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In Aotearoa New Zealand (NZ), ethnic inequities in health outcomes exist. Non-Māori experience better access to healthcare than Māori, including access to the quality use of medicines. Quality medicines use requires that medicines provide maximal therapeutic benefit with minimal harm. As older adults are more at risk of harm from medicines, and, because inequities are compounded with age, Māori older adults may be at more risk of medicines-related harm than younger and non-Māori populations. This narrative review examined ethnic variation in the quality use of medicines, including medicines utilisation and associated clinical outcomes, between Māori and non-Māori older adult populations in NZ. The review was structured around prevalence of medicine utilisation by medicine class and in particular disease states; high-risk medicines; polypharmacy; prevalence of potentially inappropriate prescribing (PIP); and association between PIP and clinical outcomes. 22 studies were included in the review. There is ethnic variation in the access to medicines in NZ, with Māori older adults often having reduced access to particular medicine types, or in particular disease states, compared with non-Māori older adults. Māori older adults are less likely than non-Māori to be prescribed medicines inappropriately, as defined by standardised tools; however, PIP is more strongly associated with adverse outcomes for Māori than non-Māori. This review identifies that inequities in quality medicines use exist and provides a starting point to develop pro-equity solutions. The aetiology of inequities in the quality use of medicines is multifactorial and our approaches to addressing the inequitable ethnic variation also need to be.

Objectives: To develop and validate a frailty index (FI) from interRAI-Community Health Assessments (CHA) on older adults in retirement villages (RVs). Methods: This is a cross-sectional analysis of a current RV research study. A FI was generated using the cumulative deficit model. Health-care utilisation measures were acute, and all, hospitalisations 12 months before baseline assessment. Associations between FI and hospitalisations were explored using multivariable logistic regression to estimate odds ratio (OR). Results: Of 577 included residents, mean (SD) age was 81 (7) and 419 (73%) were female. Mean (SD) FI was 0.16 (0.09); 260 (45%) were mildly frail, and 108 (19%) moderate-severely frail. In multivariate-adjusted analysis, odds of acute hospitalisation for mild (OR = 3.3, P

Māori (Indigenous people of New Zealand [NZ]) experience inequitable health outcomes compared to non-Māori, across the spectrum of clinical care, including those relating to medicines. Internationally, pharmacist-facilitated medicines review services have been shown to benefit older adults. Despite national policies calling for the increased implementation of these services, NZ data relating to them remain limited, and these services may increase disparities between Māori and non-Māori. There are currently no medicines review services developed specifically for Māori older adults. The current study aims to elicit stakeholder views of current and potential pharmacist services to help inform the development of a pharmacist-facilitated medicines review service for community-dwelling Māori older adults. Kaupapa Māori theory was applied within this qualitative research. Purposive sampling was used to recruit participants who were involved in providing, planning, funding developing or culturally supporting health services in Waitematā District Health Board, Auckland, NZ. Data were collected in semi-structured interviews and in a focus group and analysed using reflexive thematic analysis. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative research. Eleven participants took part in the research in one focus group (n = 4) and seven semi-structured interviews, conducted between November 2018 and March 2019. Three main themes were generated: (a) moving out of the shadows – claiming pharmacists’ unique role within a healthcare whānau (family); (b) ‘give them the power to be able to ask’ – upholding the mana (self-esteem, pride, standing) and autonomy of kaumātua (Māori older adults) and (c) rights versus realities – reimagining pro-equity Māori health services within the constraints of the colonial health system. The right of Māori to experience equitable health outcomes needs to be included in policy and also operationalised in relation to medicines review services through improved utilisation of pharmacist skills and improving Māori older adults’ autonomy and control.

Background There is increasing interest among older people in moving into retirement villages (RVs), an attractive option for those seeking a supportive community as they age, while still maintaining independence. Currently in New Zealand there is limited knowledge of the medical, service supports, social status and needs of RV residents. The objective of this study is to explore RV facilities and services, the health and functional status of RV residents, prospectively study their healthcare trajectories and to implement a multidisciplinary team intervention to potentially decrease dependency and impact healthcare utilization. Methods All RVs located in two large district health boards in Auckland, New Zealand were eligible to participate. This three-year project comprised three phases: The survey phase provided a description of RVs, residents’ characteristics and health and functional status. RV managers completed a survey of size, facilities and recreational and healthcare services provided in the village. Residents were surveyed to establish reasons for entry to the village and underwent a Gerontology Nurse Specialist (GNS) assessment providing details of demographics, social engagement, health and functional status. The cohort study phase examines residents’ healthcare trajectories and adverse outcomes, over three years. The final phase is a randomised controlled trial of a multidisciplinary team intervention aimed to improve health outcomes for more vulnerable residents. Residents who triggered potential unmet health needs during the assessment in the survey phase were randomised to intervention or usual care groups. Multidisciplinary team meetings included the resident and support person, a geriatrician or gerontology nurse practitioner, GNS, pharmacist and General Practitioner. The primary outcome of the randomised controlled trial will be first acute hospitalization. Secondary outcomes include all acute hospitalizations, long-term care admissions, and all-cause mortality. Discussion This paper describes the study protocol of this complex study. The study aims to inform policies and practices around health care services for residents in retirement villages. The results of this trial are expected early 2020 with publication subsequently. Trial registration Australia and New Zealand Clinical Trials Registry: ACTRN12616000685415. Registered 25.5.2016. Universal Trial Number (UTN): U111–1173-6083.

OBJECTIVE To describe survival and six-month outcomes (residence, community supports) in the very old (≥80 years) admitted to intensive care in Waitemata District Health Board, New Zealand. METHODS Hospital records of patients 80 years and over admitted from August 2015 to June 2017 were reviewed. RESULTS One hundred and seventeen patients were admitted (median age: 83). Standard ICU risk scores predicted survival to hospital discharge. Patients admitted electively were more likely to survive to discharge than emergency ICU/HDU admissions (P = .007). Ninety-two (79%) survived to hospital discharge, and 84 (72%) survived to 6 months. Eighty-four were discharged home (91% of survivors), and 79 were living at home at 6 months (94% of survivors). Community supports increased from admission (34, 29%) to 6 months later (34, 43% of community dwellers). Forty-four (47.8% surviving to discharge) were readmitted within 6 months. CONCLUSIONS Most patients are alive at discharge and 6 months, with a majority requiring no formal supports.

BACKGROUND Retirement villages (RVs), also known as continuing care retirement communities, are an increasingly popular housing choice for older adults. The RV population has significant health needs, possibly representing a group with needs in between community-dwelling older adults and those in long-term residential care (LTC). Our previous work shows Gerontology Nurse Specialist (GNS)-facilitated multidisciplinary team (MDT) interventions may reduce hospitalizations from LTC. This study tested whether a similar intervention reduced hospitalizations in RV residents. METHODS Open-label randomized controlled trial in which 412 older residents of 33 RVs were randomized (1:1) to an MDT intervention or usual care. SETTING RVs across two District Health Boards in Auckland, New Zealand. Residents were eligible if considered high risk of health/functional decline (triggering ≥3 interRAI Clinical Assessment Protocols or needing special consideration identified by GNS). INTERVENTION GNS-facilitated MDT intervention, including geriatrician/nurse practitioner and clinical pharmacist, versus usual care. Primary outcome was time from randomization to first acute hospitalization. Secondary outcomes were rate of acute hospitalizations, LTC admission, and mortality. Twelve residents died before randomization; all others (n = 400: MDT intervention = 199; usual care = 201) were included in intention-to-treat analyses. RESULTS Mean (SD) age was 82.2 (6.9) years, 302 (75.5%) were women, and 378 (94.5%) were European. Over median 1.5 years follow-up, no difference was found in hazard of acute hospitalization between the MDT intervention (51.8%) and usual care (49.3%) groups (Hazard ratio [HR] = 1.01, 95% CI = 0.77-1.34). No difference was found in the incidence rate of acute hospitalizations between the MDT intervention (0.69 per person-year) and usual care (0.86 per person-year) groups (incidence rate ratio = 0.81, 95% CI = 0.59-1.10). Similar results were seen for the proportion of residents with LTC transition (HR = 1.18, 95% CI = 0.65-2.11) and mortality (HR = 0.70, 95% CI = 0.36-1.35). CONCLUSION Further studies are needed to assess the effects of other patient-centered interventions and outcomes with adequate primary care integration.

Background Pharmacist involvement in medicines reviews for older adults can improve prescribing and reduce adverse drug reactions. Māori experience poorer health outcomes than non-Māori resulting, in part, from inequitable access to and quality of medicine-related care. Despite international data showing benefit, it is unclear whether pharmacist-led medicines review services can improve outcomes for Māori older adults. Objective This systematic review aims to describe pharmacist-led medicines review services for community-dwelling adults in New Zealand, assess effectiveness of these interventions and identify their effect on health equity for Māori and older adults. Methods The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses – Equity (PRISMA-E 2012). Observational studies were included. The intervention in included studies had to involve a pharmacist, occur in the outpatient setting in New Zealand, and involve review of all medicines for an individual patient. At least one patient-related outcome had to be reported. Results The search identified seven observational studies with 542 total participants. Study interventions included adherence-based reviews in community pharmacies and multi-step comprehensive clinical reviews in outpatient haemodialysis units. Medicines reviews identified up to a median of 3 drug-related problems per review. The effect of interventions on medicines adherence and knowledge was not clear. Māori may have been less likely than non-Māori to benefit from improved medicines knowledge as a result of interventions. None of the studies incorporated aspects in study design or delivery to address inequities for Māori. Conclusion Further investigation is needed to understand whether the development of culturally safe pharmacist-led medicines review services, responsive to community identified needs, can help to achieve equity in health outcomes for Māori older adults.

Older age has long been linked to risk of diverticulitis, but the epidemiology is seldom described for a national population. The aim of this study was to investigate age- and gender differences in incidence, temporal trends, lifetime risk and prevalence related to acute diverticulitis hospitalisations in New Zealand. Records of all hospitalisations with diverticulitis the primary diagnosis were obtained from the Ministry of Health for the period 2000–2015. The first acute diverticulitis admission recorded for an individual was taken as an incident event; all others were classified as recurrent. Trends in age- and sex-specific and age-standardised incidence rates are described, and lifetime risk and prevalence estimated. Over the 16 years from 2000 to 2015, 37,234 acute hospitalisations for diverticulitis were recorded in 28,329 people aged 30 + years (median = 66 years). Rates of incident hospitalisations rose with age, from 5/10,000 person-years at age 50–54 years to 19/10,000py by age 80–84 years. Rates for women were lower than men before age 55 years, but higher thereafter. Age-standardised rates rose 0.2/10,000py annually, but approximately doubled among men aged

This study aimed to describe the diet quality of pre-frail community-dwelling older adults to extend the evidence of nutrition in frailty prevention. Pre-frailty, the transition state between a robust state and frailty, was ascertained using the FRAIL scale. Socio-demographic, health status, and 24-h dietary recalls were collected from 465 community-dwelling adults aged 75+ (60 years for Māori and Pacific people) across New Zealand. Diet quality was ascertained with the Diet Quality Index-International (DQI-I). Participants (median (IQR) age 80 (77–84), 59% female) had a moderately healthful diet, DQI-I score: 60.3 (54.0–64.7). Women scored slightly higher than men (p = 0.042). DQI-I components identified better dietary variety in men (p = 0.044), and dietary moderation in women (p = 0.002), both sexes performed equally well in dietary adequacy and poorly in dietary balance scores (73% and 47% of maximum scores, respectively). Low energy 20.3 (15.4–25.3) kcal/kg body weight (BW) and protein intakes 0.8 (0.6–1.0) g/kg BW were coupled with a high prevalence of mineral inadequacies: calcium (86%), magnesium (68%), selenium (79%), and zinc (men 82%). In conclusion, the diet quality of pre-frail older adults was moderately high in variety and adequacy but poor in moderation and balance. Our findings support targeted dietary interventions to ameliorate frailty.

INTRODUCTION: te Tiriti o Waitangi guarantees Māori the right to: self-determination, equitable health outcomes, be well informed, health care options, including kaupapa Māori and culturally safe mainstream services, and partnership in the health care journey. Despite integration of these principles into policy, there remains a lack of application in health service development, and health inequities remain. AIM: We aimed to use te Tiriti o Waitangi to structure the development of a culturally safe health intervention, using as an exemplar pharmacist-facilitated medicines review for Māori older adults. METHODS: Previous research undertaken by our group (a systematic review, and interviews with stakeholders including Māori older adults) was used to inform the aspects to include in the intervention. Kaupapa Māori theory was used to underpin the approach. Intended outcomes, requirements for change, and outcome measures to assess change were mapped to te Tiriti o Waitangi principles as a way to structure the pharmacist-facilitated medicines review intervention and research processes. RESULTS: Findings from our previous research identified 12 intended intervention outcomes, including that the intervention be flexible to adapt to diverse needs in a way that is acceptable and culturally safe for Māori and that it supports Māori older adults to control and have confidence in their medicine treatment and wellbeing. DISCUSSION: We present an approach to the development of a pharmacist-facilitated medicines review intervention for Māori older adults, structured around the principles of te Tiriti o Waitangi, to support the implementation of a culturally safe, pro-equity intervention.

Background Pharmacist-facilitated medicines review services have been postulated as a way to address current inequities in health outcomes between Māori and non-Māori. These interventions have been shown internationally to improve the appropriate use of medicines but remain underutilised in Aotearoa New Zealand (NZ). By reviewing the literature and engaging with key stakeholders, we developed an intervention, which included collaborative goal-setting, education and medicines optimisation, for testing in a feasibility study. Objective To determine the feasibility (recruitment, intervention delivery, and data collection methods) of a pharmacist-facilitated medicines review intervention for Māori older adults, and proposed intervention outcomes. Methods This study was reported in accordance with the CONSORT 2010 statement: extension to randomised controlled pilot and feasibility trials and the Consolidated criteria for strengthening reporting of health research involving indigenous peoples: the CONSIDER statement. Participant eligibility criteria were: Māori; aged 55-plus; community-dwelling; enrolled in a general practice in Waitematā District Health Board (Auckland, NZ). Consented participants engaged in a medicines education component (participant and pharmacist) and an optional medicines optimisation component (participant, pharmacist and prescriber). Outcomes measures included: the feasibility of data collection tools and methods, time taken to conduct the intervention and research processes; medicines knowledge, medicines appropriateness and quality of life (QoL); pharmacist recommendations and prescriber acceptance rate. Results Seventeen consented participants took part in the intervention from December 2019–March 2020 with the majority (n = 12) recruited through general practice mail-outs. Data collection was feasible using the predetermined outcome measure tools and was complete for all patient participants. Pharmacist intervention delivery was feasible. A mean of 9.5 recommendations were made per participant with a prescriber acceptance rate of 95%. These included non-medicine-related recommendations. Conclusion The feasibility testing of pharmacist-facilitated medicines review intervention developed for (and with) community-dwelling Māori older adults allows for intervention refinement and can be utilised for further studies relating to pharmacist services in primary care.

ObjectivesRetirement villages (RV) have expanded rapidly, now housing perhaps one in eight people aged 75+ years in New Zealand. Health service initiatives might better support residents and offer cost advantages, but little is known of resident demographics, health status or needs. This study describes village residents—their demographics, socio-behavioural and health status—noting differences between participants who volunteered and those who were sampled.DesignCross-sectional study of village residents. The cohort formed will also be used for a longitudinal study and a randomised controlled trial. Village managers (sometimes after consulting residents) decided if representative sampling could be undertaken in each village. Where sampling was not approved, volunteers were sought.Setting33 RV were included from a total of 65 villages in Auckland, New Zealand.ParticipantsResidents (n=578) were recruited either by sampling (n=217) or as volunteers (n=361) during 2016–2018. Each completed a survey and an International Resident Assessment Instrument (interRAI) health needs assessment with a gerontology nurse specialist.ResultsMedian age of residents was 82 years, 158 (27%) were men; 61% lived alone. Downsizing (77%), less stress (63%) and access to healthcare assistance (61%) were most common reasons for entry. During the 2 weeks prior to survey, 34% received home supports and 10% personal care. Hypertension, heart disease, arthritis and pain were reported by over 40%. Most common unmet needs related to managing cardiorespiratory symptoms (50%) and pain (48%). Volunteers and sampled residents differed significantly, mainly in socio-behavioural respects.ConclusionsCommon conditions including hypertension, arthritis and atrial fibrillation, are recorded in interRAI as text, and thus overlooked in interRAI reports. Levels of unmet need indicate opportunities to improve health services to better manage chronic conditions. Healthcare service providers and village operators could cooperate to design and test service initiatives that better meet residents’ needs and offer cost benefits.Trial registration numberACTRN12616000685415.

Background Frailty is a multidimensional geriatric syndrome associated with functional loss. The Senior Chef (SC, nutrition) and SAYGO (strength and balance exercise) programmes are well accepted among older adults but the impact of each, or a combination of both, on the frailty syndrome in pre-frail older adults is unknown. Aims To determine the effectiveness and cost-effectiveness of a complex intervention consisting of the SC and/or SAYGO programmes to prevent progression of frailty in pre-frail older adults. Methods A multi-centre randomised controlled assessor-blinded study. The four intervention groups are SC, an 8-week nutrition education and cooking class; SAYGO, a 10-week strength and balance exercise class; SC plus SAYGO, and a social group (Control). Community-dwelling adults aged 75+ (60 + Māori and Pasifika) in New Zealand are recruited through health providers. Participants are not terminally ill or with advanced dementia, and have a score of 1 or 2 on the FRAIL questionnaire. Baseline assessments are completed using standardised questionnaires prior to randomisation. Four follow-up assessments are completed: immediately after intervention, 6, 12 and 24 months post-intervention. The primary outcome is frailty score, secondary outcomes are falls, physical function, quality of life, food intake, physical activity, and sustainability of the strategy. Study outcomes will be analysed using intention-to-treat approach. Cost analyses will be completed to determine if interventions are cost effective relative to the control group. Discussion This trial is designed to be a real world rigorous assessment of whether the two intervention strategies can prevent progression of frailty in older people. If successful, this will generate valuable information about effectiveness of this nutrition and exercise strategy, and provide insights for their implementation. Trial registration Australian and New Zealand Clinical Trials Registry number—ACTRN12614000827639.

Objectives:The number of older people choosing to relocate to retirement villages (RVs) is increasing rapidly. This choice is often a way to decrease social isolation while still living independently. Loneliness is a significant health issue and contributes to overall frailty, yet RV resident loneliness is poorly understood. Our aim is to describe the prevalence of loneliness and associated factors in a New Zealand RV population.Design:A resident survey was used to collect demographics, social engagement, loneliness, and function, as well as a comprehensive geriatric assessment (international Resident Assessment Instrument [interRAI]) as part of the “Older People in Retirement Villages Study.”Setting:RVs, Auckland, New Zealand.Participants:Participants included RV residents living in 33 RVs (n = 578).Measurements:Two types of recruitment: randomly sampled cohort (n = 217) and volunteer sample (n = 361). Independently associated factors for loneliness were determined through multiple logistic regression with odds ratios (ORs).Results:Of the participants, 420 (72.7%) were female, 353 (61.1%) lived alone, with the mean age of 81.3 years. InterRAI assessment loneliness (yes/no question) was 25.8% (n = 149), and the resident survey found that 37.4% (n = 216) feel lonely sometimes/often/always. Factors independently associated with interRAI loneliness included being widowed (adjusted OR 8.27; 95% confidence interval [CI] 4.15–16.48), being divorced/separated/never married (OR 4.76; 95% CI 2.15–10.54), poor/fair quality of life (OR 3.37; 95% CI 1.43–7.94), moving to an RV to gain more social connections (OR 1.55; 95% CI 0.99–2.43), and depression risk (medium risk: OR 2.58, 95% CI 1.53–4.35; high risk: OR 4.20, 95% CI 1.47–11.95).Conclusion:A considerable proportion of older people living in RVs reported feelings of loneliness, particularly those who were without partners, at risk of depression and decreased quality of life and those who had moved into RVs to increase social connections. Early identification of factors for loneliness in RV residents could support interventions to improve quality of life and positively impact RV resident health and well-being.

Driving anxiety is a heterogeneous experience that can impact on everyday activities. Little is known about whether older adults experience driving anxiety and, if so, what impact it has on their health, functioning, and quality of life. This is particularly important given the ageing population and driving patterns of older drivers. The present study examines the extent of self-reported driving anxiety in older adult drivers.Population survey of community-dwelling older drivers.New Zealand.1170 adults aged 65 and over.Self-reported ratings of driving anxiety.62.3% of participants reported no driving anxiety, 27.0% reported mild driving anxiety and 10.7% endorsed more moderate to extreme levels of driving anxiety, which is higher than has been identified with adults aged 55-72. Women were significantly more often (p .01) represented in the groups of mildly and moderately anxious drivers, and those who were moderately to extremely anxious were more likely to be aged 70+ (p .04). Those with moderate to severe driving anxiety tended to drive less often, for shorter distances, and to use alternative modes of transport more often than those with mild or no driving anxiety.Driving anxiety is experienced by many older adults, with quite a large proportion reporting high levels of driving anxiety and associated differences in driving patterns. Further research is needed to better understand why older drivers experience driving anxiety, and how it impacts health and wellbeing as well as driving self-regulation and cessation.

Background multi-morbidity is associated with poor outcomes and increased healthcare utilisation. We aim to identify multi-morbidity patterns and associations with potentially inappropriate prescribing (PIP), subsequent hospitalisation and mortality in octogenarians. Methods life and Living in Advanced Age; a Cohort Study in New Zealand (LiLACS NZ) examined health outcomes of 421 Māori (indigenous to New Zealand), aged 80-90 and 516 non-Māori, aged 85 years in 2010. Presence of 14 chronic conditions was ascertained from self-report, general practice and hospitalisation records and physical assessments. Agglomerative hierarchical cluster analysis identified clusters of participants with co-existing conditions. Multivariate regression models examined the associations between clusters and PIP, 48-month hospitalisations and mortality. Results six clusters were identified for Māori and non-Māori, respectively. The associations between clusters and outcomes differed between Māori and non-Māori. In Māori, those in the complex multi-morbidity cluster had the highest prevalence of inappropriately prescribed medications and in cluster 'diabetes' (20% of sample) had higher risk of hospitalisation and mortality at 48-month follow-up. In non-Māori, those in the 'depression-arthritis' (17% of the sample) cluster had both highest prevalence of inappropriate medications and risk of hospitalisation and mortality. Conclusions in octogenarians, hospitalisation and mortality are better predicted by profiles of clusters of conditions rather than the presence or absence of a specific condition. Further research is required to determine if the cluster approach can be used to target patients to optimise resource allocation and improve outcomes.

Introduction Along with ageing populations, highly-motorised countries have increasing numbers of ageing older drivers. In many of these jurisdictions, health practitioners are responsible for undertaking the screening of older drivers, via medical assessment of fitness to drive (FtD), to ascertain suitability to continue to hold a driver's licence. In New Zealand, all older drivers are required to have a medical FtD assessment at ages 75 years, 80 years and then biennially. This study aims to understand the experience of the assessment practice from the perspective of general practitioners (GPs) responsible for conducting medical FtD assessments. Methods Interpretive description qualitative methodology was used to guide the research. Design and data analysis. GPs were purposively sampled and interviewed until saturation of themes was reached (N = 10, 40% rural practitioners). Results The results indicate that GPs use the FtD assessment as a way of staging a clinical conversation about mobility and driving cessation. But the assessment process challenges a patient-centric approach and can impact GPs’ relationships with patients. GPs reported differences in use of tools, such as driving restrictions, to support patients near the end of their driving careers. Access issues were a substantive barrier to the use of specialist driving assessments. Conclusions GPs carrying out medical FtD assessment in the clinical setting is not evidence-based, but continues to be used in some jurisdictions, including NZ. The assessment process is problematic because it is not patient-centred and can give rise to breakdowns in clinical relationships. This study also demonstrates a lack of training and support for GPs working with patients toward the end of their driving careers. A knowledge and information gap exists among GPs, limiting their capacity to provide best practice FtD assessments and mobility counselling for older adults.

Background Pharmacists have a role to play in supporting the optimal use of medicines to ensure older adults receive therapeutic benefit whilst minimising medicines-related harm. In Aotearoa New Zealand (NZ), Māori (Indigenous people of NZ) experience inequities in the determinants of health, including access to medicines, resulting in increased morbidity, earlier onset of chronic conditions and reduced life expectancy. This study aims to test the feasibility of a pharmacist-led medicines review intervention in community-dwelling Māori older adults. Method This is a non-randomised, non-controlled feasibility study undertaken within a kaupapa Māori methodological framework which supports the right of Māori to be included throughout the research process and seeks to potentiate transformational, positive change for Māori. The research pharmacist will recruit 30 participants (Māori; 55 years or older; community-dwelling). Participants will undergo a medicines education session with the pharmacist (medicines reconciliation, medicines information, well-being goal setting), with the option to proceed to a medicines optimisation session that includes the participant, pharmacist and primary prescriber (review of potentially inappropriate prescribing (PIP); medicines management plan development). Primary outcomes: participant and prescriber acceptability of intervention. Secondary outcomes include baseline and post-intervention medicines knowledge, PIP and quality of life scores, and number of changes made to the medicines regimen. Ethics and dissemination Ethical approval was granted by the Northern B Health and Disability Committee (9/NTB/106). Study results will be disseminated to various stakeholders including Māori communities, health practitioners and providers, and researchers through meetings and conference presentations, lay summaries and peer-reviewed journals. This study is an example of health service design, delivery and evaluation, informed by Indigenous knowledge and methodology, developed explicitly to address inequities in health outcomes for, and with, Māori and will inform the decision to proceed to a randomised controlled trial to test the effect of this intervention. Trial registration number ACTRN12619001070123.

Background Prescribing for older people is complex, and many studies have highlighted that appropriate prescribing in this cohort is not always achieved. However, the long-term effect of inappropriate prescribing on outcomes such as hospitalisation and mortality has not been demonstrated. The aim of this study was to determine the level of potentially inappropriate prescribing (PIP) for participants of the Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ) study at baseline and examine the association between PIP and hospitalisation and mortality at 12-months follow-up. Methods PIP was determined using STOPP/START. STOPP identified potentially inappropriate medicines (PIMs) prescribed, START identified potential prescribing omissions (PPOs). STOPP/START were applied to all LiLACS NZ study participants, a longitudinal study of ageing, which includes 421 Māori aged 80–90 years and 516 non-Māori aged 85 years. Participants’ details (e.g. age, sex, living arrangements, socioeconomic status, physical functioning, medical conditions) were gathered by trained interviewers. Some participants completed a core questionnaire only, which did not include medications details. Medical conditions were established from a combination of self-report, review of hospital discharge and general practitioner records. Binary logistic regression, controlled for multiple potential confounders, was conducted to determine if either PIMs or PPOs were associated with hospital admissions and mortality (p Results Full data were obtained for 267 Māori and 404 non-Māori. The mean age for Māori was 82.3(±2.6) years, and 84.6(±0.53) years for non-Māori. 247 potentially inappropriate medicines were identified, affecting 24.3% Māori and 28.0% non-Māori. PIMs were not associated with 12-month mortality or hospitalisation for either cohort (p > 0.05; adjusted models). 590 potential prescribing omissions were identified, affecting 58.1% Māori and 49.0% non-Māori. PPOs were associated with hospitalisation (p = 0.001 for Māori), but were not associated with risk of mortality (p > 0.05) for either cohort within the 12-month follow-up (adjusted models). Conclusion PPOs were more common than PIMs and were associated with an increased risk of hospitalisation for Māori. This study highlights the importance of carefully considering all indicated medicines when deciding what to prescribe. Further follow-up is necessary to determine the long-term effects of PIP on mortality and hospitalisation.

Background Long-term residential care (LTC) supports the most vulnerable and is increasingly relevant with demographic ageing. This study aims to describe entry to LTC and identify predictive factors for older Māori (indigenous people of New Zealand) and non-Māori. Methods LiLACS-NZ cohort project recruited Māori and non-Māori octogenarians resident in a defined geographical area in 2010. This study used multivariable log-binomial regressions to assess factors associated with subsequent entry to LTC including: self-identified ethnicity, demographic characteristics, self-rated health, depressive symptoms and activities of daily living [ADL] as recorded at baseline. LTC entry was identified from: place of residence at LiLACS-NZ interviews, LTC subsidy, needs assessment conducted in LTC, hospital discharge to LTC, and place of death. Results Of 937 surveyed at baseline (421 Māori, 516 non-Māori), 77 already in LTC were excluded, leaving 860 participants (mean age 82.6 +/− 2.71 years Māori, 84.6 +/− 0.52 years non-Māori). Over a mean follow-up of 4.9 years, 278 (41% of non-Māori, 22% of Māori) entered LTC; of the 582 who did not, 323 (55%) were still living and may yet enter LTC. In a model including both Māori and non-Māori, independent risks factors for LTC entry were: living alone (RR = 1.52, 95%CI:1.15–2.02), self-rated health poor/fair compared to very good/excellent (RR = 1.40, 95%CI:1.12–1.77), depressive symptoms (RR = 1.28, 95%CI:1.05–1.56) and more dependent ADLs (RR = 1.09, 95%CI:1.05–1.13). For non-Māori compared to Māori the RR was 1.77 (95%CI:1.39–2.23). In a Māori-only model, predictive factors were older age and living alone. For non-Māori, factors were dependence in more ADLs and poor/fair self-rated health. Conclusions Non-Māori participants (predominantly European) entered LTC at almost twice the rate of Māori. Factors differed between Māori and non-Māori. Potentially, the needs, preferences, expectations and/or values may differ correspondingly. Research with different cultural/ethnic groups is required to determine how these differences should inform service development.

AIM Hospitalizations are frequent among acutely ill older people, and might be reduced by post-discharge secondary care (PDSC). We aimed to determine the proportion of older patients planned to receive or attending PDSC after acute hospitalization and the association with undesirable outcomes. METHODS A retrospective observational study was carried out using an electronic health record system in two hospitals in New Zealand. Patients were aged ≥75 years, initially presented at an emergency department (ED) and were discharged from medical, surgical, geriatrics or orthopedics wards in three 2-week periods. Planned PDSC at discharge, attended PDSC, ED presentation, long-term care (LTC) admission and death in 90 days after discharge were obtained through the health record system. Proportional hazards regression assessed the associations of planned or attended PDSC with undesirable outcomes (ED presentation, LTC admission and death) within 90 days of discharge. RESULTS Clinical records for 1085 patients were extracted, 963 were eligible. Of these, 413 (42.9%) had planned PDSC in discharge summaries, and 573 (59.5%) actually attended in 90 days. Patients planned for PDSC had a similarly adjusted hazard of ED presentation (HR 0.99, P = 0.92), LTC admission (HR 0.73, P = 0.25) and death (HR 0.80, P = 0.34) within 90 days of discharge, compared with those not planned. Similar non-significant associations were observed between attended PDSC and undesirable outcomes. CONCLUSIONS In patients aged ≥75 years in New Zealand, we did not find "planned PDSC" at discharge or "attended PDSC" after an acute hospitalization to be associated with ED presentation, LTC admission and death within 90 days after discharge. Other potential benefits of planned or attended PDSC require further investigation. Geriatr Gerontol Int 2019; 19: 1048-1053.

Introduction long-term care (LTC) residents have higher hospitalisation rates than non-LTC residents. Rapid decline may follow hospitalisations, hence the importance of preventing unnecessary hospitalisations. Literature describes diagnosis-specific interventions (for cardiac failure, ischaemic heart disease, chronic obstructive pulmonary disease, stroke, pneumonia-termed 'big five' diagnoses), impacting on hospitalisations of older community-dwellers, but few RCTs show reductions in acute admissions from LTC. Methods LTC facilities with higher than expected hospitalisations were recruited for a cluster-randomised controlled trial (RCT) of facility-based complex, non-disease-specific, 9-month intervention comprising gerontology nurse specialist (GNS)-led staff education, facility benchmarking, GNS resident review and multidisciplinary discussion of residents selected using standard criteria. In this post hoc exploratory analysis, the outcome was acute hospitalisations for 'big five' diagnoses. Re-randomisation analyses were used for end points during months 1-14. For end points during months 4-14, proportional hazards models are adjusted for within-facility clustering. Results we recruited 36 facilities with 1,998 residents (1,408 female; mean age 82.9 years); 1,924 were alive at 3 months. The intervention did not impact overall rates of acute hospitalisations or mortality (previously published), but resulted in fewer 'big five' admissions (RR = 0.73, 95% CI = 0.54-0.99; P = 0.043) with no significant difference in the rate of other acute admissions. When considering events occurring after 3 months (only), the intervention group were 34.7% (HR = 0.65; 95% CI = 0.49-0.88; P = 0.005) less likely to have a 'big five' acute admission than controls, with no differences in likelihood of acute admissions for other diagnoses (P = 0.96). Conclusions this generic intervention may reduce admissions for common conditions which the literature shows are impacted by disease-specific admission reduction strategies.

IntroductionA recent WHO multi-country study on maternal and newborn health concluded that there was no evidence of an association between high coverage with essential interventions and reduced mortality in health care facilities, or improvement in other outcomes.1 According to Horton the missing ingredient in this relation is quality of care.2 Quality improvement in healthcare has adopted techniques mainly from industries such as manufacturing and has been used widely in Europe and US. However, evidence of success of these techniques in healthcare is not very conclusive, especially in low and middle-income countries. There have been limited efforts to critically analyse the techniques used in quality improvement interventions. One of the main challenges in evaluating quality improvement is the complexity of the interventions themselves and the complex nature of the systems in which they are implemented. Robust evidence regarding quality improvement interventions for resource poor settings is generally lacking.The MaiKhanda trial looked at the effect of QI interventions and community women's groups on maternal and newborn mortality in 3 central districts in Malawi.3 The impact evaluation measuring effect on newborn mortality for the QI interventions, using a cluster RCT approach, remained inconclusive. We use a Theory-Based Evaluation (TBE) approach to understand why improvement interventions undertaken by MaiKhanda for new-born care did not show an effect. Absence of effect could be attributed to a failure of theory, a failure of implementation, an evaluation failure or a combination of these.Our primary objective was to understand the mechanisms by which the QI interventions worked (or not) and explore the interaction between the various factors that mediated the lack of effect on neonatal mortality that was observed in the cluster randomized control trial.MethodsOur research strategy consisted of developing a post-hoc Theory of Change, consolidating and synthesizing all the available evidence using an appropriate framework, and analysing the program and implementation theory using theory based approaches to evaluation.Data synthesis was conducted using the Consolidate Framework for Implementation Research (CFIR).4 The synthesis takes into consideration the various reports and documents accumulated through the life of the project and complements the process evaluation studies conducted during the same period. In doing so, it draws a picture of the intervention with a multi-dimensional perspective, which provides insights into the evolution of the project. The framework is very comprehensive covering 5 major domains and a range of constructs, not all of which were included in our study. As this was post-hoc analysis, the choice of constructs was based on the availability of data rather than prioritizing the key constructs to consider.CFIR helps to produce structured and comprehensive data that is then used for analysing the program theory in relation to the intervention outcome. The program theory thus generated for the MaiKhanda intervention is compared with the program theories of the Michigan Keystone Project, which used similar collaborative methods to successfully reduce their central venous line blood stream infections in 106 participating ICUs.5 The rationale for such a comparison is that while the interventions per se are very unique and specific to their context, the program theories underlying the use of collaborative methods in both the interventions is the same and therefore comparable. Theories offer a higher level of abstraction that can be comparable across different settings.6 ResultsThe key finding from analysis of the program theory is that similar intervention strategies that triggered successful mechanisms for improvement in the Keystone Project failed to generate such mechanisms in MaiKhanda project.The Model for Improvement used in MaiKhanda was built around Deming's improvement theory7 and Roger's diffusion of innovation theory.8 The former theory considers improvement as a product of subject matter knowledge and profound knowledge. Subject matter knowledge on essential and emergency newborn care was generally lacking among health care providers in Malawi. Similarly, understanding variations within the health systems is an acquired skill. While the implementing partners, provided ample opportunities for the Malawian health system to learn the Institute for Healthcare Improvement (IHI) model for improvement, in general, QI teams lacked capacity to collate data and analyse the variations between the health facilities. QI was a fairly new concept in Malawi and MaiKhanda's attempts to embed it within existing health system was limited by challenges of the health systems context, MaiKhanda's own organizational transition and QI and clinical capacity of health care providers.The main challenge for MaiKhanda was to simultaneously implement and sustain the various change packages it had introduced in the different facilities. While there were isolated instances of successful intervention activities within MaiKhanda, it did not build enough momentum to generate mechanisms across a critical mass of the facilities that would eventually result in improved newborn outcomes. This can be attributed to the implementation strength, context and complexity of MaiKhanda's interventions. This is explored further using the implementation theory.Implementation was based on diffusion theories where better performing facilities were to act as role models for other facilities to emulate. The cRCT design for measuring impact evaluation required a random allocation of the improvement facilities and this conflicted with innovation diffusion theories, which prescribed a gradual organic spread of the interventions by strategically engaging the innovators and early adapters.Limitations of the evaluation design notwithstanding, the implementation strength characterized by the dose, duration, intensity and specificity of the intervention was sub-optimal.Implementation strength is not the only factor triggering an intervention mechanism and cannot be measured independent of the intervention complexity or the intervention context. For example, MaiKhanda struggled to show an effect of its interventions, despite having a long pre-intervention period to refine its interventions, while the Michigan study produced results within 18 month period. This could be because of other factors related to intervention complexity such as the long implementation chain for intervention delivery, the subjective perception of the agency (QI teams) regarding QI and contextual factors such as organizational readiness, the health systems context, QI team capacity to deliver QI interventions and MaiKhanda's own internal capacity.Human agency is at the heart of implementation and the intervention required a continuous and prolonged time and effort, than was anticipated, to engage and train the health facility QI teams on the improvement model.One of the key factors affecting the uptake of strategies was MaiKhanda's positioning within the health system and the degree of influence it could exert on other actors. This factor has a significant role to play in country where projects are donor supported and perhaps also donor driven. The period of the intervention also saw MaiKhanda going through a period of rapid organizational transition, which affected intervention implementation on the ground. Furthermore, MaiKhanda's own understanding of QI concepts was evolving gradually and this coupled with its long implementation chain, influenced the subjective understanding of the QI teams regarding QI concepts. Health facility staff also lacked the necessary skills and knowledge related to management of newborn health.Limited resources within the health facilities meant that gains achieved in some aspects of the intervention could not be sustained in the long run. External contextual factors such as fuel shortages contributed to poor implementation. Changes in policy such as government ban on TBAs, affected intervention uptake and resulted in an increase in health facility deliveries, overwhelming the already under-resourced staff capacity in the health facilities. It is conceivable that quality improvement was not on top of their priority list. But, ‘motivation’ to be involved in QI Collaboratives remained high. In resource constrained settings, ‘motivation’ can be influenced by the lure of personal incentives (such as per diems for attending workshops and meetings) as much as individual's commitment to broader social gains (ie reduction in newborn case fatality rates in their facility). The improvement model was competing against other existing models and it was difficult to get enough stakeholder commitment to the prescribed model as there were huge expectations fuelled by the poverty and poor governance structures and a culture of “perdiemitis” was prevalent in Malawian health care system.9 DiscussionAs is evident from the study, a single research method will not be able to provide justice to evaluation of a complex set of factors that influence newborn outcomes. We propose a research strategy that includes developing a Theory of Change, followed by evaluation of the program theory, measuring implementation strength, analysing implementation theory and comparing this in relation to the outcomes of the intervention observed through the impact evaluation. The results arising from such a comprehensive evaluation will contribute to the growth of improvement science with the accumulation of knowledge and explanation rather than being just a bedrock of observational facts.More generally, we propose that design, implementation and evaluation of QI activities, particularly in resource-poor settings, should consider five key principles i.e it should include whole systems thinking, accountability, participatory approach, should be evidence-based and adapt innovative methods.10

Purpose: An underlying connective tissue disorder (CTD) may predispose to formation of intestinal diverticula. We assess the association of diverticulosis with nine selected CTDs, to inform the pathophysiology of diverticula. Methods: A population-based period-prevalence study. Individuals (3.5 million New Zealand residents born 1901–1986) with a health system record 1999–2016 were grouped into those with a hospital diagnosis of diverticulosis or diverticulitis (ICD-10-AM K57), and those without. Also recorded were any hospital diagnoses of nine selected CTDs. The association of exposure to diverticulosis and each CTD was assessed using logistic regressions adjusted for age, gender, ethnicity and region. Results: In all, 85,958 (2.4%) people had a hospital diagnosis of diverticulosis. Hospitalisation with diverticulosis was highly significantly associated with rectal prolapse (adjusted odds ratio [OR] = 3.9), polycystic kidney disease (OR = 3.8), heritable syndromes (Marfan or Ehlers-Danlos) (OR = 2.4), female genital prolapse (OR = 2.3), non-aortic aneurysm (OR = 2.3), aortic aneurysm (OR = 2.2), inguinal hernia (OR = 1.9) and dislocations of shoulder and other joints (OR = 1.7), but not subarachnoid haemorrhage (OR = 1.0). Conclusion: People with diverticulosis are more likely to have colonic extracellular matrix (ECM)/connective tissue alterations in anatomical areas other than the bowel, suggesting linked ECM/connective tissue pathology. Although biases may exist, the results indicate large-scale integrated studies are needed to investigate underlying genetic pathophysiology of colonic diverticula, together with fundamental biological studies to investigate cellular phenotypes and ECM changes.

Introduction The complexity of care required by many older people living in long-term care (LTC) facilities poses challenges that can lead to potentially avoidable referrals to a hospital emergency department (ED). The Aged Residential Care Intervention Project (ARCHIP) ran an implementation study to evaluate a multidisciplinary team (MDT) intervention supporting LTC facility staff to decrease potentially avoidable ED presentations by residents. Methods ARCHIP (conducted in 21 facilities [1,296 beds] with previously noted high ED referral rates) comprised clinical coaching for LTC facility staff by a gerontology nurse specialist (GNS) and an MDT (facility senior nurse, resident’s general practitioner, GNS, geriatrician, pharmacist) review of selected high-risk residents’ care-plans. A before-after repeated measures analysis was conducted for 9 months before and 9 months after intervention commencement (a 29-month period because of staggered facility enrolment). Modelling was adjusted for time trend, seasonality, facility size, and cluster effect. Results ED admission rate ratio post- versus pre-intervention was 0.75 (95% C.I. 0.63, 0.89, p-value = 0.0008), a 25% reduction in ED presentations post-intervention. A sensitivity model used a shorter, staggered time period centred on intervention start (9 months pre-intervention and 9 months post-intervention) for each facility, and a four-level categorical intervention variable testing intervention effect over time. The sensitivity test showed a 24% reduction in ED presentations in months 1–3 post-intervention (p-value = 0.07), a 34% reduction in months 4–6 (p-value = 0.01), and a 32% reduction in ED presentations in months 7–9 (p-value = 0.03). However, when the higher ED referral rates for 3 months immediately pre-intervention were modelled, the impact of the intervention on ED presentation rates reverted almost to previous levels. Key Conclusions A GNS-led MDT outreach intervention, targeted at selected conditions, decreases avoidable ED admissions of high-risk residents from selected facilities.

Health monitoring systems have rapidly evolved during the past two decades and have the potential to change the way healthcare is currently delivered. Currently hospital falls are a major healthcare concern worldwide because of the ageing population. Current observational data and vital signs give the critical information related to the patient's physiology, and motion data provide an additional tool in falls risk assessment. These data combined with the patient's medical history potentially may give the interpretation model high information accessibility to predict falls risk. This study aims to develop a robust falls risk assessment system, in order to avoid falls and its related long-term disabilities in hospitals especially among older adults. The proposed system employs real-time vital signs, motion data, falls history and other clinical information. The falls risk assessment model has been tested and evaluated with 30 patients. The results of the proposed system have been compared with and evaluated against the hospital's falls scoring scale.

Aim To compare the prevalence in residential aged care (RAC) of preventative and potentially inappropriate medications (PIMs) in those who died within 12 months versus those alive after 12 months. Methods Firstly, a cross-sectional survey of 6196 people living in RAC in Auckland. Secondly, a research physician searched electronic hospital records in one District Health Board for a sub-sample (n = 222) of these residents. Classes of medications and dates of death were obtained from the Ministry of Health databases. Those who died versus those alive at 12 months were compared. Results Over half of the 6196 participants received antihypertensives and/or antiplatelet agents. Cardiovascular preventative medications were significantly more common in those who died within 12 months. Seventy percent in high-level care received psychotropics. PIMs were commonly used. Conclusions Use of preventative medications is common in RAC, especially during the last year of life. Psychotropics are very commonly used, despite being potentially inappropriate.

Health monitoring systems have rapidly evolved during the past two decades and have the potential to change the way healthcare is currently delivered. Smart monitoring systems automate patient monitoring tasks and thereby improve patient workflow management. Moreover, expert systems have the potential to assist clinicians and improve their performance by accurately executing repetitive tasks, to which humans are ill-suited. Clinicians working in hospital wards are responsible for conducting a multitude of tasks which require constant vigilance, and thus the need for a smart decision support system has arisen. In particular, wireless patient monitoring systems are emerging as a low cost, reliable and accurate means of healthcare delivery. Vital signs monitoring systems are rapidly becoming part of today's healthcare delivery. The paradigm has shifted from traditional and manual recording to computer-based electronic records and, further, to handheld devices as versatile and innovative healthcare monitoring systems. The current study focuses on interpreting multiple physical signs and early warning for hospitalized older adults so that severe consequences can be minimized. Data from a total of 30 patients have been collated in New Zealand hospitals under local and national ethics approvals. The system records blood pressure, heart rate (pulse), oxygen saturation (SpO2), ear temperature and blood glucose levels from hospitalized patients and transfers this information to a web-based software application for remote monitoring and further interpretation. Ultimately, this system is aimed to achieve a high level of agreement with clinicians' interpretation when assessing specific physical signs such as bradycardia, tachycardia, hypertension, hypotension, hypoxaemia, fever and hypothermia to generate early warnings. The performance of the vital signs interpretation system was validated through off-line as well as real-time tests with a high level of agreement between the system and physician.

Objective: To investigate factors related to hospital admission for infection, specifically examining nutrient intakes of Māori in advanced age (80+ years). Method: Face-to-face interviews with 200 Māori (85 men) to obtain demographic, social and health information. Diagnoses were validated against medical records. Detailed nutritional assessment using the 24-hour multiple-pass recall method was collected on two separate days. FOODfiles was used to analyse nutrient intake. National Health Index (NHI) numbers were matched to hospitalisations over a two-year period (12 months prior and 12 months following dietary assessment). Selected International Classification of Disease (ICD) codes were used to identify admissions related to infection. Results: A total of 18% of participants were hospitalised due to infection, most commonly lower respiratory tract infection. Controlling for age, gender, NZ deprivation index, diabetes, CVD and chronic lung disease, a lower energy-adjusted protein intake was independently associated with hospitalisation due to infection: OR (95%CI) 1.14 (1.00–1.29), p=0.046. Conclusions: Protein intake may have a protective effect on the nutrition-related morbidity of older Māori. Improving dietary protein intake is a simple strategy for dietary modification aiming to decrease the risk of infections that lead to hospitalisation and other morbidities.

Objectives: In New Zealand (NZ), place of death among decedents aged 65+ years has been reported as residential aged care (RAC, 38%), acute hospital (34%) or elsewhere (28%). However, lifetime risk of use of RAC (or nursing homes) is unknown. A simple method of estimation is demonstrated for NZ and Australia, with comparisons to other countries. Methods: Deaths of RAC residents in acute hospitals were estimated for NZ from four separate studies and added to deaths occurring in RAC, to derive the likelihood of using RAC after age 65 years. Academic and other sources were searched for comparative reports. Results: An estimated 18% of RAC residents died in acute hospital in NZ. When added to those who died in RAC, the proportion using RAC for late-life care was estimated at over 47% (66% if aged 85+ years). Of 12 US reports, the median report was 41%. Elsewhere, Finland was 47%, UK 28%, Australia 34% to 53%, and Germany 22% & 26%. Conclusions: Simple estimation using existing data demonstrates that RAC in late life is common. Implications: Late-life care services will continue to evolve. Monitoring RAC utilisation is necessary for informed debate about palliative care provision in RAC, use of hospital by RAC residents and for planning and policy setting.

Vital signs are often considered as critical information to assess initial health condition and underlying health issues. Vital signs can contribute towards early detection, early diagnosis and risk reduction of fatal incidents. Today’s advanced monitoring systems incorporate the balanced combination of clinical and technological aspects to give an innovative healthcare outcome. Vital signs monitoring systems are rapidly becoming the core of today’s healthcare deliveries. The paradigm shifted from traditional and manual recording to computer based electronic records and further to smartphones as versatile and innovative healthcare monitoring systems. In this paper, the vital signs monitoring systems are classified as wearable, wireless and mobile monitoring systems and patient acceptability of some of these systems has been evaluated using 30 participants. Moreover, a comprehensive review of related literature in the context of acceptability, mobility, reliability and efficiency of vital signs monitoring systems in healthcare delivery and handling physiological measurements is presented. The outcome of this study indicates that despite some limitations commented by patients and clinicians, these systems should be more compact and simple to operate and they should be available to healthcare professionals with minimum interruption to normal daily life activities (ADLs).

Abnormalities of cardiac structure and function are common in a wide range of populations including those with and without established clinical cardiovascular disease (CVD). This study reports the prevalence of left ventricular hypertrophy (LVH), the four patterns of LV geometry and establishes clinical characteristics and five-year outcomes of each group in people of advanced age.A study conducted in general practices and Māori Health Services in three New Zealand North Island locations. One hundred participants had a full clinical echocardiogram performed and analysed in 2008 by one experienced cardiologist blinded to the participant's clinical history.Two-thirds of the participants had CVD. Thirty-two participants had echocardiographic LVH. Those with LVH had higher left atrial area [median (IQR) 26.4cm(2) (10.9) vs. 22.0cm(2) (7.0), p0.01] and E/e' [median (IQR) 13 (6.8) vs.10.8 (4.1), p=0.01] than those without LVH. Of those with LVH, 10 demonstrated concentric hypertrophy (CH) and 22 eccentric hypertrophy (EH); 12 concentric remodelling (CR) and 40 normal geometry (NG). Both CR and EH were independently associated with higher risk of all-cause mortality (p0.01) and hospital admissions (p0.05) than those with NG. Those with EH also had a higher risk of CVD events (p=0.029).Despite a high prevalence of CVD and hypertension in this sample, half had normal LV geometry. Concentric remodelling and eccentric hypertrophy were associated with higher mortality and adverse CVD outcomes in people of advanced age.

Objective To assess effect of a complex, multidisciplinary intervention aimed at reducing avoidable acute hospitalization of residents of residential aged care (RAC) facilities. Design Cluster randomized controlled trial. Setting RAC facilities with higher than expected hospitalizations in Auckland, New Zealand, were recruited and randomized to intervention or control. Participants A total of 1998 residents of 18 intervention facilities and 18 control facilities. Intervention A facility-based complex intervention of 9 months' duration. The intervention comprised gerontology nurse specialist (GNS)-led staff education, facility bench-marking, GNS resident review, and multidisciplinary (geriatrician, primary-care physician, pharmacist, GNS, and facility nurse) discussion of residents selected using standard criteria. Main outcome measures Primary end point was avoidable hospitalizations. Secondary end points were all acute admissions, mortality, and acute bed-days. Follow-up was for a total of 14 months. Results The intervention did not affect main study end points: number of acute avoidable hospital admissions (RR 1.07; 95% CI 0.85–1.36; P = .59) or mortality (RR 1.11; 95% CI 0.76–1.61; P = .62). Conclusions This multidisciplinary intervention, packaging selected case review, and staff education had no overall impact on acute hospital admissions or mortality. This may have considerable implications for resourcing in the acute and RAC sectors in the face of population aging.

Adverse outcomes associated with advanced diseases are often exacerbated by polypharmacy.The current study investigated an association between exposure to anticholinergic and sedative medicines and falls in community-dwelling older people, after controlling for potential confounders.We conducted a retrospective cross-sectional study of a continuously recruited national cohort of community-dwelling New Zealanders aged 65 years and over. Participants had an International Resident Assessment Instrument-Home Care (interRAI-HC) assessment between 1 September 2012 and 31 January 2016. InterRAI-HC is a comprehensive, multi-domain, standardised assessment. This study captured 18 variables, including fall frequency, from the interRAI. These data were deterministically matched with the Drug Burden Index (DBI) for each participant, derived from an anonymised national dispensed pharmaceuticals database. DBI groupings were statistically ascertained, and ordinal regression models employed.Overall, there were 71,856 participants, with a mean age of 82.7 years (range 65-106); 43,802 (61.0%) were female, and 63,578 (88.5%) were New Zealand European. In unadjusted and adjusted analyses, DBI groupings were related to falls (p 0.001). A DBI score 3 was associated with a 41% increase in falls compared with a DBI score of 0 (p 0.001). There was a 'dose-response' relationship between DBI levels and falls risk.DBI was found to be independently and positively associated with a greater risk of falls in this cohort after adjustment for 18 known confounders. We suggest that the DBI could be a valuable tool for clinicians to use alongside electronic prescribing to help reduce falls in older people.

Introduction: Many studies have investigated the process of healthcare implementation to understand better how to bridge gaps between recommended practice, the needs and demands of healthcare consumers, and what they actually receive. However, in the implementation of integrated community-based and integrated health care, it is still not well known which approaches work best. Methods: We conducted a systematic review and metanarrative synthesis of literature on implementation frameworks, theories and models in support of a research programme investigating CBPHC for older adults with chronic health problems. Results: Thirty-five reviews met our inclusion criteria and were appraised, summarised, and synthesised. Five metanarratives emerged 1) theoretical constructs; 2) multiple influencing factors; 3) development of new frameworks; 4) application of existing frameworks; and 5) effectiveness of interventions within frameworks/models. Four themes were generated that exposed the contradictions and synergies among the metanarratives. Person-centred care is fundamental to integrated CBPHC at all levels in the health care delivery system, yet many implementation theories and frameworks neglect this cornerstone. Discussion: The research identified perspectives central to integrated CBPHC that were missing in the literature. Context played a key role in determining success and in how consumers and their families, providers, organisations and policy-makers stay connected to implementing the best care possible. Conclusions: All phases of implementation of a new model of CBPHC call for collaborative partnerships with all stakeholders, the most important being the person receiving care in terms of what matters most to them.

OBJECTIVE This article estimates length of completed stay and resident transitions for RAC residents over 12 months in Auckland. METHODS Data from a census-type survey of nursing home residents (n = 6816) were linked with national mortality data. Transitions described include entry to residential aged care (RAC), movement between RAC facilities and deaths. RESULTS When reweighted for missing data and adjusted for length bias, an estimated 9676 residents (95% CI 8368-10 985) used care over a 12-month period. Half of new residents entered RAC via an acute hospital. Median survival was 2.0 years; 17% died within 3 months, and 23% survived over 5 years. CONCLUSION Cross-sectional survey data, when appropriately adjusted for length-biased sampling, enable estimates of period prevalence and transition probabilities that are useful for simulation studies. Given population ageing and the costs of ongoing care, these results can inform policy and planning for long-term care needs of older people.

PurposePeople are now living longer, but disability may affect the quality of those additional years of life. We undertook a trial to assess whether case finding reduces disability among older primary care patients.MethodsWe conducted a cluster-randomized trial of the Brief Risk Identification Geriatric Health Tool (BRIGHT) among 60 primary care practices in New Zealand, assigning them to an intervention or control group. Intervention practices sent a BRIGHT screening tool to older adults every birthday; those with a score of 3 or higher were referred to regional geriatric services for assessment and, if needed, service provision. Control practices provided usual care. Main outcomes, assessed in blinded fashion, were residential care placement and hospitalization, and secondary outcomes were disability, assessed with Nottingham Extended Activities of Daily Living Scale (NEADL), and quality of life, assessed with the World Health Organization Quality of Life scale, abbreviated version (WHOQOL-BREF).ResultsAll 8,308 community-dwelling patients aged 75 years and older were approached; 3,893 (47%) participated, of whom 3,010 (77%) completed the trial. Their mean age was 80.3 (SD 4.5) years, and 55% were women. Overall, 88% of the intervention group returned a BRIGHT tool; 549 patients were referred. After 36 months, patients in the intervention group were more likely than those in the control group to have been placed in residential care: 8.4% vs 6.2% (hazard ratio = 1.32; 95% CI, 1.04-1.68; P = .02). Intervention patients had smaller declines in mean scores for physical health-related quality of life (1.6 vs 2.9 points, P = .007) and psychological health-related quality of life (1.1 vs 2.4 points, P = .005). Hospitalization, disability, and use of services did not differ between groups, however.ConclusionsOur case-finding strategy was effective in increasing identification of older adults with disability, but there was little evidence of improved outcomes. Further research could trial stronger primary care integration strategies.

Residents of long-term care facilities have highly complex care needs and quality of care is of international concern. Maintaining resident wellness through proactive assessment and early intervention is key to decreasing the need for acute hospitalization. The Residential Aged Care Integration Program (RACIP) is a quality improvement intervention to support residential aged care staff and includes on-site support, education, clinical coaching, and care coordination provided by gerontology nurse specialists (GNSs) employed by a large district health board. The effect of the outreach program was evaluated through a randomized comparison of hospitalization 1 year before and after program implementation. The sample included 29 intervention facilities (1,425 residents) and 25 comparison facilities (1,128 residents) receiving usual care. Acute hospitalization rate unexpectedly increased for both groups after program implementation, although the rate of increase was significantly less for the intervention facilities. The hospitalization rate after the intervention increased 59% for the comparison group and 16% for the intervention group (rate ratio (RR) = 0.73, 95% confidence interval (CI) = 0.61-0.86, P < .001). Subgroup analysis showed a significantly lower rate change for those admitted for medical reasons for the intervention group (13% increase) than the comparison group (69% increase) (RR = 0.67, 95% CI = 0.56-0.82, P < .001). Conversely, there was no significant difference in the RR for surgical admissions between the intervention and comparison groups (RR = 1.0, 95% CI = 0.68-1.46, P = .99). The integration of GNS expertise through the RACIP intervention may be one approach to support staff to provide optimal care and potentially improve resident health.

BackgroundThe literature regarding diverticular disease of the intestines (DDI) almost entirely concerns hospital-based care; DDI managed in primary care settings is rarely addressed.AimTo estimate how often DDI is managed in primary care, using antibiotics dispensing data.Design and settingHospitalisation records of New Zealand residents aged 30+ years during 2007-2016 were individually linked to databases of community-dispensed oral antibiotics.MethodPatients with an index hospital admission 2007-2016 including a DDI diagnosis (ICD-10-AM = K57) were grouped by acute/non-acute hospitalisation. We compared use of guideline-recommended oral antibiotics for the period 2007-2016 for these people with ten individually-matched non-DDI residents, taking the case's index date. Multivariable negative binomial models were used to estimate rates of antibiotic use.ResultsFrom almost 3.5 million eligible residents, data were extracted for 51,059 index cases (20,880 acute, 30,179 non-acute) and 510,581 matched controls; mean follow-up = 8.9 years. Dispensing rates rose gradually over time among controls, from 47 per 100 person-years (/100py) prior to the index date, to 60/100py after 3 months. In comparison, dispensing was significantly higher for those with DDI: for those with acute DDI, rates were 84/100py prior to the index date, 325/100py near the index date, and 141/100py after 3 months, while for those with non-acute DDI 75/100py, 108/100py and 99/100py respectively. Following an acute DDI admission, community-dispensed antibiotics were dispensed at more than twice the rate of their non-DDI counterparts for years, and were elevated even before the index DDI hospitalisation.ConclusionDDI patients experience high use of antibiotics. Evidence is needed that covers primary-care and informs self-management of recurrent, chronic or persistent DDI.

Objective: Population ageing is driving many countries to review health and social care policies. For many, an important component is residential long-term care (LTC). This study uses New Zealand to ascertain the extent different reports provide consistent and accurate estimates of LTC use. Methods: We searched for available cross-sectional information about use of LTC by people aged 65 years or over in NZ's population since 1988. In addition, for one geographic region, Auckland, we compared research survey data at three time-points with the nearest census estimates. Results: Fifty-eight national-level estimates (census, subsidy payments and population surveys) were found. Since 2000, estimates of the proportion of older people reportedly living in long-term care ranged from 3.4% to 9.2%. Comparisons with Auckland studies demonstrated improved reporting in the 2006 census. Conclusion: Estimates of the proportion of people living in residential LTC varied widely. OECD reports, often used for cross-national comparisons, were particularly inconsistent. Implications: While estimates of the proportion of people living in residential LTC in NZ are inconsistent, improvements are evident in census and subsidy data. Reconciling new data with previous reports prior to publication may reduce variations in reporting. Improved reliability will assist understanding of within-country trends and international comparisons, and better inform decisions shaping health services for older people.

This paper is a response to our recognition that approaches to equity and consumer involvement in research differed in emphasis between our researchers and jurisdictions. Whilst we shared common aspirations we varied in our priorities between equity groups and methods to represent consumer interests. New Zealand has a historical focus on equity for indigenous Maori and shares with Canada concern about enduring inequalities that affect people’s lives.

Background: Cognitive impairments are common in patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF). To date there are no meta- analyses that have investigated the prevalence of mild cognitive impairment (MCI) in patients with COPD and CHF. Aims: To examine the individual study data set using meta-analysis to estimate the prevalence of MCI in patients with COPD and CHF. Methods Data sources: We identified relevant studies for COPD and CHF by searching published literature from inception to February 2016 using the MEDLINE and Web of Science databases. Study selection: Studies were included if they documented the prevalence of MCI and CHF for patients without dementia and employed appropriate screening tool for cognitive impairment. Data extraction and synthesis: 17 studies of CHF patients (n= 29,456) and 14 studies of COPD patients (n= 23, 116) were included for the meta-analysis. Main outcome measures : Prevalence of MCI in patients with COPD and CHF. The pooled prevalence of MCI for patients with COPD was estimated at 24% (95% CI: 12%, 38%). The prevalence of MCI in patients with CHF was 35% (95% CI: 25%, 45%). In the jackknife sensitivity analysis, both pooled estimates did not substantially vary when the meta-analysis was repeated with each included study being excluded one at a time. Conclusions: Approximately, 24% COPD patients and 35% CHF patients respectively had MCI. Studies are needed to examine the efficacy of intervention on MCI.

This review provides an overview of the literature on a broad range of tablet-based healthcare applications in hospital care settings. Most of the systems described are either in their development stage or simulation stage but not actually implemented in the hospital care (exceptions to systems conducted clinical trials). Further focused research is required in such applications with respect to their clinical implementation, end-user acceptability, evaluation by medical professionals and security and privacy.

Place of death, specifically the percentage who die in hospital or residential aged care, is largely unreported. This paper presents a cross-national comparison of location of death information from published reports and available data. Reports of deaths occurring in hospitals, residential aged care facilities, and other locations for periods since 2001 were compiled. Over 16 million deaths are reported in 45 populations. Half reported 54 % or more of all deaths occurred in hospitals, ranging from Japan (78 %) to China (20 %). Of 21 populations reporting deaths of older people, a median of 18 % died in residential aged care, with percentages doubling with each 10-year increase in age, and 40 % higher among women. This place of death study includes more populations than any other known. In many populations, residential aged care was an important site of death for older people, indicating the need to optimise models of end-of-life care in this setting. For many countries, more standardised reporting of place of death would inform policies and planning of services to support end-of-life care.

To describe changes in aged care residents' dependency over a 20-year period.All residents in 1988, 1993, 1998, and 2008 were assessed using the same 23-item functional ability survey.Residential aged care facilities in Auckland, New Zealand.In 1988 there were 7516 participants (99% response rate), 6972 in 1993 (85% response rate), 5056 in 1998 (65% response rate), and 6828 in 2008 (89% response rate). Data were weighted to accommodate variation in response.A composite dependency score with 5 ordinal levels was derived from a census-type survey reporting mobility, activities of daily living ability, continence, and cognitive function.The proportion of "apparently independent" residents decreased from 18% in 1988 to 9% in 1993, 5% in 1998, and 4% in 2008, whereas those "highly dependent" increased from 16% in 1988, to 18% in 1993, 19% in 1998, to 21% in 2008. All functional indicators demonstrated increased dependency over the 20-year period (P.0001). However, between 1998 and 2008 there were significant increases in dependency for continence, mobility, self-care, and orientation, but no significant changes in memory and behavior.The increased dependency over 20 years directly affects care requirements for this population.

Background in Auckland, New Zealand in 1988, 7.7% of those aged over 65 years lived in licenced residential aged care. Age-specific rates approximately doubled for each 5-year age group after the age of 65 years. Even with changes in policies and market forces since 1988, population increases are forecast to drive large growth in demand. This study shows previously unrecognised 20-year trends in rates of care in a geographically defined population. Methods four cross-sectional surveys of all facilities (rest homes and hospitals) licenced for long-term care of older people were conducted in Auckland, New Zealand in 1988, 1993, 1998 and 2008. Facility staff completed survey forms for each resident. Numbers of licenced and occupied beds and trends in age-specific and age-standardised rates in residential aged care are reported. Results over the 20-year period, Auckland's population aged over 65 years increased by 43% (from 91,000 to 130,000) but actual numbers in care reduced slightly. Among those aged over 65 years, the proportion living in care facilities reduced from 1 in 13 to 1 in 18. Age-standardised rates in rest-home level care reduced from 65 to 33 per thousand, and in hospital level care, from 29 to 23 per thousand. Had rates remained stable, over 13,200 people, 74% more than observed, would have been in care in 2008. Conclusion growth predicted in the residential aged care sector is not yet evident. The introduction of standardised needs assessments before entry, increased availability of home-based services, and growth in retirement villages may have led to reduced utilisation.