Dale Bramley

Do u smoke after txt? Results of a randomised trial of smoking cessation using mobile phone text messaging

Objectives: To determine the effectiveness of a mobile phone text messaging smoking cessation programme. Design: Randomised controlled trial Setting: New Zealand Participants: 1705 smokers from throughout New Zealand who wanted to quit, were aged over 15 years, and owned a mobile phone were randomised to an intervention group that received regular, personalised text messages providing smoking cessation advice, support, and distraction, or to a control group. All participants received a free month of text messaging; starting for the intervention group on their quit day to assist with quitting, and starting for the control group at six months to encourage follow up. Follow up data were available for 1624 (95%) at six weeks and 1265 (74%) at six months. Main outcome measures: The main trial outcome was current non-smoking (that is, not smoking in the past week) six weeks after randomisation. Secondary outcomes included current non-smoking at 12 and 26 weeks. Results: More participants had quit at six weeks in the intervention compared to the control group: 239 (28%) v 109 (13%), relative risk 2.20 (95% confidence interval 1.79 to 2.70), p < 0.0001. This treatment effect was consistent across subgroups defined by age, sex, income level, or geographic location (p homogeneity > 0.2). The relative risk estimates were similar in sensitivity analyses adjusting for missing data and salivary cotinine verification tests. Reported quit rates remained high at six months, but there was some uncertainty about between group differences because of incomplete follow up. Conclusions: This programme offers potential for a new way to help young smokers to quit, being affordable, personalised, age appropriate, and not location dependent. Future research should test these findings in different settings, and provide further assessment of long term quit rates.

Disparities in Indigenous Health: A Cross-Country Comparison Between New Zealand and the United States

OBJECTIVES We compared the health statuses of the indigenous populations of New Zealand and the United States with those of the numerically dominant populations of these countries. METHODS Health indicators compared included health outcome measures, preventive care measures, modifiable risk factor prevalence, and treatment measures. RESULTS In the case of nearly every health status indicator assessed, disparities (both absolute and relative) were more pronounced for Maoris than for American Indians/Alaska Natives. Both indigenous populations suffered from disparities across a range of health indicators. However, no disparities were observed for American Indians/Alaska Natives in regard to immunization coverage. CONCLUSIONS Ethnic health disparities appear to be more pronounced in New Zealand than in the United States. These disparities are not necessarily intractable. Although differences in national health sector responses exist, New Zealand may be well placed in the future to evaluate the effectiveness of new strategies to reduce these disparities given the extent and quality of Maori-specific health information available.

Integrated electronic decision support increases cardiovascular disease risk assessment four fold in routine primary care practice

Background A decade of cardiovascular disease (CVD) risk-based guidelines, education programmes and widespread availability of paper-based risk prediction charts have not significantly influenced targeting of CVD risk management in New Zealand primary care practice. A web-based decision support system (PREDICT-CVD), integrated with primary care electronic medical record software was developed as one strategy to address this problem. Methods A before-after audit of 3564 electronic patient records assessed the impact of electronic decision support on documentation of CVD risk and CVD risk factors. Participants were patients meeting national guideline criteria for CVD risk assessment, registered with 84/107 (78.5%) general practitioners (GPs) in one large primary care organization who used electronic patient medical records, and had PREDICT-CVD installed. The GPs received group education sessions, practice IT support and a small risk assessment payment. Four weeks of practice visit records were audited from 1 month after installation of PREDICT-CVD, and during the same 4-week period 12 months earlier. Results Less than 3% of eligible patients had a documented CVD risk before PREDICT-CVD installation. This increased four-fold (RR = 4.0; 95% confidence interval 2.4–6.5) after installation and documentation of all relevant CVD risk factors also increased significantly. Conclusion Documentation of CVD risk in primary care patient records in New Zealand is negligible, despite being recommended as a prerequisite for targeted treatment for over 10 years, suggesting that previous strategies were ineffective. We demonstrate that integrated electronic decision support can quadruple CVD risk assessment in just one cycle of patient visits.

Effect of fixed dose combination treatment on adherence and risk factor control among patients at high risk of cardiovascular disease: randomised controlled trial in primary care

Objective To evaluate whether provision of fixed dose combination treatment improves adherence and risk factor control compared with usual care of patients at high risk of cardiovascular disease in primary care. Design Open label randomised control trial: IMPACT (IMProving Adherence using Combination Therapy). Setting 54 general practices in the Auckland and Waikato regions of New Zealand, July 2010 to August 2013. Participants 513 adults (including 257 indigenous Māori) at high risk of cardiovascular disease (established cardiovascular disease or five year risk ≥15%) who were recommended for treatment with antiplatelet, statin, and two or more blood pressure lowering drugs. 497 (97%) completed 12 months’ follow-up. Interventions Participants were randomised to continued usual care or to fixed dose combination treatment (with two versions available: aspirin 75 mg, simvastatin 40 mg, and lisinopril 10 mg with either atenolol 50 mg or hydrochlorothiazide 12.5 mg). All drugs in both treatment arms were prescribed by their usual general practitioners and dispensed by local community pharmacists. Main outcome measures Primary outcomes were self reported adherence to recommended drugs (antiplatelet, statin, and two or more blood pressure lowering agents) and mean change in blood pressure and low density lipoprotein cholesterol at 12 months. Results Adherence to all four recommended drugs was greater among fixed dose combination than usual care participants at 12 months (81% v 46%; relative risk 1.75, 95% confidence interval 1.52 to 2.03, P<0.001; number needed to treat 2.9, 95% confidence interval 2.3 to 3.7). Adherence for each drug type at 12 months was high in both groups but especially in the fixed dose combination group: for antiplatelet treatment it was 93% fixed dose combination v 83% usual care (P<0.001), for statin 94% v 89% (P=0.06), for combination blood pressure lowering 89% v 59% (P<0.001), and for any blood pressure lowering 96% v 91% (P=0.02). Self reported adherence was highly concordant with dispensing data (dispensing of all four recommended drugs 79% fixed dose combination v 47% usual care, relative risk 1.67, 95% confidence interval 1.44 to 1.93, P<0.001). There was no statistically significant improvement in risk factor control between the fixed dose combination and usual care groups over 12 months: the difference in systolic blood pressure was −2.2 mm Hg (−4.5 v −2.3, 95% confidence interval −5.6 to 1.2, P=0.21), in diastolic blood pressure −1.2 mm Hg (−2.1 v −0.9, −3.2 to 0.8, P=0.22) and in low density lipoprotein cholesterol −0.05 mmol/L (−0.20 v −0.15, −0.17 to 0.08, P=0.46). The number of participants with cardiovascular events or serious adverse events was similar in both treatment groups (fixed dose combination 16 v usual care 18 (P=0.73), 99 v 93 (P=0.56), respectively). Fixed dose combination treatment was discontinued in 94 participants (37%). The most commonly reported reason for discontinuation was a side effect (54/75, 72%). Overall, 89% (227/256) of fixed dose combination participants’ general practitioners completed a post-trial survey, and the fixed dose combination strategy was rated as satisfactory or very satisfactory for starting treatment (206/227, 91%), blood pressure control (180/220, 82%), cholesterol control (170/218, 78%), tolerability (181/223, 81%), and prescribing according to local guidelines (185/219, 84%). When participants were asked at 12 months how easy they found taking their prescribed drugs, most responded very easy or easy (224/246, 91% fixed dose combination v 212/246, 86% usual care, P=0.09). At 12 months the change in other lipid fractions, difference in EuroQol-5D, and difference in barriers to adherence did not differ significantly between the treatment groups. Conclusions Among this well treated primary care population, fixed dose combination treatment improved adherence to the combination of all recommended drugs but improvements in clinical risk factors were small and did not reach statistical significance. Acceptability was high for both general practitioners and patients, although the discontinuation rate was high. Trial registration Australian New Zealand Clinical Trial Registry ACTRN12606000067572.

Derivation and Validation of a New Cardiovascular Risk Score for People With Type 2 Diabetes: The New Zealand Diabetes Cohort Study

OBJECTIVE To derive a 5-year cardiovascular disease (CVD) risk equation from usual-care data that is appropriate for people with type 2 diabetes from a wide range of ethnic groups, variable glycemic control, and high rates of albuminuria in New Zealand. RESEARCH DESIGN AND METHODS This prospective open-cohort study used primary-care data from 36,127 people with type 2 diabetes without previous CVD to derive a CVD equation using Cox proportional hazards regression models. Data from 12,626 people from a geographically different area were used for validation. Outcome measure was time to first fatal or nonfatal cardiovascular event, derived from national hospitalization and mortality records. Risk factors were age at diagnosis, diabetes duration, sex, systolic blood pressure, smoking status, total cholesterol–to–HDL ratio, ethnicity, glycated hemoglobin (A1C), and urine albumin-to-creatinine ratio. RESULTS Baseline median age was 59 years, 51% were women, 55% were of non-European ethnicity, and 33% had micro- or macroalbuminuria. Median follow-up was 3.9 years (141,169 person-years), including 10,030 individuals followed for at least 5 years. At total of 6,479 first cardiovascular events occurred during follow-up. The 5-year observed risk was 20.8% (95% CI 20.3–21.3). Risk increased with each 1% A1C (adjusted hazard ratio 1.06 [95% CI 1.05–1.08]), when macroalbuminuria was present (2.04 [1.89–2.21]), and in Indo-Asians (1.29 [1.14–1.46]) and Maori (1.23 [1.14–1.32]) compared with Europeans. The derived risk equations performed well on the validation cohort compared with other risk equations. CONCLUSIONS Renal function, ethnicity, and glycemic control contribute significantly to cardiovascular risk prediction. Population-appropriate risk equations can be derived from routinely collected data.

Cohort Profile: The PREDICT Cardiovascular Disease Cohort in New Zealand Primary Care (PREDICT-CVD 19)

Cohort Profile: The PREDICT Cardiovascular Disease Cohort in New Zealand Primary Care (PREDICT-CVD 19) Sue Wells,* Tania Riddell, Andrew Kerr, Romana Pylypchuk, Carol Chelimo, Roger Marshall, Daniel J. Exeter, Suneela Mehta, Jeff Harrison, Cam Kyle, Corina Grey, Patricia Metcalf, Jim Warren, Tim Kenealy, Paul L. Drury, Matire Harwood, Dale Bramley, Geeta Gala and Rod Jackson School of Population Health, University of Auckland, Auckland, New Zealand, Middlemore Hospital, Cardiology Department, Auckland, New Zealand, School of Pharmacy, University of Auckland, Auckland, New Zealand, Endocrinology Services, Auckland District Health Board, Auckland, New Zealand, Computer Sciences, University of Auckland, School of Medicine, University of Auckland, Auckland, New Zealand, Waitemata District Health Board, Auckland, New Zealand and Northern Regional Alliance, Auckland, New Zealand

An association between ethnicity and cardiovascular outcomes for people with Type 2 diabetes in New Zealand

Aims  To investigate the association between ethnicity and risk of first cardiovascular (CV) event for people with Type 2 diabetes in New Zealand.

Interpretation of two nutrition content claims: a New Zealand survey

Objective: To determine how various population groups in New Zealand interpret the nutrition content claims ‘97% fat free’ and ‘no added sugar’ on food labels.

Initiation and maintenance of cardiovascular medications following cardiovascular risk assessment in a large primary care cohort: PREDICT CVD-16.

Aim: To examine whether use of a standardized cardiovascular disease (CVD) risk assessment recommended by national guidelines is associated with appropriate initiation and maintenance of medication in a large primary care cohort. Methods and design: A total of 90,631 people aged 30−80 years were followed for up to 3 years after a formal CVD risk assessment was undertaken between January 2006 and October 2009, during routine primary care visits in New Zealand. Patients either had prior CVD or had their CVD risk estimated using a modified Framingham prediction equation for fatal or non-fatal CVD events. The individual risk profiles were anonymously linked to national dispensing data for blood-pressure-lowering and lipid-lowering medications in the 6-month period before and in consecutive 6-month blocks after the baseline CVD risk assessment. Results: At baseline, a combination of blood-pressure-lowering and lipid-lowering therapy was already being used by about two-thirds of patients with prior CVD, one-quarter with a 5-year CVD risk greater than 10% (approximately 20% 10-year risk), and one-tenth with CVD risk below this level. Among these previously treated patients, dispensing rates for blood-pressure-lowering, lipid-lowering, or both medications together declined by only 4⊟16% up to 3 years after baseline assessment, irrespective of risk category. Among patients untreated at baseline, combination therapy was initiated within 6 months for 21% with prior CVD, 16% with 5-year CVD risk greater than 15% (approximately 30% 10-year risk and the national drug-treatment threshold), 10% with 5-year CVD risk between 10 and 14% (approximately 20⊟29% 10-year risk), and 3% in the lowest risk category. Across the study population, patients with prior CVD had the highest dispensing rates for each category of medication, and incrementally higher dispensing rates were noted as CVD risk group increased. Conclusions: In this primary care cohort, most patients already using CVD medications at the time of the baseline CVD risk assessment maintained treatment over a maximum of 3 years follow up, irrespective of their estimated baseline risk. Among patients untreated at baseline, subsequent dispensing rates were strongly related to estimated CVD risk group. Around 15⊟20% of untreated patients meeting national drug-treatment criteria commenced combination pharmacotherapy within 6 months of CVD risk assessment.

Reducing ethnic disparities in the quality of trauma care: an important research gap.

OBJECTIVE To identify interventions for reducing ethnic disparities in the quality of trauma care. BACKGROUND Variation in the quality of health care is recognized as an important contributor to ethnic disparities in many domains of health. Although recent articles document ethnic variations in the quality of trauma care in several countries, strategies that address these disparities have received little attention. METHODS Systematic review of intervention studies designed to reduce ethnic disparities in trauma care. RESULTS Our systematic literature review revealed no evaluations of interventions designed to reduce ethnic disparities in trauma care. A scan of the equivalent literature in other health care settings revealed 3 types of strategies that could serve as promising interventions that warrant further investigation in the trauma care setting: (1) improving cultural competency of service providers, (2) addressing the effects of health literacy on the quality of trauma care, and (3) quality improvement strategies that recognize equity as a key dimension of quality. The trauma coordinator role may help address some aspects relating to these themes although reducing disparities is likely to require broader system-wide policies. CONCLUSIONS The implementation and robust evaluation of strategies designed to reduce ethnic disparities in trauma care are long overdue.