The New Zealand Medical Journal is out tomorrow

New Zealand Medical Journal vol 131, no 1475, 18 May 2018

Editorial

How simple mistakes and short-term bias elevate cardiovascular risk
Ralph AH Stewart

Articles

Symptoms of bowel dysfunction and their management after spinal cord injury in a New Zealand centre
​​​​​​​Edwin P Arnold, Giovanni Losco, Sharon English, Frank Frizelle, Angelo Anthony

Summary

This study looked at two groups of patients that were admitted to the Burwood Spinal Unit over a 20-year period. Burwood is one of only two spinal units in New Zealand, draining a population of over two million. We were particularly interested to understand how bowel function is affected in these men and women. The findings showed that there are no good predictors of bowel outcome but most people do suffer significant long-term bother from bowel issues after a spinal injury.

Key Points

• Bowel function does not correlate well with level of injury
• There is no relationship between bowel sensation, continence or management
• Bowel function does not correlate well with bladder function and dysfunction
• Long-term follow-up of bowel function in spinal injury patients is important

Inappropriate prescribing of antibiotics following discharge after major surgery: an area for improvement
Mary De Almeida, Catherine Gerrard, Joshua T Freeman, Eamon Duffy, Sally A Roberts

Summary

This study examined the indications for antibiotic use in 378 patients discharged from Auckland City Hospital after major surgery. Overall, one-third of antibiotic use was inappropriate and in another 13%, the indication for antibiotic use was not assessable. This study demonstrates that a significant proportion of antibiotics prescribed in patients discharged following surgery are inappropriate and there is a need for enhanced antimicrobial stewardship in this area. 

Key points

• On average, 34% of patients discharged following major surgery at New Zealand public hospitals in 2013 were dispensed an antibiotic within 30 days of discharge.  This contrasts with the average 2.6% of patients being recorded as having an infection after major surgery.   
• • In this retrospective study of adult patients discharged following major surgery at Auckland City Hospital, clear evidence to support antibiotic use was only present for half of the patients. 
• • One-third of antibiotics prescribed were inappropriate,  and in another 13% the indication was not assessable.
• • This study demonstrates that a significant proportion of antibiotics prescribed in patients discharged following surgery are inappropriate and there is a need for enhanced antimicrobial stewardship in this area.

Is general practice identification of prior cardiovascular disease at the time of CVD risk assessment accurate and does it matter?
Sue Wells, Katrina K Poppe, Vanessa Selak, Andrew Kerr, Romana Pylypchuk, Billy Wu, Wing Cheuk Chan, Corina Grey, Suneela Mehta, Dudley GR Gentles, Rod Jackson

​​​​​​​Summary

It is important for patient care to identify a patient’s full clinical history so that they may be offered the most appropriate treatment known to improve health outcomes. For people with a history of prior cardiovascular disease (CVD) such as heart attack, stroke or narrowing of major blood vessels, triple therapy (a combination of blood pressure-lowering, lipid-lowering and antiplatelet/anticoagulant medications) could reduce the risk of recurrent events by at least 50% over five years. Information may get lost in multiple ways from hospital to general practice to the patient visit. We found that lack of accurate recording at the time of a first CVD risk assessment did impact on patients’ receiving evidence-based medications and was worse for people aged less than 55 years, women and those of non-European ethnicities. This study highlights the need for ‘whole of system’ clinical information to be available via robust data sharing, automation of coding and clinical reminders to better support patients and general practices at the time of clinical decision making and address inequities in health outcomes.

Key Points

• 1.About 10% of people aged 35-74 years have a history of prior cardiovascular disease (CVD) such as heart attack, stroke or narrowing of major arteries. For these people, triple therapy is recommended. This is a combination of blood pressure-lowering, lipid-lowering and antiplatelet/anticoagulant medications. If taken together, these medications could reduce the risk of recurrent events by at least 50% over five years.
• 2. We investigated whether a prior history of hospitalised CVD was accurately recorded at the time of a patient visit for their first CVD risk assessment in general practices and if this recording affected whether people would get dispensed triple therapy.
• 3.Of people with a prior CVD hospitalisation, 39%were NOT recorded as such at the time of their first CVD risk assessment in general practice.
• 4.If prior CVD was recorded in a decision support template at the time of risk assessment then dispensing of triple therapy was 69% compared to 43% if not recorded.
• People aged less than 55 years, women and those of non-European ethnicities were less likely to have accurate recording whereas smokers and people with diabetes were more likely to have their prior CVD hospitalisations accurately recorded.
• 5.The lack of correct classification of patient prior clinical history at the time of first risk assessment is likely due to information loss in multiple ways from hospital to general practice to the patient visit. This study highlights the need for ‘whole of system’ clinical information to be available via robust data sharing, automation of coding and clinical reminders to better support patients and general practices at the time of clinical decision making and address inequities in health outcomes.

Examples of where information might get lost, hospital discharge summaries may go to the wrong general practice or patients move GP or have no GP, the discharge summaries may not be saved in GP records, CVD events may not be coded or classified in the patients’ electronic health records, if classified, the codes may not be compatible with the risk assessment template and triple therapy on discharge may not be reconciled with patients’ long term medication lists. GPs and practice nurses may not double check when filling out a decision support template at a patient visit and patients may not realise that they need to continue these medications long term, particularly after coronary procedures (eg, stenting).

Excess cost and inpatient stay of treating deep spinal surgical site infections
James Barnacle, Dianne Wilson, Christopher Little, Christopher Hoffman, Nigel Raymond

Summary

This study identified inpatients treated for deep infections following spinal surgery at a regional tertiary spinal centre between 2009 and 2016. Excess hospital cost and length of stay (LOS) were calculated from the hospital costing systems, and compared with people who had the same spinal surgery without an infection. Twenty-eight patients were identified. The average excess cost per patient was NZ$51,434 (range $1,398–$262,206.16) and LOS 37.1 days. In patients whose original surgery required metal implants there was a greater average cost ($56,258.90) and LOS (40.4 days), than the cost ($11,228.61) and LOS (9.7 days) following operations not requiring implants.

Key Points

• Deep surgical site infections (SSIs) are uncommon but serious after spinal surgery, requiring very prolonged antibiotic treatment, usually one or more further operations, and commonly with considerable patient pain and delayed recovery.
• This study learned from all 28 affected people cared for at Wellington Hospital during 2009-2016. They had each been under the care of orthopaedic surgeons, with input from infectious diseases specialists.
• For affected patients, there was an average 37 days extra hospital length of inpatient stay and $51,434 extra inpatient cost (with a large range).
• When there had been metal implants required in the original spinal surgery to stabilize the spine, treating deep infection is more difficult. This was reflected in an even longer length of stay and greater cost.
• The significant impact for affected patients highlights the importance of further research and implementation of infection prevention measures.

The impact of different tumour subtypes on management and survival of New Zealand women with Stage I–III breast cancer
Ross Lawrenson, Chunhuan Lao, Ian Campbell, Vernon Harvey, Sanjeewa Seneviratne, Mark Elwood, Diana Sarfati, Marion Kuper-Hommel

Summary

There are 3,000 new cases of breast cancer diagnosed in New Zealand each year. Pathologists test the tumours for the presence of different hormonal markers. These markers are important in helping to guide treatment which is personalised to the woman’s cancer including her particular hormonal subtype. Sixty percent of women will have Luminal A subtype, which has a very good prognosis, but women with non-Luminal A cancer will generally have a poorer prognosis and be offered more aggressive treatment. This paper describes the characteristics of women with five different subtypes, shows what treatment is usually used and informs them of their likely prognosis.

Key points

• Breast cancer cases in New Zealand can be categorised into a number of different groups based on the presence of different biomarkers
• We have demonstrated differences in patient age, ethnicity and tumour grade and stage depending on the breast cancer subtype
• The treatment of women with localised breast cancer is personalised depending on the molecular phenotype
• There is major variation in the prognosis of women with localised  breast cancer depending on the breast cancer subtype.

Incidence, demographics and surgical outcomes of cutaneous squamous cell carcinoma diagnosed in Northland, New Zealand
Brodie M Elliott, Benjamin R Douglass, Daniel McConnell, Blair Johnson, Christopher Harmston

Summary

We examined all the cutaneous squamous cell carcinomas diagnosed in Northland in 2015.  This is a form of skin cancer which is more common and different to melanoma. Health funding has been based off studies almost 20 years old and it has been shown that the rates of non-melanoma skin cancer have been increasing since. Our study calculated that 668 per 100,000 Northlanders were treated for this disease in one year, which when accounted for age and ethnicity, extrapolates to 24,605 lesions in New Zealand per year.

Key points

• Cutaneous Squamous Cell Carcinoma is incredibly common yet isn’t included in the National Cancer Registry like other cancers.
• Healthcare funding is based off a study from 1998 and the incidence has increased since then.
• Over 1000 lesions were biopsied or surgically removed in Northland in 2015 alone.
• Adjusting for age and ethnicity this gives 580 lesions per 100,000 people a year.
• This extrapolates to 24,605 lesions in New Zealand a year.

Development of an otitis media strategy in the Pacific: key informant perspectives
Elizabeth A-L Holt, Judith McCool, Vili Nosa, Peter R Thorne

Summary

There are very few health services to prevent, detect, and treat childhood ear and hearing disorders in Pacific Island countries and territories, despite a high need. Key informants interviewed for this study expressed that while there is the potential to develop better services to address this need, the success of any strategy is dependent on a number of factors. Factors include improving data collection systems, focusing on the education and prevention of childhood ear disease, training a locally-mentored ear and hearing health workforce and nestling the strategy within the existing health and education infrastructure to maximise synergies across established health programmes. Long-term success of any strategy must be developed by local people for the benefit of local communities, and nestled within a culturally appropriate framework.

Key Points

• Otitis media, an inflammatory ear condition in childhood, is a common condition within the paediatric population in Pacific island countries and territories (PICTs).  Without timely and appropriate intervention, chronic otitis media can have serious long-term consequences, such as deficits in speech and language, brain development, social inclusion and employment.
• Factors such as resource constraints, dearth of accurate data on the impact of the condition, and relative ‘invisibility’ of hearing loss mean that very few services have been developed in PICTs to detect, prevent and treat ear and hearing disorders.
• Using Fiji as a case study, key informants interviewed for this paper expressed that there is potential for the development of better strategies to prevent and treat otitis media, and develop rehabilitation strategies, despite considerable challenges to resource availability. 
• Key factors for strategy success relies on a public health approach – embedding any strategy into the health, education and grass-roots sector, having a strong emphasis on prevention, education and detection of the condition and developing robust data collection systems to allow for assessing strategy effectiveness.
• Long-term sustainability of any strategy must be developed by local people, for the benefit of local communities, and nestled within a culturally- appropriate framework. Specialist support can provided by external sources in order to support the development and sustainability of a Pacific-based ear and hearing health workforce.

Achilles tenotomy as an office procedure and current practising trends among New Zealand orthopaedic surgeons
Lewis Agius, Angus Wickham, Joshua Knudsen, Cameron Walker

Summary

Achilles tenotomy as an outpatient procedure has been shown to be safe and effective. We believe it can be performed safely with results comparable to that performed in theatre. It avoids any potential risks associated with general anaesthesia and potential delays associated with theatre lists. Pain can be controlled adequately, and there is no increased risk of complications or re-tenotomy rate. Parental satisfaction to this procedure is excellent and there are significant financial savings.

Key Points

• Performing Achilles tenotomy is safe in a clinic setting
• Performing Achilles tenotomy is cost effective in a clinic setting
• The majority of surgeons perform Achilles tenotomy in a theatre setting

Clinical Correspondence

Pharyngoconjunctival fever,
Kate E Alfeld, Simon C Dalton