Andrew M. Tomlin

Risk factors for hospitalization due to diabetes complications

AIM To determine risk factors monitored in primary care that were significantly associated with diabetes complications requiring hospitalization. METHODS We examined clinical and demographic data for 1080 Type 1 and 11,283 Type 2 New Zealand diabetes patients attending a free primary care diabetes examination between 2000 and 2002. Hospital admissions data for the 2 years following the index examination were linked for each patient using a unique National Health Index code. Logistic regression was used to determine odds ratios for the likelihood of developing diabetic complications adjusted for each variable. RESULTS In the Type 1 cohort, 222 patients (20.6%) were hospitalized for diabetes complications and 1948 patients (17.3%) in the Type 2 cohort. In both cohorts, patients admitted with diabetes complications had significantly higher mean glycosylated haemoglobin (HbA1c) (p<0.001) and triglyceride levels (p<0.001), urine albumin:creatinine ratios (p<0.001) and duration of diabetes (p<0.01 Type 1: p<0.001 Type 2) than patients not admitted. In Type 2 patients, age, obesity, HbA1c, urine albumin:creatinine ratios, HDL levels and treatment with insulin or oral medication were all associated with increased odds of admission. CONCLUSIONS Although it is well known that HbA1c is a significant predictor of diabetes complications, this study shows that urine albumin:creatinine ratio, body mass index, triglycerides and high density lipoproteins are also independent predictors of hospitalization for diabetes complications. Attention to all these factors in the primary care setting is indicated if the burden of diabetes complications to hospital services is to be minimized.

Ethnic disparities in asthma treatment and outcomes in children aged under 15 years in New Zealand: analysis of national databases

Background: Mãori and Pacific children experience poorer outcomes relating to asthma management than other ethnicities. Aims: To measure recommended treatment and outcomes for asthma in all New Zealand children by age, sex, and ethnic group. Methods: Children aged <15 years dispensed ≥2 asthma medicines (N=80,514) were identified from the national pharmaceutical claims database. We measured the number of children dispensed oral steroids ≥2 times and hospital admissions with a primary diagnosis of asthma and compared asthma treatment steps and hospitalisation by age and ethnicity. Results: 16.0% of children were dispensed asthma medicines, 9.2% were dispensed medicine ≥2 times, 3.6% of children were hospitalised at least once for asthma and 98.9% of admissions were acute. Mãori (OR 1.46, 95% CI 1.41 to 1.51) and Pacific children (OR 2.38, 95% CI 2.28 to 2.47) were more likely to remain on the lowest step of treatment. At all steps of treatment, Mãori and Pacific children had higher rates of oral steroid use. In all age groups, more Mãori children (5.1%, OR 1.88, 95% CI 1.73 to 2.04) and Pacific children (5.6%, OR 2.05, 95% CI 1.84 to 2.29) were hospitalised for asthma than children of other ethnicities (2.8%). Conclusions: Mãori and Pacific children are less likely to have their treatment escalated to a higher step than other children. They are also more likely to use oral steroids to control asthma exacerbations and be admitted to hospital for severe asthma episodes. New Zealand databases can be used to monitor these outcomes.

Better use of primary care laboratory services following interventions to ‘market’ clinical guidelines in New Zealand: a controlled before-and-after study

Context Laboratory tests for inflammatory response, thyroid function and infectious diarrhoea were not being ordered as recommended by clinical guidelines. Objective To measure changes in community laboratory-test ordering following marketing programmes promoting guidelines recommendations. Design Controlled before-and-after study involving 2 years of national laboratory payment data before and after each intervention. Comparisons were with doctors ordering the same tests but not receiving interventions. Setting New Zealand primary care. Participants 3161, 3140 and 3335 general practitioners and 2424, 2443 and 2766 Comparison doctors ordering inflammatory response, thyroid function and acute diarrhoea tests from community laboratories, July 2003 to March 2009. Interventions Three separate marketing programmes to general practitioners, each comprising written material advising of guidelines recommendations, individual laboratory-test use feedback and professional development opportunities. Main outcome measures Number of tests, tests/doctor, patients having tests and tested patients/doctor/year before and after each intervention. Change in expenditure from before each intervention to after. Results For Intervention doctors, erythrocyte sedimentation rate tests decreased 60.0% after the intervention; tests for C-reactive protein increased 63.1%; simultaneous erythrocyte sedimentation rate and C-reactive protein orders decreased 32.6%. Tests for free thyroxine and free triiodothyronine decreased 44.1% and 36.0%. The proportion of thyroid function tests where thyroid-stimulating hormone was the sole test ordered increased from 43.2% before the intervention to 65.2% afterwards (p<0.001; 95% CI 21.7% to 22.2%). Testing for faecal culture decreased 31.5%, giardia and cryptosporidium 31.5%, and ova and parasites 56.9%. Faecal culture as the sole initial test increased from 31.4% to 39.1% (p<0.001; 95% CI 7.2% to 8.2%). Testing by Comparison doctors changed in the same direction but with significantly less magnitude. The estimated reduction in expenditure for study tests was 23.5%. Conclusions Clear information marketed to general practitioners improved the quality of laboratory test ordering for patients in New Zealand.

Atrial fibrillation in New Zealand primary care: Prevalence, risk factors for stroke and the management of thromboembolic risk

Background Atrial fibrillation is a major risk factor for stroke and heart disease but there is limited information on its prevalence in New Zealand primary care or the treatment provided to manage thromboembolic risk. Our aim was to estimate the prevalence of atrial fibrillation, assess patient risk for thromboembolism and evaluate the appropriateness of risk reduction using antiplatelet and oral anticoagulation therapy. Design A retrospective cohort study utilising electronic medical records for 739,000 patients registered with 170 general practices in 2014. Methods Patient diagnoses and prescriptions from 2010–2014 were analysed to identify patients with atrial fibrillation in 2014 and co-morbidities included in the CHA2DS2-VASc algorithm. Adjusted prevalence of atrial fibrillation by patient demographic group and the proportion of patients following recommended antithrombotic therapy were calculated. Results 12,712 patients were identified with AF (1.72%, 95% confidence interval 1.69%–1.75%). Prevalence was significantly higher for Maori (odds ratio 1.91, 95% confidence interval 1.80–2.03) than Europeans after adjusting for age, sex, deprivation and clinical risk factors. Stroke risk for Maori and Pacific Island patients was higher than for Europeans across all age groups. Of the 10,406 patients (81.9%) at high risk for thromboembolism, 60.5% were using anticoagulants, 24.1% aspirin monotherapy and 15.4% neither anticoagulants nor aspirin. Oral anticoagulants were used by 31.5% of patients at low risk (CHA2DS2-VASc <2). Conclusions Oral anticoagulants are under-utilised in the management of thromboembolic risk in high risk patients with atrial fibrillation. Better promotion of guideline recommendations for the treatment of patients with atrial fibrillation may be required to improve clinician and patient decision-making.

Methods for Retrospective Detection of Drug Safety Signals and Adverse Events in Electronic General Practice Records

AbstractBackground: Examination of clinical data routinely recorded in general practice provides significant opportunities for identifying and quantifying medicine-related adverse events not captured by spontaneous adverse reaction reporting systems. Robust pharmacovigilance methods for detecting and monitoring adverse events due to treatment with new and existing medicines are required to estimate the true extent of adverse events experienced by primary care patients. Objectives: The aim of the study was to examine evidence of adverse events contained in general practice electronic records and to study observed events related to selective serotonin reuptake inhibitors (SSRIs) as an example of drug-specific pharmaceutical surveillance achievable with these data. Methods: Electronic clinical records for a cohort of 338 931 patients consulting from 2002 to 2007 were extracted from the patient management systems of 30 primary care clinics in New Zealand. Medical warnings files, prescription records and free text consultation notes were used to identify physician-recorded treatment cautions, including adverse events and medicines they were associated with. A structured chronological analysis of prescriptions, consultation notes and adverse events relating to patients prescribed the SSRI citalopram was undertaken, and included investigating reasons for switching treatment to another SSRI (fluoxetine or paroxetine) as a method for detecting evidence of drug safety signals. We compared the number of adverse events identified for patients at one practice with the number spontaneously reported to New Zealand’s Centre for Adverse Reactions Monitoring (CARM). Results: During the 6-year study period, 173 478 patients received 4811 561 prescriptions. There were 37 397 allergies, adverse events and other warnings recorded for 24994 patients (7.4%); adverse events relating to 65 different types of drug were reported. Medicines most frequently implicated in adverse event reports were antibacterials, analgesics, antihypertensive medicines, lipid-modifying agents and skin preparations. Citalopram was prescribed for 5612 patients, and 701 adverse events relating to citalopram were identified in the electronic health records of 473 (8.4%) patients. A total of 713 (12.7%) patients changed treatment from citalopram to another SSRI, and 164 reasons for the switch were identified: suspected adverse drug effects for 129 (78.7%), lack of effect for 29 (17.7%) and patient preference for 6 (3.7%). The most common adverse events preceding the switch were anxiety, nausea and headaches. Of the 725 adverse events and medical warnings recorded at one practice, 21 (2.9%) were spontaneously reported to the CARM. Conclusions: Routinely recorded general practice data provide a wealth of opportunities for monitoring drug safety signals and for other patient safety issues. Medical warning records and consultation notes contain a wealth of information on adverse events but structured search methodologies are often required to identify these.

Patient outcomes from 10 years of annual diabetes reviews in New Zealand

AIMS To examine trends in patient health outcomes 2001-2010 for patients receiving free annual diabetes reviews in New Zealand. METHODS Clinical, demographic and hospital admissions data were analysed for 2175 Type 1 and 25,436 Type 2 diabetes mellitus patients presenting at 170 general practices. Changes in clinical measures and proportions of patients achieving guideline targets and receiving recommended processes of care were assessed by calendar year and for patients returning for successive annual diabetes reviews. We also examined trends in hospital admission rates for diabetes complications over the ten years. RESULTS The proportion of patients achieving guideline levels for blood pressure and cholesterol increased significantly and there were decreases in smoking rates and mean BMI for patients reviewed five times. The proportion of patients meeting guideline levels for HbA1c increased by year but decreased in patients returning for five reviews. There was also a reduction in the proportion of patients with poor glycaemic control (HbA1c>9.0% (75 mmol/mol)). The proportion of Type 2 patients using oral hypoglycaemic agents or insulin and receiving a retinal exam in the last two years increased significantly, and over 90% of patients received foot checks. Hospital admission rates for ischaemic heart disease, peripheral circulatory disorders, and ketoacidosis all decreased over the period 2001-2010 but inpatient admissions for eye, neurological and renal problems specific to diabetes increased. CONCLUSIONS There have been many improvements in health outcomes for these diabetes patients participating in the New Zealand governments programme to provide free annual health checks, despite the increasing age and diabetes duration of the patient cohorts.

Trends in Outpatient Prescription Medicine Use in New Zealand Children 2010–2015: A National Population-Based Study

BackgroundResearch examining trends in the outpatient prescription medicine use of New Zealand children is limited.ObjectivesOur objective was to provide an overview of prescription medicine use in New Zealand children and assess changing patterns in use from 2010 to 2015.MethodsWe conducted a retrospective cohort study including all New Zealand primary care-registered children aged < 18 years using data from the national pharmaceutical claims database. We calculated the prevalence of use within four age groups in each year by anatomical therapeutic class, therapeutic group and drug. Rate ratios were calculated to compare the prevalence of use in 2010 and 2015.ResultsIn total, 1,496,026 children with a mean of 2.7 years of potential drug exposure were included. The overall prevalence of drug use was 70% in 2010 and 73% in 2015. In 2015, medicine use was highest in children aged < 2 years (90%) and lowest in children aged 12–17 years (65%). Antibacterials, analgesics, topical corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs) and antihistamines were the most widely used medicines. The prevalence of use of systemic and topical antibiotics decreased by 2 and 10%, respectively, between 2010 and 2015, but there was increased use of analgesics (10%), NSAIDs (39%), antihistamines (15%) and antinausea and vertigo agents (306%).ConclusionsOur findings indicate areas for further research focusing on inappropriate prescribing to children and safety issues in children’s medicine use. Monitoring changing patterns of use over time is important for the evaluation of effective therapies in children and any potential harmful consequences of prescribing.

Understanding medicines with a propensity to increase the risk of heart failure: Combining existing knowledge with targeted population assessment

Existing knowledge of medicines that increase the risk of an adverse event may be corroborated and augmented by population studies specifically assessing the risk associated with the concurrent use of these medicines and use by patients with existing comorbidity. An American Heart Association review recently identified a variety of medicines that may cause or exacerbate heart failure (HF), many with evidence from limited evaluation of population data. We assessed the risk of first‐time HF associated with the use of 50 of these medicines by New Zealands primary care population.

The Prevalence and Risk Factors for Chronic Kidney Disease in Primary Health Care in the Southern Region of New Zealand: Chronic Kidney Disease in Southern New Zealand

While the prevalence of end stage kidney disease in New Zealand (NZ) is well defined, the prevalence of chronic kidney disease (CKD) in NZ is unknown. To estimate the prevalence of and risk factors for CKD in the southern region of New Zealand.