Toni Ashton

Azithromycin for prevention of exacerbations in non-cystic fibrosis bronchiectasis (EMBRACE): a randomised, double-blind, placebo-controlled trial

BACKGROUND Azithromycin is a macrolide antibiotic with anti-inflammatory and immunomodulatory properties. We tested the hypothesis that azithromycin would decrease the frequency of exacerbations, increase lung function, and improve health-related quality of life in patients with non-cystic fibrosis bronchiectasis. METHODS We undertook a randomised, double-blind, placebo-controlled trial at three centres in New Zealand. Between Feb 12, 2008, and Oct 15, 2009, we enrolled patients who were 18 years or older, had had at least one pulmonary exacerbation requiring antibiotic treatment in the past year, and had a diagnosis of bronchiectasis defined by high-resolution CT scan. We randomly assigned patients to receive 500 mg azithromycin or placebo three times a week for 6 months in a 1:1 ratio, with a permuted block size of six and sequential assignment stratified by centre. Participants, research assistants, and investigators were masked to treatment allocation. The coprimary endpoints were rate of event-based exacerbations in the 6-month treatment period, change in forced expiratory volume in 1 s (FEV(1)) before bronchodilation, and change in total score on St Georges respiratory questionnaire (SGRQ). Analyses were by intention to treat. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12607000641493. FINDINGS 71 patients were in the azithromycin group and 70 in the placebo group. The rate of event-based exacerbations was 0·59 per patient in the azithromycin group and 1·57 per patient in the placebo group in the 6-month treatment period (rate ratio 0·38, 95% CI 0·26-0·54; p<0·0001). Prebronchodilator FEV(1) did not change from baseline in the azithromycin group and decreased by 0·04 L in the placebo group, but the difference was not significant (0·04 L, 95% CI -0·03 to 0·12; p=0·251). Additionally, change in SGRQ total score did not differ between the azithromycin (-5·17 units) and placebo groups (-1·92 units; difference -3·25, 95% CI -7·21 to 0·72; p=0·108). INTERPRETATION Azithromycin is a new option for prevention of exacerbations in patients with non-cystic fibrosis bronchiectasis with a history of at least one exacerbation in the past year. FUNDING Health Research Council of New Zealand and Auckland District Health Board Charitable Trust.

Health care costs of obesity in New Zealand

OBJECTIVE: To estimate the costs of health care that are attributable to obesity in New Zealand. METHODS: The 1991 health care costs of non-insulin dependent diabetes, coronary heart disease, hypertension, gallstone disease, post-menopausal breast cancer and colon cancer were estimated and multiplied by the population attributable factor for obesity for each condition. The relative risk estimates were taken from the literature, the obesity prevalence from a 1990 New Zealand survey, and the costs and volumes of services were taken from a variety of sources and covered hospital (inpatient and outpatient) services, general practitioner consultations, pharmaceuticals, laboratory tests and ambulance services. Calculations were conservative and net of goods and services tax. RESULTS: A conservative estimate of the health care costs attributable to obesity for the six conditions was NZ

Contracting for health services in New Zealand: A transaction cost analysis

135 million. This represents about 2.5% of total health care costs which is similar to analyses from other countries. CONCLUSIONS: The health care costs of obesity as estimated are considerable. However, the total cost of overfatness to the New Zealand population is far greater than this because lesser degrees of overfatness, the health care costs of other obesity-related conditions such as arthritis, the costs to individuals of weight-loss programs and the indirect and intangible costs were not included in the analysis. A substantial and wide-ranging public health effort is needed to turn around the increasing prevalence and costs of obesity.

Drugs, sex, money and power: an HPV vaccine case study.

The splitting of the functions of purchaser and provider in the New Zealand health system in 1993 necessitated the use of explicit contracts between the two parties. This paper examines contracting experiences during the first two years of operation. The study focuses on four services: rest homes, primary care clinics, surgical services, and acute mental health services. The insights of transaction cost economics form the theoretical framework. The objective of this study was to examine whether the transaction costs associated with contracting vary across the four different services, and whether different types of contracts and contractual relationships are emerging as transactors attempt to reduce these costs. Information was collected in a series of 53 interviews with purchasers and providers, together with any relevant documentation. The results suggest that the costs of contracting are indeed greater for some services than for others. Other variables such as the style of negotiations, the type and specificity of contracts and the degree of monitoring also differ across the four services. At this early stage of the reform process, there was little evidence that purchasers and providers were attempting to reduce transaction costs by negotiating more flexible, longer-term, relational contracts. The main benefit from contracting to date has been improved accountability of service providers.

Health care and lost productivity costs of overweight and obesity in New Zealand

In this paper we compare the experiences of seven industrialized countries in considering approval and introduction of the worlds first cervical cancer-preventing vaccine. Based on case studies, articles from public agencies, professional journals and newspapers we analyse the public debate about the vaccine, examine positions of stakeholder groups and their influence on the course and outcome of this policy process. The analysis shows that the countries considered here approved the vaccine and established related immunization programs exceptionally quickly even though there still exist many uncertainties as to the vaccines long-term effectiveness, cost-effectiveness and safety. Some countries even bypassed established decision-making processes. The voice of special interest groups has been prominent in all countries, drawing on societal values and fears of the public. Even though positions differed among countries, all seven decided to publicly fund the vaccine, illustrating a widespread convergence of interests. It is important that decision-makers adhere to transparent and robust guidelines in making funding decisions in the future to avoid capture by vested interests and potentially negative effects on access and equity.

The organization and financing of dialysis and kidney transplantation services in New Zealand

Objective: To estimate the costs of health care and lost productivity attributable to overweight and obesity in New Zealand (NZ) in 2006.

Healthy Steps Trial: Pedometer-Based Advice and Physical Activity for Low-Active Older Adults

In New Zealand, patients receive treatment for end-stage renal disease (ESRD) within the tax-funded health system. All hospital and specialist outpatient services are free, while general practitioner consultations and pharmaceuticals prescribed outside of hospitals incur copayments. Total ESRD prevalence is 0.07%, half the U.S. rate, and the prevalence of home-based and self-care dialysis is the highest in the world. Medical staff are not subject to direct financial incentives that could affect treatment choice. Estimated total expenditure per ESRD patient is relatively low. Funding constraints encourage physicians and patients to consider the probable benefit of dialysis for a patient before treatment is prescribed.

Recent developments in the funding and organisation of the New Zealand health system

PURPOSE We compared the effectiveness of 2 physical activity prescriptions delivered in primary care—the standard time-based Green Prescription and a pedometer step-based Green Prescription—on physical activity, body mass index (BMI), blood pressure, and quality of life in low-active older adults. METHODS We undertook a randomized controlled trial involving 330 low-active older adults (aged =65 years) recruited through their primary care physicians’ patient databases. Participants were randomized to either the pedometer step-based Green Prescription group (n = 165) or the standard Green Prescription group (n = 165). Both groups had a visit with the primary care practitioner and 3 telephone counseling sessions over 12 weeks aimed at increasing physical activity. Outcomes were the changes in physical activity (assessed with the Auckland Heart Study Physical Activity Questionnaire), blood pressure, BMI, quality of life (assessed with the 36-Item Short Form Health Survey), physical function status (assessed with the Short Physical Performance Battery), and falls over a 12-month period. RESULTS Of the patients invited to participate, 57% responded. At 12 months, leisure walking increased by 49.6 min/wk for the pedometer Green Prescription compared with 28.1 min/wk for the standard Green Prescription (P=.03). For both groups, there were significant increases across all physical activity domains at 3 months (end of intervention) that were largely maintained after 12 months of follow-up. BMI did not change in either group. Significant improvements in blood pressure were observed for both groups without any differences between them. CONCLUSIONS Pedometer use resulted in a greater increase in leisure walking without any impact on overall activity level. All participants increased physical activity, and on average, their blood pressure decreased over 12 months, although the clinical relevance is unknown.

Nurse turnover in New Zealand: costs and relationships with staffing practises and patient outcomes

During the 1990s, the New Zealand health sector went through a decade of turbulence with a series of major structural changes being introduced in a relatively short period of time. The new millennium brought further change, with the establishment of 21 district health boards and the restoration of a less commercially-oriented system. The sector now appears to be more stable. However many incremental changes are in train and there has been considerable turbulence below the surface as key players jostle for position. This paper reports on some of the recent changes that have occurred in the restructuring of the New Zealand health system. Three issues are discussed: the devolution of funds and decision-making to district health boards, developments in primary health care, and the position of the private health insurance industry.

The effectiveness, acceptability and costs of a hospital-at-home service compared with acute hospital care: a randomized controlled trial

AIMS To determine the rates and costs of nurse turnover, the relationships with staffing practises, and the impacts on outcomes for nurses and patients. BACKGROUND In the context of nursing shortages, information on the rates and costs of nursing turnover can improve nursing staff management and quality of care. METHODS Quantitative and qualitative data were collected prospectively for 12 months. A re-analysis of these data used descriptive statistics and correlational analysis techniques. RESULTS The cost per registered nurse turnover represents half an average salary. The highest costs were related to temporary cover, followed by productivity loss. Both are associated with adverse patient events. Flexible management of nursing resources (staffing below budgeted levels and reliance on temporary cover), and a reliance on new graduates and international recruitment to replace nurses who left, contributed to turnover and costs. CONCLUSIONS Nurse turnover is embedded in staffing levels and practises, with costs attributable to both. A culture of turnover was found that is inconsistent with nursing as a knowledge workforce. IMPLICATIONS FOR NURSING MANAGEMENT Nurse managers did not challenge flexible staffing practices and high turnover rates. Information on turnover and costs is needed to develop strategies that retain nurses as knowledge-based workers.