Calum Fraser, Frank Frizelle Short-term outcomes following METHUSELAH cytoreductive surgery and heated intra-peritoneal chemotherapy at 76 Neuraminidase inhibitors during Waikato Jasen Ly, Linus Wu, Ralph Van Dalen, pregnancy and risk of adverse Simione Lolohea neonatal outcomes and congenital malformations 43 A cross-disciplinary assessment 100 YEARS AGO of student loans debt, nancial 77 support for study and career Mobilisation of the Profession preferences upon graduation PROPOSALS OF THE MINISTER OF Craig S Webster, Christopher Ling, PUBLIC HEALTH Mark Barrow, Phillippa Poole, Marcus Henning PROCEEDINGS 54 79 30-day mortality a er Proceedings of the scienti c percutaneous coronary meetings of the Health Research intervention in New Zealand Society of Canterbury public hospitals (ANZACS-QI 18) Andrew J Kerr, Michael Williams, Harvey 82 White, Corina Grey, Yannan Jiang, Chris The Diabesity Crisis Nunn, on behalf of the ANZACS-QI Jim Mann, Rachael Taylor, Wayne investigators Cutfield

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Demographic and psychological correlates of satisfaction with healthcare access in New Zealand Carol HJ Lee, Chris G Sibley This study found that the majority of New Zealanders were highly satisfi ed with their access to healthcare when needed (68.4%), while 25.3% were moderately satisfi ed and 6.1% expressed low satisfaction. Additionally, we found that younger individuals, those of Māori, Pacifi c, or Asian ethnicity, and those with higher deprivation and lower income were less satisfi ed with their healthcare access. Conversely, those with a partner, living in an urban area and non-parents showed greater satisfaction. Personality traits were also associated with differences in level of satisfaction. Those who scored higher on Extraversion, Agree- ableness, Conscientiousness and Honesty-Humility, but lower on Neuroticism and Openness were found to express higher satisfaction. Appendicitis presenting as the rst manifestation of colorectal carcinoma: a 13-year retrospective study Rebecca J Shine, Abigail Zarifeh, Chris Frampton, Jeremy Rossaak This is the fi rst study of its kind conducted in Australasia. This study found patients ≥45 years who present with appendicitis have signifi cantly increased risk of underlying colorectal cancer. Until further research is conducted the authors recommend clinicians consider colonic investigation for older adults following a diagnosis of appendicitis. Short-term outcomes following cytoreductive surgery and heated intra-peritoneal chemotherapy at Waikato Jasen Ly, Linus Wu, Ralph Van Dalen, Simione Lolohea This article presents Waikato’s experience with cytoreductive surgery and heated intraperi- toneal chemotherapy for predominantly patients with pseudomyxoma peritonei. This rare disease arises from a growth within the appendix that perforates and leads to the accumulation of an abundance of mucin within the abdomen. Performed only elsewhere in New Zealand in Wellington, this is the largest series of the technique in New Zealand. The technique involves extensive surgery to remove all visible disease from within the abdomen, sometimes involving the removal of multiple organs, and is coupled with the addition of intraoperative heated chemotherapy for 90 minutes. This provides a cure for patients who would have otherwise had an ultimately fatal disease. A cross-disciplinary assessment of student loans debt, nancial support for study and career preferences upon graduation Craig S Webster, Christopher Ling, Mark Barrow, Phillippa Poole, Marcus Henning We explored relationships between student loans debt, fi nancial support and career prefer- ences upon graduation in 2,405 students across all healthcare disciplines offered at the Faculty of Medical and Health Sciences, University of Auckland. Students in health sciences, nursing and pharmacy typically accrue levels of student loans debt of around $15,000 to $29,999, while optometry students accrue debt around $15,000 higher. Medical students show debt distributed around both ends of the scale at $0 and $90,000 or more. All students typically access three sources of fi nancial support during study. Career preferences at graduation were found to reduce to four categories for all health disciplines, and fi ve signifi cant effects were found, involving students in health sciences, medicine and pharmacy, relating the number of sources of fi nancial support to a category of career preference. No signifi cant effects were found related to level of student loans debt. Our results suggest that fi nancial support is a more strongly determining factor in career choices than the level of student loans debt.

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30-day mortality a er percutaneous coronary intervention in New Zealand public hospitals (ANZACS-QI 18) Andrew J Kerr, Michael Williams, Harvey White, Corina Grey, Yannan Jiang, Chris Nunn, on behalf of the ANZACS-QI investigators Cardiovascular disease (CVD) is a leading cause of death in New Zealand, and the most common form of CVD is coronary artery disease. Various treatments are recommended for patients with coronary artery disease, including lifestyle changes, medication and interven- tional procedures. The most common interventional procedure performed on patients with coronary artery disease is percutaneous coronary intervention (PCI), which involves using balloons and stents to open up narrowed or blocked arteries. We used data from the All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI) registry to provide hospitals in New Zealand with feedback regarding their own outcomes for these PCI procedures to allow them to examine the quality of their own care, compare it both with other New Zealand units and with international comparison data, and identify opportunities for improvement in their quality of care. After correcting for differences in the characteristics of the patients treated at each hospital we found that mortality rates in the fi rst 30 days after a PCI are low and comparable across New Zealand public hospitals. The New Zealand outcomes are also comparable with the New York State experience. Where to from here? Posthumous healthcare data, digital e(lectronic)-mortality and New Zealand’s healthcare future Katie Hoeksema, Richman Wee, Alastair Macdonald, Parry Guilford, Jesse Wall, Jon Cornwall Digitisation and utilisation of large healthcare data sets is becoming increasingly common around the world, with such use leading to benefi ts in healthcare and disease prevention. The largest and arguably most important healthcare data set will become posthumous healthcare data sets. New Zealand is increasingly digitising and centralising healthcare records, and there would be benefi t to utilising posthumous healthcare records for research and management purposes. However, there is a lack of clarity surrounding the regulatory control around such data sets, and therefore it is unclear how to best utilise such data for the benefi t of all New Zealanders. This paper explores an issue which is becoming increasingly relevant to all New Zealanders.

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Do robots get burnout? Frank Frizelle, Roger Mulder

ne in 15 American doctors contem- are more common and patients may be plated suicide last year.1 Although harmed.6,7 Family members, friends and Oaccurate data are diffi cult to obtain, close colleagues may begin to note erratic a reasonable estimate is that 400 medical and unusual behaviours. Coworkers may be students or medical doctors commit suicide subjected to non-professional interactions, annually in the US.2 The lifetime rate of de- including verbal abuse. The burned-out pression among medical doctors is similar to physician’s unpredictable behaviour, mood that of the general population, however, the swings and propensity for errors can insidi- suicide rate (in the US) is disproportionately ously undermine, or even destroy, the ability high: 1.5 to 3.8 times higher among male of the medical team to function effectively. doctors and 3.7 to 4.5 times higher among Left unchecked, the harmful consequences female doctors as compared with the gen- of burnout worsen, and damage to patient eral population.3,4 This high suicide rate has care and satisfaction are impaired, at times been attributed to the high rates of burnout even leading to public disciplinary fi ndings, in doctors, a syndrome which most know is thus hurting the reputation of the doctor, characterised by exhaustion, cynicism and their colleagues and entire healthcare organ- reduced effectiveness. Physician burnout isations. Although burnout is a systemic has been shown to infl uence not just physi- issue, most institutions operate under the cian safety but quality of care, patient safety, erroneous framework that burnout and physician turnover and patient satisfaction.5 professional satisfaction are solely the 5 This data was presented at a recent responsibility of the individual physician. meeting in Seattle, which one of us attended Stress-induced burnout among medical last month. More surprising than that students, physicians in training and prac- was that this was a surgical, not a psychi- ticing physicians is not new, but until recently atric or general practice meeting. Usually it was generally assumed to be infrequent surgical meetings are full of famous insti- and controllable.8 Unfortunately, interna- tutions telling us about how good they are tional studies suggest that at least one-third at treating rare (or not so rare) conditions and up to half of doctors are experiencing or and about new toys which will allow you to will experience professional burnout.5 do operations better, such as how a robot The term burnout fi rst appeared in the (at 3M$US) does an operation better than a literature in 1974 when American psychol- laparoscope (20K$US), which is better than ogist Herbert Freudenberger9 coined the a pair of gloved human hands (7.5$US), term to describe the consequences of severe or even more surprisingly that two robots or prolonged stress and anxiety experienced (6M$US) are better than one. Suddenly all by people working in the “healing profes- the chatter about new robots disappears as sions”. He suggested their “high ideals” and the very human topic of physician health the need to repeatedly sacrifi ce themselves and burnout dominates the podium to very to help others put them at risk of job-in- full house. For the main session to be on duced emotional and physical exhaustion. burnout was a surprise—or was it? The term burnout, however, was soon being Burnout is important. As most of us used to describe the results of stress in other know, a doctor with burnout suffers occupations, not just in healthcare. from emotional exhaustion, depersonal- The origins of burnout were assumed to isation and a sense of reduced personal be rooted in the personal characteristics of accomplishment, and this is a problem for a few susceptible individuals. As noted by themselves, their family, their colleagues, Balch and Shanafelt, “one of the tragic para- their institution and most importantly their doxes of burnout is that those who are most patients. As burnout evolves, the physician’s susceptible seem to be the most dedicated, work performance deteriorates, errors conscientious, responsible and motivated.

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Individuals with these traits are often ideal- of years in practice; and 7) a high number of istic and have perfectionist qualities…”.10 hours worked per week.15,16 Those are the very traits sought by most Burnout develops gradually over time. medical schools, most training programmes Kraft17 summarised the work of Freuden- and fellowships, most patients seeking a berger,9 describing 12 stages of burnout: 1) doctor, and most doctors seeking to hire a a compulsion to prove oneself, 2) working new associate. Idealism, perfectionism and harder, 3) neglecting one’s own needs, 4) a strong work ethic lead some physicians displacement of confl icts, 5) revision of to “submerse themselves in their work values, 6) denial of emerging problems, 7) and devote themselves to it until they have withdrawal, 8) obvious behaviour changes, 10 nothing left to give.” 9) depersonalisation, 10) inner emptiness, In the mid-1990s, Linzer et al11–13 iden- 11) depression and 12) burnout syndrome. tifi ed four factors associated with burnout These stages are not necessarily sequential, in primary care practices: 1) a lack of and not all are necessarily involved in a control over work conditions and decision specifi c case. The duration of each stage making; 2) time pressure such that there varies, and sometimes several stages occur was a perception by physicians that they simultaneously. The onset of each case were only valued for their productivity; 3) is unique, making it diffi cult to identify a chaotic and ineffi cient work environment burnout early in its course. that inappropriately used physicians to Both proven and novel interventions are do clerical and other mundane tasks; and being promoted and assessed in a variety of 4) a lack of alignment among physicians healthcare and other settings. Many doctors and executives regarding values, mission, have developed their own responses to purpose and compensation. A key fi nding in dealing with the stresses of their work. Some their study was that physician satisfaction have adopted a healthy lifestyle, including was derived primarily from patient relation- nutritious diets, exercise routines and sports ships, not compensation. activities. Others have turned to religion, Shanafelt and Noseworthy14 proposed that meditation, yoga and mindfulness activities. the local work environment is a major factor Still others focus on their family, social inter- in determining whether physicians are actions, volunteer work and hobbies (eg, likely to develop burnout or, alternatively, to traveling, reading non-medical books and become fully engaged and dedicated to their writing journals).5 work. They grouped drivers of physician Anecdotal evidence suggests that these burnout versus engagement into seven personal approaches are useful, but for dimensions within the modern workplace: physicians to be engaged and productive 1) workload and job demands, 2) effi ciency caregivers, the healthcare organisations and resources, 3) fl exibility/control over must work to control or eliminate known work, 4) work–life integration, 5) alignment drivers of burnout and must help enhance of individual and organisational culture and physician defenses and support systems. values, 6) social support/sense of community A recent comprehensive systematic at work, and 7) the degree of meaning review and meta-analysis of 15 randomised derived from work. controlled trials and 37 observational 5 Rotherberger reports that based on studies assessing the effect of interventions a multivariate logistic analysis, seven on burnout showed that both individu- factors were independently associated with al-focused and structural or organisational burnout among the 7,905 surgeons who strategies decreased physician burnout.18 A participated in the ACS survey: 1) subspe- review in the Lancet reports that the results cialty choice (higher risk among trauma, substantiate that both individual-focused urologic, otolaryngologic, vascular, and and structural or organisational inter- general surgeons); 2) youngest child age ≤21 ventions can reduce physician burnout.19 years; 3) compensation based entirely on Although no specifi c physician burnout billing/productivity; 4) spouse working as a interventions have been shown to be better healthcare professional; 5) a high number than other interventions, both strategies of nights on call per week; 6) a high number are probably necessary. However, their

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combination has not been studied. The professional challenges. This support most commonly studied interventions have can be formal or informal and encom- involved mindfulness, stress management passes a wide range of activities, and small group discussions, and the results including celebrating achievements suggest that these strategies can be effective (eg, personal and professional mile- approaches to reduce burnout domain stones), supporting one another scores. Duty hour limitation policies also through challenging experiences (eg, appear effective. loss of a patient, medical errors, a The Mayo Clinic is currently applying malpractice suit), and sharing ideas on nine organisational strategies to promote how to navigate the ups and downs of physician well-being.18 As stated by the a career in medicine. authors, these are:18 5. Use rewards and incentives wisely. 1. Acknowledge and assess the problem. People can be motivated by rewards. Acknowledging the problem of To harness this principle, many burnout and demonstrating that the healthcare organisations have linked organisation cares about the well- physicians’ fi nancial compensation being of its physicians is a necessary to productivity. In some settings, fi rst step toward making progress. physicians’ income is entirely based on productivity, and in others it is 2. Harness the power of leadership. structured as a base salary with a Although the importance of leadership productivity bonus. Physicians are not for organisational success is obvious, salespeople. Although some variation its direct effect on the professional in productivity (eg, patient volumes satisfaction of individual physi- and relative value unit generation) cians is underappreciated. Recent can be attributed to physicians’ evidence suggests that the leadership experience, effi ciency and skill, such behaviors of the physician supervisor variation is relatively narrow. Physi- play a critical role in the well-being cians in an equally effi cient practice of the physicians they lead. To be environment primarily increase effective, leaders must also recognise productivity or revenue generation the unique talents of the individual in three ways: (1) shortening the physicians on their team and know time spent per patient, (2) ordering what motivates them.20 Evidence more tests/procedures or (3) working suggests that physicians who spend at longer. The fi rst two approaches least 20% of their professional effort may erode quality of care and the focused on the dimension of work third approach increases the risk of they fi nd most meaningful are at physician burnout and may, therefore, dramatically lower risk for burnout. be self-defeating in the long run. 3. Develop and implement targeted Consistent with this notion, evidence interventions. Ineffi ciency in the suggests that productivity-based practice environment (including compensation increases the risk of clerical load) is a universal driver physician burnout. of dissatisfaction and burnout, but 6. Align values and strengthen culture. how it manifests and the specifi c Most healthcare organisations have factors that create ineffi ciency vary an altruistic mission statement that widely among surgical, primary care, centres on serving patients and radiology, and pathology work units providing them the best possible (and among organisations). medical care. An organisation’s 4. Cultivate community at work. Physi- culture, values and principles in large cians deal with unique challenges and part determine whether it will achieve have a professional identity and role its mission. It is critical for organisa- that is distinct from other disciplines. tions to (1) be mindful of factors that Peer support has always been critical infl uence culture, (2) assess ways to to helping physicians navigate these keep values fresh, and (3) periodically

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take stock of whether actions and Other healthcare organisations can and values are aligned. should develop their own strategies by 7. Promote fl exibility and work-life following these three generic action steps: integration. The high work hours 1. Recognise and acknowledge that expected of a full-time position in physician burnout is a major threat to medicine make it diffi cult for physi- the healthcare system. cians to integrate their personal and 2. Use what we now know about professional lives. These challenges the drivers of burnout (discussed may be even more problematic for above) to improve the workplace women physicians due to different environment and build physician cultural and societal expectations. well-being. Providing physicians with the option 3. Build an economic case to justify to adjust professional work effort expenditures to remedy burnout. (with a commensurate reduction in compensation) allows them to Burnout is common and can be very tailor their work hours to meet both destructive so we need to look after personal and professional obligations. ourselves, we also need institutions to realise that we are not robots. Without appropriate 8. Provide resources to promote resil- organisational support and structure to ience and self-care. Providing deliver our care, not only do doctors suffer, individual physicians with tools for but so does patient care, as well as the insti- self-calibration, resources to promote tutions within which we work. self care, and training in skills that promote resilience are three tangible As individual doctors we need to look ways that organisations can help indi- after ourselves. This involves ensuring our viduals care for themselves. work environment is a positive infl uence, and includes taking our annual leave, not 9. Facilitate and fund organisational working when we are sick, knowing our science. Instituting operational individual limits, sharing the load with efforts to reduce burnout and colleagues and learning to say no. But above promote physician engagement will all, remembering, as healthcare providers, be the primary objective for most we are a team of human beings, not robots. medical centres.

Competing interests: Nil. Author information: Frank Frizelle, Department of Surgery, Christchurch Hospital, Christchurch; Roger Mulder, Psychological Medicine, University of Otago, Christchurch. Corresponding author: Professor Frank Frizelle, Department of Surgery, Christchurch Hospital, Christchurch. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459- 21-july-2017/7312

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REFERENCES: 1. Shanafelt TD. Burnout 8. Center C, Davis M, Detre leadership and physician amongst physicians T, et al. Confronting well-being: nine orga- presented at ASCRS depression and suicide nizational strategies to tripartite meeting in physicians: a consen- promote engagement and Seattle June 2017. sus statement. JAMA. reduce burnout. Mayo 2. Andrew LB. Physician 2003; 289:3161–3166. Clin Proc. 2016: 1–18. suicide. Medscape. 2015. 9. Freudenberger HJ. Staff 15. Shanafelt TD, Balch http://emedicine.medscape. burn-out. J Social Issues. CM, Bechamps GJ, et com/article/806779-over- 1974; 30:159–165. al. Burnout and career view. Accessed May 4, 2016. 10. Balch CM, Shanafelt T. satisfaction among 3. Shanafelt TD, Balch CM, Combating stress and American surgeons. Ann Dyrbye L, et al. Special burnout in surgical Surg. 2009; 250:463–471. report: suicidal ideation practice: a review. Adv 16. Balch CM, Shanafelt TD, among American surgeons. Surg. 2010; 44:29–47. Dyrbye L, et al. Surgeon Arch Surg. 2011; 146:54–62. 11. Linzer M, Manwell LB, distress as calibrated by 4. Frank E, Biola H, Burnett Williams ES, et al; MEMO hours worked and nights CA. Mortality rates (Minimizing Error, on call. J Am Coll Surg. and causes among U.S. Maximizing Outcome) 2010; 211:609–619. physicians. Am J Prev Investigators. Working 17. Kraft U. Burned out. Med. 2000; 19:155–159. conditions in primary care: Scientifi c American 5. Rothenberger DA. physician reactions and Mind. 2006; 17:28–33. Physician Burnout and care quality. Ann Intern 18. Shanafelt TD, Nose- Well-Being: A Systematic Med. 2009; 151:28–36, W6. worthy JH. Executive Review and Framework for 12. Linzer M, Konrad TR, leadership and physician Action.Dis Colon Rectum. Douglas J, et al. Managed well-being: nine orga- 2017 Jun; 60(6):567–576. care, time pressure, and nizational strategies to 6. Shanafelt TD, Balch CM, physician job satisfaction: promote engagement and Bechamps G, et al. Burnout results from the physician reduce burnout. Mayo and medical errors among worklife study. J Gen Intern Clin Proc. 2016: 1–18. American surgeons. Ann Med. 2000; 15:441–450. 19. West CP, Dyrbye LN, Erwin Surg. 2010; 251:995–1000. 13. Linzer M, Visser MR, Oort PJ, Shanafelt TD. Inter- 7. Williams ES, Manwell FJ, Smets EM, McMurray ventions to prevent and LB, Konrad TR, Linzer JE, de Haes HC; Society of reduce physician burnout: M. The relationship of General Internal Medicine a systematic review and organizational culture, (SGIM) Career Satisfaction meta-analysis. Lancet. stress, satisfaction, and Study Group (CSSG). 2016; 388:2272–2281. burnout with physi- Predicting and preventing 20. Horowitz CR, Suchman cian-reported error and physician burnout: results AL, Branch WT Jr, Frankel suboptimal patient care: from the United States RM. What do doctors fi nd results from the MEMO and the Netherlands. Am meaningful about their study. Health Care Manage J Med. 2001; 111:170–175. work? Ann Intern Med. Rev. 2007; 32:203–212. 14. Shanafelt TD, Nose- 2003; 138(9):772–775. worthy JH. Executive

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Demographic and psychological correlates of satisfaction with healthcare access in New Zealand Carol HJ Lee, Chris G Sibley

ABSTRACT AIMS: To explore the distribution of New Zealanders’ satisfaction with their healthcare access and identify various demographic and psychological factors associated with this satisfaction. METHODS: 15,822 participants responded to the 2014/15 New Zealand Attitudes and Values Study (NZAVS) survey. This survey included questions on participants’ demographic and psychological characteristics, and an item asking for their level of satisfaction with “your access to healthcare when you need it”. RESULTS: The majority of participants were highly satisfied with their access to healthcare when needed (68.4%), while 25.3% were moderately satisfied and 6.1% expressed low satisfaction. Younger individuals, those of Māori, Pacific, or Asian ethnicity, and those with higher deprivation and lower income, exhibited lower satisfaction. Conversely, those with a partner, living in an urban area and non-parents showed greater satisfaction. These e ects remained significant even a er controlling for various psychological factors. In terms of personality, those high on Extraversion, Agreeableness, Conscientiousness and Honesty-Humility, but low on Neuroticism and Openness also expressed higher satisfaction. Lastly, higher self-rated health was associated with greater satisfaction. CONCLUSION: The majority of New Zealanders are highly satisfied with their access to healthcare when needed, but a considerable number of people express some degree of dissatisfaction. This is broadly consistent with the New Zealand Health Survey (NZHS), and substantiates the finding that approximately 28–32% of New Zealanders experience low healthcare access. Our findings make a novel contribution to the literature by showing that the Big-Six personality traits are reliably associated with New Zealanders’ satisfaction with their healthcare access.

ne primary goal of the New Zealand and women were found to exhibit higher healthcare system is ensuring that all rates of unmet need.5 Previous NZHS studies groups have equitable access to ade- show similar fi ndings,3,4 suggesting that O 1 quate healthcare services. However, many certain groups are continuing to experience studies continue to note group disparities in inequalities in healthcare access over time. healthcare access.2–6 The Kiwis Count Survey, Building on the NZHS, the current study which investigates New Zealanders’ level of uses a national probability sample of New trust and satisfaction with public services Zealanders to explore the distribution of over time, indicates that the majority of New people’s satisfaction with their healthcare Zealanders are generally satisfi ed with their access when needed. It also aims to identify experience of health services (see Table 1).7 various demographic and psychological cor- However, the 2015/16 NZHS found that 29% relates of people’s satisfaction with access. of New Zealand adults reported experienc- According to the 2015/16 NZHS, inability 5 ing ‘unmet need for primary healthcare’. to get an appointment at their usual medical In regard to group differences, Māori and centre within a day (18%), and the cost Pacifi c peoples, those living in the most of general practitioner (GP) consultations deprived areas, aged between 25–54 years, (14%) and after-hour services (7%) are

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the most commonly reported barriers.5 unable to effectively communicate with or However, the type or extent to which these provide culturally relevant care for Pacifi c barriers are experienced depends on one’s and Asian peoples.11,12 demographic or psychological character- In addition to cultural factors, some istics. For instance, women, those of Māori studies have investigated the link between or Pacifi c ethnicity, with high deprivation various psychological factors and satis- and aged between 25–44 years were found faction with healthcare. For example, to be more likely to report GP cost as a Goldzweig et al13 found that cancer patients 5 barrier to healthcare. Smokers and those with higher levels of psychological distress with high levels of psychological distress tended to report lower patient satisfaction. were also found more likely to defer Moreover, Breemhaar et al14 found that 6 primary healthcare due to costs. As for having greater gratitude and an external those living in rural areas, longer travel locus of control was associated with times have been associated with a lower increased healthcare satisfaction. Extending 8 rate of healthcare utilisation. on past research, the current study aims Group disparities in the quality of to investigate the effect of the Big-Six healthcare service received have also been personality traits on people’s satisfaction noted. The 2006/7 NZHS found that Māori, with healthcare access. These traits consist Pacifi c and Asian adults, and those living of; Extraversion, Agreeableness, Consci- in deprived areas were less likely to report entiousness, Neuroticism, Openness to being ‘treated with respect and dignity all Experience and Honesty-Humility (see Table the time’, while Māori women and those 2).15 Personality traits have previously been from the most deprived areas were less associated with differences in health status likely to report being ‘listened to care- or healthcare need,16,17 but little is known fully all the time’.2 Additionally, the 2015 about their infl uence on people’s satisfaction Kiwis Count Survey found that younger with their healthcare access. Although a people, females and those of Pacifi c or study in the Netherlands (N=237) found Māori ethnicity showed lower levels of that the Big-Five personality traits (without overall satisfaction in public services, which Honesty-Humility) showed marginal associ- included healthcare.7 These fi ndings have ations with patient satisfaction with hospital important implications, as experiences care (including accessibility),18 this rela- of low-quality healthcare experiences tionship has not been investigated using a may negatively affect people’s perception population-based sample, and it remains an of medical professionals, leading to low open question whether such research gener- healthcare utilisation, and eventually alises to the unique context of New Zealand. 9,10 decrease their healthcare access. Therefore, the present study uses a large The persistence of racial discrimination probability sample of New Zealanders and cultural barriers in the health setting to explore the distribution, and demo- are likely contributing to Māori experiences graphic and psychological correlates of of low-quality healthcare.9,10 Doctors were people’s satisfaction with their healthcare found to spend less time consulting Māori, access when needed. We assess the asso- and are less likely to order further tests ciation between satisfaction ratings and a for or build rapport with Māori patients.9 wide range of variables including gender, Consequently, a considerable proportion of ethnicity and the Big-Six personality traits. Māori perceive that health professionals are To our knowledge, this study is the fi rst to disrespectful and do not appreciate Māori investigate the relationship between the cultural values.10 Similarly, Pacifi c and Asian Big-Six personality traits and satisfaction peoples commonly encounter language with healthcare access in New Zealand. and cultural barriers to appropriate Ultimately, we aim to identify those with low healthcare.11,12 Due to their lack of cultural satisfaction with their healthcare access and competence, some New Zealand doctors are in need of improved healthcare services.

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Table 1: Kiwi Count Scores for quality of public healthcare service.

Annual service quality scores (out of 100)

Type of service 2013 2014 2015 (N=2,371) (N=6,099) (N=2,365)

Stayed in a public hospital 74 72 77

Received outpatient services form a public hospital 74 73 75

Used an 0800 number for health information 75 74 76

Obtaining family services or counseling 69 70 66

Average scores 73 72.25 73.5

Source: 2015 Kiwis Count Survey.7

Table 2: Interpretation of each Mini-IPIP6 factor, including example traits, and likely adaptive benefi t and costs resulting from high levels of each personality dimension (adapted from Sibley et al,19 p. 144, which was in turn adapted from Ashton and Lee15 p. 156).

Factor Interpretation Example traits Likely adaptive Likely costs of high benefits of high levels level (in evolutionary (in evolutionary history) history) Extraversion Engagement in Sociability, Social gains (friends, Energy and time; risks social endeavours leadership, mates, allies) from social environment exhibition

Agreeableness Ingroup Tolerance, Gains from Losses due to increased cooperation forgiveness, (low) cooperation, risk of exploitation in and tolerance; quarrelsomeness primarily with ingroup short-term exchanges reciprocal altruism (mutual help and in HEXACO model nonaggression)

Conscientiousness Engagement Diligence, Material gains Energy and time; risks in task-related organisation, (improved use of from social environment endeavours attention to resources), reduced risk detail

Neuroticism Monitoring of Anxiety, Maintenance of Loss of potential gains (low Emotional inclusionary status insecurity, attachment relations; associated with risks to Stability) and attachment (low) calmness survival of kin in attachment relations. relations; kin HEXACO model altruism in HEXACO model.

Openness to Engagement in Curiosity, Material and social Energy and time; risks Experience ideas-related imaginativeness, gains (resulting from from social and natural endeavours (low) need for discovery) environment cognitive closure and (low) need for certainty

Honesty-Humility Reciprocal Fairness, Gains from Loss of potential gains altruism (fairness) sincerity, (low) cooperation, (mutual that would result from entitlement and help and non- the exploitation of (low) narcissism aggression) others (and in particular outgroup members)

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Education (1,114 missing) was coded as Method a 10-point ordinal variable ranging from The NZAVS is a longitudinal panel 0 (none) to 10 (PhD/equivalent degree, survey that aims to track changes in New M=5.05, SD=2.85). Zealanders’ attitudes and life circumstances over time. This not-for-profi t study was Measures Participants were asked to “rate your level fi rst started by Professor Chris Sibley in of satisfaction with the following aspects 2009, and is funded from various not-for- of your life in New Zealand” on a number profi t research grant agencies and internal of statements, which included “your access funding from the University of Auckland. to healthcare when you need it (eg, doctor, Sampling procedure GP)”, on a scale of 0 (completely dissatisfi ed) The Time 1 (2009) NZAVS recruited partic- to 10 (completely satisfi ed). This scale was ipants by randomly sampling from the developed for the NZAVS. New Zealand electoral roll (response rate: Participants also provided demographic 16.6%).20 A booster sample was recruited at information, including their ethnicity, Time 3 (2011) through an unrelated survey relationship status and annual household posted on a major New Zealand newspaper income. Ethnicity was measured using website. Further booster samples were the standard New Zealand Census item, in recruited from the 2012 and 2014 electoral which participants indicated their identi- roll in subsequent waves (response rates: fi cation with one or more ethnic groups. 6.2–12.33%, retention rates: around 60% Participants were priority coded into four across waves). The Time 6 (2014/15) NZAVS mutually exclusive ethnic groups (order sample, containing 15,822 participants, was of prioritisation: ‘Māori’, ‘Pacifi c’, ‘Asian’, used for this study (retention rate: 57.2% ‘European/Pākehā’, other ethnic groups over fi ve years, 81.5% from previous year).20 coded as missing). Big-Six Personality traits Although the Time 1 response rate of 16.6% were measured using the Mini-IPIP scale.19 may seem low, it is in keeping with other Deprivation was measured using the 2013 international studies. The Pew Research New Zealand Deprivation Index,23 while Centre, for example, have reported that socio-economic status was measured using their general survey response rates have the socio-economic index.24 Subjective been declining, with their 2012 telephone health satisfaction was measured using poll response rate being 9%.21 However, three marker items from the Short-Form research by Pew and others highlight that Health Questionnaire.25 after applying sample weighting, tele- phone surveys are still found to provide To estimate representative population an accurate refl ection of the general public proportions, the NZAVS uses a post-stratifi - on social and economic measures.21 Simi- cation weight that corrects for sample bias 26 larly, the NZAVS applies sample weighting in gender and ethnic group identifi cation. on demographics and its validity in As the Time 4 (2012) sample included monitoring changes in New Zealanders’ regional booster samples, weights from political attitudes over time has been Time 4 onwards included regional infor- well-demonstrated.22 mation. In this study (using Time 6 data), the weighting procedure weighted men Participants and women from each of the four primary 15,822 participants (10,003 female, 5,800 ethnic groups separately as well as region male; 19 missing) completed the Time 6 of residence based on data from the 2013 questionnaire. Participants’ mean age New Zealand Census.26 was 49.34 years (SD=14.04, range 18–95; For descriptive purposes (see Table 3), 9 missing). The medians of the annual the following scale ranges were used to household income quartile groups were describe high satisfaction (ratings of 8–10; $33,900, $73,000, $110,000 and $190,000 68.6% weighted, 69.4% unweighted), (1,143 missing). Additionally, 74.6% (259 moderate satisfaction (ratings of 4–7; 25.3% missing) were parents, 74.7% (640 missing) weighted, 24.7% unweighted) and low were in a committed romantic relationship satisfaction (ratings of 0–3; 6.1% weighted, and 77% (188 missing) were employed. 5.9% unweighted) in this study. The overall

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Table 3: Operationalisation of satisfaction groups in this study.

Group Operationalisation

High satisfaction Ratings of 8 to 10 on an 11-point scale assessing people’s satisfaction with their “access to healthcare when they need it (eg, doctor, GP)”

Moderate satisfaction Ratings of 4 to 7 on the same scale as above

Low satisfaction Ratings of 0 to 3 on the same scale as above mean score was 7.84 (SD= 2.21) after applying weighting (M=7.89, SD=2.19 before Results weighting). As illustrated in Figure 1 and Table 4, most participants expressed high satisfaction with Statistical analyses their healthcare access (68.6%), but almost A step-wise regression predicting people’s one-third of participants (31.4%) indicated satisfaction with healthcare access was some degree of dissatisfaction. In terms of conducted on M plus. ‘Model one’ only ethnic differences (see Figure 2 and 3), all included demographic predictors, while ethnic groups showed a positively skewed ‘Model two’ included both demographic distribution of satisfaction scores, but Euro- and psychological predictors. This method peans/Pākehā exhibited a signifi cantly greater allowed us to examine the extent to which rate of high satisfaction, and lower rate of low psychological variables may explain satisfaction compared to ethnic minorities. or attenuate the effect of demographic While Māori, Pacifi c and Asian peoples variables on people’s satisfaction with showed similar levels of high satisfaction healthcare access. Missing data for exog- (around 61–63%), Asian peoples reported a enous variables were estimated using signifi cantly higher rate of moderate satis- Rubin’s procedure27 for multiple impu- faction compared to all other ethnic groups. tation procedure with parameter estimates Overall, Māori exhibited the lowest rate of averaged over 1,000 data sets (thinned every high satisfaction and highest rate of low satis- 200th iteration). faction. (Refer to Appendix for satisfaction ratings within district health boards).

Figure 1: Satisfaction with healthcare access among the general New Zealand public (weighted on gen- der, ethnicity and region of residence).

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Table 4: Weighted percentage of high, moderate and low satisfaction across ethnic groups.

European/Pākehā Māori Pacific Asian Total (N=10,810) (N=1,932) (N=889) (N=1,960) (N=15,758)

High satisfaction 71.8%a 61.1%b 63.4%b 62.2%b 68.6%

Moderate satisfaction 23.4%a 27.9%b 26.9%b 31.5%c 25.3%

Low satisfaction 4.8%a 11.0%b 9.7%b 6.3%c 6.1% Note: Di erent subscript letters for proportions indicate significant di erences across columns. Percentages for ‘Total’ included those who did not identify with the four primary ethnicities.

Figure 2: Box plots showing the distribution of satisfaction with healthcare access by ethnic group.

Figure 3: Satisfaction with healthcare access across priority-coded ethnic groups (Europeans/Pākehā, Māori, Pacifi c and Asian peoples) after applying sample weighting.

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Regressions predicting satisfaction women, men expressed greater satisfaction with healthcare access with their healthcare access (b=.107). Most demographic variables continued to show Model one: As presented in Table 5, age relatively strong associations with satis- showed a curvilinear effect (b=.014, b2=.001), faction scores in Model two. For example, whereby satisfaction scores increased with Māori (b=-.356), Pacifi c (b=-.271) and Asian age and showed a steeper rate of growth peoples (b=-.266) were still found to express among those of older age. Compared to lower satisfaction than Europeans/Pākehā. Europeans/Pākehā (reference group), Māori Although the strength of relationship (b=-.381), Pacifi c (b=-.262) and Asian peoples slightly decreased, having a partner (b=.520) (b=-.288) all exhibited lower satisfaction also remained signifi cantly associated with with their healthcare access. Those with a higher satisfaction. higher (log) household income (b=.185) or socio-economic status (b= .006) were more Furthermore, being high on the satisfi ed, while those with higher depri- personality traits, Extraversion (b=.091), vation (b=-.044) were less satisfi ed with their Agreeableness (b=.108), Conscientiousness healthcare access. Having a partner (b=.596) (b=.108) and Honesty-Humility (b=.056) and living in an urban area (b=.192) were were associated with increased satisfaction associated with greater satisfaction, while with healthcare access. In contrast, being being a parent (b=-.106) was associated with high on Neuroticism (b=-.172) and Openness lower satisfaction with healthcare access. (b=-.037) were associated with decreased Gender, religion, education and employment satisfaction. Those with higher subjective did not show a signifi cant effect. health ratings also exhibited greater satis- faction with their healthcare access (b=.305). Model two: The effect of gender was Overall, having a partner and higher signifi cant after including psychological subjective health exhibited the strongest variables in our model. Compared to association with people’s satisfaction ratings.

Table 5: Step-wise regression predicting satisfaction with healthcare access: Model one (without psychological predictors) and Model two (with psychological predictors).

Beta b SE Lower Upper t bivariate r Beta b SE Lower Upper t bivariate r 95%CI 95%CI 95%CI 95%CI

Constant 1.952 4.280 .206 3.775 4.786 Constant 1.130 2.479 .317 1.858 3.100

Gender -.001 -.003 .036 -.072 .065 -.088 .027 Gender .024 .107 .037 .035 .179 2.911** .027

Age .090 .014 .001 .011 .017 9.771** .077 Age .056 .009 .001 .006 .011 6.105** .077

Age squared .102 .001 .000 .001 .001 11.463** .055 Age squared .097 .001 .000 .001 .001 11.300** .055

Māori -.057 -.381 .053 -. 502 -.260 -6.183** -.097 Māori -.054 -.356 .060 -.473 -.238 -5.913** -.097

Pacific -.021 -.262 .097 -. 490 -.033 -2.244* -.045 Pacific -.022 -.271 .114 -.493 -.048 -2.385* -.045

Asian -.027 -.288 .085 -. 457 -.120 -3.350** -.026 Asian -.025 -.266 .085 -.432 -.100 -3.143** -.026

Income (log) .098 .185 .017 . 143 .228 8.541** .142 Income (log) .082 .115 .021 .113 .196 7.307** .139

NZ Deprivation -.055 -.044 .007 -. 058 -.031 -6.417** -.128 NZ Deprivation -.036 -.029 .007 -.042 -.016 -4.330** -.128

Education .014 .011 .008 -.004 .026 1.413 .073 Education .007 .005 .008 -.010 .021 .657 .074

Socio-economic .044 .006 .001 .003 .009 4.415** .096 Socio-economic .036 .005 .001 .002 .008 3.644** .097 status status

Employed .012 .061 .046 -.038 .161 1.214 .012 Employed -.013 -.067 .049 -.164 .029 -1.367 .011

Partnered .118 .596 .043 .502 .690 12.398** .147 Partnered .103 .520 .048 .427 .613 10.943** .144

Parent -.021 -.106 .047 -.199 -.014 -2.252* .029 Parent -.031 -.156 .046 -.246 -.066 -3.390** .030

Religion .012 .052 .035 -.017 .121 1.465 .005 Religion .005 .021 .035 -.048 .090 .594 .004

Urban area .041 .192 .037 .116 .267 4.947** .055 Urban area .048 .223 .038 .149 .297 5.908** .055

*Note: N=15756, * p< .05, ** p< .01, Coding: 0=women, 1=men for ‘Gender’, Extraversion .048 .091 .016 .061 .122 5.863** .095 0=no 1=yes for ‘Māori’, ‘Pacific’, ‘Asian’, ‘Employed’, ‘partnered’, ‘parent’, Agreeableness .047 .108 .021 .067 .150 5.156** .091 ‘religion’, 0=rural and 1=urban for ‘Urban area’, 0=low and 10=high for NZ Deprivation and Education. Model fit statistics for ‘Model 2’: R2=.125 (p<.001), Conscientiousness .050 .108 .018 .074 .143 6.090** .120 AIC=67409.917, BIC=67593.876. Neuroticism -.086 -.172 .017 -.206 -.137 -9.841** -.180

Openness -.018 -.037 .017 -.070 -.004 -2.183* .024

Honesty-Humility .031 .056 .016 .024 .088 3.464** .101

Subjective health .163 .305 .017 .271 .339 17.597** .234

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satisfaction with their healthcare access Discussion than Europeans/Pākehā. This result can be Using a nationally representative sample linked to fi ndings that ethnic minorities are of New Zealand adults, the present study more inclined to experience language, infor- investigated people’s satisfaction with their mation and cultural barriers to healthcare, access to healthcare when needed. We and the lack of cultural competence among assessed the distribution of people’s satis- medical professionals.2,9–12 Our fi ndings faction with their healthcare access and further suggest that perceptions of low examined its association with a broad range healthcare access among ethnic minorities of demographic and psychological factors. cannot be fully explained by population Results from our analyses reveal group differences in socio-economic or person- inequalities in healthcare access. ality factors. Hence, in order to increase Over two-thirds of New Zealanders (68.4%) healthcare access for ethnic minorities, it is were highly satisfi ed with their access to essential to develop tailored health interven- healthcare when needed, while 25.3% were tions that target the unique cultural barriers moderately satisfi ed and 6.1% expressed encountered by these groups. low satisfaction. These fi ndings are broadly Similar to previous studies,3–6 those with consistent with previous NZHS studies,3–5 lower income or socio-economic status and which found that around 28% of New high deprivation exhibited decreased satis- Zealand adults reported an ‘unmet need for faction with their healthcare access. Those primary healthcare’. This indicates that more who did not have a partner, were a parent than a quarter of New Zealanders express or living in a rural area also expressed some degree of dissatisfaction in their lower satisfaction. In contrast, age showed healthcare access. Such dissatisfaction can be a curvilinear effect whereby satisfaction linked to a wide range of factors, including scores increased as age increased with a diffi culty making appointments, transport, steeper rate of growth among those of older costs and perceptions of unfair treatment.5,9–12 age. This may be because older people Our results revealed considerable in New Zealand tend to receive focused ethnic differences in levels of satisfaction support services and are less likely to defer with healthcare access. Relative to Euro- primary healthcare due to costs.28 The effect peans/Pākehā, ethnic minorities exhibited of these demographic factors remained a higher rate of low satisfaction (4.8% signifi cant even after we controlled for indi- versus 6.3–11.0%) and a lower rate of high vidual differences in personality traits and satisfaction (71.8% versus 61.1–63.4%). subjective wellbeing. Interestingly, women Compared to Māori and Pacifi c peoples, were only found to express lower satis- Asian peoples showed a smaller proportion faction compared to men after controlling of low satisfaction but higher proportion for psychological factors. of moderate satisfaction (27.9%, 26.9% Our study provides a novel contribution and 31.5% respectively).These fi ndings to the literature by revealing that the are somewhat consistent with the 2015/16 Big-Six personality traits are associated NZHS,5 in which Māori (39.3%) and Pacifi c with New Zealanders’ satisfaction with their peoples (34.2%) reported higher rates of healthcare access. Specifi cally, those high one or more ‘unmet need for primary on Extraversion, Agreeableness, Conscien- healthcare’ than Asian peoples (22.8%) tiousness and Honesty-Humility expressed and European/Pākehā and Others (28.4%). greater satisfaction, while those high on However, it is important to note that Neuroticism and Openness exhibited lower the NZHS asked for instances of ‘unmet satisfaction with their healthcare access. healthcare need’ in the past year due to As Conscientious people tend to engage in various reasons (eg, cost, transport), while positive health behaviors and have good our study asked for participants’ general health,16 their higher rate of satisfaction is levels of satisfaction with their healthcare not surprising. On the other hand, those high access when needed. on Neuroticism may be more inclined to After controlling for various demographic express low satisfaction perhaps due to their and psychological factors, Māori, Pacifi c and higher susceptibility to various illnesses and Asian peoples were found to express lower increased healthcare need.16,17 Our fi ndings

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suggest that recognising differences in that future studies employ more compre- patients’ personality traits may help doctors hensive measures of ‘healthcare access’ identify and respond appropriately to those and examine the specifi c barriers expe- in need of greater reassurance and support. rienced by diverse groups to inform the Lastly, those who had a more positive development of more effective healthcare subjective wellbeing showed higher satis- interventions for target populations. faction with their healthcare access. Put another way, those with negative percep- Concluding comments tions of their own health, and hence higher This study investigated people’s satis- healthcare need, tend to exhibit the lowest faction with their access to healthcare level of satisfaction with their healthcare when needed using a national probability access. This fi nding increases insight into the New Zealand sample. The majority of New previously identifi ed link between poor self- Zealanders expressed high satisfaction, 29 rated health and greater health decline, while over a quarter expressed moderate indicating that reduced healthcare access or low satisfaction. Those of Māori, Pacifi c may be an important contributor to the or Asian ethnicity, younger age and those health deterioration of those with negative with higher deprivation and lower income subjective health. Further research on these exhibited lower satisfaction. Conversely, novel effects is needed to identify the more those with a partner, living in an urban accurate motives driving people’s attitudes area and non-parents showed greater satis- towards healthcare services. faction. After controlling for psychological Caveats factors, the effect of these demographic The cross-sectional nature of our study factors remained signifi cant, and women is a major limitation, as we cannot imply were additionally found to express lower causation from our results. Furthermore, satisfaction. Furthermore, those high on our single item measure was unable to Extraversion, Agreeableness, Conscien- assess the specifi c reasons why people tiousness and Honesty-Humility, but low express high or low satisfaction, or account on Neuroticism and Openness, and those for potential differences in interpre- with positive self-rated health expressed tation of the term ‘access’. According to greater satisfaction. Our study presents Levesque, Harris and Russell,30 ‘healthcare novel fi ndings regarding the effect of the access’ involves multiple subcategories, Big-Six personality traits on New Zealanders’ including one’s ability to seek or reach satisfaction with healthcare access, and healthcare services as well as the appro- help identify target populations in need of priateness of the service received. It is vital healthcare interventions.

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Appendix Distribution of satisfaction ratings within district health boards (Y-axis: percentage of participants, X-axis: healthcare access satisfaction scores from 0 (completely dissatisfi ed) to 10 (completely satisfi ed)).

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Competing interests: All authors report grants from Templeton World Charity Foundation during the conduct of the study. Author information: Carol HJ Lee, Post-Graduate Student, School of Psychology, University of Auckland, Auckland; Chris G Sibley, Professor, School of Psychology, University of Auckland, Auckland. Corresponding author: Carol HJ Lee, Post-Graduate Student, School of Psychology, University of Auckland, Auckland. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459- 21-july-2017/7313

REFERENCES: 1. Cumming J, McDonald J, 9. Jansen P, Smith K. Maori 15. Lee K, Ashton MC. Barr C, et al. (ed). New experiences of primary Psychometric properties Zealand Health System health care. NZFP. of the HEXACO personality Review. Genva: World 2006; 33:298–300. inventory. Multivariate Health Organization. 2014. 10. Jansen P, Bacal K, Crengle Behav Res. 2004; 39:329–58. 2. Ministry of Health. A S. He Ritenga Whakaaro: 16. Goodwin RD, Friedman Portrait of Health. Key Māori experiences of HS. Health status and Results of the 2006/7 New health services. Hospi- the fi ve-factor personal- Zealand Health survey. tal. 2008; 200:30–7. ity traits in a nationally Wellington: Author. 2008. 11. Statistics New Zealand and representative sample. 3. Ministry of Health. Ministry of Pacifi c Island Journal of health psychol- Annual Update of Key Affairs. Health and Pacifi c ogy. 2006; 11:643–54. Results 2013/14: New peoples in New Zealand. 17. Seekles WM, Cuijpers Zealand Health Survey. Wellington: Statistics New P, Van de Ven P, et al. Wellington: Author. 2014. Zealand and Ministry of Personality and perceived 4. Ministry of Health. Pacifi c Island Affairs. 2011. need for mental health Annual Update of Key 12. Wong A. Challenges for care among primary care Results 2014/15: New Asian health and Asian patients. J Affect Disord. Zealand Health Survey. health promotion in 2012; 136:666–74. Wellington: Author. 2015. New Zealand. Auckland: 18. Hendriks AA, Smets EM, 5. Ministry of Health. Health promotion Forum Vrielink MR, Van Es SQ, Annual Update of Key of New Zealand. 2015. De Haes JC. Is personality Results 2015/16: New 13. Goldzweig G, Meirowitz a determinant of patient Zealand Health Survey. A, Hubert A, Brenner satisfaction with hospital Wellington: Author. 2016. B, Walach N, Perry S, care?. Int J Qual Health Care. 2006; 18:152–8. 6. Jatrana S, Crampton P. Hasson-Ohayon I, Baider Primary health care in L. Meeting expectations 19. Sibley CG, Luyten N, Purno- New Zealand: who has of patients with cancer: mo M, Moberly A, et al. access? Health Policy. relationship between The Mini-IPIP6: Validation 2009; 93(1):1–10. patient satisfaction, and extension of a short depression, and coping. J measure of the Big-Six 7. States Services Commis- Clin Oncol. 2010; 28:1560–5. factors of personality in sion. Kiwis Count: June New Zealand. New Zealand 2015 Annual Report. 14. Breemhaar B, Visser Journal of Psychology. Wellington: Author. AP, Kleijnen JG. Percep- tions and behaviour 2011; 40:142–59. 8. Hiscock R, Pearce J, among elderly hospital 20. Sibley CG. Sampling proce- Blakely T, Witten K. Is patients: description dure and sample details for neighborhood access to and explanation of age the New Zealand Attitudes health care provision differences in satisfaction, and Values Study. NZAVS associated with individ- knowledge, emotions Technical Documents. ual-level utilization and and behaviour. Soc Sci 2014; e01. http://www. satisfaction? Health Serv Med. 1990; 31:1377–85. psych.auckland.ac.nz/ Res. 2008; 43:2183–200.

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en/about/our-research/ Wellington: Statistics few imputations when research-groups/new-zea- New Zealand. 2013. fractions of missing infor- land-attitudes-and-val- 25. Ware Jr JE, Sherbourne CD. mation are modest: The SIR ues-study/nzavs-tech-docs. The MOS 36-item short- algorithm. Journal of the html form health survey (SF-36): American Statistical Asso- 21. Pew Research Centre. I. Conceptual framework ciation. 1987; 82:543–46. Assessing the Repre- and item selection. Med 28. Minstry of Health. Older sentativeness of Public care. 1992; 30:473–83. people’s health data Opinion Surveys. Wash- 26. Sibley CG. Procedures for and stats. Wellington: ington D.C: Author. 2012. estimating post-stratifi ca- Author. 2016. http:// 22. Sibley CG, Robertson A, tion NZAVS sample weights. www.health.govt.nz/ Osborne D, et al. Bias 2014. http://cdn.auckland. nz-health-statistics/health- and tracking accuracy in ac.nz/assets/psych/about/ statistics-and-data-sets/ voting projections using our-research/nzavs/NZAVS- older-peoples-health- the New Zealand attitudes TechnicalDocuments/ data-and-stats and values study. Political NZAVS-Technical-Doc- 29. DeSalvo KB, Bloser N, Science. Forthcoming 2016. uments-e08-Proce- Reynolds K, et al. Mortality 23. Atkinson J, Salmond C, dures-for-Estimating-Sam- prediction with a single Crampton P. NZDep2013 ple-Weights.pdf general self-rated health Index of Deprivation. 27. Rubin DB. The calculation question. Journal of general Department of Public of posterior distributions internal medicine. Health, University of by data augmentation: 30. Levesque JF, Harris MF, Otago Wellington. 2014. Comment: A noniterative Russell G. Patient-centred 24. Milne BJ, Byun U, Lee A. sampling/importance access to health care: New Zealand socio-eco- resampling alternative conceptualising access nomic index 2006. to the data augmentation at the interface of health algorithm for creating a systems and populations.

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Appendicitis presenting as the rst manifestation of colorectal carcinoma: a 13-year retrospective study Rebecca J Shine, Abigail Zarifeh, Chris Frampton, Jeremy Rossaak

ABSTRACT AIM: Appendicitis in older adults may present as the first sign of underlying colorectal cancer. We aim to determine whether there was a di erence in the rate of diagnosis of colorectal carcinoma for patients ≥45 years following a presentation with appendicitis, compared with New Zealand standardised rates. METHOD: Retrospective study of patients ≥45 years with a confirmed diagnosis of appendicitis from 2003 to 2015 inclusive. The rate of colorectal carcinoma diagnosed during the 36-month follow-up period was calculated and compared to standardised rates, as per the New Zealand cancer registry. RESULTS: Six hundred and twenty-nine patients were included for analysis, 15 had a diagnosis of colorectal cancer in the follow-up period. Patients ≥45 years had a 6.3-fold (CI 3.6–10.2) increased risk of colorectal carcinoma than predicted given the population demographics. Those patients aged between 45–60 years had a 17-fold (95% CI 8–32.2) increased standardised risk ratio. CONCLUSION: This is the first study of its kind conducted in Australasia. This study found patients ≥45 years who present with appendicitis have significantly increased risk of underlying colorectal cancer. Until further research is conducted the authors recommend clinicians consider colonic investigation for older adults following a diagnosis of appendicitis.

olorectal cancer (CRC) rates in New appendicitis. Alternatively, immune-me- Zealand are among the highest in the diated lymphoid hyperplasia associated Western world, with an overall rate with malignancy may lead to appendiceal C 3,4 of ~50/100,000 person years and between obstruction and appendicitis. 1,2 1,100 and 1,200 deaths each year. Early In the early 1980s, a number of small diagnosis and treatment are paramount to studies and case reports indicated improving outcomes for colorectal cancer. increased rates of CRC in older patients However, symptoms can be vague, and presenting with appendicitis.4–8 Interest patients often have advanced disease at waned with the advent of computed presentation. tomography and laparoscopic surgery Acute appendicitis in older adults is in the management of appendicitis with relatively uncommon and could represent the theory one could visualise the cecum the fi rst presentation of an underlying through these interventions. However, a colorectal carcinoma, affording the oppor- Taiwanese study in 2006 reported an almost tunity for earlier diagnosis and treatment. 40-fold increase in odds ratio for under- Colorectal carcinoma may cause acute lying colorectal cancer in patients over 40 appendicitis either by way of direct presenting with acute appendicitis.9 Given obstruction of the appendiceal lumen or the higher rates of colorectal cancer and a as a result of adjacent infl ammation and predominance of left-sided malignancies oedema. Also, a partial downstream colonic in the western world,1,2 it is diffi cult to obstruction may result in increased luminal interpret the results of the Taiwanese study pressures and thus predispose to acute in the New Zealand population.

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A recent survey presented at the New bias that would be created by a longer Zealand Association of General Surgeons follow-up, as patients may ‘develop’ a new (NZAGS) conference10 (March 2016) has cancer during a longer follow-up that was shown a signifi cant dichotomy in practice unrelated to the episode of appendicitis. among general surgeons with regards A 36-month follow-up period was thought to colonic investigation in older adults most appropriate as cancers existing at the following appendicitis. The survey found time of appendicectomy would likely have almost a 50:50 split with regards to colonic become symptomatic and been diagnosed investigation following appendicitis in older by three years, and those that may have adults, indicating the current uncertainty developed subsequently would be less likely and limited evidence relating to this issue. to be diagnosed. The aim of this study was to determine A rate ‘per person years’ was deter- whether there was a difference in the mined for each patient dependent on the rate of diagnosis of colorectal carcinoma duration they were included in the study for patients ≥45 years in the 36 months (duration until diagnosis of CRC, death, or following a presentation with appendicitis for 36 months maximum) and from this, to the Bay of Plenty DHB, compared with the the ‘observed rate’ for this study popu- New Zealand population standardised rates. lation was established. An ‘expected rate’ of colorectal carcinoma was calculated for Methods each patient based on age, gender, year of diagnosis and ethnicity (Māori or non- All patients ≥45 years with a certain Māori) status as extracted from the New pathological or radiological diagnosis of Zealand cancer register ICD codes 9 and 10. appendicitis from January 2003 to April The ‘standardised rate ratio’ was then calcu- 2015 inclusive were eligible to be included lated as the ratio of ‘observed’ rates over in the study. Cases were identifi ed through the ‘expected’ population rate. The Poisson a database code for ‘Appendicitis’ or related approximation was used to estimate the codes from the Bay of Plenty District Health 95% confi dence limits for the standardised Board’s (BOPDHB) admission and theatre ratio estimates. database. Diagnostic and demographic data for all patients were extracted, and this information was cross-referenced with Results the pathological (PATHLAB) database for A total of 667 patients were identifi ed ‘appendicitis’ and ‘colorectal cancer’ in initially from the BOPDHB database with a patients ≥45 years to ensure no cases were diagnosis of acute appendicitis within the missed. Each case was then reviewed both study period. This was cross-referenced electronically and from paper charts for with the PATHLAB database, and no addi- date of diagnosis of appendicitis, subsequent tional patients were identifi ed. 38 patients colonoscopy date and fi ndings, pre-existing were excluded (25 with a normal appendix risk factors for colorectal cancer and, for on histology, 10 patients had an alternative those patients diagnosed with colorectal diagnosis such as diverticulitis or undiffer- cancer, histology, staging and date of diag- entiated abdominal pain and three patients nosis. Stage of colorectal cancer was defi ned had acute appendicitis diagnosed intra-op- according to the American Cancer Society eratively during a bowel resection for an TNM staging 7th edition. already known colorectal cancer). Two The study focus was to identify patients patients were diagnosed with colorectal who had colorectal cancer at the time of cancer >36 months after their admission presentation with appendicitis, with the for appendicitis, and these patients were theory being that the tumour may have included only as ‘appendicitis’ patients. precipitated the appendicitis. For this The average follow-up period was 30.36 reason, a 36-month follow-up period was months as patients presenting towards the elected. This was chosen to minimise the end of the study period did not have a full 36-month follow-up period.

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Table 1: Demographic profi le. Table 2: Findings, management and location of colorectal cancer. Demographic N Percentage profile Initial findings, N Percentage management and Age (median, 57 years location range) (45–97 Appendix histology years) Acute appendicitis 541 86% 45–59 years 358 57.1% Chronic 19 3.0% 60–79 years 227 36.2% appendicitis 80+ years 42 6.7% Mucinous 15 2.4% Gender cystadenoma

Male 330 52.5% Neuroendocrine 4 0.6% Female 299 47.5% tumour

Ethnicity Acute appendicitis 7 1.1% and benign polyp NZ European 528 83.9% Acute 8 1.3% Māori 72 11.4% appendicitis and Asian 14 2.2% Adenocarcinoma

Other 15 2.4% No operation 36 5.7%

Pre-operative CT 263 41.8% Table 1 highlights the demographic profi le for this patient group, which is represen- scan tative of the BOPDHB population during this Colonoscopy 74 11% period. ‘Acute appendicitis’ was the most (within 36 months) * Mean = common histological fi nding, although an 8 months alternative neoplastic process other than colorectal carcinoma was found in 4.1% of Follow-up period Mean = specimens (Table 2). Thirty-six patients had 30.36 their appendicitis managed non-operatively, Months 14 of whom (39%) went on to have either a CTC or colonoscopy at the request of the Location of CRC N (%) consultant surgeon. One of these patients Appendix 4 26.7% had a diagnosis of caecal carcinoma detected at the time of colonoscopy four weeks later, Caecum 6 40% the CT of this patient had shown an infl am- Ascending/ 2 13.3% matory mass and acute appendicitis. There transverse was no protocol or guideline in place in BOPDHB at the time of this study to dictate Sigmoid/rectum 3 20% whether patients had colonic investigation after non-operative management of appen- The expected risk of colorectal cancer was dicitis, and this decision was at the surgeons’ established for each patient in this study, discretion. Interval appendicectomy was dependent on their age, gender, ethnicity not common practice, and only two patients and year of diagnosis. From this, the who were managed non-operatively initially, ‘study-population’ expected rate of cancer went on to have further surgery—the was calculated. The expected number of patient who had cecal cancer detected and colorectal cancers among this study popu- another who had an ongoing appendiceal lation was two (0.4%). However, 15 patients abscess that was treated with a right hemi- (2.4%) were found to have colorectal cancer colectomy (histology benign). in the study period (Table 3). This equated

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Table 3: The number of expected and observed colorectal carcinoma cases by age group.

Age range Expected Observed Standardised risk Confidence interval number number ratio (SR) (95%)

All 2.37 15 6.4 3.67–10.2

45–60 0.46 8 17.27 8.02–32.79

60–80 1.43 6 4.20 1.70–8.73

>80 0.48 1 2.09 0.10–10.30 to a six-fold increased standardised risk colonoscopy one month later (performed for ratio (SR 6.3, 95% CI 3.6–10.2) of under- appendiceal abscess on initial CT), the other lying colorectal malignancy than would presented 28 months later with abdominal be expected given the population demo- pain due to a T4 cecal cancer. graphics. They were all European and After excluding those patients diagnosed predominantly male (male n=13, 86.6%) on initial histology, Table 4 demonstrates with a median age of 59 (46 to 84) years. 7/621 (1.1%) patients were subsequently Right-sided malignancies accounted for 74%. diagnosed with CRC. This represented a Ten of the 15 patients had cancer located three-fold increased standardised risk ratio in the cecum or appendix (six and four (SR 2.96, 95% CI 1.2–5.8). Patients age 45–60 respectively), two in the ascending/trans- continued to have more than a six-fold verse colon and three located in the sigmoid/ increased risk (SR 6.52, 95% CI 1.7–17.7) of rectum (Table 2). The median duration to underlying colorectal cancer, with an inci- diagnosis was 12.7 months with a range of dence of 2.2%. one to 30 months. Within the age group 45 Of the 629 patients included in the study, to 60 there was a 17.3-fold increased stan- only 74 (11%) had a colonoscopy/colonog- dardised risk ratio (CI 8.02–32.79) as shown raphy within 36 months of appendicitis, in Table 3. Across all age ranges there was with the average duration to colonoscopy an increased risk, though this did not reach being eight months (Table 2). The indications statistical signifi cance for patients over 80 for colonoscopy for those patients found (SR 2.09, CI 0.1–10.3). to have malignancy varied. Aside from Eight patients (53%) with CRC were diag- the patient already mentioned above, fi ve nosed as a result of the histology from the patients had ‘adenocarcinoma diagnosed initial specimen. Of these, four patients had on initial histology’ and required complete cancer arising from the appendix, and the colonoscopy. Two patients underwent other four were found to have cecal cancer surveillance colonoscopy for chronic colitis that involved the base of the appendix. (ulcerative and chrons) and were diagnosed Of the remaining two patients with cecal with CRC two and six months post-appendi- cancers; one was the patient managed citis. One patient presented with PR bleeding non-operatively who was diagnosed on 12 months later and was found to have a

Table 4: The number of expected and observed colorectal carcinoma cases by age group after excluding those diagnosed on initial histology.

Age range Expected Observed Standardised risk Confidence interval number number ratio (SR) (95%)

All 2.36 7 2.96 1.29–5.6

45–60 0.46 3 6.5 1.6–17.75

60–80 1.2 4 3.33 1.06–8.4

Expected number = Expected number of colorectal cancers derived from the national age, gender, year of diagnosis and ethnicity population rates. Observed number = Actual number of cancers observed. Standardised risk ratio = Ratio of the number of observed over the expected colorectal carcinoma cases based on national age, gender, year of diagnosis and ethnicity population rates.

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T3 rectal cancer. One patient presented six unprepared bowel and even less so in the months later with a large bowel obstruction setting of acute appendicitis.11,12 secondary to a T3, N2 rectosigmoid cancer Shears fi rst entertained the relationship and underwent completion colonoscopy of right-sided colon cancer presenting with post-Hartmann’s procedure. Finally, the last acute appendicitis in 1906.5 Since then there patient with a CRC presented 28 months have been a number of small case reports later with change in bowel habit, and a highlighting this relationship.4–6,8 This study colonoscopy found a T2, N2 tumour at the supports the work by Lai HW et al in demon- splenic fl exure. strating an increased risk of underlying The four remaining patients diagnosed colon cancer in older adults with appendi- with CRC did not have colonic investigation citis. Our study has a lower risk than was within BOPDHB. One patient underwent an identifi ed in this Taiwanese study, which acute right colectomy for an appendiceal found an almost 40-fold increased odds abscess that contained malignancy and then ratio of colon cancer in over 40-year-olds.6 moved out of area; another was diagnosed However, that study did not control for age, with metastatic disease on staging CT scan gender or ethnicity as was done in our study after appendiceal histology found malig- and compared only to the overall national nancy and was palliated. The third patient incidence of colorectal cancer in Taiwan was diagnosed with a T4, N0, M0 cecal in the year 2000, and is therefore likely to cancer two and a half years later and ulti- have overstated the relationship. It also had mately died from their disease. This patient a longer follow-up period of fi ve years and did have a colonoscopy eventually, but it was may have bias associated with this. >36 months after diagnosis and eight months Although appendiceal adenocarcinoma post-diagnosis of CRC. Finally, the last is rare, with an expected incidence of patient diagnosed with CRC on appendiceal 0.08–0.2%,13,14 within this study popu- histology was too co-morbid to undergo any lation, four patients (0.6%) were diagnosed further investigations or surgery. with adenocarcinoma of the appendix. The study may be criticised for including Discussion these patients in the analysis as 60–70% Patients aged between 45–60 years will present with symptoms suggestive of 12 presenting with acute appendicitis had appendicitis and the diagnosis will ulti- more than a 17-fold increased risk of an mately be confi rmed by histology. However, underlying CRC than would be expected appendiceal adenocarcinomas are included given the study population demographics. in the ICD codes 9 and 10 for CRC as per the Throughout all age groups, there was an New Zealand Cancer Registry and therefore increased risk of CRC with an overall risk were included in the case defi nitions for this six times greater than expected. This study analysis as they are included in the baseline supports the hypothesis that a presentation population rate used for comparison. with appendicitis in patients ≥45 years may Synchronous colonic neoplasms are found constitute a sign of underlying colorectal in up to three percent of patients with 13 malignancy. After excluding those diag- appendiceal tumours, and this in itself nosed on initial histology there remained an should warrant complete colonic investi- increased risk especially in the age group gation before defi nitive surgery. 45–60 with over a six-fold increased risk of Eight patients of the 10 patients with underlying malignancy. right-sided malignancies were diagnosed It may be stated if the patient has had as a result of the histological fi ndings from a reassuring pre-operative CT scan then the initial surgery, which included 70% no further investigation is required, of the cecal tumours. This supports the however, in this study seven patients who hypothesis that an underlying colorectal were ultimately diagnosed with colorectal cancer, especially a right-sided cancer, can cancer underwent a pre-operative CT scan, lead to appendicitis. Of the two remaining only two of which raised the suspicion patients with right-sided malignancies; one of colorectal cancer. A CT scan is a poor was diagnosed one month later on follow-up diagnostic tool with only 70% sensitivity colonoscopy, and the other was diagnosed for detecting colonic malignancies in an 28 months later with abdominal pain due

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to a T4 cecal cancer. The remaining fi ve included in this study up until January 2015, patients (33%) were detected a median of and consequently some patients had only 12 months later, suggesting these cancers a short period of follow-up. If anything, were also present at the time of appendicitis. this would minimise the fi ndings of this After excluding those patients diagnosed on study as it may have missed a CRC diagnosis initial histology, there remained a three-fold for these patients during the subsequent increased risk among remaining patients follow-up period. (1.1% observed rate of CRC, expected rate It is also important to emphasise that 0.38%), and a six-fold increased risk in given this is a retrospective non-ran- patients aged 45–60 years (2.2% observed domised study the difference in CRC rate, excepted rate 0.13%). demonstrated in this population group Seventy-four percent of tumours were could be due to a number of underlying located on the right side (Table 2) with the factors that cannot be controlled for in this majority within the cecum. This distribution study design. However, this study is unique differs from that of the general population in that it standardised for age, gender and for colonic tumours in New Zealand,2 with ethnicity, and therefore these attributing right-sided tumours making up less than factors should be minimised. 30% of all colorectal malignancies. This The fi ndings of this study support the supports the theory of obstruction of the hypothesis that appendicitis is associated appendiceal lumen, either through direct with an increased rate of underlying tumour contact or infl ammatory change colorectal malignancy and may be a sign around the tumour. However, the majority of an undiagnosed colorectal cancer. This of these tumours were diagnosed as a result increased risk may be attributed to those of initial histology or early after diagnosis patients with appendiceal/cecal cancers with due to abnormal imaging, indicating our the majority of patients these diagnosed on current detection of these lesions is rela- initial histology or abnormal imaging. All tively safe. The remaining fi ve tumours patients diagnosed with colorectal cancer located in the transverse and recto-sigmoid as a result of their initial histology warrant region still represent higher than expected completion colonoscopy prior to defi nitive numbers (Table 4). As mentioned earlier, the surgical intervention. hypothesis of immune-mediated lymphoid In those whom the histology from appen- hyperplasia leading to appendicitis has been dicectomy was benign, colonic investigation raised previously and may account for this is more controversial. Three patients were increased rate, however, given the numbers ultimately diagnosed with CRC due to classic are small in this study it is diffi cult to make symptoms attributed to bowel cancer; large any clear conclusions. bowel obstruction, PR bleeding and change Limitations included the nature of the in bowel habit (six, 12 and 28 months later study design, being a single-centred study, respectively). Two patients were diag- which limits its generalisability. However, nosed through surveillance programmes despite variation in CRC rates throughout for colitis, which has a known increased New Zealand, the Bay of Plenty has an risk of CRC, and one patient presented >2 age-standardised rate equivalent to national years later with abdominal pain due to a T4 rates, and the results of this study should caecal cancer. After excluding those diag- therefore be comparable to those of the nosed on initial histology, there remained a 15 general population. The study could also three-fold increased SR (1.1% incidence) in be susceptible to a type two statistical error, patients >45 years and a six-fold increased given the smaller study size with a rare risk in patients aged 45–60 (2.2% incidence). event as the outcome studied. However, the Given the numbers are small within this results are similar to and supported by other population group, it is diffi cult to make any 4–9 studies in this area. defi nitive conclusions. The association of Thorough cross-referencing between distal CRC attributing to appendicitis could electronic clinical records and the pathology be theoretically explained by either distal database mitigated some of the potential partial colonic obstruction or immune-me- limitations due to the retrospective database diated lymphoid hyperplasia within the nature of the study. Also, patients were appendix, however, with small study

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numbers susceptible to type two error it always be kept in mind, and clinicians would be a bold statement to recommend should pay particular attention to any universal colonic investigation for these factors that may raise the suspicion of CRC. patients until further prospective studies are If a patient is managed non-operatively completed. or the histology of the initial specimen This is the fi rst study of its kind conducted reveals malignancy, these patients should in Australasia. The study reinforces the all be offered colonic investigation. In adult limited evidence that appendicitis is asso- patients with benign histology following ciated with increased risk of underlying CRC appendicitis, the authors recommend clini- in middle-aged and older adult patients. cians consider colonic investigation, taking In patients ≥45 years who present with into consideration individual risk factors symptoms of appendicitis, the possibility and symptoms, particularly for those in the of a co-existent colonic neoplasm should age range of 45–60 years.

Competing interests: Nil. Author information: Rebecca J Shine, Registrar General Surgery, Bay of Plenty DHB; Abigail Zarifeh, House Offi cer, Bay of Plenty DHB; Chris Frampton, Biostatistician, University of Otago, Christchurch; Jeremy Rossaak, Consultant Upper Gastrointestinal and General Surgeon, Bay of Plenty DHB, Senior Lecturer, University of Auckland, Auckland. Corresponding author: Dr Rebecca Jasmine Shine, 3/22 Verbena Road, Birkdale, Auckland. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459- 21-july-2017/7314

REFERENCES: 1. Center MM, Jemal A, Smith 4. Peltokallio P. Acute appen- the literature. J Natl Med RA, Ward E. Worldwide dicitis associated with Assoc. 1981; 73(5):449–451. Variations in Colorectal carcinoma of the colon. 8. Fabri PJ, Carey LC. Cecal Cancer. CA: A Cancer Diseases of the Colon & carcinoma presenting Journal for Clinicians. 2009; Rectum. 1966; 9(6):453–456. as acute appendicitis: a 59(6):366–378. 5. J Hill DJL. Acute appen- reappraisal. Journal of 2. Shah AB, Sarfati D, Blakely dicitis and carcinoma of clinical gastroenterology. T, Atkinson J, Dennett the colon. Journal of the 1980; 2(2):173–4. ER. Trends in colorectal Royal Society of Medicine. 9. Lai HW, Loong CC, Tai cancer incidence rates in 1986; 79(11):678–680. LC, Wu CW, Lui WY. New Zealand, 1981–2004. 6. Arnbjörnsson E. Acute Incidence and odds ratio ANZ Journal of Surgery. appendicitis as a sign of appendicitis as fi rst 2012; 82(4):258–264. of a colorectal carci- manifestation of colon 3. Gaetke-Udager K, Maturen noma. J Surg Oncol. cancer: A retrospective KE, Hammer SG. Beyond 1982; 20(1):17–20. analysis of 1,873 patients. acute appendicitis: 7. Temple DF, Carnevale N. J Gastroenterol Hepatol. imaging and pathologic Acute appendicitis as an 2006; 21(11):1693–1696. spectrum of appendiceal early manifestation of 10. A Zarrifeh, R Shine, J pathology. Emerg Radiol. carcinoma of the cecum: a Rossaak. Current Practice 2014; 21(5):535–542. case report and review of Of Colonic Investigation

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Following Acute Appen- EM, Coakley FV. Computed 14. Whitfi eld CG, Amin dicitis Throughout New tomography fi ndings SN, Garner JP. Surgical Zealand General Surgeons. mimicking appendicitis as a management of primary Poster presentation, manifestation of colorectal appendiceal malignancy. NZAGS Conference 2016. cancer. Clinical Imaging. Colorectal Disease. 2012; 11. Lee SA, Poh A. Unsuspected 2009; 33(6):430–432. 14(12):1507–1511. colorectal carcinoma on 13. Cerame MA. A 25-year 15. Ministry of Health 2011. routine abdominopelvic review of adenocarcino- Cancer: Major Sites by computed tomography. ma of the appendix. A DHB Region of Residence Singapore Med J. 2015; frequently perforating 2006–2008. Wellington, 56(5):248–56–quiz257. carcinoma. Diseases of New Zealand; 2011:1–35. 12. Watchorn RE, Poder L, the Colon & Rectum. Wang ZJ, Yeh BM, Webb 1988; 31(2):145–150.

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Short-term outcomes following cytoreductive surgery and heated intra- peritoneal chemotherapy at Waikato Jasen Ly, Linus Wu, Ralph Van Dalen, Simione Lolohea

ABSTRACT AIM: Pseudomyxoma peritonei is a rare disease that a ects 1–2 per million population per year. Treatment with cytoreductive surgery with heated intraperitoneal chemotherapy (CRS with IPC) has been well described. The purpose of this study was to look at the short-term outcomes following CRS with IPC for all such patients treated in Waikato. METHOD: Records for all patients presenting to surgery for CRS with IPC were retrospectively reviewed. CRS with IPC was performed in accordance with the techniques described by Sugarbaker. Data recorded included patient characteristics, characteristics of surgical treatment and early post-operative outcomes. RESULTS: Sixty-eight patients underwent 72 procedures. Fourteen patients were deemed unresectable at surgery and were treated palliatively. The median age was 57 with the majority being female (59%). The median time, from the decision made for surgery to CRS with IPC, was three months. The median prior surgical score was 1 and the median peritoneal cancer index (PCI) was 19.5. The median operating time was 9.08 hours (5.43–15.20). The majority of patients (76%) had pseudomyxoma peritonei, while the remainder had a combination of other appendiceal, colorectal, ovarian, gastric and primary mesothelial primaries. The major complication rate was 24% and the 30-day mortality rate was 1.4%. The median hospital stay was 12 days. CONCLUSION: Short-term outcomes following CRS with IPC at Waikato are comparable to those published in the literature. Further follow-up is anticipated for the publication of survival and recurrence data.

ytoreductive surgery with heated major complication and mortality rates as intraperitoneal chemotherapy (CRS low as 24% and 2% respectively.1 Cwith IPC) has been well established Classically, pseudomyxoma peritonei as a standard of care for the treatment of has been divided into low- and high-grade 1,2 pseudomyxoma peritonei. Previously subtypes with numerous classifi cation recognised as a fatal disease, the potential for systems having been described previously cure through this technique can be attributed such as that by Ronnett, Misdraji and to Sugarbaker and the work performed by Bradley.8–10 Commonly cited in the literature 1–4 other high-volume centres. Traditional is that by Ronnett whereby pseudomyxoma debulking procedures resulted in no chance peritonei is classifi ed as either dissemi- for cure and, except for palliation, can largely nated peritoneal adenomucinosis (DPAM) be considered historical with survival rates or peri-toneal mucinous carcinomatosis as low as 34% and 15% having been reported (PMCA), with numerous studies demon- 5–7 at three and fi ve years. With CRS with IPC, strating a signifi cantly poorer overall a recent multi-institutional review published survival with the high-grade subtype in 2012 demonstrated survival rates of 63% (PMCA).1–3,10–15 The more recent WHO and and 59% at 10 and 15 years, together with AJCC equivalent describes pseudomyxoma

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peritonei as either low-grade or high- included the peritoneal cancer index, grade mucinous adenocarcinoma, and this number of visceral resections, number of refl ects the slow but malignant potential peritonectomies, completeness of cytore- of the disease, and the ultimately fatal duction score, type of IPC, stoma formation, outcome without treatment.8 intraoperative transfusion requirement While much of the literature describes CRS and duration of operation. Post-operative with IPC in relation to the treatment of pseu- outcome included post-operative compli- domyxoma peritonei, there is increasing cations, 30-day mortality and duration of evidence to support the use of the technique hospital stay. for peritoneal metastases secondary to Referrals for treatment were received other malignant diseases. This includes both from other centres throughout New Zealand colorectal cancer and peritoneal malignant as well as from within the Waikato region. mesothelioma, and to a lesser degree meta- Patients were seen at the outpatient clinic static ovarian and gastric cancer.16–19 in Waikato and investigated with a combi- Waikato is one of only two centres in New nation of CT scans, colonoscopy, staging Zealand receiving nationwide referrals for laparoscopy and tumour markers if not cytoreductive surgery. Recently, Wheeler et already performed in the referring centre. al published their experience of 25 patients Details of their mode of presentation as with pseudomyxoma peritonei over a 12-year well as number and type (as denoted by a period at Wellington Hospital from 1997 prior surgical score) of previous surgery to 2011.15 They demonstrated an overall were usually documented in the outpa- fi ve-year survival rate of 64%, and had 17 tient clinic or referral letter. Once the Clavien-Dindo grade 3 or 4 complications decision had been made that a patient was in seven of the 25 patients, with no 30-day a candidate for surgery, they were placed mortality. In slight contrast, Waikato has been on the waiting list, consented for CRS performing cytoreductive surgery with the with IPC and were given an anaesthetic addition of heated intraoperative intraperi- appointment for review. The prior surgical toneal mitomycin C, similar to the techniques score as described by Sugarbaker is a score described by Sugarbaker and that by other from PSS-0 to PSS-3 and was assigned to major centres performing cytoreductive patients according to the extent of previous surgery internationally.20 The technique was surgery performed (PSS-0: biopsy only fi rst introduced at our institution in 2008 or laparoscopy plus biopsy, PSS-1: prior and the following study examines our expe- exploratory laparotomy, PSS-2: exploratory rience with CRS with IPC over the subsequent laparotomy with some resection, PSS-3: 21,22 seven-year period to 2014. attempted complete cytoreduction). Patients were admitted to hospital the Method day before surgery and given full bowel preparation. Cytoreductive surgery was A prospective database of all patients performed by three surgeons according referred for treatment to both Waikato to the techniques described by Sugar- (public) and Braemar (private) hospitals baker.21,22 The patients were positioned in since 2008 was kept by a single surgeon. the modifi ed Lloyd Davis position with the This database was retrospectively analysed left arm abducted such that fi xed table- from a combination of clinic letters, patient based retraction could be used for exposure progress notes and pathology, radiology as well as for formation of the ‘coliseum’ for and operative reports. The information IPC. Intraoperatively, all patients were given was divided into three categories and a peritoneal cancer index (PCI) score, which included pre-operative patient character- is derived from the summation (up to 39) of istics, characteristics of surgical treatment the lesion size score (LSS 1:<0.5cm, LSS 2: and post-operative outcome. Pre-operative 0.5–5cm, LSS 3:>5cm or confl uent nodules of patient characteristics included basic demo- tumour) in the 13 abdomino-pelvic regions graphic features, mode of presentation, time as described by Sugarbaker.21,22 For pseu- since the decision to operate to surgery, domyxoma peritonei, a completeness of prior surgical score, number of prior oper- cytoreduction score of either 0 or 1 was ations, prior chemotherapy and histology. attempted, while for other malignancies Characteristics of surgical treatment

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Figure 1: Peritoneal cancer index.22

a completeness of cytoreduction score of and gastric cancer. Once chemotherapy was 0 was attempted. This score relates to the complete, the construction of any anasto- extent of residual disease present (CC-0: moses was performed, drains were placed, no disease, CC-1:<0.25cm, CC-2:0.25–2.5cm, the abdomen was closed, and any stomas CC-3>2.5cm).21,22 If the disease process was were fashioned. Chest drains were not deemed incurable, palliative debulking routinely inserted unless there had been a was either attempted or the procedure defi nite diaphragmatic perforation. was abandoned without intraperitoneal Post-operatively, patients were trans- chemotherapy. ferred to a high dependency unit for 48–72 Once cytoreduction was complete, a hours. The use of TPN was not routine as ‘coliseum’ was set up for the instillation of has been described in other centres.15,23 DVT intraperitoneal chemotherapy, before the prophylaxis was commenced immediately construction of anastomoses. Ring-based post-operatively and included compression fi xed table retraction was used to which stockings, sequential calf compressors and the skin was sutured with interrupted 1–0 prophylactic dose clexane. Diet and mobili- nylon to prevent spillage of chemotherapy. sation were progressed according to clinical Layers of opsite were then placed over assessment. Urine output was monitored the ring-based retractor and abdominal strictly, especially in cases where cisplatin wall to fashion the watertight ‘coliseum’. had been used where a higher urine fl ow Tubing consisted of one infl ow tube and rate was achieved. Convalescent care at three outfl ow tubes, a temperature probe the referring hospital was considered upon and a smoke evacuator. Mitomycin C was discharge for patients outside of the Waikato delivered by a perfusionist for 90 minutes at region. Post-operative complications were 41–42ºC at a dose of 10mg/m2 for women and recorded and classifi ed according to the 12.5mg/m2 for men. The dose was reduced Clavien-Dindo classifi cation. by 33% in those who had received heavy Following discharge, patients were prior chemotherapy, had marginal renal seen at six weeks and the post-operative function, were aged over 60, had extensive histology was reviewed at a fortnightly prior intraoperative trauma to the small pathology multidisciplinary team meeting, bowel surfaces or who had prior radio- which was attended by pathologists, therapy. The addition of cisplatin was used surgeons and a medical oncologist. Follow for patients with malignant mesothelioma up consisted of four-monthly CEA, CA19-9

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and CA125. CT scans were performed at Table 2: Number by referral location. one, two and three years. Patients with recurrent disease discovered on surveil- Referral centre lance were discussed and considered for Waikato 26 either no treatment, systemic chemotherapy or further CRS with IPC. Auckland 13 Results Christchurch 7 Dunedin 5 Since 2008, 72 operations were performed on 68 patients with the intention of Whangarei 4 performing CRS with IPC. Fourteen patients Hawke’s Bay 2 were deemed to be incurable at the time of surgery and either had a palliative Timaru 1 debulking procedure (8) or the procedure Invercargill 2 was abandoned (6). Fifty-eight cases of CRS with IPC were performed on 54 patients, Taranaki 2 16 of which were performed in a private Tauranga 4 hospital (Braemar Hospital). Four cases were redo operations whereby further CRS with Rotorua 2 IPC was performed for four patients who Palmerston North 2 developed recurrent disease. Wellington 2 Table 1: Demographic features.

Number of patients Patient characteristics Referrals were received from all Public 48 throughout New Zealand, although a Private 20 reasonable proportion were from within the Waikato region (36%). Mode of presen- Unresectable 14 (4 private, 10 public) tation was most commonly abdominal pain Redo 4 (2 public, 2 private) (44%) or distension (25%). There were 28 (41%) men and 40 (59%) women with a Patient characteristics median age of 57 years (30–80) and BMI of Median age (range) 57 (30–80) 28 (20–45). Median ASA was 2. From the time the decision was made that a patient Sex was a candidate for CRS with IPC, patients Male 28 received their operations at a median of three months, ranging from one to 12 Female 40 months. The median number of prior opera- Median BMI (range) 28 (20–45) tions was one, and the median prior surgical score was one. Fourteen patients received Median ASA 2 systemic chemotherapy prior to being operated on, fi ve of whom turned out to be Mode of presentation incurable. Five of these 14 patients (one of Abdominal pain 32 whom was incurable) had pseudomyxoma peritonei, fi ve had colorectal cancer (two Abdominal distension 18 of whom were incurable), two had ovarian Abdominal mass 7 cancer (one of whom was incurable), one had gastric cancer and one had an adenocar- Surveillance 11 cinoid of the appendix. Hernia 4

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Figure 2: Number of cases per year.

Characteristics of surgical mesothelioma and gastric cancer. The treatment median operative time was 9.08 hours (range 5.43–15.20 hours). The median number of Of the 58 operations where CRS with IPC visceral resections was two and the median was performed, the median PCI at lapa- number of peritonectomies was four. Thirty rotomy was 19.5 (3–39). The PCI for those of the 58 cases treated with CRS with IPC with incurable disease was not well docu- required a stoma of some type (21 end mented and therefore not included. Table 3 ileostomies, seven loop ileostomies, two end shows the completeness of cytoreduction for colostomies). Twenty-three patients required each histological type. a blood transfusion with a median of four Heated intraoperative intraperitoneal units of red blood cells, fi ve units of fresh chemotherapy with mitomycin C was used frozen plasma, one unit of platelets and two in 54 cases, while mitomycin C with cisplatin units of cryoprecipitate. was used in the four cases of peritoneal

Table 3: Total numbers by histological type and completeness of cytoreduction.

Complete Incomplete Total number Pseudomyxoma peritonei 40 8 48

Appendix adenocarcinoma 2 2 4

Adenocarcinoid 1 2 3

Colon cancer 5 4 9

Peritoneal mesothelioma 3 0 3

Ovarian cancer 1 2 3

Gastric cancer 1 0 1

Mixed 1 0 1

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Post-operative outcome led to criticisms regarding the safety, cost Thirty patients (42%) experienced compli- effectiveness and general acceptance of the 27–30 cations, three of which occurred in the 14 technique. Overcoming these issues at incurable patients (one medication side our own institution has therefore required effect, one relook laparotomy for a wound a signifi cant collaborative effort between complication and one death). Seventeen administrative, nursing, medical and allied patients (24%) had either grade 3 or 4 health staff. At the present time, our expe- Clavien-Dindo complications. One out of rience with CRS with IPC is also no doubt the 72 cases died within 30 days as above early by international standards, and there (incurable patient), giving an overall 30-day is a recognised learning curve associated mortality rate of 1.4%. Of 11 cases requiring with the procedure that improves with expe- a return to theatre (15.2%), the reasons were rience and translates to decreased morbidity 3,5,31,32 anastomotic leak (3), bowel obstruction and improved survival over time. This (1), gastric perforation (1), enterotomy (1), relates not only to surgical expertise, but bleeding (1), bile leak (1), wound compli- also importantly to patient selection, inter- cations (2) and removal of a drain end (1). pretation of pathology, anaesthetic, nursing 33 The median duration of hospital stay was 12 and medical post-operative care. days (range fi ve to 104 days), although was To date, we have had a series now of only 8.5 days (fi ve to 21 days) for those who 58 cases over a seven-year period that had incurable disease. have been treated with CRS with IPC. Our short-term outcomes with respect Table 4: Number of patients with complications, to operative times, transfusion require- grouped by most severe complication by Cla- vien-Dindo grading. ments and hospital stay are comparable to those published.1,4,15,24,25,34 We had a 30-day Clavien-Dindo grading Number mortality rate of 1.4%, comparable to that published by Moran’s group of 5% in their Grade 1 6 early experience of 123 patients, and a 24 Grade 2 6 major complication rate of 24%. In 2009, Chua et al published the morbidity and Grade 3a 5 mortality outcomes of 24 institutions, 11 Grade 3b 11 of which were considered high-volume tertiary centres with between 103 and 460 Grade 4a 1 cases at the time of publication.27 Overall Grade 5 1 mortality rates ranged from 0 to 17%, with sub analysis of high-volume centres demon- Total 30 strating mortality rates of between 0.9 to 5.8%. The most common causes of death were sepsis and multi-organ failure from Discussion surgical complications. The overall rate of Pseudomyxoma peritonei is a rare disease, grade 3/4 complications ranged from 0 to but worldwide there has been increasing 52%, and for high-volume centres ranged experience with treatment with CRS with from 12 to 52%, with the most common IPC, with good long-term outcome.11,12,24–26 In complications being sepsis, fi stula, abscess, this article, we presented our early expe- ileus, perforation, anastomotic leak, DVT/PE, rience with the technique, not only for haematological toxicity and renal insuffi - patients with pseudomyxoma peritonei, ciency. Rates of reoperation ranged from 0 but also for a small series of patients with to 23% in the perioperative period, which in adenocarcinoid of the appendix, malignant our series was 15.2%. mesothelioma and metastatic colon, gastric At our institution, we have only ever and ovarian cancer. used heated intraoperative intraperitoneal Traditionally, CRS with IPC has been chemotherapy (HIPEC) with mitomycin C, considered a morbid, expensive and adding cisplatin for patients with malignant time-consuming procedure. The potential mesothelioma and gastric cancer. The main for multiple major visceral resections and advantages of HIPEC are even exposure peritonectomy procedures, long operating of the peritoneal surface to chemotherapy times and intensive post-operative care has before the formation of adhesions and the

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ability to use hyperthermia. Heat theoreti- period, though we did include four patients cally decreases the interstitial pressure of in our study who had repeat CRS with IPC the tumour tissue to increase penetration for recurrent disease. In the above study of the chemotherapeutic agent, increases by Chua et al, the median progression-free the cytotoxicity of the chemotherapeutic survival was reported as 8.2 years, with agent and has a direct cytotoxic effect on prior chemotherapy, the high grade subtype, tumour tissue.21,22 The systemic absorption major post-operative complications, higher of mitomycin C is also limited because PCI and debulking surgery being predictors of its high molecular weight and in our of poorer progression-free survival on series we encountered no complications multivariate analysis.1 Repeat CRS with IPC related to cytotoxicity, though both renal in selected patients has been shown to be and haematological toxicity have been feasible, and in some patients’ third time reported. In the literature, renal toxicity and even fourth time CRS with IPC may be ranged from 1.3–5.7% and haematological possible with improved survival.37 In this toxicity between 4.6–18.6%.35 The principal particular study by the Sugarbaker group, disadvantages of HIPEC are the increased recurrence was most frequently noted in the operative times, the need for specialised small bowel initially and then in the pelvis perfusion equipment and personnel, and the at subsequent CRS with IPC, with focal recur- limited number of heat stable chemothera- rences being more common than diffuse. peutic agents available for use.21,22 Patients were generally operated on within The alternatively described technique a few months of diagnosis, translating to is early post-operative intraperitoneal better performance status, lower reoper- chemotherapy (EPIC), either alone or ative PCI, and tumours that were relatively in combination with HIPEC.34,36 EPIC easier to remove by complete cytoreduction. requires less operative time, equipment While timely surgery may be possible for and personnel, has a broader range of patients from within the Waikato region, available agents, and patients can receive it may be diffi cult to achieve for patients multiple cycles of treatment beginning as referred from elsewhere in New Zealand. early as the day after surgery. Port compli- Current evidence suggests that CRS cations may, however, interfere with the with IPC also has a role in the treatment ability to complete the intended duration of other malignancies with peritoneal of EPIC, and post-operative adhesions may surface disease,16–19,38–41 and our series interfere with chemotherapy distribution. includes patients with adenocarcinoid of Patients may also develop uncomfortable the appendix, appendix adenocarcinoma, abdominal distension and special precau- malignant mesothelioma and metastatic tions are required during the administration colon, gastric and ovarian cancer. Emerging of chemotherapy, which is undertaken on evidence into the use of the technique is either the ward or in ICU. particularly important in colorectal cancer, Due to the relatively short follow-up data in whom patients are traditionally expected of our series at the time of publication, we to have a dismal prognosis and are generally did not examine the survival outcomes for treated with a palliative intent. In a recent our cohort of patients. In the multi-institu- systematic review, however, the potential tional review by Chua et al in 2012 of 2,298 for a doubling in the median survival of patients with pseudomyxoma peritonei, the patients with peritoneal disease treated with median overall survival was 16.3 years with CRS with IPC was demonstrated compared 19 3-, 5-, 10- and 15-year survival rates of 80%, to systemic chemotherapy. Only patients 74%, 63% and 59% respectively.1 Studies with a relatively lower PCI are considered to which reported on overall survival and benefi t from treatment (<20), and the main performed multivariate analyses of asso- problem at the present time is in identifying ciated factors found that older age, major which patients will benefi t from CRS with post-operative complications, debulking IPC, and in establishing suitable scoring surgery (CC 2/3), prior chemotherapy and systems and algorithms for referral and high-grade subtype were independent treatment. Currently the peritoneal surface predictors of poorer overall survival.1,11,12,26 disease severity score (PSDSS) is one such prognostic scoring system42,43 that has been We also did not report on the number incorporated into a suggested algorithm for of recurrences at the end of the follow-up

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treatment.44,45 In addition there is a move with time and in the near future will report to try to identify patients with colorectal on our overall and disease-free survival cancer at high risk for peritoneal recur- outcomes. Furthermore, as CRS with IPC rence in whom a staged relook could be has been accepted as standard of care for performed with a view to offering them CRS patients with pseudomyxoma peritonei, we with IPC. In a study by Elias et al, 41 patients anticipate that this increased awareness were treated in this manner, with 23 going will lead to an increase in the number of on to have CRS with IPC, giving an overall referrals. Coupled with increasing interest fi ve-year survival of 90%.46 in CRS with IPC for colorectal cancer, this This study demonstrates our institution’s will mean the need for a more streamlined short-term outcomes following CRS with and protocolised national referral process, IPC. By comparison, we have yet to gain proper patient selection, prompt patient the volume and experience achieved by treatment, clear guidelines for post-operative other international centres performing CRS follow up, equal accessibility to discussion with IPC, though we hope to achieve this and treatment of recurrent disease, and further audit and review of our outcomes.

Competing interests: Nil. Author information: Ngov Jasen Ly, Colorectal Surgeon, General Surgery Department, Waikato Hospital, Hamilton; Linus Wu, Colorectal Surgeon, General Surgery Department, Waikato Hospital, Hamilton; Ralph Van Dalen, Colorectal Surgeon, General Surgery Department, Waikato Hospital, Hamilton; Simione Lolohea, General Surgery Department, Colorectal Surgeon, Waikato Hospital, Hamilton. Corresponding author: Simione Lolohea, General Surgery Department, Waikato Hospital, Hamilton. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459- 21-july-2017/7315

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28. Bryant J, Clegg AJ, Sidhu adenocarcinoma of the of perioperative systemic Mk, et al. Clinical effec- appendix. Int Surg. 2015 chemotherapy in diffuse tiveness and costs of the Jan; 100(1):21–8. malignant peritoneal Sugarbaker procedure 35. Canda AE, Sokmen S, mesothelioma patients for the treatment of Terzi C, et al. Complica- treated with cytoreductive pseudomyxoma peritonei. tions and toxicities after surgery and hyperthermic Health Technol Assess. cytoreductive surgery intraperitoneal chemo- 2004 Feb; 8(7):iii, 1–54. and hyperthermic therapy. Ann Surg Oncol 29. Chua TC, Saxena A, intraperitoneal chemo- 2013 Apr; 20(4):1093–100. Schellekens JF, et al. therapy. Ann Surg Oncol. 42. Esquivel J, Lowy A, Morbidity and mortality 2013 Apr; 20(4):1082–7. Markman M, et al. out-comes of cytoreductive 36. Wagner PL, Jones D, The American Society surgery and perioperative Aronova A, et al. Early of Peritoneal Surface intraperitoneal chemo- postoperative intraper- Malignancies (ASPSM) therapy at a single tertiary itoneal chemotherapy Multiinstitution Evaluation institution: towards a new following cytoreductive of the Peritoneal Surface perspective of this treat- surgery for appendiceal Disease Severity Score ment. Ann Surg 2010 mucinous neoplasms with (PSDSS) in 1,013 Patients Jan; 251(1):101–6. isolated peritoneal metas- with Colorectal Cancer with 30. Moran BJ. Establishment tasis. Dis Colon Rectum. Peritoneal Carcinomatosis. of a peritoneal malig- 2012 Apr; 55(4):407–15. Ann Surg Oncol. 2014 Dec; 21(13):4195–201. nancy treatment centre 37. Yan TD, Bijelic L, in the United Kingdom. Sugarbaker PH. Critical 43. Simkens GA, van Oudheus- Eur J Surg Oncol. 2006 analysis of treatment den TR, Nieboer D, et al. Aug; 32(6):614–8. failure after complete Development of a Prognos- 31. Yan TD, Links M, Fransi cytoreductive surgery and tic Nomogram for Patients S, et al. Learning curve perioperative intraperi- with Peritoneally Metas- for cytoreductive surgery toneal chemotherapy for tasized Colorectal Cancer and perioperative peritoneal dissemination Treated with Cytoreductive intraperitoneal chemother- from appendiceal muci- Surgery and HIPEC. Ann apy for peritoneal surface nous neoplasms. Ann Surg Oncol. 2016 Dec; malignancy - a journey Surg Oncol. 2007 Aug; 23(13):4214–4221. to becoming a Nationally 14(8):2289–99. 44. Esquivel J, Elias D, Baratti Funded Peritonectomy 38. Passot G, Vaudoyer D, Ville- D, et al. Consensus Center. Ann Surg Oncol. neuve L, et al. What made statement on the loco 2007 Aug; 14(8):2270–80. hyperthermic intraperi- regional treatment of 32. Smeenk RM, Verwaal VJ, toneal chemotherapy an colorectal cancer with Zoetmulder Fa. Learning effective curative treatment peritoneal dissemina- curve of combined modal- for peritoneal surface tion. J Surg Oncol. 2008 ity treatment in peritoneal malignancy: A 25-year Sep 15; 98(4):263–7. surface disease. Br J Surv. experience with 1,125 45. Esquivel J. Cytoreductive 2007 Nov; 94(11):1408–14. procedures. J Surg Oncol. surgery and hyperthermic 33. Bell JC, Rylah BG, Chambers 2016 Jun; 113(7)796–803. intraperitoneal chemo- RW, et al. Perioperative 39. Gamblin TC, Alexander therapy for colorectal management of patients HR, Edwards R, Bartlett cancer: survival outcomes undergoing cytoreductive Dl. Regional therapies for and patient selection. surgery combined with cancer. Ann Surg Oncol. J Gastrointest Oncol. heated intraperitoneal 2013 Apr; 20(4):1053–5. 2016 Feb; 7(1):72–8. chemotherapy for perito- 40. Mirnezami R, Moran 46. Elias D, Honore C, Dumont neal surface malignancy: a BJ, Harvey K, et al. F, et al. Results of system- multi-institutional expe- Cytoreductive surgery atic second-look surgery rience. Ann Surg Oncol. and intraperitoneal plus HIPEC in asymptom- 2012 Dec; 19(13):4244–51. chemotherapy for atic patients presenting 34. Sparks DS, Morris B, Xu W, colorectal peritoneal a high risk of developing et al. Cytoreductive surgery metastases. World J Gas-tro- colorectal peritoneal and heated intraperito- enterol. 2014 Oct 14; carcinomatosis. Ann Surg. neal chemotherapy for 20(38):14018–32. 2011 Aug; 254(2):289–93. peritoneal carcinomatosis 41. Deraco M, Baratti D, secondary to mucinous Hutanu I, et al. The role

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A cross-disciplinary assessment of student loans debt, nancial support for study and career preferences upon graduation Craig S Webster, Christopher Ling, Mark Barrow, Phillippa Poole, Marcus Henning

ABSTRACT AIM: To explore relationships between student loans debt, financial support and career preferences upon graduation for all healthcare disciplines o ered at the Faculty of Medical and Health Sciences, University of Auckland. METHODS: The Faculty Tracking Project is a longitudinal study which invites students to complete a questionnaire at the beginning and end of their educational programmes, including questions on debt, financial support and career preference. Our analysis comprised three phases: (1) a descriptive analysis of data related to debt and financial support; (2) a principal component analysis in order to find related categories of career choice; and (3) logistic regression models to determine how career preference categories could be explained by either levels of student loans debt or financial support. RESULTS: Data from 2,405 participating students were included. Students in health sciences, nursing and pharmacy typically accrue levels of student loans debt of around $15,000 to $29,999, while optometry students accrue debt around $15,000 higher. Medical students show debt distributed around modes of $0 and $90,000 or more. All students typically access three sources of financial support during study. Career preferences at graduation reduced to four categories for all health disciplines. We found five significant e ects, involving students in health sciences, medicine and pharmacy, relating the number of sources of financial support to the four categories of career preference. No significant e ects were found related to level of student loans debt. CONCLUSIONS: Our results suggest that financial support is a more strongly determining factor in career choices than the level of student loans debt. The four-category framework for student career preferences appears to be a useful model for further research.

student’s career choices may be infl u- other undergraduate programmes. This can enced by many factors, including per- place a fi nancial burden on healthcare stu- sonal interest, fi nancial compensa- dents, which may also negatively impact on A 4–6 tion, the cost and perceived level of diffi culty their wellbeing. Some evidence suggests of the training programme and lifestyle that the rising cost of healthcare education preferences.1–3 A number of these factors ap- is causing some medical students to seek pear to be particularly relevant in the case specialties perceived to be more highly paid. of students studying towards a career in These specialties are often in cities, thus healthcare. This is due to the typically high- their selection potentially undersupplies er fees and often greater number of years of primary healthcare and rural locations.7–8 study required in healthcare compared to

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In New Zealand, primary healthcare Faculty Tracking Project (as described workers from a range of professional back- below) allows such comparisons to be made, grounds are responsible for the provision of across disciplines, using comparable data. comprehensive and continuous patient care, Therefore, our present aim was to conduct thus forming the foundation of an effective an exploratory study analysing relationships health system.9–10 New Zealand’s aging popu- between student debt, sources of fi nancial lation places further demands on primary support and career preferences upon gradu- healthcare providers and there is a growing ation for all healthcare disciplines offered in need to encourage a signifi cant proportion the Faculty of Medical and Health Sciences of graduates to specialise in primary at the University of Auckland. healthcare. This is especially the case in rural areas where healthcare workers are Methods already in short supply.11 Data for the present study were drawn To date, the relationship between from the existing database of the Faculty student debt at graduation and future Tracking Project at the University of career choices has almost exclusively been Auckland for all participating disciplines. 1,6,12,13 studied in medical students. The The Faculty Tracking Project is a longitu- results of such studies have been mixed, dinal study that began in 2006, and invites however, with some fi nding no signif- students to complete a questionnaire icant relationship between debt levels, upon entry to, and exit from, their health career choices and specialisation—even education programmes. In the present in relation to students with higher levels study only exit questionnaire data were 6,8,12,14–17 of debt. Furthermore, two studies used, and all identifying student infor- found that students with lower debt mation was removed upon extraction of levels were less likely to select a career in data from the database. The New Zealand 8,12 primary care. Other analyses suggest Government student loans (GSLs) scheme that debt levels of medical students are is available for domestic students, and such manageable even if they select a career loans may be used to cover compulsory 15 in the primary healthcare sector. These student fees, course-related costs up to the confl icting fi ndings may in part be due to value of $1,000 and living costs up to $177 the confounding infl uence of socioeconomic per week. In questionnaires, participants status, and age upon entry into educational were asked to disclose their total student 8,12,16 programmes. loans debt, the sources of fi nancial support There are very few reports of the infl u- accessed during their study and their career ences of debt or income on career choice preferences upon graduation. Specifi c in other health professions. In one national questions are apparent from our reported study of dentists in Canada, almost half results, and copies of the discipline-specifi c reported incurring substantially more debt questionnaires are available from the corre- during their education than they had antic- sponding author. ipated, but in two-thirds this did not affect In 2012, the Faculty Tracking Project 18 their career choice. A study of psycholo- became part of the Australian Medical gists in New Zealand found that participants Schools Outcomes Database and Longitu- borrowed more when they anticipated dinal Tracking Project (MSOD). This change greater earnings in their intended career, involved the substantial redesign of the but overall took longer to repay their questionnaire form for medicine, particu- 19 student loan than they had anticipated. larly involving the way career preferences However, we know of no research which has are coded.20 This presented diffi culties considered the wider context of healthcare with the planned inferential data analysis education by taking a cross-disciplinary regarding career preference in terms of approach when considering the relationship data continuity. Therefore we have included between student debt levels and career data for medicine related to income and choice. Such a cross-disciplinary approach debt for the seven years from 2006 to 2012, is important in terms of gaining insight into but have excluded the career preference how best to provide the range of healthcare data collected using the new form in 2012. workers needed in New Zealand, and the Optometry was recruited to the Tracking

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Project in 2013, and these data have been debt as a covariate. We designated p<0.05 as included in the initial descriptive analysis statistically signifi cant, and given the explor- of the study for comparison purposes. For atory nature of our study we did not correct the disciplines of health sciences, nursing for multiple comparisons.21,22 and pharmacy we have included data from the eight-year period from 2006 to 2013 Results (see Discipline column, Table 1). This study Data from a total of 2,405 students were was conducted under the ethics approval of included in our study—this comprised the Faculty Tracking Project granted by the 199 health sciences students, 890 medical University of Auckland Human Participants students, 572 nursing students, 710 Ethics Committee. pharmacy students and 34 optometry Data analysis students. There was a high question- Our planned data analysis comprised naire response rate for medical, nursing, three distinct phases. First we conducted optometry and pharmacy students (81–95%), a descriptive and exploratory analysis of but this was considerably lower for health all data related to student loans debt and sciences students (47%). fi nancial support. Second, we conducted a Phase one principal component analysis within each of the four disciplines of health sciences, Student debt levels medicine, nursing and pharmacy in order Levels of student loans debt were reported to identify factors of similar career pref- using eight categories in increments of erences. This was necessary because the $15,000 each, spanning the range from $0 to career choices listed in the questionnaire for $90,000 or more. Figure 1 shows the distri- each discipline were different in type and butions of debt for all disciplines included number (between eight and 19 choices)— in our study. The most common level of thus signifi cantly complicating subsequent debt was the same for health sciences, analysis and comparisons between disci- nursing and pharmacy students, peaking plines without some reduction in factors. in the $15,000 to $29,999 range. Optometry Third, we conducted two separate logistic students reported modal debt in the next regressions to explore how career pref- highest debt category, at $30,000 to $44,999. erence factors could be explained by either By contrast, levels of student loans debt levels of student loans debt or numbers reported by medical students showed a of sources of fi nancial support (SPSS, IBM much fl atter distribution with a nadir in the Corporation, New York). We also considered range in which other disciplines showed how career preference factors could be their peaks, and peaks at both extreme ends explained by levels of fi nancial support with of the scale, namely $0 and $90,000 or more.

Figure 1: Histogram of the distribution of student loans debt at completion of the educational programme for each participating discipline.

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Owing to the different distributions of Sources of financial support student loans debt and the fact that some Sources of fi nancial support reported categories contained only a small number on the Tracking Project questionnaire of respondents, we elected to use two comprised support from parents, student categories for the analysis of debt levels— loans, student allowance, part-time namely low and high debt, defi ned as debt employment, partner’s income, savings, less than $30,000 and greater than $30,000 scholarships and other. Students were asked respectively. Using two categories in this to indicate the total number of sources of way allowed us to use binary logistic fi nancial support that they had accessed regression in phase three of our study in during their studies. Despite different debt order to explore the relationships with levels, the most common number of sources career preferences. We chose $30,000 as of fi nancial support was the same for all the threshold between categories because disciplines, with a mode of three sources approximately half the overall respondents (range 0–8 for medicine, 0–7 for health fell into each category. However, compared sciences and nursing, 0–6 for pharmacy with student loans debt overall (Figure 1), and 1–6 for optometry). For the purposes the proportions of low to high debt between of further analysis we elected to create two disciplines varied signifi cantly (p<0.001, categories for the number of sources of chi square—Table 1). This effect was due to fi nancial support—namely low (three or less the fact that proportionally more students sources) and high (four or more sources). in medicine and optometry had high debt, Despite similar modal numbers of sources while proportionally more students in of fi nancial support, the proportions of health sciences, nursing and pharmacy had low to high numbers varied signifi cantly low debt (post hoc testing, Table 1). between disciplines (p<0.005, chi square— Table 1). This effect was due to the fact that

Table 1: Proportions of student loans debt and sources of fi nancial support falling into low and high categories.

Discipline (sample period) Debt** Sources of financial support (p<0.001, chi square) (p<0.005, chi square)

Low High Low High (<$30,000) (>$30,000) (3 or less) (4 or more)

Health science Participant n=199 138* 59 120 79 (2006–2013) Within discipline % 70% 30% 60% 40%

Medicine Participant n=890 242 625* 488 402* (2006–2012) Within discipline % 28% 72% 55% 45%

Nursing Participant n=572 400* 147 346 226 (2006–2013) Within discipline % 73% 27% 60% 40%

Pharmacy Participant n=710 463* 212 451* 259 (2006–2013) Within discipline % 69% 31% 64% 36%

Optometry Participant n=34 8 26* 16 18 (2013) Within discipline % 24% 76% 47% 53%

Total Participant n=2,405 1,251 1,069 1,421 984

*Significant post hoc e ect (z-score >1.96). **Missing values indicate participants who declined to disclose their level of student loans debt.

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proportionally more students in medicine Phase three had a high number of sources of fi nancial support, while proportionally more students Relationships between career in pharmacy had a low number of sources categories, student loans debt and of fi nancial support—with other disciplines financial support showing no signifi cant effects (post hoc We used a binary logistic regression model testing, Table 1). Given the small number of to explore relationships between levels optometry respondents, this discipline was of student loans debt, fi nancial support not included in further analysis. used during study and categories of career preference (outputs for regression models Phase two are shown in Table 3).23,24 The fi rst model Principal component analysis of explored student loans debt and its rela- career preferences tionship to the four career preference In order to use regression analysis to categories across all disciplines, but demon- investigate possible relationships between strated no signifi cant results (Table 3). debt levels, fi nancial support and career Conducting the same exploratory regression preferences upon graduation, we fi rst model in relation to sources of fi nancial attempted to fi nd whether career prefer- support used during study and categories ences factored into similar types in order to of career preference demonstrated six reduce the number of factors for analysis. signifi cant effects. Having a low number Students indicated their career preferences of sources of fi nancial support meant in the questionnaire by recording strong that health sciences students favoured a interest, some interest or no interest in each career in Category 4, and medical students potential career choice. For our analysis favoured a career in Category 1 (Table 3). we coded this level of interest numerically, Alternatively, having a high number of using a value of 2 for strong interest, 1 for sources of fi nancial support meant that some interest and 0 for no interest. Of the medical and nursing students favoured 890 medical students included in the study, a career in Category 4, and pharmacy 145 from the year 2012 were excluded due students favoured a career in Categories to differently coded data. 1 and 2 (Table 3). Although student loans The principal components method was debt appeared not to be a determining used to perform factor analysis extraction factor in these effects, it could nevertheless in order to identify career choice factors be a moderating factor. We therefore also using the level-of-interest score as the clus- conducted the second regression model with tering factor. Initial analysis demonstrated student loans debt included as a covariate. that between three and fi ve categories of This approach increased the percentage career preference were evident across the of total variance explained in the model— different disciplines. In order to consol- for example, in medicine, the variance idate categories further we used Varimax explained doubled from 4% to 8% (Table 3). rotation, suppression of loadings below 0.3, Only one effect failed to reach signifi cance and the rule that category membership of with the addition of debt as a covariate possible career options was determined by (the effect for nursing), suggesting that the loading with the highest absolute value. we may have additional confi dence in the This approach lead to the emergence of four fi ve remaining effects for health sciences, distinct career preference categories for medicine and pharmacy. each discipline, with acceptable levels of total variance explained (between 46% and 68%—Table 2).23–25

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Table 2: Principal component analysis of career preferences based on level of interest reported by students.*

Career options Career preference categories Paediatrics .743 on questionnaire (neonatology) 1 2 3 4 General practice .418 Health science (total VE** 64%) Psychiatry .404 Health .862 promotion Obstetrics and .351 gynaecology Community .809 outreach Nursing (total VE 57%) Academic .816 Public health .745 research Primary .693 Postgraduate .748 healthcare study Mental health .636 Medicine .448 Older persons’ .595 Health policy .771 health

Health .771 Academic .469 management research

Pharmacy .740 Surgery .820 (general) Nursing .726 Surgery .811 Medicine (total VE 46%) (subspecialty) Medicine .810 Theatre .645 (general) Medicine .843 Medicine .702 (general) (subspecialty) Medicine .819 Geriatrics .569 (subspecialty) Postgraduate .761 Paediatrics .834 study Obstetrics and .517 Academic .748 gynaecology research Emergency care .425 Medical sciences .585

Public health .584 Pharmacy (total VE 68%) Postgraduate .886 Pathology .383 study Surgery .626 Academic .881 (subspecialty) research Surgery .616 Management .758 (general) Regulatory .691 Radiology .609 a airs Anaesthesia .591 Industry .651 Emergency .372 Community -.844 medicine Hospital .628 Paediatrics .792 (general) Veterinary .989

*Career choices were clustered into categories using Varimax rotation with Kaiser normalisation, and the rule that category allocation was determined by the loading with the highest absolute value. **VE—variance explained.

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Table 3: Outputs of logistic regression models relating career category to student loans debt and fi nancial support.

Discipline Career Careers included in category Debt, p Financial Financial Implications from category value support, support significant e ects number p value with debt covariate, p value

Health 1 Health promotion, community outreach 0.634 0.332 0.299 science 2 Academic research, postgraduate study, 0.444 0.323 0.307 medicine

3 Health policy, health management 0.970 0.584 0.665

4 Pharmacy, nursing 0.977 0.039 0.046 Favoured by those with a low number of financial supports

VE* 1% 5% 5%

Medicine 1 Medicine (general), medicine (subspecialty), 0.069 <0.001 0.001 Favoured by those geriatrics with a low number of financial supports

2 Postgraduate study, academic research, 0.146 0.074 0.069 medical sciences, public health, pathology

3 Surgery (general), surgery (subspecialty), 0.317 0.149 0.304 radiology, anaesthesia, emergency medicine

4 Paediatrics (general), paediatrics 0.158 0.002 0.004 Favoured by those (neonatology), general practice, psychiatry, with a high number obstetrics and gynaecology of financial supports

VE 2% 4% 8%

Nursing 1 Public health, primary healthcare, mental 0.918 0.621 0.911 health, older person’s health, academic research

2 Surgery (general), surgery (subspecialty), 0.567 0.416 0.559 theatre

3 Medicine (general), medicine (subspecialty) 0.823 0.550 0.669

4 Paediatrics, obstetrics and gynaecology, 0.500 0.045 0.076 Favoured by those emergency care with a high number of financial supports

VE <1% 1% 2%

Pharmacy 1 Postgraduate study, academic research 0.863 0.013 0.029 Favoured by those with a high number of financial supports

2 Management, regulatory a airs, industry 0.729 0.044 0.035 Favoured by those with a high number of financial supports

3 Community, hospital 0.176 0.918 0.759

4 Veterinary 0.589 0.961 0.821

VE 1% 3% 4%

*Variance explained

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students at $15,000–$29,999 could be Discussion explained by the fact that the total tuition Our exploratory study found a number of costs of these degrees are around $18,000– fi ndings of interest, including some signif- $24,000 (Figure 1).26 The higher peak for icant relationships between sources of optometry is likely to be the result of the fi nancial support and career preferences degree being of a greater length (fi ve years) upon graduation. Student loans debt in all and the fees being around $1,500 more (from disciplines showed a distribution with a year two onward). In addition to this, there single mode, except in medicine. Principal is a requirement for students to purchase component analysis of career preferences equipment during their degree costing upon graduation demonstrated that despite around $10,000.26,27 In medicine, the 15% of different kinds and number of career students showing no debt could potentially options in each discipline, choices were able be explained by this group containing inter- to be clustered into four categories of related national students who do not have access choices within each discipline. The career to the New Zealand Government student preferences included in each category loans scheme and those students who have resulting from our principal component more substantial parental support. The large analysis largely make intuitive sense in number of medical students with debt in terms of the vocational similarities of the the higher range, on the other hand, is likely careers within each category and the dissim- to indicate graduate students entering the ilarities between categories—thus making medical programme, who may already have it plausible that a student with an interest some student loans debt, and the six-year in one career choice in a given category length of the degree programme with higher may also have more interest in others in course fees (approximately $14,000 per year the same category than those in different as opposed to $6,200 for health sciences, categories (Table 2). Career categories nursing and pharmacy).26 across disciplines also appeared to contain Our results suggest that the number of similar combinations of career options— sources of fi nancial support more strongly for example, in the three disciplines where determines career choice than the level of postgraduate study and academic research student loans debt per se. However, it is were career options, these always clustered important to note that the level of student together—suggesting emergent natural loans debt incurred under the Government types of career choice. We had no a priori student loans (GSLs) scheme is only a proxy expectation that the disparate career choices for the total debt a student may incur during included on the questionnaire for each their studies. Learning more about the discipline could be meaningfully reduced nature of the sources of fi nancial support to a manageable number of categories, let available to students may shed light on such alone the same number of categories for all effects. For example, students who have disciplines. The fact that we were able to do access to sources of income that they are this made subsequent analysis considerably not required to pay back (eg, scholarships less complicated, and also allowed for more or parental support) may be expected to be comparable relationships to be explored less encumbered by debt and make different across disciplines. Thus, the framework career choices than those students who of career preference categories generated do have to pay back sources of fi nancial by this study is, in itself, a substantial support (eg, GSLs). Although students were outcome—it is evidence based, shows asked to indicate all the sources of fi nancial acceptable levels of variance explained, support used during their study, this did and would potentially form a useful basis not allow us to ascertain the student’s main for further analysis using other methods of source of fi nancial support or give an indi- understanding student choice and career cation of the degree of support received pathways. It is conceivable it could also from each source. guide aspects of curriculum design or the placement options offered to students. General practice is included in medicine’s career Category 4 in our results, which is The peak in the debt distribution for a category favoured by medical students health Sciences, nursing and pharmacy with a high number of sources of fi nancial

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support (three or more)—but this result, study has not been conducted previously. in itself, tells us little about possible career Potential limitations of our research include pathways to primary healthcare (Table 3). the fact that we did not exclude interna- Category 4 in both nursing and medicine tional students from our analysis, and the contains paediatrics, and obstetrics and somewhat limiting nature of some of the gynaecology, and is favoured by students in questions included in the questionnaire. both disciplines who have a high number International students do not have access of sources of fi nancial support. It is also to the New Zealand Government loans worth noting that Category 4 in health scheme—however, even students who do sciences likely represents an alternative have access to the scheme may not take up route into professionally registered careers GSLs. In the questionnaire, students were in pharmacy and nursing, and is favoured asked to select a range to indicate their by students with a low number of sources level of student loans debt upon exit from of fi nancial support (Table 3). Some further their educational programme, rather than targeted data collection using additional asking them to record a total value for questionnaires or interviews in students their debt. Although this made the question who indicate a preference for particular easier for students to answer, it effectively categories, could allow us to better under- transformed a continuous measure into a stand such career choices. It is also unclear categorical one, thus likely reducing the whether preference for certain career cate- discriminability of the variable in relation to gories over others is related to the perceived other factors, and increasing the complexity remuneration associated with those careers. of the data for analysis. In future work, The signifi cant effect in pharmacy involving categories of debt could be converted to a a preference for Category 2 may suggest pseudo-continuous measure by taking the that this category, relative to the others in numeric mid-point of each category rather the discipline, offers higher paid opportu- than using a binary approach as in the nities. However, further research is needed present study. The changes to the question- to properly estimate the earning potential of naire for medicine in 2012, when the Faculty each career category in our results (Table 3). Tracking Project became part of the MSOD Although some of the results relating research project, presented diffi culties category of career preference with fi nancial with data continuity and analysis. This led support were highly signifi cant (Table 3), us to exclude the data after these changes and the inclusion of debt as a covariate in were made from our analysis. However, it these models increased the rates of variance is possible that in future work, a method of explained, the fi nal rates of variance equating data across the two periods could explained remained relatively small. be devised, therefore allowing all data in the However, we chose the variables of student database to be including in a larger-scale loans debt and fi nancial support a priori, analysis. It is also worth noting that career and there is no single acceptable level of preferences indicated upon exit from an variance explained in regression studies. educational programme may have little Furthermore, smaller rates of variance bearing on the jobs that students ultimately explained remain useful when attempting end up working in. However, including to detect relatively weak signals in noisy variables such as gender and ethnicity into systems—a type of system to which student career preference models in future work career choice clearly belongs. Future work may further inform such models. may allow more precise targeting of cohorts of student who are making specifi c choices Conclusion and so increase the explanatory power of Students in health sciences, nursing and our models. pharmacy typically accrue similar levels A strength of our study lies in the large of student loans debt of around $15,000 to number of participants included and the $29,999, while optometry students accrue high questionnaire response rates, which debt around $15,000 higher. Medical were higher than that typically reported in students demonstrate a fl atter distribution questionnaire studies.28,29 To our knowledge, of student loans debt, with debt distributed this kind of cross-disciplinary comparison around both ends of the scale—that is, no

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debt and $90,000 or more. Students typically of sources of fi nancial support to career access three sources of fi nancial support preference categories involving students in during study. We have developed and health sciences, medicine and pharmacy. demonstrated the effi cacy of a four-category Our results suggest that the number of career preference framework to explore sources of fi nancial support is a more the relationship between student loans strongly determining factor in career pref- debt, fi nancial support and career prefer- erence than the level of student loans debt ences upon graduation. Overall, we found per se, but this requires further study. fi ve signifi cant effects relating the number

Competing interests: Nil. Acknowledgements: This research was supported by a summer studentship stipend from the Faculty of Medical and Health Sciences, University of Auckland, New Zealand. We thank Antonia Verstappen of the Faculty Tracking Project, University of Auckland for assistance with data extraction. The Faculty Tracking Project, University of Auckland, is supported by a grant from Health Workforce New Zealand. Author information: Craig S Webster, Senior Lecturer, Centre for Medical and Health Sciences Education, Uni- versity of Auckland, Auckland; Christopher Ling, House Offi cer, Counties Manukau District Health Board; Mark Barrow, Associate Dean – Academic, Faculty of Medical and Health Sci- ences, University of Auckland, Auckland; Phillippa Poole, Head of Department of Medicine, University of Auckland, Auckland; Marcus Henning, Senior Lecturer, Centre for Medical and Health Sciences Education, University of Auckland, Auckland. Corresponding author: Dr Craig Webster, Centre for Medical and Health Sciences Education, University of Auckland, Private Bag 92-019, Auckland 1142. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459- 21-july-2017/7316

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30-day mortality a er percutaneous coronary intervention in New Zealand public hospitals (ANZACS-QI 18) Andrew J Kerr, Michael Williams, Harvey White, Corina Grey, Yannan Jiang, Chris Nunn, on behalf of the ANZACS-QI investigators

ABSTRACT AIM: The aim of this report is to provide hospitals in New Zealand with data about their own outcomes for percutaneous coronary intervention (PCI) procedures and allow comparisons with other New Zealand units and with international data. METHODS: All PCI procedures (n=5,033) were identified in nine public hospital catheterisation laboratories between 1 October 2014 and 30 September 2015. Risk-adjusted mortality rates were derived for each hospital and compared with the national rate. RESULTS: The overall 30-day mortality rate a er PCI was 1.23%. The national 30-day mortality rates were 3.28% for the subgroup of patients treated for a ST segment elevation myocardial infarct and 0.66% for those treated for other acute coronary syndrome (ACS) or non-ACS indications. There were no statistically significant di erences in outcomes between the di erent New Zealand public hospital catheterisation laboratories, either overall or for each patient subgroup. CONCLUSIONS: Mortality rates in the first 30 days a er PCI are low and comparable across New Zealand public hospitals. The outcomes are comparable with international experience.

n response to calls for public release common form of CVD is atherosclerotic of hospital performance data and to coronary artery disease. Various treat- support high-quality health care in New ments are recommended for patients with I 1 Zealand the Health Ombudsman and the coronary artery disease, including lifestyle Health Quality and Safety Commission changes, medication and interventional (HQSC)2 in 2016 called for more transparent procedures. The most common interven- and public reporting of the performance of tional procedure performed on patients New Zealand healthcare services. The HQSC with coronary artery disease is percuta- made several recommendations. These neous coronary intervention (PCI). included public reporting of judiciously The All New Zealand Acute Coronary chosen, adequately risk-adjusted measures Syndrome Quality Improvement programme at the team, unit or organisational level (ANZACS-QI) is a clinician-led initiative rather than the individual clinician level, which was implemented in 2012 with developing agreed national standards of New Zealand Ministry of Health (MOH) data collection, relevant defi nitions and funding to support appropriate, evidence- measures across New Zealand, and having based management of patients with acute standardised risk adjustment models to coronary syndromes (ACS) and cardiac account for case complexity and risk. conditions.3 An important goal of ANZACS-QI Cardiovascular disease (CVD) is a leading is to improve the quality of care in relation cause of death in New Zealand and the most to PCI in New Zealand.

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Providing clinicians in New Zealand with Cohort data regarding their own outcomes for these The fi rst complete CathPCI registry record procedures will allow them to examine the for each patient, which recorded a PCI quality of their own care, compare it both procedure between 1 October 2014 and with other New Zealand units and with 30 September 2015, was included in this international comparison data, and identify analysis. There were 5,033 patients iden- opportunities for improvement in their tifi ed in nine public hospital catheterisation quality of care. laboratories, of which 4,977 had complete data for analysis. Fifty-six patients had Methods missing information on diabetes, creatinine Overview and smoking status. The ANZACS-QI programme utilises two A further 102 (2%) patients undergoing PCI complementary data sources to generate for ST elevation MI (STEMI) who had cardio- two overlapping cohorts: genic shock were excluded from the cohort for analysis. These patients are extremely 1. The ACS-CathPCI Registry cohort, high-risk, but for some, PCI may be their generated using web-based software best chance for survival. Furthermore, the that enables secondary care clinicians magnitude of the risk is not easily deter- to systematically collect data on ACS mined using registry data. Consistent with patients, coronary angiography and practice in the New York State PCI reporting PCI procedures in all New Zealand methodology,4 hospitals. these cases were excluded in an effort to ensure that physicians could 2. The ACS Routine Information cohort, accept these cases where appropriate derived directly from national health without concern over a detrimental impact data sets, which includes mortality on their reported outcomes. and rehospitalisation data. For the remaining 4,875 eligible patients, While the ACS Routine Information cohort three subgroups were identifi ed: (1) STEMI, includes all New Zealand ACS patients, it is (2) Other ACS (other suspected/known acute relatively limited in content. In contrast, the coronary syndrome, and (3) Non-ACS. The ACS-CathPCI Registry cohort captures more total number of patients in each subgroup in-depth data on every ACS patient who has was 1,068 (22%), 2,587 (53%) and 1,220 a coronary angiogram in New Zealand and (25%), respectively. Initial analyses showed all other patients having coronary angiog- similar outcomes in the ‘other ACS’ and raphy procedures. The two overlapping data ‘non-ACS’ subgroups, so these groups were sources were linked using the encrypted combined for reporting purposes. National Health Index number and used to report mortality within 30 days of hospital Outcomes analysis admission. This was done for this report by All-cause 30-day mortality was obtained using the ANZACS-QI registry data to adjust from the MOH mortality data linked to each for these differences to see what each hospi- patient. The national mortality rate was tal’s mortality rate would have been if the calculated as the proportion of deaths in hospital had a mix of patients similar to the the total eligible cohort. Prior studies have 4– 6 national mix. identifi ed potential confounding variables. Those used for risk adjustment for this Patients referred for coronary angiog- report included: age, sex, ethnicity (Māori/ raphy in each of the nine New Zealand Pacifi c/Other), current smoker, diabetes, public hospital cardiac catheterisation prior coronary artery bypass grafting laboratories have data recorded in the (CABG), elevated creatinine (≥150umol/), and ANZACS-QI CathPCI registry. A detailed worst Killip class in hospital (I to III), which description of the ANZACS-QI programme, is a measure of the severity of heart failure. including development, implementation, ethics, data audit, data sets and defi nitions Following the statistical methodologies 6 and data-linkage methodology has been reported in New York State the following published previously. key measurements were calculated:

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• The observed mortality rate (OMR) in signifi cantly higher rates than expected %, which is the observed number of after adjusting for risk are those with 95% deaths divided by the total number of CIs above the national rate. Catheterisation cases and then multiplied by 100. laboratories with signifi cantly lower rates • The expected mortality rate (EMR) in than expected have 95% CIs below the %, which is the sum of the predicted national rate. probabilities of death for all patients The 95% CI for the RAMR was calcu- divided by the total number of lated using the Byar’s approximation to patients and then multiplied by the Poisson distribution7 RAMRs for each 100. To calculate the EMR, logistic hospital’s catheterisation laboratory are regression models were used to reported for the entire cohort and for estimate the predicted probability of two subgroups—‘STE’ and ‘other ACS and death for each patient. The odds ratio non-ACS’ separately. for each predictor/confounder in the Report development model was also estimated. The results This report was prepared by a working are shown in the Appendix. group of the ANZACS-QI group. It was then • The risk-adjusted mortality rate refi ned based on feedback received from the (RAMR) is the best estimate, based wider ANZACS-QI governance group and the on the regression model, of what Interventional Working Group of the New the providers’ mortality rate would Zealand branch of the Cardiac Society of have been if the hospital had a mix of Australia and New Zealand. The report has patients similar to the national mix. It been approved for release by these groups. is obtained by fi rst dividing the OMR by the EMR, and then multiplying that Results quotient by the national mortality rate In the 102 cases excluded due to cardio- for the subgroup of patients. genic shock, the mortality rate was 51% The RAMR for each hospital was (n=52). There were 60 other deaths within compared with the national rate. The 95% 30 days of a PCI, 35 associated with STEMI confi dence interval (CI) for the RAMR indi- and 25 with a non-STEMI diagnosis. Table 1 cates which catheterisation laboratories presents demographic and clinical charac- had signifi cantly more or fewer deaths teristics of all eligible patients by sub-cohort than expected given the risk factors of their and 30-day mortality. patients. Catheterisation laboratories with

Table 1: Eligible patients undergoing PCI between October 2014 and September 2015 (N=4,875).

STEMI Other ACS and non-ACS Overall Total Death by 30 Total Death by 30 Total Death in 30 (N=1,068) days (n=35) (N=3,807) days (n=25) (N=4,875) days (n=60)

Age, mean ± SD 63±12 70±14 66±11 71±9 65±12 70±12

Male, n (%) 804 (75) 21 (60) 2753 (72) 22 (88) 3,557 (73) 43 (72)

Ethnicity, n (%) Māori 96 (9) 6 (17) 286 (8) 1 (4) 382 (8) 7 (12)

Pacific 46 (4) 2 (6) 152 (4) 0 (0) 198 (4) 2 (3)

Other 926 (87) 27 (77) 3,369 (88) 24 (96) 4,295 (88) 51 (85)

Diabetes, n (%) 153 (14) 8 (23) 905 (24) 13 (52) 1,058 (22) 21 (35)

Prior CABG, n (%) 32 (3) 5 (14) 362 (10) 4 (16) 394 (8) 9 (15)

Serum Creatinine ≥150µmol/l, n (%) 33 (3) 6 (17) 174 (5) 7 (28) 207 (4) 13 (22)

Current smoker, n (%) 299 (28) 3 (9) 604 (16) 3 (12) 903 (19) 6 (10)

Worst Killip, n (%) Class I 923 (86) 20 (57) 3,570 (94) 15 (60) 4,493 (92) 35 (59)

Class II 89 (8) 7 (20) 157 (4) 4 (16) 246 (5) 11 (18)

Class III 56 (5) 8 (23) 80 (2) 6 (24) 136 (3) 14 (23)

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Table 2: Risk-adjusted 30-day mortality rate after PCI (overall) (total number of deaths=60, national rate=1.23%).

Cathlabs Number of Observed Expected OMR EMR RAMR 95% patients deaths deaths confidence interval Middlemore 292 3 2 1.03 0.78 1.61 0.32 4.72

Auckland City 817 12 14 1.47 1.73 1.05 0.54 1.83

North Shore 586 2 5 0.34 0.85 0.49 0.06 1.78

Tauranga 181 2 1 1.10 0.68 1.99 0.22 7.20

Waikato 729 8 8 1.10 1.15 1.17 0.50 2.31

Wellington 785 14 10 1.78 1.25 1.75 0.96 2.94

Nelson 236 5 3 2.12 1.08 2.41 0.78 5.63

Christchurch 782 10 12 1.28 1.48 1.06 0.51 1.96

Dunedin 467 4 5 0.86 1.08 0.98 0.26 2.50

All Cath-PCI patients (N=4,875) STEMI patients (N=1,068) None of the nine catheter laboratories had No STEMI patient died during the study a RAMR signifi cantly higher or lower than period at Middlemore or Tauranga hospitals. national rate (1.23%). None of the nine catheterisation laboratories had a RAMR signifi cantly higher or lower than the national rate (3.28%).

Figure 1: Risk-adjusted 30-day mortality rates (±95% confi dence intervals) after All PCI in New Zealand public hospitals.

The horizontal line is the national mortality rate (1.23%).

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Table 3: Risk-adjusted 30-day mortality rate after PCI (STEMI) (total number of deaths=35, national rate=3.28%).

Cathlab Number of Observed Expected OMR EMR RAMR 95% patients deaths deaths confidence interval Middlemore 29 0 1 0.00 2.77 - - -

Auckland City 327 9 10 2.75 3.21 2.81 1.28 5.34

North Shore 46 1 2 2.17 3.71 1.92 0.03 10.69

Tauranga 19 0 0 0.00 2.41 - - -

Waikato 139 5 4 3.60 2.80 4.21 1.36 9.82

Wellington 179 7 7 3.91 3.68 3.49 1.40 7.19

Nelson 49 3 1 6.12 2.58 7.78 1.56 22.72

Christchurch 204 9 8 4.41 3.74 3.87 1.77 7.35

Dunedin 76 1 2 1.32 2.86 1.51 0.02 8.39

Other ACS and non-ACS patients Although the cohort subgroup defi nitions (N=3,807) were slightly different, the New York State registry for 2010 to 2012 reported a similar None of the nine catheterisation labora- overall 30-day mortality rate of 1% (vs New tories had a RAMR signifi cantly higher or Zealand’s 1.23%).6 Their 30-day mortality lower than national rate (0.66%). rate in emergency cases was 2.77% (vs New Zealand STEMI rate 3.28%) and in non-emer- Discussion gency cases 0.64% (vs New Zealand ‘other’ This is the fi rst report of mortality rate 0.66%).6 outcomes after PCI procedures in New In this analysis we chose to report Zealand. The overall 30-day mortality rate outcomes at the overall catheterisation after PCI was low at 1.23%. There were laboratory level. Each catheterisation labo- no statistically signifi cant differences ratory services one or multiple New Zealand in outcomes between the different New district health board (DHB) regions and all Zealand public hospital catheterisation labs. the hospitals which assess patients with

Table 4: Risk-adjusted 30-day mortality rate after PCI (Other ACS and non-ACS) (total number of deaths=25, national rate=0.66%).

Cathlab Number of Observed Expected OMR EMR RAMR 95% patients deaths deaths confidence interval Middlemore 263 3 2 1.14 0.72 1.04 0.21 3.05

Auckland City 490 3 4 0.61 0.75 0.54 0.11 1.57

North Shore 540 1 3 0.19 0.62 0.20 0.00 1.09

Tauranga 162 2 1 1.23 0.39 2.10 0.24 7.57

Waikato 590 3 5 0.51 0.77 0.43 0.09 1.27

Wellington 606 7 4 1.16 0.70 1.09 0.44 2.24

Nelson 187 2 1 1.07 0.54 1.32 0.15 4.76

Christchurch 578 1 3 0.17 0.57 0.20 0.00 1.12

Dunedin 391 3 2 0.77 0.60 0.84 0.17 2.47

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suspected coronary artery disease in those quite wide, particularly for catheteri- DHBs. The outcomes reported are deter- sation laboratories with smaller volumes. mined by the cumulative impact of all health However, the numbers of outcomes per system processes and interactions from the catheterisation laboratory are in a similar initial presentation, through the inpatient range to those reported in the New York care to the early post-discharge care. In the State registry. There are several ways the catheterisation laboratory the outcomes numbers of outcomes could be increased, depend on multiple factors, including which can be explored but all have their patient selection, equipment, nursing and limitations. Outcomes could be reported radiographer performance, intensive care for a two- or three-year cohort, rather than unit and surgical support as well the abilities a one-year cohort, however, processes of the individual interventional cardiol- and staff change over time and such ogist. Although there have been calls for the reporting would be less relevant to current reporting of outcomes for individual oper- performance. Alternatively, one-year ators, their performance is only part of the mortality rather than 30-day mortality overall system of care, and both the HQSC could be reported. However, one-year and health ombudsman have recommended outcomes would refl ect both the care in that the appropriate level for reporting the community as well as the immediate to achieve improved quality of care is the hospital performance and so differences overall team level.1,2 would be more diffi cult to interpret. In Comparison of outcomes between addition, reporting would be delayed by hospitals is also complicated because nearly a year, thus losing immediacy. different hospitals treat different types of The recent editorial in the New Zealand patients. Hospitals with sicker patients may Medical Journal from the HQSC by Richard have higher rates of complications and Hamblin et al2 summarises the evidence death than other hospitals. To allow compar- for potential benefi ts and risks of public isons between hospitals it is therefore reporting of medical procedures. For PCI necessary to take account of the differences in particular, in the US it has been found in patient risk between hospitals. Appro- that patients who underwent a procedure priate risk adjustment requires accurate in states with mandated public reporting information regarding the most important of outcomes had similar predicted risks determinants of outcome. For PCI these but signifi cantly lower observed risks of include measures of heart failure (Killip death.8 However, the use of PCI after MI has Class), renal function and type of ACS. Those been lower in states with public reporting, with cardiogenic shock were excluded. The and while an initial report indicated ANZACS-QI registry collects this information no difference in mortality between the prospectively with consistent training, defi - reporting and non-reporting states,9 a more nitions and data entry templates, supported recent report suggests evidence of higher by regular audit. overall mortality after MI in the states with The clinical data used for risk adjustment public reporting. This higher mortality was in this report is not available in the national particularly in those who did not undergo 10 administrative data sets, and without the PCI. One possible reason for these lower ANZACS-QI registry this report would not be rates of PCI and better results in those who possible. In the longer-term integration of do have PCI is that physicians in states with the clinical registries, data collection with public reporting may be more reluctant the routinely collected electronic health to offer treatment to very sick patients, record may streamline the collection of data particularly those with cardiogenic shock. for this and related reports. Without revascularisation treatment these patients have a mortality rate in excess There are challenges in statistically of 50%.11 In our cohort there were only comparing the performance of catheter- 102 such patients, but half of them died, isation laboratories when the numbers accounting for just under a half of all PCI of deaths are quite low. In our analysis procedure-associated deaths. However, we sought to overcome this by reporting for these very high-risk patients an emer- the overall ‘All Cath-PCI’ outcomes as well gency procedure is often the best hope, as the subgroups. Despite this, the confi - and there is concern both in New Zealand dence intervals around the estimates are

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and internationally that if these patients the ANZACS-QI registry and such patients were included in routine PCI outcome will be excluded in future reporting. reporting that it would deter clinicians for accepting them for potentially life-saving Limitations procedures. To address this concern such In this report the focus was on short-term patients have been excluded from reporting 30-day mortality. Later mortality and other in more recent New York and Massachusetts events including readmissions and bleeding reporting. In New York this change has been complications are also relevant and will associated with an increase in the use of PCI be addressed in future reporting. Due to for cardiac shock and an improvement in the anonymised linkage methodology used outcomes.12 Following the more recent New detailed case review to ascertain the cause York State methodology we also excluded of death and its relationship to the PCI STEMI patients who presented with cardio- procedure is not possible. genic shock from our analyses. There is another similar high-risk group which was not excluded. These are patients Conclusions presenting after a cardiac arrest who subse- Mortality rates in the fi rst 30 days after PCI quently die, not as a complication of the PCI, are low and comparable across New Zealand but of cerebral hypoxia occurring at the time public hospitals. The outcomes are compa- of the cardiac arrest. In the New York state rable with international experience. Release PCI registry reporting these patients are also of a consumer version of this report with excluded so clinicians are not deterred from appropriate interpretation is planned via the accepting patients who might have cerebral HQSC Atlas of Healthcare Variation website. hypoxia. This outcome has been added to Appendix The estimated odds ratios, 95% confi dence intervals and associated p-values on model predictors were reported below for each analysis cohort. All Cath-PCI patients (n=4,875) Table 1.1: Logistic regression analysis to predict the probability of 30-day death.

Model predictors Odds ratios

Estimate 95% confidence interval P value Female 0.953 0.518 1.755 0.8775

Other ethnicities reference

Māori 1.970 0.808 4.802 0.1358

Pacific 0.504 0.109 2.343 0.3824

Age (year) 1.033 1.006 1.061 0.0179

Current smoker 0.563 0.221 1.436 0.2294

Diabetes 1.905 1.054 3.442 0.0328

Prior CABG 2.165 0.993 4.718 0.0520

Serum Creatinine ≥150umol/l 4.182 2.015 8.676 0.0001

Worst Killip Class I reference

Worst Killip Class II 3.308 1.577 6.940 0.0016

Worst Killip Class III 7.513 3.727 15.144 <.0001

Non-ACS reference

STEMI 4.482 2.081 9.652 0.0001

Other ACS 0.596 0.260 1.367 0.2217

CABG, coronary artery bypass gra ing; ACS, acute coronary syndrome; STEMI, ST segment elevation myocardial infarct.

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STEMI patients (n=1,068)

Table 2.1: Logistic regression analysis to predict the probability of 30-day death.

Logistic regression parameters Odds ratios

Estimate 95% confidence interval P value Female 1.832 0.843 3.982 0.1262

Other ethnicities reference

Māori 3.679 1.251 10.820 0.0180

Pacific 1.221 0.223 6.679 0.8178

Age (year) 1.029 0.994 1.065 0.1045

Current smoker 0.277 0.076 1.015 0.0527

Diabetes 1.195 0.491 2.906 0.6943

Prior CABG 5.764 1.867 17.791 0.0023

Serum Creatinine ≥150umol/l 5.445 1.815 16.336 0.0025

Worst Killip Class I reference

Worst Killip Class II 2.602 0.990 6.835 0.0523

Worst Killip Class III 5.330 2.057 13.811 0.0006

CABG, coronary artery bypass gra ing; ACS, acute coronary syndrome; STEMI, ST segment elevation myocardial infarct.

Other or non-ACS patients (n=3,807)

Table 3.1: Logistic regression analysis to predict the probability of 30-day death.

Logistic regression parameters Odds ratios

Estimate 95% confidence interval P value Female 0.288 0.084 0.994 0.0490

Māori 0.566 0.070 4.573 0.5936

Age (year) 1.036 0.993 1.082 0.1050

Current smoker 1.589 0.421 5.999 0.4943

Diabetes 2.854 1.226 6.646 0.0150

Prior CABG 0.953 0.308 2.949 0.9328

Serum Creatinine ≥150umol/l 3.174 1.170 8.610 0.0233

Worst Killip Class I reference

Worst Killip Class II 4.614 1.383 15.389 0.0128

Worst Killip Class III 13.389 4.539 39.490 <.0001

Other ACS 0.566 0.241 1.330 0.1913

CABG, coronary artery bypass gra ing; ACS, acute coronary syndrome; STEMI, ST segment elevation myocardial infarct.

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Competing interests: Dr White reports grants from Sanofi Aventis, Eli Lilly and Company, and National Institute of Health, personal fees and non-fi nancial support from AstraZeneca, grants and personal fees from Omthera Pharmaceuticals, Pfi zer and Elsai Inc, grants from DalGen Products and Services, personal fees from Sirtex and Acetelion, outside the submitted work. Dr Kerr reports affi liation with Ministry of Health (NZ) and grants from Health Research Council during the conduct of the study. Dr Grey reports grants from Health Research Council and National Heart Foundation during the conduct of the study. Acknowledgements: ANZACS-QI programme implementation, coordination and analysis: The ANZACS-QI software was developed and supported by Enigma Solutions. Programme implementation is coordinated by the National Institute for Health Innovation (NIHI) at the University of Auckland. The ANZACS-QI programme is funded by the New Zealand Ministry of Health. ANZACS-QI research is supported by grants from the New Zealand Health Research Council and National Heart Foundation. ANZACS-QI Governance group: Andrew Aitken, Paul Bridgeman, Gerry Devlin, Karen Evison, Andrew Kerr (chair), Peter Larsen, Kim Marshall, Chris Nunn, Tony Scott, David Smyth, Ralph Stewart, Gary Sutcliffe, Harvey White, Michael Williams. ANZACS-QI Project management: Kristin Sutherland, Charmaine Flynn (Northern coordinator), Maxine Rhodes (Southern coordinator). Data management and analysis: Mildred Lee, Michelle Jenkins, John Faatui We acknowledge all the New Zealand cardiologists, physicians, nursing staff and radiographers who have supported and contributed to ANZACS-QI. ANZACS-QI hospital coordinators: Whangarei, S Valancey; Kaitaia, R Thompson; Kawakawa, A Farland; Dargaville, K Katipa; Bay of Islands, C Lomas; North Shore and Waitakere, R Newcombe, L Gray; Auckland City, J Donald, K Marshall; Middlemore, C Flynn, A Escondo; Waikato, C Emerson, L Warner; Tauranga, J Goodson, J Money; Whakatane, E Taylor; Tokoroa, V Huitema, P Ropitini; Taupo Hospital, T Liddell; Rotorua, A Colby; Thames, J Radonich; Taumaranui, N Smith; Te Kuiti, T TeWano; Taranaki, J Quinn; Hawkes Bay, P Grant, G Brown; Palmerston North, D Kinloch, J Juyoprasanth; Whanganui, T Thompson; Masterton, T Matthews, K Lee; Wellington, D Wylie, B Scott; Nelson Hospital, J Besley, J Tomlinson; Blenheim, M McNabb; Christchurch Hospital, M Rhodes, J Sutherland, S McLaren, R Avis, J Murphy; Grey Base, L Smith; Oamaru, M Collins, R Gonzales; Dunedin Hospital, P Sharp; Clutha, G Lindley, J McIlrea; Dunstan, M Shaw, R Klahn; Gore, F March; Southland, R Byers. Author information: Andrew Kerr, Cardiologist, Cardiology Department, Middlemore Hospital, Auckland—and Honorary Associate Professor of Medicine, University of Auckland; Michael JA Williams, Cardiologist, Cardiology Department, Dunedin Hospital, Dunedin—and Clinical Professor, Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Harvey White, Cardiologist, Green Lane Cardiovascular Service, Auckland City Hospital— and Honorary Professor of Medicine, University of Auckland; Corina Grey, Public Health Physician—and National Heart Foundation Fellow; Yannan Jiang, Biostatistician, University of Auckland, Auckland; Chris Nunn, Cardiologist, Cardiology Department, Waikato Hospital, Hamilton —and Chair of the New Zealand Interventional Group. Corresponding author: Andrew Kerr, Department of Cardiology, Middlemore Hospital, Otahuhu, Auckland 93311. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459- 21-july-2017/7317

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REFERENCES: 1. Paterson R. Request for year 2012 report: Hospi- intervention with utili- surgical complications tal risk-standardised zation and outcomes data. Offi ce of the in-hospital mortality among Medicare Ombudsman, NZ, 2016. rates. Massachusetts Data benefi ciaries with acute 2. Hamblin R, Shuker C, Analysis Center, Harvard myocardial infarction. Stolarek I, et al. Public Medical School, 2014. JAMA. 2012; 308:1460–8. reporting of health care 6. Percutaneous Coronary 10. Waldo SW, McCabe JM, performance data: what we Interventions (PCI) in New O’Brien C, et al. Association know and what we should York State, 2010–2012. between public reporting do. New Zealand Medical New York State Depart- of outcomes with proce- Journal. 2016; 129:7–17. ment of Health, 2015. dural management and 3. Kerr A, Williams MJ, 7. Hannan EL, Wu C, DeLong mortality for patients White H, et al. The All ER, Raudenbush SW. with acute myocardial New Zealand Acute Predicting risk-adjusted infarction. J Am Coll Coronary Syndrome mortality for CABG surgery: Cardiol. 2015; 65:1119–26. Quality Improvement logistic versus hierarchical 11. Hochman JS, Sleeper Programme: Implemen- logistic models. Medical LA, Webb JG, et al. Early tation, Methodology and Care. 2005; 43:726–35. revascularization in acute Cohorts (ANZACS-QI 9). 8. Cavender MA, Joynt KE, myocardial infarction New Zealand Medical Parzynski CS, et al. State complicated by cardio- Journal. 2016; 129:23–36. mandated public reporting genic shock. New England 4. Percutaneous Coronary and outcomes of percutane- Journal of Medicine. Interventions (PCI) in New ous coronary intervention 1999; 341:625–34. York State, 2009–2011. in the United States. Amer- 12. McCabe JM, Waldo SW, New York State Depart- ican Journal of Cardiology. Kennedy KF, Yeh RW. ment of Health, 2014. 2015; 115:1494–501. Treatment and outcomes of 5. Adult percutaneous 9. Joynt KE, Blumenthal DM, acute myocardial infarction coronary intervention Orav EJ, et al. Association complicated by shock after in the Commonwealth of public reporting for public reporting policy of Massachusetts, fi scal percutaneous coronary changes in New York. JAMA Cardiol. 2016; 1:648–54.

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Where to from here? Posthumous healthcare data, digital e(lectronic)- mortality and New Zealand’s healthcare future Katie Hoeksema, Richman Wee, Alastair Macdonald, Parry Guilford, Jesse Wall, Jon Cornwall

ABSTRACT Ongoing improvements in digital data acquisition and storage has led to the phenomenon of e(lectronic)- mortality, where digital data can now exist for a potentially infinite period. Globally, many countries are facilitating the acquisition and researcher-led access to large-scale, population-based digitised healthcare data sets. Their utilisation has led to numerous positive advances in healthcare. New Zealand’s medical record system is becoming increasingly digitised, and as a consequence there will be an ever-increasing resource of posthumous healthcare data stored digitally, including genomic information. Such data could be utilised for research purposes, and developing such a consolidated resource could improve healthcare outcomes in our own nation and allow us to parallel global progress in healthcare research trends. This viewpoint article explores the issues surrounding, and potential for utilisation of, a national resource of posthumous digital healthcare data. Currently, there appear to be no legal barriers to the large-scale acquisition and utilisation of posthumous healthcare data in New Zealand, however, previous legislation may not have been developed with developments in technology or e-mortality in mind. Ethically, culturally and socially there are many challenges to address, including issues surrounding obtaining consent, respecting privacy, management of incidental findings, maintaining anonymity and ensuring community support for such a resource. Despite the potential for widespread health benefits that utilisation of posthumous healthcare data in this country may facilitate, wide and ongoing consultation is required to examine how such a precious resource can be enabled for the downstream benefit of all New Zealanders.

igitisation of health data, includ- Coinciding with recent advances in digital ing medical records and genomic technology and information storage is the Dinformation, is becoming common development and utilisation of genomic practice in many countries around the medicine. The parallel growth within both world. With this improvement in digi- domains has serendipitously provided the tal technology, a new phenomenon has foundation for large-scale studies involving emerged because of the indefi nite period digital health data. Globally, many studies that information can now be stored: an era are being conducted that allow scrutiny of ‘e(lectronic)-mortality’ has arrived, where of health data from large populations to digital information can potentially exist, and further an understanding in such areas as be accessed, for an infi nite period. As a con- disease processes, drug interactions and sequence of these new developments there epidemiology.1–3 are major ramifi cations in many different New Zealand’s medical record system is areas, and particularly in regard to health increasingly becoming digitised in order research where large data sets are a rapidly to increase effi ciencies in our health developing reality. system. It is therefore timely to refl ect

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on the choices available in the context of in research could then be utilised to reveal the posthumous use of digital healthcare genetic links to specifi c diseases and explore data. New Zealand’s digitised healthcare how effective different medications might data, and in particular digitised genomic be for different individuals. Expanding data, could be used posthumously and has this technology to large-scale genomic data useful potential to advance the diagnosis sets sequenced from entire genomes may and treatment of diseases. Healthcare data elucidate secondary associations when digitisation has allowed large-scale genomic pooled with data from other individuals, sets of data to be used for research that has and has a direct medical application. This societal benefi t at a personal, community could mean potential improvements in and nationwide level.4 Although large digi- selecting drugs to maximise their effi cacy for tised healthcare sets are being developed individual patients,8 or advances in the diag- and used in other countries, this is a ‘new’ nostic accuracy of rare conditions, which resource in our country, and its potential would translate to improvements in New adoption, utilisation and implementation as Zealand’s healthcare, including research that a resource in a specifi cally ‘New Zealand’ specifi cally examines and provides benefi ts context requires consideration. for Māori and Pacifi c populations. The use of human data in this digitised manner will Science and medicine: also allow scientifi c and medical advances in current technology New Zealand to parallel global progress. and the utility of Utilisation of digital digitised health data healthcare data: Genomic data is derived from examination global trends of a person’s DNA, with the information Globally, many countries have initiated stored via digital fi le. Genome-wide studies large-scale digitisation of healthcare records, can uncover associations between genetic and are using these for research purposes. variation and medical conditions that Numerous research successes from inves- cannot be diagnosed from the bedside. It tigations via genomics have been seen in follows that the use of this technology has many countries, with collaborative digital great potential to advance the diagnosis and databases revealing genetic associations treatment of diseases.5 Scientifi c progress with multiple cancers, identifi ed mecha- using genomic information will develop nisms for cancer development, revealed most rapidly through widespread access to genetic causes of smoking behaviour and genomic data that is linked to healthcare identifi ed genes involved in body fat distri- information gathered by agencies and bution.1–3,9 Over the last two decades, Iceland biobanks.6,7 Furthermore, this data has has used a large database to advance the potential to be shared across research population genetics and uncover genes projects in order to address a wide range of involved in various diseases. This project research questions. has been supported within the community, Digitisation of healthcare records can with half the population participating in potentially allow genomic data sets to be research projects.10 The UK Biobank collects used for collaborative research, and this has prospective lifestyle information, medical potential for wider societal benefi t. In order information and biological samples from for this information to be widely applicable 500,000 consenting adults,11 with consent across multiple research fi elds and retain permitting the use and retention of post- its value in the future, data is required to humous data. be presented in a standardised format. In Estonia, the Human Genes Research This may include information such as Act (2000) was implemented to encompass nutrition, medications and illness outcomes. the use of genotypes, phenotypes, health Information that is presented in such a and geographical information, with partic- format can then be processed, collated and ipants giving broad informed consent.12 examined in a similar manner to produce The national genetics research database in high-quality outcomes. The subsequent use Iceland integrates genealogical and genetic of digital, post-mortem health information

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data under the Health Sector Database Act examine some of the issues surrounding the (1998), with existing medical records of use of posthumous, digitised healthcare in citizens computerised and integrated into New Zealand. These include the legal and the database without requiring consent ethical rights to use, consent, anonymity and from the individuals. However, individuals issues underpinning the ethical right to use. can opt out of this project to withhold their Considerations surrounding legal medical information.13 right to use The Biobank Act (2012) in Finland There are currently no legal barriers to supports research using human biological the posthumous use of digitised healthcare material and technical records of the information in New Zealand. Use of post- material, including global collaborations. humous, digitised healthcare information Similarly, existing clinical and research may seem, at face value, to be a breach of samples can be transferred to the biobank privacy. However, the Privacy Act (1993), provided the individual does not opt out, which aims to promote and protect indi- and there has so far been no indication vidual privacy, defi nes an individual as that the person, if they were alive, would a natural person other than a deceased 14 object to the use of the samples. In Poland, natural person.17 Therefore, legally, a collection of human tissues and cells is deceased individual cannot have their governed under the Cell, Tissue and Organ privacy breached when they are no longer Recovery, Storage and Transplantation alive to be harmed.18 Act, which also reversed the system of The duration for which posthumous acquiring consent; consent is presumed healthcare data can be used following and prospective donors can opt out of acquisition is not specifi cally legally this system to retain their autonomy.15 restricted. The Health (Retention of Health In countries where an opt-out system is Information) Regulations apply to health implemented, the relatives of the deceased information of an identifi able individual, are also entitled to oppose donation at the and defi ne an individual as a natural time of death to avoid additional psycho- person, including a deceased natural logical stress.16 While there have been many person.19 The regulations state that health positive outcomes from large-scale utili- information must be kept for 10 years sation of digitised healthcare information (Section 5). However, in the context of presented above, there are also issues that using posthumous health information for have generated debate on the nature of the research, the maximum duration for which informed consent and of appropriate use data can be stored and used is not specifi ed of the acquired data from large-scale and in the above regulations or in the Standard national healthcare-information databases. Operating Procedures for Health and Legal and ethical Disability Ethics Committees.20 The HIPC (Rule 9) states “A health agency considerations that holds health information must not keep A major challenge associated with post- that information for longer than is required humous healthcare research is ensuring for the purposes for which the information that the data is used in an appropriate way. may lawfully be used”.21 The Code acknowl- The legal perspectives on the use of human edges that there may be plausible reasons data were established at a time when digital for which records can be retained after technology was in its infancy and e-mor- they are no longer relevant to their primary tality was not a relevant consideration, purpose, as long as there is still some lawful before digital storage and widespread purpose. Information which is stored by genomic investigations were common. health agencies is covered under the rules Current research policies address the use of disclosure under the HIPC for 20 years of genetic material of living participants, beyond the death of an individual. There but few consider what happens to this data is a further acknowledgement that health following the death of the individual and information can still be sensitive after a subsequent information disclosure for person has died. Therefore, healthcare infor- further research. It is therefore relevant to mation is currently held by health boards

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and healthcare providers, who have a duty family has the fi nal say.18 Currently in the of care that encompasses use of the infor- US, a biospecimen can be used in a research mation. However, there is no legal barrier capacity without explicit consent, provided to the use of such information for research the sample has already been collected for purposes, and no restriction to the length of another purpose.25 Similarly, The Royal time that such information can be used.22 Liverpool Children’s Inquiry recommended Comprehensive collation of healthcare that once informed consent has been information increases the likelihood of obtained for a tissue specimen, consent discovering incidental fi ndings, particularly should remain valid, provided the specimen when examining genetic data. The identi- is used for ethically approved research 26 fi cation of incidental fi ndings has impact projects. This would prevent repeated on family members and relatives who may requests to the next of kin for consent, and be affected, such as when diseases and allow data to be used for new projects. heritable disorders are recognised. Proce- The above examples provide a consent dures regarding disclosure of information pathway for downstream posthumous and providing treatment to those individuals tissue use, however, this is only for current who are then classifi ed as ‘at-risk’ should or previous research projects and does not be established to manage this information, provide the benefi t of gaining access to with decisions made in regard to how inci- data from a larger cohort. It does, however, dental fi ndings would be considered, who suggest a precedent for gaining one consent would manage such information and for during a person’s lifetime and having this what purpose any information would be support posthumous information use. used. In a survey conducted in Australia, the Wide consultation is therefore required to majority of citizens stated they would like examine what sort of consent framework to be informed of any incidental fi ndings could be implemented that would satisfy in their data, although the extent of desired New Zealand’s culturally and ethnically information differed between individuals.23 diverse community. Consent Anonymity An inherent diffi culty with posthumous Anonymity is diffi cult to adhere to as data is that patients are unable to consent much genetic data is correlated with medical after their death. While many legal and (and therefore personally identifi able) ethical guidelines exist regarding the information. The HIPC (Rule 10) states “A acquisition and use of healthcare data health agency that holds health information for individuals that are alive, it is unclear obtained in connection with one purpose how this applies to the use of post- must not use the information for any humous digitised healthcare data. In the other purpose unless the health agency case of utilisation of public healthcare believes… that the information is used in records, discussion with the wider public a form in which the individual concerned and consumer groups is required as to is not identifi ed; or… is used for research determine how consent processes should be purposes and will not be published in a implemented, with this including consider- form that could reasonably be expected ation of options such as opt-in and opt-out to identify the individual concerned.”21 To consent processes. effectively utilise digitised healthcare data, There is also the question of who has the some elements of personal and medical authority to consent to the acquisition of information are required, however, issues genomic data on behalf of the deceased. surrounding the security and privacy of The deceased have no way of implementing digital healthcare resources have been 22 an action unless they have explicitly stated raised. The specifi c issues were in regard their wishes prior to their death, and people to the implementation of digitisation and do not tend to make decisions regarding integration of a large number of health the posthumous applications of their records, and with particular reference to medical information.24 The wishes of an anonymisation. Anonymous data implies individual regarding the course of action it has been collected and used without for their body after their death may differ any associated personal identifi ers, and from those of the family, yet as it stands the useful genomic data may never be truly

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anonymous.27 In addition, with the increase reduced the faith they have in the medical in publicly available data bases, large-scale profession,26 signalling the important role data linkage between healthcare data and of communication in generating support for personal information also becomes more healthcare research. possible, further decreasing the potential Community support and acceptance of for ‘true’ anonymisation. Data linking in an accessible digital healthcare database is New Zealand is already possible by use essential to prevent ethical repercussions, of the Information Data Infrastructure, a with transparency and communication digital resource which stores data from a between researchers, healthcare profes- range of government and non-government sionals and the public regarding the organisations. There is therefore the acquisition and intended use of digitised necessity to differentiate between data being healthcare data paramount to maintaining suffi ciently anonymous for the purposes of social support. Sharing information of the legal and ethical standards, and data being deceased without prior consent may violate ‘truly’ anonymous in a scientifi c sense, in their pre-mortem wishes, yet withholding order to inform guidelines for utilisation of such information from medical research digital healthcare information. may prevent a potential benefi t that could The development of a controlled, digi- be delivered to society. Therefore, the tised database where medical records are decision to allow use of healthcare infor- integrated across the population provides mation of the deceased must be weighed an elegant solution to attenuate challenges carefully, with full consideration of the associated with anonymity. Data is separated range and scope of the potential benefi ts and from any identifying information and coded risks associated with such access. in a secure database to ensure privacy to the individual in the future. Protection of elec- Conclusion tronic data is important, particularly when New Zealand has a history of being data may be shared globally.5 In Estonia, a a pioneering country that brings about chief processor only releases data in a coded change through public, community and form and any identifi able data cannot be cultural support, and has already proven accessed through an external network to itself capable of undertaking large-scale ensure secure use and storage of genomic research projects that span over decades.28 data.12 Similarly, digital data collected by A small nation with an established health the UK Biobank is separated from any system coupled with the technology to identifying information by coding it in a support a digital database presents an ideal restricted-access database.11 opportunity to develop a unique platform Issues underpinning the ethical for biomedical research using posthumous, right to use digitised healthcare data. Such a resource As presented, there appears to be no legal would assist our understanding of the rela- barrier to the use of posthumous, digitised tionship between genetics, environment and healthcare information in New Zealand, disease, facilitate improved drug adminis- though this does not mean it should be tration and create new opportunities for performed. The way scientifi c research is prevention and treatment in healthcare, conducted and how fi ndings are dissem- including those that benefi t European, inated into the community infl uence the Māori and Pacifi c populations. support or objection of the public. The Royal There are currently no apparent legal Liverpool Children’s Inquiry was conducted barriers prohibiting the utilisation, for following the revelation that organs and research purposes, of posthumous digital tissues were being retained from deceased healthcare data in New Zealand, and the children and babies without the knowledge barriers to its use appear largely ethical. of the parents. During this inquiry, parents However, this does not necessarily mean it expressed that they would have considered should proceed on an organised basis, with donating tissue from their children for decisions on consent, anonymity and ethical education or research if they had been use requiring further consideration. Estab- approached in an open manner. However, lishing and accessing such a resource will the betrayal of trust without permission require strict oversight in order to prevent

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misuse or exploitation, and to establish trust culturally appropriate manner will enable between those gathering the data, those util- New Zealand to provide more effective ising the information, and the public who healthcare for its citizens and remain at the will be contributing to it. Further discussion forefront of healthcare research. There are is required in order to explore the idea inherent problems associated in the utili- of utilising digitised healthcare data on a sation of such digital information following national scale in order to discover whether death,29 and undoubtedly new legal and and how such utilisation should occur. ethical situations will continue to unfold If a decision to proceed is forthcoming, with advancing technology.30 However, the implementation and introduction of these should not be seen as permanent appropriate systems to regulate e-mortal barriers to the implementation and use of a healthcare data in New Zealand’s unique successful and effective system that allows cultural, social and ethnic environment posthumous digital healthcare data to be can then be planned through appropriate sensitively and effectively utilised. Similarly, consultation. Failure to undertake consul- the risks of allowing posthumous digital tation and implement frameworks that are healthcare information to be utilised must appropriately informed has the potential also be considered in any decision about to undermine any trust in the relationship information use, including the potential between those giving and those utilising range and scope of any proposed benefi ts. digitised healthcare information. Under- Wide and appropriate consultation should taking wide and thorough consultation is be undertaken in order for participants and therefore necessary to establish a robust end-users to contribute perspectives on a and evidence-based platform that can guide collective way forward and guide appro- stakeholder behaviour. priate utilisation of this precious resource. New Zealand currently has the oppor- The development of such a uniquely ‘New tunity to establish a system that effectively Zealand’ resource will likely provide benefi t and effi ciently utilises posthumous digi- for all New Zealanders over time, with its talised healthcare data. Implementing a establishment echoing global trends in system that does this in an ethically and healthcare research.

Competing interests: Miss Hoeksema reports grants from University of Otago Centre for Society, Governance and Science during the conduct of the study. Acknowledgements: KH was the grateful recipient of a summer student scholarship from the Centre for Society, Governance and Science at the University of Otago. Author information: Katie Hoeksema, Fifth Year Medical Student, School of Medicine, University of Otago, Wellington; Richman Wee, Project Manager and Researcher, Centre for Society, Governance and Science, Faculty of Law, University of Otago, Dunedin; Alastair Macdonald, Retired Renal Physician and Current Clinical Ethics Advisor, Capital and Coast District Health Board, Wellington; Parry Guilford, Department of Biochemistry, University of Otago, Dunedin; Jesse Wall, Senior Lecturer, Faculty of Law, University of Otago, Dunedin; Jon Cornwall, Programme Director and Senior Lecturer, Faculty of Health, Victoria University of Wellington, Wellington. Corresponding author: Jon Cornwall, Faculty of Health, Victoria University of Wellington. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459- 21-july-2017/7318

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REFERENCES: 1. Fehringer G, Kraft Genome-wide association 21. Privacy Commissioner. P, Pharoah PD, et al. studies in oesophageal Health Information Privacy Cross-cancer genome- adenocarcinoma and Code. New Zealand; 1994. wide analysis of lung, Barrett’s oesophagus: A 22. Stevens R. Medical record ovary, breast, prostate, large-scale meta-anal- databases. Just what you and colorectal cancer ysis. Lancet Oncol. need? New Zealand; 1998. reveals novel pleiotropic 2016; 17:1363–73. 23. Fleming J, Critchley C, associations. Cancer 10. Arnar DO, Andersen K, Otlowski M, et al. Attitudes Res. 2016; 76:5103–14. Thorgeirsson G. Genetics of the general public 2. Wain LV, Shrine N, Miller of cardiovascular diseases: towards the disclosure S, et al. Novel insights into Lessons learned from of individual research the genetics of smoking a decade of genomics results and incidental behaviour, lung function, research in Iceland. Scand fi ndings from biobank and chronic obstructive Cardiovasc J. 2016; 1–6. genomic research in pulmonary disease 11. UK Biobank. Ethics and Australia. Intern Med (UK BiLEVE): A genetic Governance Frame- J. 2015; 45:1274–9. association study in UK work. UK; 2007. 24. Choong KA, Bonnici JPM. Biobank. Lancet Respir 12. Keis A. Biobanking in Posthumous medical Med. 2015; 3:769–81. Estonia. J Law Med confi dentiality. Eur J Comp 3. Shungin D, Winkler TW, Ethics. 2016; 44:20–3. Law Gov. 2014; 1:106–19. Croteau-Chonka DC, et 13. Merz JF, McGee GE, Sankar 25. Beskow LM. Lessons al. New genetic loci link P. “Iceland Inc.”?: On from HeLa Cells: The adipose and insulin biology the ethics of commercial Ethics and Policy of to body fat distribution. population genomics. Soc Biospecimens. Annu Rev Nature. 2015; 518:187–96. Sci Med. 2004; 58:1201–9. Genomics Hum Genet. 4. Collins FS, Green ED, 14. Ministry of Social Affairs 2016 Aug; 17:395–417. Guttmacher AE, Guyer and Health. Biobank 26. Redfern M, Keeling J, MS. A vision for the future Act. Finland; 2012. Powell E. The report of the of genomics research. Royal Liverpool children’s Nature. 2003; 422:835–47. 15. Offi cial Journal of Acts Dziennik Ustaw. The Cell, inquiry. London; 2001. 5. Winkler EC, Wiemann Tissue and Organ Recovery, 27. National Ethics Advisory. S. Findings made in Storage and Transplanta- Ethical guidelines for gene panel to whole tion Act. Poland; 2005. observational studies: genome sequencing: Data, Observational research, knowledge, ethics – and 16. Malanowski P, audits and related activi- consequences? Expert Rev Antoszkiewicz K, Jakubows- ties. New Zealand; 2012. Mol Diagn. 2016; 1–12. ka-Winecka A, et al. Central Register of Objections 28. Dunedin Multidisciplinary 6. Kaye J, Boddington P, de for deceased donation in Health and Development Vries J, et al. Ethical impli- Poland 1996 to 2014: The Research Unit. Dunedin cations of the use of whole country with an opting- Multidisciplinary Health genome methods in medi- out system. Transplant & Development Study cal research. Eur J Hum Proc. 2016; 48:1337–40. [Internet]. [Cited 2017 Jan Genet. 2010; 18:398–403. 17. Ministry of Justice. Privacy 17] Available from: http:// 7. Pui C-H, Yang JJ, Hunger Act. New Zealand; 1993. dunedinstudy.otago.ac.nz SP, et al. Childhood acute 29. InternetNZ. Death and lymphoblastic leukemia: 18. Wilkinson TM. Last rights: the internet. [Internet]. Progress through collab- The ethics of research 2016 [Cited 2017 Jan 17]. oration. J Clin Oncol. on the dead. J Appl Available from: https:// 2015; 33:2938–48. Philos. 2002; 19:31–41. internetnz.nz/event/ 19. Boys MH. Health 8. Ullman-Cullere MH, death-and-internet Mathew JP. Emerging (Retention of Health 30. Cornwall J, Slatter T, Print landscape of genomics in Information) Regulations. C, Guilford P, Henaghan M, the electronic health record New Zealand; 1996. Wee R. Culture, law, ethics, for personalized medicine. 20. Ministry of Health. and social implications: Is Hum Mutat. 2011; 32:512–6. Standard Operating society ready for advanced Procedures for Health and 9. Gharahkhani P, Fitzgerald genomic medicine? Austral Disability Ethics Commit- RC, Vaughan TL, et al. Med J. 2014; 7:200–2. tees. New Zealand; 2014.

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The thumb sign Satvinder Bakshi

34-year-old male presented with a Streptococcus pneumoniae.1,2 Non-infectious two-day history of fever and pain causes include thermal injury, trauma, caus- A while swallowing. On examination tic ingestion and foreign body impaction. the patient was febrile, dyspneic and his Patients present with fever, odynophagia, saturation was 88% on room air. The plain muffl ed voice, drooling of saliva and stridor. x-ray lateral view of the neck revealed Diagnosis is by lateral cervical spine x-ray, ‘thumb sign’ (Figure 1) typical of acute which shows the characteristic thumb sign, epiglottitis. The patient was treated with although it may be absent in early stages.1 ceftriaxone, dexamethasone and humidifi ed The differential diagnosis includes periton- oxygen and was closely monitored for any sillar abscess, croup and retropharyngeal airway compromise. He recovered com- abscess.2 Treatment is by third generation pletely and is asymptomatic at fi ve months cephalosporins and steroids; other support- of follow up. Acute epiglottitis is cellulitis ive measures include humidifi ed oxygen.2 of the epiglottis and adjacent tissue. The The risk of death due to sudden airway ob- most common pathogen in unimmunised struction is high, therefore close monitoring children is Haemophilus infl uenzae type b of these patients is of utmost importance.2 and in adults are Staphylococcus aureus and

Figure 1: Plain x-ray of the neck lateral view showing a swollen epiglottis ['Thumb sign', arrow].

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Competing interests: Nil. Author information: Satvinder Singh Bakshi, Assistant Professor of ENT, Dept of ENT and Head & Neck Surgery, Mahatma Gandhi Medical College and Research Institute, Pillaiyarkuppam, Pondicherry 607402, India; Gaurav Balpande, Junior Resident in Radiology, Dept of Radiology, Mahatma Gandhi Medical College and Research Institute, Pillaiyarkuppam, Pondicherry 607402, India. Corresponding author: Dr Satvinder Singh Bakshi, Assistant Professor of ENT, Mahatma Gandhi Medical College and Research Institute, Piliaiyarkuppam, Pondicherry 607402, India. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459- 21-july-2017/7319

REFERENCES: 1. Darras KE, Roston AT, 2. Shapira Galitz Y, Shof- goscope. 2017 May 11. Yewchuk LK. Imaging fel-Havakuk H, Cohen doi: 10.1002/lary.26609. Acute Airway Obstruction O, Halperin D, Lahav Y. [Epub ahead of print]. in Infants and Children. Adult acute supraglottitis: Radiographics. 2015 Nov– Analysis of 358 patients Dec; 35(7):2064–79. doi: for predictors of airway 10.1148/rg.2015150096. intervention. Laryn-

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A villous adenoma of bladder/urachus origin located in the perineum Calum Fraser, Frank Frizelle

60-year-old male with a background solid component. A follow-up MRI in 2014 of congenital bladder extrophy pre- showed a small increase in the size of the A sented with a painful pelvic mass af- lesion with unchanged characteristics. ter riding a push bike and sliding off the seat At this time it was felt this represented a onto the cross bar. As a child (>50 years ago) lymphatic malformation/lymphocele. The he had undergone an abdominal perineal patient remained asymptomatic and a watch resection and formation of an ileal conduit, and wait approach was taken. Yearly moni- the records of which were not available. toring continued to show a slow increase in The mass described was fi rst noted by the size only (Figure 1). patient as a non-painful lump in July 2013 When the patient developed pain in and assessed with USS, which described autumn 2016 after blunt trauma, a more a superfi cial perineal lump with complex defi nitive management option was explored. cystic-solid characteristics communicating Blood tests including CRP and PSA were with a deeper tract and central pelvic normal. After consideration of possible cyst. No communication with other pelvic options, the decision was made to surgically structures were identifi ed. This was origi- excise the lesion (Figure 2). nally thought to be malpositioned seminal Histology of the cystic perineal lesion vesicles. MRI was recommended and this showed macroscopic fi ndings of an ovoid reported a 100x50x70mm multiloculated nodule of tan fi brous tissue 80x70x45mm. cystic lesion with components deep and Microscopic fi ndings showed mucin-fi lled superfi cial to the pelvic fl oor musculature. spaces within fi brous tissue. There was no It was described as non-specifi c but had evidence of high-grade dysplasia or other benign features without any identifi able features of malignancy. The features were

Figure 1: Last pre-operative MRI scan in 2016 showing the perineal cystic lesion.

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Figure 2: Complete excised villous adenoma lesion.

of a villous adenoma of bladder/urachal to obtain tissue for histology to achieve a origin. Excision with clear margins was formal diagnosis and determine if further thought to be curative. investigations are needed and what 6,7 The patient was discharged the following management is required. Good clinical day and made a good recovery. The agreed outcomes have been observed in patients course of follow up was with repeat MRI. with isolated villous adenoma or villous He remains pain free and has developed no adenoma plus adenocarcinoma in situ after long-term complications. complete surgical resection, with rarely any recurrence.4,5,7 Those cases with co-existing adenocarcinoma or other invasive malig- Discussion nancies do less well and may experience Villous adenomas of the urinary system metastases or recurrence requiring further 1,2,4,6 are rare. There are no cases available investigations and management options.3 in the literature describing these lesions of bladder/urachal origin found outside the urinary system in the perineum. They Learning points have been found in the bladder, urachus, In conclusion, villous adenomas renal pelvis, ureter and urethra, and have of bladder/urachal origin found in the morphologic features similar to those of the pelvis/perineum are rare with no previous colonic adenomas.1,3,4 examples described in the literature. These lesions can be slow to increase in size and There are reports in the literature patients can be asymptomatic. These lesions showing bladder/urachus villous adenomas can often be associated with malignancy so associated with malignant tumours histology is of high importance. This case including adenocarcinoma, squamous report highlights that complete surgical cell carcinoma and urothelial carcinomas, excision of these lesions with clear margins which can metastasize or recur after initial can result in good clinical outcomes. management.2,3,5,6 It is therefore crucial

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Competing interests: Nil. Acknowledgements: I would like to thank the patient for allowing them to share their case and imaging. I would like to thank Professor Frizelle for his assistance and time in putting this case report together. Author information: Calum Fraser, Department of General Surgery, Christchurch Hospital, Christchurch; Frank Frizelle, Department of General Surgery, Christchurch Hospital, Christchurch. Corresponding author: Dr Calum Fraser, Department of General Surgery, Christchurch Hospital, Christchurch. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459- 21-july-2017/7320

REFERENCES: 1. Ratanarapee, et al. Villous noma. Am J Surg Pathol, non-muscle invasive adenoma of the urinary 23 (1999), pp. 764–771. bladder cancer arising in bladder: a case report. 4. Sung, et al. Villous the bladder: a case report J Med Assoc Thai. 2010 adenoma of the urinary and review of the litera- Nov; 93(11):1336–9. bladder. Int J Urol. 2008 Jun; ture. BMC Urol. 2013; 13:36. 2. Seibel, et al. Villous adeno- 15(6):551–3. doi: 10.1111/j.1442- 7. Bhargava K, Vardhana, ma of the urinary tract: A 2042.2008.02041.x. Reddy R, Malleswari G, lesion frequently associat- 5. Joniau, et al. A Giant Rajgopal, Satish Arora KV, ed with malignancy. Hum Mucinous Adenocarcinoma Venkata Harish C. ”Recur- Pathol. 2002 Feb; 33(2):236. Arising within a Villous rent Villous Adenoma 3. Cheng L, Montironi R, Adenoma of the Urachus: of Urinary Bladder and Bostwick DG. Villous Case Report and Review Ureter: A Case Report”. adenoma of the urinary of the Literature. Case Rep Journal of Evidence based tract: A report of 23 Med. 2009; 2009: 818646. Medicine and Healthcare; Volume 2, Issue 12, March cases, including 8 with 6. Kato, et al. Concurrence 23 , 2015:1838–1841. coexistent adenocarci- of villous adenoma and

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Neuraminidase inhibitors during pregnancy and risk of adverse neonatal outcomes and congenital malformations Neuraminidase inhibitors such as oseltamivir or zanamivir are often used as treatment for, or prophylaxis against, infl uenza. However, doubts have been raised about the safety of their use in pregnant women. This concern is evaluated in this population-based cohort study. It included almost 6,000 exposed infants and 700,000 unexposed infants. Exposure was defi ned as the mother having a prescription for either of these drugs during pregnancy. The study did not assess risks of adverse outcomes before gestational week 22. The fi ndings suggest that the use of neuraminidase inhibitors is not associated with increased risks of adverse foetal or neonatal outcomes. BMJ 2017; 356:j629 Triggering of acute myocardial infarction by respiratory infection There is increasing recognition that myocardial infarction (MI) can be precipitated by a respiratory infection, with evidence indicating that pneumonia, bronchitis and infl uenza confer an increased transient risk of MI. The authors of this paper note that most of the previous studies have been conducted without angiographic confi rmation of the MI. In their study, 578 patients with an angiographically confi rmed MI were evaluated with respect to whether or not that they had experienced a respiratory infection. Symptoms of respiratory infection were reported by 100 (17%) and 123 (21%) within seven and 35 days, respectively, prior to MI. The relative risk for MI occurring within 1–7 days after respiratory infection symptoms was 17.0 These fi ndings confi rm previous reports of the association. Internal Medicine Journal 2017; 47:522–529 Rivaroxaban or aspirin for extended treatment of venous thromboembolism The direct oral anticoagulant rivaroxaban is considered to be superior to warfarin in the management of these conditions. This study reviews and compares the effects of the long-term use of rivaroxaban and aspirin. In this randomised trial, the researchers assigned 3,396 patients with venous thrombo- embolism to receive either once-daily rivaroxaban (at doses of 20mg or 10mg) or 100mg of aspirin. Both doses of rivaroxaban were found to be superior to aspirin in reducing the risk of recurrent thromboembolism. The risk of bleeding was similar in all three groups. It was concluded that the risk of a recurrent event was signifi cantly lower with rivaroxaban at either a treatment dose (20mg) or a prophylactic dose (10mg) than with aspirin, without a signifi cant increase in bleeding rates. N Engl J Med 2017; 376:1211–22

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Mobilisation of the Profession PROPOSALS OF THE MINISTER OF PUBLIC HEALTH

he Hon. Mr. Russell, Minister of Public utterly impracticable. The question for him Health, when he attended the meeting to consider now was how to set up a scheme Tof the Council on 12th June, expressed by which in a large scattered district a his pleasure at meeting the executive of a medical man could be provided. profession the members of which, at great He could hardly expect busy men to leave sacrifi ce to themselves, had so willingly and their practices and their patients and their ungrudgingly assisted the Government since responsibilities in the cities to offer to go out the war started. He understood from the into a scattered district voluntarily. Some Chief Health Offi cer that one medical man men might be prepared to do it, but the was required for every 2000 of the popula- question arose whether, in a matter of this tion. Since the war started the proportion kind, there should not be something in the had been reduced to very near the dan- nature of equality of sacrifi ce. This was why, ger-line, and the demand on the part of the in his letter to the Association dated 31st military authorities for medical men still May, he had ventured to express the opinion continued. The Hon. the Minister of Defence that the voluntary system, even backed by had stated that he could get the men he an Advisory Board, was unworkable. So wanted for service in connection with the far as it was possible to utilise the services soldiers, and the matter was absolutely in of the proposed Advisory Board he was his hands. But no account had been taken prepared to accept it. The Minister of by the military authorities up to the present Defence said it would not be necessary to set of the needs of the civil population, and the up an Advisory Board simply to deal with time had, in his (Mr. Russell’s) opinion, come military requirements. when the necessities of the civil population As regards the civil services, he (Mr. must be considered. He did not antici- Russell), with the session in view, felt pate any diffi culty as regards meeting the bound to make provision for all contin- demands of the military authorities for the gencies. If he could not get medical men remainder of the war, but he could not shut voluntarily, then some means must be his eyes to the fact that already they were provided for obtaining them compulsorily, feeling a tremendous strain with regard to and what he had in his mind was this: to the necessities of the civil population. set up machinery by Act of Parliament At the present time along about 300 miles which could be utilised if necessity arose of the West Coast of the South Island there for mobilising the medical services of the was only one medical man, and although country. It would be a very diffi cult Bill the population in that district was sparse to draw up, but he would give his guar- it was impossible that a medical service antee that every safeguard that could be over so extensive an area of country could suggested to prevent injustice would be be run effectively by one doctor, and the provided. He would refer to a paragraph Inspector-General did not know where to in the “British Medical Journal” which look for another man. There were other stated that at a conference of Local War places in New Zealand which previously Committees for Scotland the following reso- were carrying two and three doctors fully lution was adopted: “That this conference of employed, and which now had only one. secretaries of Local War Committees, being Applications had been made to have the informed that further substantial calls are doctors’ residences connected by telephone likely to be made on the profession, is of with all sorts of outlying places, in order to opinion that these calls can only be met by meet urgent calls, but such a scheme was mobilising the whole profession.”

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If this recommendation was given effect come to New Zealand since the war started, to it meant that every medical man came though Parliament would probably agree under the control of the Government for that such a clause would be quite fair as military service or home service until the applied to those who might come in here- war was over. In his opinion the conditions after. With regard to the remuneration of in New Zealand as regards sparseness of the men who might be sent compulsorily to population and in other respects approxi- districts requiring them, his idea was that mated to some extent those of Scotland. It it should be much on the same basis as that was in the working out of the details of the of medical offi cers on military service. A problem that diffi culties presented them- captain’s pay was about £560 per annum. selves. He would not feel disposed to say The Government would be prepared to that a man who was making, say, £2000 guarantee that. Of course, if a doctor was a year should be sent to a district where making, say, £1000 a year out of the practice his income would only be £500 a year for it would not be necessary for the State the remainder of the war, while another to pay anything, but the salary could be medical man in the same street who had guaranteed. been making only £300 a year should A member: What about means of remain behind without making any sacrifi ce conveyance? at all. The scheme must make provision, The Hon. Mr. Russell thought, where as far as possible, for equality of sacrifi ce. necessary, motorcar and upkeep of car He was prepared to accept the policy of might be provided. There would be no the Medical Association, and lay it down, diffi culty in getting from the Defence if necessary, by statute, that, while the war Department an estimate of what the position was on, any doctor who newly registered of a captain was worth, and his opinion in New Zealand must offer his services to was that where compulsion was applied the military authorities or the public health the income of the civilian doctor who went authorities at whatever salary might be into the fi eld to work for the people of the determined before being allowed to enter country should be not less than that which into private practice. the military were paid. That should be guar- Dr. Guthrie: Could such a provision be anteed. He thought they could start upon made retrospective and applied to men who that basis. have registered since the war began? In reply to questions, Mr. Russell said The Hon. Mr. Russell said that would probably the basis he had mentioned was be impossible. A hint had reached him not high enough. If a doctor was sent into a the other day that if he were to utter one district where the farmers were doing well word there would probably be a hundred he might make anything £1000 to £2000 medical men over from America as soon a year. He was quite prepared to ask his as a ship could bring them, and no doubt colleagues to take into consideration the members of the Council had noticed in the question of establishing a pension system press that he had received a letter from for medical men who might die while on the Japanese Consul at Sydney asking him home service. He would be pleased to meet the terms upon which medical men fully the Council again after they had considered qualifi ed, belonging to Japan, could come the proposals he had placed before them. and join New Zealand, and he was sending The Chairman thanked the Minister for his an answer to that communication that day. kindness and consideration in attending the It would be quite impossible to impose such meeting and explaining the proposals of the a condition with regard to doctors who had Government, and the Minister withdrew.

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Proceedings of the scienti c meetings of the Health Research Society of Canterbury 2017

Towards 3D culture by developing novel three– Collaborative models for the dimensional (3D) co-culture opportunities at systems to grow human investigation of breast adipocytes and breast Canterbury Health adipocyte/tumour cancer cells together. Mature Laboratories—a interaction breast adipocytes were either tertiary-level encapsulated in 5% gelatin E Phillips,1 K Lim,2 T Woodfield,2 MJ diagnostics laboratory hydrogel alone or in a mixed Currie1 co-culture with breast cancer K Doudney 1 Mackenzie Cancer Research cell lines (MCF7; ER+, PR+, Canterbury Health Laboratories, Group (MCRG), University of HER-), (MDA-MB-231; ER-, Christchurch, New Zealand. Otago Christchurch, Christchurch HER-, PR-) and (HCC1954; ER-, 8011, New Zealand; 2Christchurch Canterbury Health Labo- Regenerative Medicine and Tissue PR-, HER+). Breast cell lines ratories provides pathology Engineering (CReaTE) Group, were also grown alone in 5% services, primarily for Christ- University of Otago Christchurch, gelatin hydrogel. Cell viability church Hospital and other Christchurch 8011, New Zealand. and metabolic activity of the New Zealand health service The tumour microenvi- cells and the co-cultures was centres, but also undertakes ronment (TME) encompasses assessed using Alamar Blue specialist clinical investigations the tumour and its surrounding assay, and immunofl uorescence either within the organisation area; it consists of many types of staining for ki67 was used to or by collaboration with other cells, extracellular matrix and determine proliferation. institutions such as universities also additional physical factors, Results and crown research Institutes. including nutrient and oxygen The 3D cultured cancer cells, This talk will mention a few gradients and mechanical and 3D co-cultured adipocytes examples of these interac- rigidity. In traditional 2D cell and cancer cells remained func- tions and touch on some new culture, the impact of the TME tionally viable after seven days horizons for the laboratories. on cancer cells is understudied, of encapsulation in 5% gelatin Aim largely due to impracticality hydrogels. After seven days, To disseminate the role of incorporation of other cells. the breast cancer cells co-cul- and collaborative interac- Using a two-dimensional (2D) tured with adipocytes appear tions of Canterbury District transwell co-culture is one more metabolically active and Health Board’s main specialist method of incorporating at least proliferative than the same cells pathology laboratory, one other cell type. We have grown alone. Canterbury Health Laboratories. successfully used this system Conclusion Methods to show that adipocytes can Development of more phys- The laboratory employs interact with breast cancer cells iological 3D models in which approximately 400 staff to in vitro and that this interaction to test drug effects and study undertake over 2,000 core enables breast cancer cells to breast cancer-stromal cell and specialist diagnostic tests survive chemotherapy doses interactions will improve our for local, national and inter- that would otherwise be lethal. understanding of the mecha- national medical science Aim nisms involved in breast cancer facilities. New technologies are The aim of this study was progression and may ultimately incorporated into the reper- to further investigate adipo- lead to improved outcomes for toire regularly, some recent cyte-breast cancer interactions breast cancer patients. examples are Droplet Digital

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PCR, mass spectrometry and Results Methods massively parallel sequencing. In all animals, ICV devel- To date, 45 females aged Results opment was non-linear. between 16 and 40 years have In the course of work carried Controls reached maximum been recruited for the study out at CHL in various pathology ICV at about 15 months and who have conditions asso- disciplines, some fi ndings plateaued thereafter. In ciated with excess androgen warrant further investigation, affected animals, ICV also (mainly PCOS). Fifty-three usually involving other labora- increased initially but then healthy females have been tories within the organisation declined progressively (p<0.05) recruited for comparison. All or with another diagnostic between 5–13 months (CLN5-/- participants have completed laboratory or university. In animals) and 11–15 months medical, hormonal, cognitive these instances, we liaise and (CLN6-/- animals). and mood assessment at collaborate with a diverse Conclusions two time points (baseline range of medical or research ICV is a good surrogate for and 16 weeks). This includes institutions and colleagues brain size in growing and depression rating scales, facial nationally and internationally NCL-affected sheep. Longitu- emotion recognition measures to progress a diagnosis and dinal monitoring of ICV greatly and tasks measuring various report novel fi ndings in simplifi es in vivo treatment cognitive domains such as peer-reviewed journals. trials, as fewer animals yield verbal and spatial learning Conclusion robust data. and memory, attention and Collaboration and inter-labo- executive function. Following ratory discourse is essential for Sex hormones, baseline assessment, patients the provision of tertiary-level mood, cognitive were treated with anti-an- diagnostic care in the New function and emotion drogen medication, as deemed Zealand health system. suitable by their treating processing in women gynaecological-endocrinologist. Longitudinal M Sukhapure, K Douglas, A Fenton, The study will examine monitoring of R Porter correlations between androgen brain development Department of Psychologi- levels, depression symptoms, cal Medicine, University of cognitive function and emotion in ovine NCL Otago, Christchurch. processing at baseline, and will KN Russell, NL Mitchell, GK Barrell, Background and Aims determine whether hormonal DN Palmer Conditions associated treatment that normalises Faculty of Agriculture and Life with abnormal levels of sex androgen levels may improve Sciences, Lincoln University, hormones (androgens), such mood, cognitive function and Lincoln 7647, New Zealand. as poly-cystic ovary syndrome emotion processing. Aims (PCOS), are common clinical The neuronal ceroid-lipofus- presentations of females Development of a cinoses (Batten disease, NCLs) referred to gynaecological predictive model for are fatal neurodegenerative endocrine clinics. These condi- pulmonary elastance childhood diseases caused by tions are associated with many 1 1 1 mutations in 13 different genes. unwanted symptoms, including SE Morton, J Dickson, P Docherty, 2 1 Progressive brain atrophy is a mood disturbance. Mood distur- GM Shaw, JG Chase, defi ning feature, including in bance itself also has a number 1Department of Mechanical Engi- ovine CLN5 and CLN6 forms of features, including cognitive neering, University of Canterbury; studied as human disease impairment and diffi culties 2Intensive Care Unit, Christchurch models. Ongoing gene therapy with emotion processing. Thus, Hospital, Christchurch, New Zealand. trials have shown remarkable there are likely to be many Aims effi cacy indicated by longi- women in the general popu- Mechanical ventilation is a tudinal in vivo assessment of lation who have depression core intensive care therapy for brain atrophy using intracranial and cognitive impairment patients suffering from respi- volume (ICV) as a measure of as a result of untreated ratory failure. Lung stiffness brain size. androgen dysfunction. There and airway resistance are very Methods is limited research aiming different between patients and Computed tomography (CT) to examine directly the rela- depend on their condition. measurements of ICV and tionship between androgen Optimising mechanical venti- post mortem measurements levels and mood disturbance lation for the individual patient of brain size yielded a 1:1 in females, even though doing without causing damage to the ratio of ICV:brain size in both so could have signifi cant lung is complex in practice. affected animals (n=11) and benefi t in choosing the most Model-based ventilation can controls (n=14). Longitudinal suitable treatment option for aid this clinical practice by ICV changes in CLN5-/- (n=6) depressed females in mental providing a description of a and CLN6-/- (n=6) animals and health services who present patient’s lung elastance and controls (n=12) were deter- with abnormal levels of sex airway resistance. mined in a CT study over 3–19 hormones. months.

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Methods cmH2O is also showing prom- and mortality; 17.5 million Previously, spring-mass- ising initial results with errors people died from CVD in 2012, damper models have been used ranging from 2.5 to 9%. representing 31% of all global to describe lung mechanics. Conclusions deaths (Organis ation 2012). However, it has been found Once verifi ed on more patient Healthy and dysfunctional that elastance and resistance data, this model will allow more haemodynamics in the aortic vary with pressure and fl ow robust ventilation treatment arch and its peripheral arteries throughout each breath. Basis plans to be developed, maxi- are still not fully understood. functions have been developed mising oxygenation while Cardiovascular stents used to to capture this behaviour. In minimising lung damage. treat some forms of CVD cause addition, they appear to be poorly understood changes to able to predict the impact that In-silico modelling haemodynamics and in some changing PEEP levels will have of aortic arch cases can cause damage. This on lung mechanics. haemodynamics for presentation is about in-silico Results modelling of the aortic arch Fitting a range of recruitment surgical implant testing haemodynamics for different manoeuvres across four sets of SG Yazdi, PH Geoghegan, PD disease states and stent designs. patient data from the Christ- Docherty The modelling will be accom- church ICU has shown good plished by fabrication of Department of Mechanical results. Prediction using elas- compliant silicone phantoms Engineering, University of Canter- tance and resistance results bury, Christchurch, New Zealand. and particle image velocimetry from PEEP 14 to estimate fl ow visualisation. Cardiovascular diseases (CVD) behaviour at PEEP 18, 22 and 26 are a leading cause of morbidity

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The Diabesity Crisis Jim Mann, Rachael Taylor, Wayne Cutfield

wo recent events in March 2017 (‘The a multitude of ways, including limiting Diabesity Crisis’ Symposium and exposure to the temptation of consuming Tthe ‘Cost of Sugar’ Forum) hosted in energy-dense foods (eg, the dessert menu in Auckland by the Edgar Diabetes & Obesity a restaurant). Research Centre (EDOR) and two National The extent to which such support systems Science Challenges: Healthier Lives and can be implemented in primary care or in A Better Start aimed to be more than just other community settings depends upon the another ‘talkfest’ about the related epidem- availability of resources, but surprisingly ics of obesity and type 2 diabetes (T2DM) in they have rarely been tested. However, we New Zealand. do know that a straightforward nurse-led The organisers asked a group of interna- support programme can be as effective, and tional and national speakers with expertise indeed much less costly, than more intensive in epidemiology, endocrinology, genetics, weight management programmes involving Māori health, nutrition, physical activity, specialist guidance for maintaining weight public health and clinical medicine to loss.1 Kirsten Coppell discussed the evidence summarise the current state of knowledge base for the provision of dietary advice by and new research in order to identify prior- primary care practitioners. Several models ities for action. have been reported to achieve weight loss, Given the ever-increasing number of obese but there is little information regarding 2 children and adults in New Zealand, many long-term outcomes or cost effectiveness. with T2DM, developing a rational approach Currently, available drug treatments to prevention and management is essential. have little or no place in the management An important fi rst step is the acceptance that of obesity, so unsurprisingly the role of obesity, if untreated, is a chronic progressive bariatric surgery was an important feature disease associated with the early devel- of Rachel Batterham’s contribution to opment of comorbidities and reduction of the Symposium. The most widely under- life expectancy. Rachel Batterham, Tony taken procedure, laparoscopic sleeve Merriman and Dave Grattan all empha- gastrectomy, has a very low rate of compli- sised the role of genes and the powerful cations (similar to that of gall bladder biological mechanisms which can explain surgery) and as is the case with gastric how overweight and obesity develop as a bypass surgery, which is often still under- ‘normal’ response to the current ‘obesogenic’ taken in people with diabetes, is associated environment. Increasing awareness that with substantial weight loss as well as an obesity, like other major chronic diseases, appreciable improvement in comorbidities, results from an interaction between biology notably T2DM. Typically there is an imme- and environment helps to shift the dialogue diate post-surgical improvement in blood from a position of blame to one of solution glucose levels. Dosage of hypoglycaemic and the development of a more rational agents (oral hypoglycaemics and insulin) is approach to management. invariably reduced and often may no longer What then should we offer to the obese be necessary. patient? An important message to be taken Current criteria for surgery in New Zealand from Rachel Batterham’s presentation is are more rigid than in most Western coun- that powerful biological mechanisms also tries, and while surgery is not appropriate hamper maintenance of initial weight for all obese patients, the criteria certainly loss achieved by energy restriction. So, warrant an urgent review, especially as they approaches which provide long-term apply to obese patients with T2DM. In the support and encouragement are essential. UK it is recommended that all patients with These include targeting physical activity, recent onset T2DM and a body mass index sedentary behaviour, sleep and diet in (BMI) greater than 35kg/m2 be assessed for

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the possibility of bariatric surgery after availability, relatively low cost and largely non-surgical measures have been tried unrestricted advertising all contribute without sustained weight loss. This might to overconsumption of sugar-sweetened be a useful starting point for the discussion beverages (SSBs) and energy dense foods, about extending the criteria for surgery in which are considered to be major contrib- New Zealand. utors to excessive energy intakes. Callie Corrigan discussed issues relating Louise Baur provided strong evidence that to bariatric surgery, which are particu- intensive early childhood interventions can larly relevant to Māori. Individuals will reduce the risk of excessive weight gain, have a much more successful experience of especially in socio-economically disadvan- bariatric surgery if they are supported by taged groups who have high rates of obesity their whānau, especially the key decision and little access to such programmes. makers around kai. The challenge for However, the benefi ts are not sustained if health professionals is to provide infor- the intervention is not maintained in the mation and support, not only to individuals longer term. These fi ndings are hardly but also to their whānau. Information surprising given the pervasive nature of the needs to be provided in accessible formats, obesogenic environment, clearly illustrated taking account of Māori whakapapa and by Louise Signal using the photographic utilising oral and visual forms of commu- records of a group of New Zealand children nication as well as written ones. And wearing cameras, which continuously to enable patients to move in a positive recorded the environment to which they direction, support needs to be provided were exposed during their waking hours. from a safe, comfortable and neutral place While diet is often considered the corner- (without negative labels) that respects and stone of obesity management, behaviours values people. This can sometimes be as on the other side of the energy balance simple as having seats that are the right equation are just as important. Dave Lubans size. The capacity of the Māori health sector summarised the effectiveness of different must be increased in order to develop more approaches to increasing physical activity equal partnerships. and reducing sedentary behavior, particu- While bariatric surgery offers hope for larly in adolescents. The potential benefi ts people who have been unable to lose weight of resistance training for reducing adiposity by other means, a greater long-term hope and enhancing insulin sensitivity and the lies in developing medical therapies which appeal of high-intensity interval training mimic the mechanisms by which bariatric for overweight, but often very strong surgery achieves weight loss, reversal or adolescents should not be underestimated. improvement of comorbidities, and facil- Reducing the decline in physical activity itates the maintenance of weight loss. which typically occurs in adolescence and Professor Batterham especially emphasised developing more innovative approaches the central role of gut hormones as medi- to delivering physical activity sessions are ators of the benefi t of bariatric surgery and major challenges with this age-group. as novel targets for the development of Unlike other types of sedentary behaviour obesity therapies. such as screen time, sleep is a sedentary Measures aimed at stemming the tide activity that is clearly good for health. of the ‘diabesity’ epidemic are of equal Rachael Taylor highlighted the consis- importance to therapeutic approaches. tency of the evidence investigating the Given the dramatic increases in obesity relationship between sleep and obesity and T2DM over a remarkably short period in children, indicating that short sleepers of time, there can be little doubt that while have a two-fold greater risk of obesity than biological mechanisms explain predis- long sleepers.3 Moreover, the effect seems position, environmental factors must to persist into adulthood, indicating the account for the current alarming statistics. potential for long-term benefi ts. Confi r- Furthermore, successful maintenance of mation of sleep intervention as an effective weight loss also requires an environment obesity prevention tool is now urgently which is conducive to healthy food choices required. Given the observation that many and regular physical activity. Widespread of the adverse health outcomes associated

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with poor sleep are also more common in school communities to be more proactive Māori and Pacifi c children, it is also feasible about their health and wellbeing but does that sleep interventions hold promise for not include an enforceable healthy school reducing inequities in health. Regardless food policy. The current Code for adver- of their impact on weight, the physical tising food and beverages to New Zealand and mental health benefi ts arising from children and young people is voluntary, a good night’s sleep are numerous. Other and such industry-operated self-regulation novel approaches to obesity prevention rarely delivers benefi t to public health.11 A and management may lie within our gut. tax on SSBs has been one of the most widely Rinki Murphy and Wayne Cutfi eld reviewed discussed obesity prevention measures current evidence, largely from animal internationally, and evidence is emerging studies, suggesting that the gut micro- from countries that have implemented such biome may contribute to a wide range of taxes that they are effective.12 Furthermore, disorders, including obesity and type 2 revenue from a SSB tax could be used to diabetes mellitus. Intervention from healthy support other health programmes.13 donors increases diversity of the gut micro- The issues relating to sugar were discussed biome and has been shown to markedly in some detail at the ‘Cost of Sugar’ Forum improve insulin sensitivity in a pilot study chaired by Kim Hill. Jim Mann summarised of adults with type 2 diabetes mellitus. the science relating to the adverse health Professor Cutfi eld is currently undertaking consequences of free (or added) sugars: a gut microbiome transfer study to treat unequivocal evidence for the role of sugars severe adolescent obesity using a novel as a cause of dental caries; convincing encapsulation method for gut microbiome evidence that high intakes (especially of transfer. Similarly, obesity and diabetes SSBs) contribute to excess weight gain in research is embracing the digital world; Lisa children and to overweight and obesity in Te Morenga highlighted the opportunities adults and that restriction can reverse this; offered by mHealth (mobile health) initia- and accumulating evidence that fructose tives and emphasised the need to establish and fructose-containing sugars (sucrose close relationships with those communities, and high fructose corn syrup) have particu- which are the intended end-users of such larly adverse effects in terms of increasing programmes. Co-design of research projects insulin resistance, T2DM, gout and fatty and programmes by researchers and liver disease. The evidence relating to dental communities (or end-users) is essential. caries and body fatness was the major In 2015, the New Zealand Government determinant of the World Health Organiza- released a childhood obesity plan involving tion’s (WHO) Recommendation that “free 22 initiatives aimed at risk reduction as well sugars should contribute no more than 10% as managing childhood obesity. Speakers total calories and ideally less than 5%”. acknowledged these positive steps but Tony Blakely argued strongly that there Cliona Ni Mhurchu drew attention to several was now suffi cient evidence to implement recommendations4–8 which are considered a tax on SSBs in New Zealand despite the to be important components of public health reservations expressed by Jacqueline approaches to reducing the risk of obesity Rowarth relating to the consequences of a internationally, are consistent features of global reduction of sugar intake for sugar comparable plans in other countries9–10 and producing countries, especially developing are conspicuous by their absence in the New countries with marginal economies. Zealand plan: Callie Corrigan, Alex Brown and others • An enforceable healthy school food present in the audience reminded us all policy of the critical importance of involving the • A government-led code for advertising community, especially the Tangata Whenua food to children and those in high-risk groups when devel- oping approaches aimed at tackling the • A tax on sugar-sweetened beverages. ‘diabesity’ epidemic. Not only is there The New Zealand Health Promoting an obligation to do so, but without such Schools (HPS) Initiative and the Heart Foun- involvement any overall initiative is likely to dation’s Fuelled4Life programme supports be unsuccessful.

NZMJ 21 July 2017, Vol 130 No 1459 ISSN 1175-8716 © NZMA 84 www.nzma.org.nz/journal The New Zealand Childhood Obesity 1. A tax on sugar-sweetened beverages Plan (2015) and the updated guidelines (SSBs) for Management of Obesity in Childhood 2. A government-led code for food (2016) list a number of important initiatives. advertising However, the ‘Diabesity Crisis’ Symposium 3. An enforceable healthy school food and ‘Cost of Sugar’ Forum suggested a policy number of further recommendations for immediate action to help stem the tide of the 4. Review of eligibility criteria for obesity and diabetes epidemic: bariatric surgery 5. Clear recommendations regarding the role of sleep in obesity prevention.

Competing interests: Nil. Author information: Jim Mann, Director, Healthier Lives National Science Challenge; Rachael Taylor, Director, Edgar Diabetes and Obesity Research Centre, University of Otago; Wayne Cutfi eld, Director, A Better Start National Science Challenge. Presenters: Rachel Batterham, Louise Baur, Tony Blakely, Alex Brown, Kirsten Coppell, Callie Corrigan, Wayne Cutfi eld, Dave Grattan, Kim Hill, David Lubans, Jim Mann, Tony Merriman, Rinki Murphy, Cliona Ni Mhurchu, Jacqueline Rowarth, Louise Signal, Rachael Taylor, Lisa Te Morenga. Corresponding author: Professor Jim Mann, Department of Medicine, University of Otago, PO Box 56, Dunedin. [email protected] URL: http://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1459- 21-july-2017/7324

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