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Purpose: A potential complication of bariatric surgery is development of nutritional deficiencies. Study aims were to assess prevalence of micronutrient deficiencies in preoperative bariatric patients and to examine for ethnic differences. Methods: Retrospective analysis of 573 patients that underwent bariatric surgery at Counties Manukau District Health Board was carried out. Mean preoperative levels of albumin, calcium, phosphate, folate, vitamin B12, vitamin D, magnesium, haemoglobin, haematocrit, mean cell volume, mean cell haemoglobin, ferritin, iron, and transferrin were calculated. Chi square, fisher exact test, and multiple logistic regression was used to assess for differences in prevalence of micronutrient deficiencies across ethnicities. Results: The most common micronutrient deficiency was vitamin D (30.85%). There were statistically significant differences in vitamin D deficiency across ethnicities (p < 0.0001). Asians had the highest prevalence of vitamin D deficiency (60%), followed by Pacifica (44.57%), and Māori (31.68%). Asians were more likely to have vitamin D deficiency compared to NZ/Other Europeans (OR = 14.93, p < 0.001). Vitamin D deficiency was associated with higher BMI (OR = 1.05, p = 0.008). The second most common deficiency was iron (21.1%). Asians had the highest prevalence of iron deficiency (44%), followed by Māori (27.95%), and Pacifica (19.57%) (p = 0.0064). Compared to NZ/Other Europeans, Asians (OR = 4.26) and Māori (OR = 1.78) were more likely to be iron deficient (p = 0.004). Female gender was associated with iron deficiency (OR = 2.12, p = 0.007). Conclusion: Vitamin D and iron are the most common micronutrient deficiencies among preoperative bariatric patients in this cohort and ethnic differences were seen. There may be a role for preoperative supplementation in these at-risk ethnic groups. [ABSTRACT FROM AUTHOR]

Background: An increasing number of older patients are undergoing emergency laparotomy (EL). Frailty is thought to contribute to adverse outcomes in this group. The best method to assess frailty and impacts on long‐term mortality and other important functional outcomes for older EL patients have not been fully explored. Methods: A prospective multicenter study of older EL patients was conducted across four hospital sites in New Zealand from August 2017 to September 2022. The Clinical Frailty Scale (CFS) was used to measure frailty—defined as a CFS of ≥5. Primary outcomes were 30‐day and one‐year mortality. Secondary outcomes were postoperative morbidity, admission for rehabilitation, and increased care level on discharge. A multivariate logistic regression analysis was conducted, adjusting for age, sex, and ethnicity. Results: A total of 629 participants were included. Frailty prevalence was 14.6%. Frail participants demonstrated higher 30‐day and 1‐year mortality—20.7% and 39.1%. Following adjustment, frailty was directly associated with a significantly increased risk of short‐ and long‐term mortality (30‐day aRR 2.6, 95% CI 1.5, 4.3, p = <0.001, 1‐year aRR 2.0, 95% CI 1.5, 2.8, p < 0.001). Frailty was correlated with a 2‐fold increased risk of admission for rehabilitation and propensity of being discharged to an increased level of care, complications, and readmission within 30 days. Conclusion: Frailty was associated with increased risk of postoperative mortality up to 1‐year and other functional outcomes for older patients undergoing EL. Identification of frailty in older EL patients aids in patient‐centered decision‐making, which may lead to improvement in outcomes. [ABSTRACT FROM AUTHOR]

Background: The Ninth Perioperative Mortality Review Committee (POMRC) report found the likelihood of death was over three times higher in Māori youth compared to non‐Māori (age: 15–18 years) in the 30‐days following major trauma. The aim of our study is to investigate variations in care provided to Māori youth presenting to Te Whatu Ora Counties Manukau (TWO‐CM) with major trauma, to inform policies and improve care. Methods: This was a retrospective, observational study of 15–18‐year‐olds admitted to Middlemore Hospital from January 2018 to December 2021 following major trauma (Injury Severity Score (ISS) >12 or with (ISS) <12 who died). Data were obtained from the New Zealand Trauma Registry (NZTR). Six key performance indicators were studied against hospital guidelines/international consensus: Deaths, Cause‐of‐death, trauma call, RedBlanket activations, time‐to‐computed tomography (CT), and time‐to‐operating theatre (OT). Results: Of 77 patients, five deaths occurred, four non‐Māori, and one Māori (P = 0.645). Five trauma calls were not activated (P = 0.642). There was no statistically significant difference for both median time to CT (P = 0.917) and time to CT for patients with GCS >13 (P = 0.778) between Māori and non‐Māori. Five patients did not meet guidelines for time‐to‐OT (three non‐Māori and two Māori) (P = 0.377). Conclusion: No statistically significant variations in care were present for Māori youth presenting with major trauma, these findings did not match the national trend. We conducted a retrospective observational study aimed to investigate variations in care provided to Māori youth presenting to Te Whatu Ora Counties Manukau (TWO‐CM) with major trauma, to inform policies and improve care. Six Key Performance Indicators were studied against hospital guidelines/international consensus: Deaths, Cause‐of‐death, trauma call, RedBlanket activations, time‐to‐computed tomography (CT), and time‐to operating theatre (OT). We found that there were no statistically significant variations in care present for Māori youth presenting with major trauma and our findings did not match national trends. [ABSTRACT FROM AUTHOR]

Background: The National Bariatric Prioritization Tool (NBPT), developed in Aotearoa New Zealand (AoNZ), has not been validated using real patient data. The aim was to determine the predictive validity of the NBPT on health outcomes. Methods: An observational study was undertaken of consecutive patients undergoing elective bariatric surgery at Middlemore Hospital using the NBPT from December 2014 to December 2016. The primary outcome was the correlation between prioritization score and percentage total weight loss (%TWL) at 18 months follow‐up, with secondary outcomes being correlation with change in HbA1c, lipids, resolution of OSA, resolution of hypertension, and reduction in arthritis medications. Equity of access was measured by the relationship to age group, gender and ethnicity. Results: There were 294 patients included. There was no correlation between %TWL and prioritization score (correlation −0.09, P = 0.14). The benefit score correlated with %TWL (correlation 0.25, P < 0.0001). There were correlations between prioritization score and HbA1c reduction (correlation 0.28, P < 0.0001), resolution of OSA (correlation 0.20, P < 0.001) and resolution of hypertension (correlation 0.20, P < 0.001). There was a significant difference in prioritization score based on ethnicity, with Māori and Pasifika scoring higher than New Zealand European (P = 0.0023). Conclusions: While the NBPT does not correlate with %TWL, it may have predictive validity through correlations with improvement of comorbidities such as diabetes, OSA and hypertension. Given higher rates of obesity and comorbidities in Māori and Pasifika, the higher scores may suggest the tool may be used to achieve equity of access. Further modifications should be considered to optimize outcomes. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery is a proven effective method of reducing obesity and reversing or preventing obesity‐related comorbidities. The aim of this study is to describe the development of a tool to assist with the prioritization of patients with obesity for bariatric surgery. The tool would meet the criteria for being evidence‐based, fair, implementable and transparent. Methods: The development of the tool involved a validated step‐by‐step process based on the consensus of clinical judgement of the New Zealand Ministry of Health working party. The process involved elicitation of criteria, clinical ranking of vignettes and creation of weightings using the 1000Minds® tool. The concurrent validity was tested by comparing tool rankings of vignettes to clinical judgement rankings. Results: Four major criteria (impact on life, likelihood of achieving maximum benefit with respect to control of diabetes, duration of benefit and surgical risk) are used to characterize the need and potential to benefit. The impact on life criterion has the largest weighting (up to 44.3%). There was good concurrent validity with a correlation coefficient r = 0.67. Conclusion: The tool as presented is evidence‐based, transparent and internally valid. The next step is to assess the predictive validity of the tool using real patient data to evaluate the effectiveness of the tool and determine what modifications may be required. [ABSTRACT FROM AUTHOR]

Background: The 'weekend effect' is the term given to the observed discrepancy regarding patient care and outcomes on weekends compared to weekdays. This study aimed to determine whether the weekend effect exists within Aotearoa New Zealand (AoNZ) for patients undergoing emergency laparotomy (EL), given recent advances in management of EL patients. Methods: A cohort study was conducted across five hospitals, comparing the outcomes of weekend and weekday acute EL. A propensity‐score matched analysis was used to remove potential confounding patient characteristics. Results: Of the 487 patients included, 132 received EL over the weekend. There was no statistically significant difference between patients undergoing EL over the weekend compared to weekdays. Mortality rates were comparable between the weekday and weekend cohorts (P = 0.464). Conclusions: These results suggest that modern perioperative care practice in New Zealand obviates the 'weekend' effect. [ABSTRACT FROM AUTHOR]

Background: Tube thoracostomy (TT) in trauma is lifesaving. A previous audit at Counties Manukau District Health Board (CMDHB), New Zealand, showed a 22% complication rate for trauma TT. Subsequently CMDHB introduced a procedural guideline to reduce complications. The Health and Disability Commission published a report concerning oversights in TT removal. This led us to evaluate complications, documentation and procedural monitoring to identify ways to improve patient safety. Method: A 30‐month retrospective audit of patients presenting to CMDHB, with injuries which may require TT. Those who had a TT in situ, did not require a TT or whose presentation was not secondary to trauma were excluded. Results: One hundred and forty‐three TTs were performed in one hundred and fifteen patients. About 87% had injuries secondary to blunt mechanism. Penetrating injuries were more likely to require TT (P = 0.015). Non‐accidental injuries were more likely to need TT (P = 0.025). The complication rate was 25.2%. TT prior to imaging had a 31% complication rate (P < 0.03). About 23% had no TT insertion note. 40% had no TT removal note. About 9% TT insertions had no tertiary information to identify the proceduralist and a complication rate of 46%. About 22% of insertions and 4% of removals documented consent. About 2% of insertions documented anticoagulation status. Interventional radiology had the best documentation of data points assessed (P < 0.0001). Post‐procedural monitoring recommendations were documented in 1% insertions and 11% removals. Conclusions: The complication rate has not reduced despite introduction of a guideline. Procedural documentation and monitoring were inadequate, potentially impacting patient safety. [ABSTRACT FROM AUTHOR]

Background: In the context of increasing shortages in the New Zealand medical specialist workforce, this research seeks to answer the question 'Are we effectively retaining our New Zealand‐trained general surgeons?' Methods: Semi‐structured interviews were undertaken with 16 general surgeons. Participants work in New Zealand and internationally. Interviews were transcribed, coded and themed. Thematic analysis was used to interpret the findings. Results: This research finds that we are failing to effectively retain New Zealand‐trained general surgeons through haphazard workforce planning and a lack of transparent recruitment processes. General surgeons who choose to take their first SMO role overseas are pushed to do so due to a lack of certainty about job opportunities in New Zealand, bullying, and relative ease of negotiation for job composition and conditions at international hospitals. General surgeons who take their first SMO role in New Zealand feel that securing a job is down to luck, existing relationships with influential people in surgical departments and timing. Conclusion: The failure to retain New Zealand‐trained general surgeons in the New Zealand specialist workforce is amenable to improvements in workforce planning, improved coordination between clinical and administrative leadership in DHBs, and better career development support for trainees prior to receiving their FRACS and embarking on post‐fellowship subspecialist training. Further research into the experiences of trainees and SMOs in general surgery and other surgical subspecialties is required to build a complete picture of the path from trainee to SMO, and areas where interventions could improve retention of New Zealand‐trained general surgeons. [ABSTRACT FROM AUTHOR]

Aim: Haemorrhoids are frequently encountered by the general or colorectal surgeon. Although a benign disease, those with symptomatic, advanced grades frequently require excisional haemorrhoidectomy for definitive management. Despite their widespread nature, the epidemiological burden of haemorrhoids and haemorrhoidectomies on populations is not well described. This study seeks to establish the incidence of both haemorrhoids diagnosed and haemorrhoidectomies performed in New Zealand. Method: This is a population‐based cross‐sectional study examining the incidence of all patients who were newly diagnosed with haemorrhoids in New Zealand public hospital outpatient clinics and those who received excisional haemorrhoidectomy in New Zealand public hospitals from 2007 to 2016. Data were extracted and linked using the New Zealand National Minimum Dataset and the National Non‐Admitted Patient Collection. Variables collected included age group, sex, ethnicity and geographical location. Results: A total of 46 095 recorded diagnoses of haemorrhoids were made, with a total of 18 739 haemorrhoidectomies in the 10‐year period recorded. The incidence rate of diagnosis increased from 84.6 to 120.5 per 100 000 and the incidence rate of haemorrhoidectomies performed from 30.4 to 51.1 per 100 000, a significantly increased annual incidence. There was a unimodal peak prevalence in the fifth decade of life with women more affected. Europeans formed the largest group affected, with Asians showing the highest rate of increased incidence. Conclusion: There is an increasing incidence of patients with symptomatic haemorrhoids presenting to the New Zealand public healthcare system, with a preponderance in working age adults, especially women. [ABSTRACT FROM AUTHOR]

Access to publicly funded bariatric surgery in New Zealand is limited, but privileges patients who identify as New Zealand European or Other European. This example of institutional racism in the New Zealand health system further reiterates that Māori face inequitable access to gold standard medical interventions. This article analyses semi-structured interviews undertaken with Māori who had bariatric surgery at Counties Manukau Health which houses the largest public bariatric service. Thirty-one interviews were conducted, from which six themes were identified in relation to the stages of the bariatric journey. A thematic analysis of transcripts using an inductive approach was undertaken. Using Kaupapa Māori Research–aligned methodology, sites of racism, compassion, clinical barriers to positive health experiences and life-changing experiences were identified along the bariatric journey for Māori patients. [ABSTRACT FROM AUTHOR]

Background: In New Zealand (NZ), Indigenous Māori and Pacific peoples experience a higher burden of obesity and obesity-related disease. Counties Manukau Health (CMH) provides the largest public bariatric service in NZ housing a higher proportion (64%) of non-European groups (Asian, Pacific and Māori). This study investigated whether ethnic disparities in the receipt of bariatric surgery exist within one of the most ethnically diverse populations in NZ. Methods: All patients accepted on to the CMH bariatric programme between 1 January 2011 and 31 December 2017 were identified through hospitalisation records. Logistic regression modelling with multivariate adjustment was utilised to assess the likelihood (odds ratio) of receipt of bariatric surgery by ethnicity. Results: A total of 2519 referrals were received, of which 1051 proceeded to surgery. The proportion of patients referred who eventually underwent bariatric surgery was significantly higher for Other Europeans (68%) and NZ Europeans (63%) compared to Asian (42%), Māori (41%) and Pacific peoples (28%, p < 0.05). The likelihood of receipt of bariatric surgery was significantly lower for Māori (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.42–0.68) and Pacific (OR, 0.3; 95%CI, 0.23–0.40). These disparities were not explained by differences in socio-demographics, comorbidity or attrition. Conclusions: Ethnic disparities in the receipt of publicly funded bariatric surgery exist where NZ European and Other European patients are more likely to gain access to publicly funded bariatric surgery. These findings challenge current selection criteria and prompt discussion around whether equity targets based on ethnicity need to be established. [ABSTRACT FROM AUTHOR]

Background: Health equity is a fundamental right afforded to all regardless of ethnicity. However, in New Zealand (NZ), health inequities are most compelling for Indigenous Māori who experience inadequate access to services, poorer quality of care and poor health outcomes as a result. Bariatric surgery is the most effective intervention for weight loss and remission of obesity‐related disease where all other interventions have been exhausted. This Kaupapa Māori qualitative study presents Māori perspectives of bariatric surgery from the largest public bariatric centre in NZ and offers solutions for enhancing bariatric service responsiveness to Māori. Methods: This qualitative study was informed by Kaupapa Māori methodology and involved a general inductive thematic analysis of 31 semi‐structured interviews with Māori patients who had bariatric surgery at Counties Manukau Health in South Auckland, NZ. Results: Four key themes were identified following analysis: (i) Kaupapa Māori standards of health; (ii) bariatric mentors; (iii) bariatric psychologists; and (iv) community‐integrated support. These themes offer four tangible solutions for optimizing bariatric pathways for Māori from the perspectives of Māori bariatric patients. Conclusion: Kaupapa Māori, community‐centred and greater non‐surgeon aspects of bariatric supportive mechanisms comprise key areas of opportunity for public bariatric pathways in NZ. Surgical leadership is required to advance health equity and service responsiveness to Māori. [ABSTRACT FROM AUTHOR]

Background: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system was developed to aid the diagnosis of necrotizing fasciitis and guide management [1]. Aim: To validate the LRINEC score and identify clinical predictors to develop a refined diagnostic scoring tool for the diagnosis of necrotizing fasciitis at Middlemore Hospital, New Zealand. Methods: This was a retrospective case–control study of patients admitted to Middlemore Hospital with necrotizing fasciitis and severe cellulitis between January 2000 and December 2010. The LRINEC scores at admission were evaluated for performance in discriminating between cases of necrotizing fasciitis and severe cellulitis. Cases and controls were randomized into developmental and validation cohorts. Univariate and multivariate logistic regression analysis of demographic, clinical, and laboratory variables for the diagnosis of necrotizing fasciitis was performed. The identified independent predictors were used to develop a new diagnostic scoring tool. Results: The area under the receiver operating characteristic curve (C-statistic) of a LRINEC score ≥6 for the diagnosis of necrotizing fasciitis was 0.679. The newly developed SIARI score [Site other than the lower limb, Immunosuppression, Age < 60 years, Renal impairment (creatinine > 141), and Inflammatory markers (CRP ≥ 150, WCC > 25] demonstrated superior diagnostic ability compared with the LRINEC score in both the developmental (C-statistic: 0.832 vs. 0.691, p < 0.001) and validation cohorts (C-statistic: 0.847 vs. 0.667, p < 0.001). Conclusion: The LRINEC score exhibited only modest discriminative performance in this cohort, while the SIARI score is a simplified tool that demonstrates superior diagnostic ability for detecting necrotizing fasciitis. Future external validation studies are required to confirm the trends observed in this study. [ABSTRACT FROM AUTHOR]

Bariatric surgery is the most effective intervention for alleviating obesity and its complications. Indigenous people worldwide experience higher rates of obesity and obesity disease burden. However, few studies exploring bariatric surgery among Indigenous peoples are published. In this study we aimed to explore the motivation of Māori women in coming forward for bariatric surgery. Māori women who had bariatric surgery prior to December 31, 2014, were invited to participate in semi-structured interpersonal interviews. Kaupapa Māori research, an Indigenous Māori research methodology, informed this study. Interviews were recorded, transcribed and subject to inductive thematic analysis. Twenty-nine Māori women participated in semi-structured interpersonal interviews. The majority of women reported that the presence of obesity-related disease alongside the desire for a better quality of life served as the greatest sources of motivation for having bariatric surgery. Whānau (family) were key for participants achieving the preoperative milestones needed to be accepted for bariatric surgery. Interpersonal experiences of fat-shaming and yo-yo dieting also impacted their choice to have surgery. This study is one of the first to describe the motivations of Indigenous Māori women to have bariatric surgery. Our study conveys the importance of health, a desire to have a better quality of life and whānau in motivating Māori women to come forward for bariatric surgery. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery has become topical in the media worldwide, influencing wider societal attitudes towards obesity and obesity management. This study aims to explore the media portrayal of bariatric surgery in all print news articles published in New Zealand (NZ) over a decade. Methods: An electronic search of two databases (Proquest Australia/NZ Newsstream and Newztext) and two NZ news media websites (Stuff and the NZ Herald) was performed to retrieve print news articles reporting stories, opinion pieces or editorials regarding bariatric surgery published between January 2007 to June 2017. Qualitative thematic analysis was performed on all included articles. Results: From January 2007 to December 2017, 252 articles related to bariatric surgery were published. Seven major themes emerged centred around barriers to accessing bariatric surgery, deficit attitudes towards obesity and social justice. These views were driven by articles that debated the limited number of publicly funded bariatric procedures offered in NZ. In addition, healthcare professionals used the media as a platform to challenge discriminatory attitudes towards obesity and bariatric surgery. Conclusion: The NZ media is a powerful tool that still bolsters binary perspectives of obesity and bariatric surgery which may work against addressing the obesity epidemic. [ABSTRACT FROM AUTHOR]

Background Oesophageal adenocarcinoma (OAC) is a lethal condition. The management is typically multifaceted with oesophagectomy being the cornerstone of treatment. Quality performance indicators (QPIs) are objective measurements of aspects of patient's care that affect clinical outcomes. We look to measure a set of clinically relevant QPIs that can be used to capture key aspects of patient management at our institution. Methods all patients with OAC treated from 2010 to 2015, and 2020 to 2021 at Te Whatu Ora Waitemata were included. Patients with secondary metastases to the oesophagus or gastric cancer with extension to the oesophagus were excluded. Electronic data in the form of clinic letters, operation notes, histology and radiology reports were reviewed. QPI adherence was collected in binary form. Results QPIs with consistently high compliance rates include radiological staging and histological diagnosis, perioperative dietitian involvement, explanations of disease and treatment intent, and pathology report documentation. QPIs demonstrating significant change and improvement across the two groups include endoscopic resection (60.0% of patients with T1 disease in 2010 to 88.9% in 2020 group), multimodality treatment (majority ECF and ECX perioperative chemotherapy in 2010 to majority FLOT chemotherapy in 2020 group) and minimally invasive approach (30.4% hybrid in 2010 compared to 72.4% hybrid in 2020). Conclusions QPIs from the systematic review were readily measurable and were variably implemented in clinical practice. Areas requiring improvement were identified however relevance to real-world clinical outcomes require further focus of investigation. [ABSTRACT FROM AUTHOR]

Background: Junior doctors are increasingly promoted as clinical teachers but there is limited understanding of how they contribute to medical student clerkship learning. Aim: To describe contributions made by general surgical interns to the student clerkship learning environment. Methods: The mixed-methods study involved two focus groups attended by volunteer interns and Year 4 students, and a student questionnaire collecting quantitative data. Focus group transcripts were evaluated using a qualitative analysis system. Results: Six interns and five students attended focus groups in June and August 2011. Qualitative analysis found that intern contributions to student learning can be grouped under four distinct roles: physician, supervisor, teacher and person. Data from 85 questionnaires (response rate 57%) revealed that intern-student encounters occurred daily in the surgical wards and emergency department. Interns demonstrated bedside procedures, clerical/administrative tasks and interpretation of laboratory and radiological investigations. Appreciated for approachability, friendliness and ability to relate to students, interns also played a crucial role in integrating students into the surgical team. This significantly correlated to clerkship enjoyment. Conclusions: Surgical interns improve clerkship learning environments by demonstrating 'personal' skills such as friendliness, approachability and relatedness. This has important implications for preparing interns as clinical preceptors. [ABSTRACT FROM AUTHOR]

Objective: A single visual analogue scale is used in New Zealand to prioritise patients for elective general surgery. Although it reflects clinical judgement, it has been criticised for its lack of transparency. We wished to elicit generic criteria used by surgeons for prioritisation of patients for elective general surgery in order to improve the transparency of the visual analogue scale. Methods: Semi-structured interviews were undertaken with 15 general surgeons. Using the repertory grid method, surgeons were asked to explain their rationale for distinguishing between patients they considered a high, medium or low priority for treatment. Interviews were audiotaped, transcribed and analysed for themes. The accuracy of the thematic analysis was checked using a five-point Likert scale to assess surgeons' agreement with the identified themes. Further testing to check for face, content and construct validity was undertaken with a purposive sample of six surgeons prioritising patient vignettes. Results: Eight major themes were deduced: diagnosis; treatment; patient characteristics; symptomatology and sequelae to date; future complications; quality of life; psychological/emotional impact; and socio-political/logistic factors. The utilisation of these themes by surgeons was confirmed. Tests of collinearity indicated good content validity. Factor analysis confirmed the hypothesis of one underlying construct, namely priority. Conclusion: Seven of the themes became the basis for a new clinical priority assessment criteria tool using visual analogue scales to determine priority of patients for elective general surgery. Further testing of reliability and validity is needed. [ABSTRACT FROM AUTHOR]

Background: Medical electives undertaken during sixth year at medical school provide an opportunity for students to work in an overseas or New Zealand health facility to gain exposure to a health system outside their training facility. Previous work suggests that the elective experience can be profound, exposing global health inequities, or influencing future career decisions. This study assessed patterns within elective choice by students' socio demographic and programme entry characteristics. Methods: A retrospective analysis of student elective records from 2010 to 2016 was undertaken using a Kaupapa Māori research framework, an approach which prioritises positive benefits for Māori (and Pacific) participants and communities. A descriptive analysis of routinely collected de-identified aggregate secondary data included demographic variables (gender, age group, ethnicity, secondary school decile, year and route of entry), and elective site. Route of entry (into medical school) is via general, MAPAS (Māori and Pacific Admissions Scheme) and RRS (Regional and Rural Scheme). Multivariable logistic regression analysis determined the odd ratios for predictors of going overseas for elective and electives taking place in a "High" (HIC) compared to "Low- and middle-income countries" (LMIC). Results: Of the 1101 students who undertook an elective (2010–2016) the majority undertook their elective overseas; the majority spent their elective within a high-income country. Age (younger), route of entry (general) and high school decile (high) were associated with going overseas for an elective. Within the MAPAS cohort, Pacific students were more likely (than Māori) were to go overseas for their elective; Māori students were more likely to spend their elective in a HIC. Conclusion: The medical elective holds an important, pivotal opportunity for medical students to expand their clinical, professional and cultural competency. Our results suggest that targeted support may be necessary to ensure equitable access, particularly for MAPAS students the benefit of an overseas elective. [ABSTRACT FROM AUTHOR]

Clinical priority assessment criteria (CPAC) are used to generate a score by which patients are prioritized and rationed for elective surgery. It is widely believed that surgeons elevate scores to ensure their patients’ acceptance for elective surgery, colloquially called gaming. The purpose of the present paper was therefore to investigate whether there was a temporal trend to an increase in the assigned priority score from the inception of CPAC to the present. Priority and weighted inlier equivalent separations (WIES) scores between 23 April 1999 and 23 July 2002 were collected for elective general surgical cases at Auckland Hospital. A total of 5440 cases was retrospectively analysed using multiple regression techniques. Priority score was included as the dependent variable and time as an independent variable. Any change in case complexity over that period was accounted for by including the WIES score as a covariate. Multiple regression was undertaken for the combined surgeons and for individuals. The combined model was statistically significant but accounted for only 17% of the priority score variance. An increase of one WIES unit leads to an increase of 2.7 in priority score ( P = 0.0001). The relationship of priority score with time was dependent on the surgeon performing the prioritization. However, only half the surgeons had individual models that indicated gaming. The results show that gaming is occurring but that not all surgeons participate in this. The difference between surgeons’ participation in gaming is a potential source of practice variation in the prioritization process. [ABSTRACT FROM AUTHOR]

Background: The New Zealand health reforms have resulted in the requirement that surgeons utilize Clinical Priority Access Criteria (CPAC) to ration patient access to elective surgery. The validity of the tools used as CPAC has been challenged. An alter­native tool, the Linear Analogue Scale (LAS), is therefore used in our institution. Our objectives were to determine the variables that influence the priority score generated using the LAS, and the length of time waited by patients awaiting general surgical procedures. Methods: A cohort of 918 patients who were listed for elective general surgical procedures at Auckland Hospital, Auckland, New Zealand between 1 July 1998 and 31 March 1999 were studied. Patients were given a priority score generated using the LAS. For each patient, the time from assessment until his or her procedure was documented. Linear and logistic regression models were used to investigate variables (age, gender, diagnosis and surgical team) that influence priority score. Cox proportional hazards models were used to investigate variables (priority score, age, gender, and diagnosis) that influence the length of time waited. Results: Graphical presentation showed a pattern of priority scores falling into ‘bands’ for different diagnoses. Diagnosis, and to a lesser extent surgical team, influenced priority score. Survival analysis showed ‘time waited’ to be influenced by priority score, diagnosis, and patient age and gender. Conclusion: The LAS may have a useful role in the difficult sphere of patient prioritization. Its strength lies in its simplicity. Further investigation of reliability and effect on patient outcomes is required. [ABSTRACT FROM AUTHOR]

Purpose: Patient-reported measures are an important emerging metric in outcome monitoring; however, they remain ill-defined and underutilized in bariatric clinical practice. This study aimed to determine the characteristics of patient-reported measures employed in bariatric practices across Australia and Aotearoa New Zealand, including barriers to their implementation and to what extent clinicians are receptive to their use., Methods: An online survey was distributed to all bariatric surgeons actively contributing to the Australian and Aotearoa New Zealand Bariatric Surgery Registry (n = 176). Participants reported their use of patient-reported measures and identified the most important and useful outcomes of patient-reported data for clinical practice., Results: Responses from 64 participants reported on 120 public and private bariatric practices across Australia and Aotearoa New Zealand. Most participants reported no collection of any patient-reported measure (39 of 64; 60.9%), citing insufficient staff time or resources as the primary barrier to the collection of both patient-reported experience measures (34 of 102 practices; 33.3%) and patient-reported outcome measures (30 of 84 practices; 35.7%). Participants indicated data collection by the Registry would be useful (47 of 57; 82.5%), highlighting the most valuable application to be a monitoring tool, facilitating increased understanding of patient health needs, increased reporting of symptoms, and enhanced patient-physician communication., Conclusion: Despite the current lack of patient-reported measures, there is consensus that such data would be valuable in bariatric practices. Widespread collection of patient-reported measures by registries could improve the collective quality of the data, while avoiding implementation barriers faced by individual surgeons and hospitals., (© 2022. The Author(s).)

Background: Patients who are haemodynamically unstable from surgical emergencies require prompt surgical intervention, and delay to surgery may lead to poorer clinical outcomes. The Red Blanket Protocol (RBP) is a communication algorithm intended to facilitate surgery as expediently and safely as possible. By developing a protocol for these channels of communication, RBP may reduce the time to surgical intervention and improve patient outcomes. Our aim was to identify whether patient outcomes, including time to surgery, blood product use and survival were improved by the Red Blanket protocol., Methods: Haemodynamically unstable adults in Middlemore Hospital, Aotearoa New Zealand from 1/1/2014 to 31/12/2015 were compared with RBP patients from 1/4/2017 to 1/4/2020. Time from emergency department (ED) to knife-to-skin (KTS) was compared between the groups. The number of blood products used, LOS and 30- and 90-day survival were also compared between the pre-protocol and RBP groups., Results: Thirty-two patients were identified in the pre-protocol group, and 25 in the RBP group. The median time from ED to KTS reduced from 84 to 70.5 min after the implementation of RBP (P = 0.044). The median number of blood products was 21 pre-protocol and 11.5 in the RBP group (P = 0.102). The median LOS was 8 versus 4 days in the RBP group (P = 0.204). 30-day survival rate was comparable in the two groups (65% versus 60% (P 0.71))., Conclusion: RBP was associated with a shorter time to knife-to-skin for haemodynamically unstable patients. There was no significant difference in clinical outcomes between the two groups. Larger studies are required to assess clinical outcomes of the RBP., (© 2022 Royal Australasian College of Surgeons.)

Background: New Zealand health services are responsible for equitable health service delivery, particularly for Māori, the Indigenous peoples of New Zealand. Recent research has indicated the presence of inequities in publicly funded bariatric surgery in New Zealand by ethnicity, but it is unclear whether these inequities persist after adjustment for co-morbidities., Objectives: To determine whether receipt of publicly funded bariatric surgery varies by ethnicity, after adjustment for co-morbidities., Setting: New Zealand primary care., Methods: A cohort study of New Zealanders aged 30-79 years who had cardiovascular risk assessment in primary care between January 1, 2010 and June 30, 2018. Data were collated and analyzed using an encrypted unique identifier with regional and national datasets. Cox proportional hazard modeling was performed to determine the likelihood of receipt of a primary publicly funded bariatric procedure up to December 31, 2018, after adjustment for sex, age, ethnicity, locality, socioeconomic deprivation, body mass index, diabetes status, smoking status, and co-morbidities., Results: A total of 328,739 participants (44% female, median age 54 yr [interquartile range, IQR, 46-62], 54% European, 13% Māori, 13% Pacific, 20% Asian) were included in the study and followed up for a median of 5.6 years (IQR 4.1-6.9). The likelihood of receipt of bariatric surgery was lower for Māori and Pacific compared with Europeans (adjusted hazard ratio .82 [95% CI .69-.96] and .24 [.20-.29], respectively). The likelihood of receiving bariatric surgery was also inversely related with increasing socioeconomic deprivation and rurality., Conclusions: Consistent with data worldwide, there is evidence of unequal access to publicly funded bariatric surgery by ethnicity, locality as well as socioeconomic deprivation among New Zealanders who were cardiovascular risk assessed in primary care., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Long-term effects after COVID-19 may affect surgical safety. This study aimed to evaluate the literature and produce evidence-based guidance regarding the period of delay necessary for adequate recovery of patients following COVID-19 infection before undergoing surgery., Methods: A rapid review was combined with advice from a working group of 10 clinical experts across Australia and New Zealand. MEDLINE, medRxiv and grey literature were searched to 4 October 2020. The level of evidence was stratified according to the National Health and Medical Research Council evidence hierarchy., Results: A total of 1020 records were identified, from which 20 studies (12 peer-reviewed) were included. None were randomized trials. The studies comprised one case-control study (level III-2 evidence), one prospective cohort study (level III-2) and 18 case-series studies (level IV). Follow-up periods containing observable clinical characteristics ranged from 3 to 16 weeks. New or excessive fatigue and breathlessness were the most frequently reported symptoms. SARS-CoV-2 may impact the immune system for multiple months after laboratory confirmation of infection. For patients with past COVID-19 undergoing elective curative surgery for cancer, risks of pulmonary complications and mortality may be lowest at 4 weeks or later after a positive swab., Conclusion: After laboratory confirmation of SARS-CoV-2 infection, minor surgery should be delayed for at least 4 weeks and major surgery for 8-12 weeks, if patient outcome is not compromised. Comprehensive preoperative and ongoing assessment must be carried out to ensure optimal clinical decision-making., (© 2021 Royal Australasian College of Surgeons.)

Patients waitlisted for elective general surgery in New Zealand used to be prioritised by multiple tools that were inconsistent, did not reflect clinical judgement and were not validated. We describe the development and implementation of a national prioritisation tool for elective general surgery in New Zealand, which could be applicable to other OECD countries. The tool aims to achieve equity of access, transparency, reliability and should be aligned with clinical judgement. The General Surgery Prioritisation Tool Working Group commenced development of a prioritisation tool in 2014 which showed strong correlation with clinical judgement (r = 0.89), excellent test-retest reliability (r = 0.98) and significantly lower variability (p < 0.001). Preliminary findings showed no significant difference in scores attributable to age, gender or ethnicity. General Surgeons were in favour of the tool criteria and agreed on the importance of prioritisation; however a minority opposed its introduction. Health organisations and general practitioner groups were in favour, however, along with many surgeons, expressed apprehensions regarding subjectivity, manipulation, equity of access and degree of benefit. Despite reservations, the majority of stakeholders were supportive and through collaboration between clinicians and the government, the tool was implemented in 2018 in New Zealand. Overall, the prioritisation tool is a reliable method of assessing priority, demonstrating transparency and reflecting clinical judgement, with equity of access to be further assessed by evaluation in clinical practice., Competing Interests: Declaration of Competing Interest There are no conflicts of interest to disclose., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: Emergency laparotomy (EL) encompasses a high-risk group of operations, which are increasingly performed on a heterogeneous population of patients, making preoperative risk assessment potentially difficult. The UK National Emergency Laparotomy Audit (NELA) recently produced a risk predictive tool for EL that has not yet been externally validated. We aimed to externally validate and potentially improve the NELA tool for mortality prediction after EL., Methodology: We reviewed computer and paper records of EL patients from May 2012 to June 2017 at Middlemore Hospital (New Zealand). The inclusion criteria mirrored the UK NELA. We examined the NELA, Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Acute Physiology and Chronic Health Evaluation II (APACHE-II), and American College of Surgeons National Surgical Quality Improvement Programs risk predictive tools for 30-day mortality. The Hosmer-Lemeshow test was used to assess calibration, and the c statistic, to evaluate discrimination (accuracy) of the tools. We added the modified frailty index (mFI) and nutrition to improve the accuracy of risk predictive tools., Results: A total of 758 patients met the inclusion criteria, with an observed 30-day mortality of 7.9%. The NELA was the only well calibrated tool, with predicted 30-day mortality of 7.4% (p = 0.22). When combined with mFI and nutritional status, the c statistic for NELA improved from 0.83 to 0.88. American College of Surgeons National Surgical Quality Improvement Programs, APACHE-II, and P-POSSUM had lower c statistics, albeit also showing an improvement (0.84, 0.81, and 0.74, respectively)., Conclusion: We have demonstrated the NELA tool to be most predictive of mortality after EL. The NELA tool would therefore facilitate preoperative risk assessment and operative decision making most precisely in EL. Future research should consider adding mFI and nutritional status to the NELA tool., Level of Evidence: Level IV; Retrospective observational cohort study.

Background: Bariatric surgery, in recent times, has gained media attention that has influenced individual, healthcare provider and wider societal attitudes towards bariatric surgery. Studies exploring public and media levels of interest in bariatric surgery have been performed overseas but studies within New Zealand (NZ) are scarce. Analysis of Google Trends data may be a useful source of information in investigating public interest levels in bariatric surgery. We aimed to analyse Google Trends information on Internet searches in NZ and to explore sequential relationships with relevant changes in policy., Methods: Key search terms for our Google Trends query were retrieved by independently reviewing news articles relating to bariatric surgery in NZ published between January 2007 and December 2017 and following a brainstorming session. Trend analyses were performed using Microsoft Excel 14.7.2. Data were captured for both NZ and worldwide search interests in Google Trends., Results: Trend analyses showed that total search volumes for 'lap band' and 'lap band surgery' declined while 'gastric sleeve' and 'gastric sleeve surgery' increased exponentially over the 10-year period. Furthermore, search interests for key terms in NZ were comparable with those worldwide., Conclusion: Our findings reveal that search interests related to bariatric surgery in NZ mirror those worldwide. This includes the popularity of some bariatric procedures over others. The use of Google Trends may provide us with an additional tool to evaluate public interest levels related to bariatric surgery in NZ and could add value in examining the socio-cultural and political contexts of obesity and bariatric surgery., (© 2018 Royal Australasian College of Surgeons.)

Background: The prioritization of elective surgical wait-lists remains a contentious issue. Multiple new tools and systems have been developed to attempt to reliably prioritize patients. This study pilots one such system, the General Surgery Prioritization Tool and compares it to the existing triage system of clinical judgement. The aim was to determine if the new tool reflects clinical judgement. Secondary aims were to assess for any bias in its application to different patient groups or its application by different scorers., Method: A cohort of 392 patients was identified who were wait-listed for non-cancer elective surgery between July 2015 and February 2016. The General Surgery Prioritization Tool was applied after traditional prioritization using clinical judgement. The scores produced by the new tool were compared to the clinical judgement categories. Differences in scores based on gender, ethnicity, age, surgical condition and surgeon were then analysed., Results: There was statistically significant correlation in the new tool scores with traditional triage groups (P < 0.0001). There were no statistically significant differences in mean scores attributable to gender, age or ethnicity. There were minimal differences in mean scores between common surgical conditions. Except for one outlier the mean scores were consistent across 17 surgeons., Conclusion: This pilot study has found the General Surgery Prioritization Tool to reflect clinical judgement and to be generalizable by age, gender, ethnicity and prioritizing surgeon. The tool is at least as clinically reliable as traditional methods in the triage for elective general surgery with the advantage of being a more explicit process., (© 2018 Royal Australasian College of Surgeons.)

Aim: Media constructs in Aotearoa, New Zealand naturalise the dominant Western culture. Conversely, mainstream news about Māori is rare and prioritises negative stereotypical constructs that are often centred on Māori as economic threats via resource control and political activism. These narratives influence continued discrimination against Māori in New Zealand. Media representations of bariatric surgery in New Zealand are not widely understood. We explored the portrayal of Māori and bariatric surgery in print and online news media articles in New Zealand using an inductive approach to thematic analysis., Method: An electronic search of two databases (Proquest Australia/ New Zealand Newsstream and Newztext) and two New Zealand news media websites (Stuff and the New Zealand Herald) was performed to retrieve news articles reporting stories, opinion pieces or editorials concerning Māori and bariatric surgery published between January 2007 to June 2017. Articles were scored using a five-point scale to assess the level of reporting as either very negative, negative, neutral, positive or very positive. Included articles were then subjected to inductive thematic analysis using the NVIVO 11 to identify and explore common themes surrounding Māori and bariatric surgery., Results: Of 246 articles related to bariatric surgery over the 10-year study period, 31 (13%) were representative of Māori. Articles were scored as 'neutral' to 'positive' with a mean reporting score of 3.7 (Kappa score of 0.72 [95% CI, 0.66-0.78, p<0.0001]). Five main themes were identified, these were: Attitudes towards bariatric surgery; complexity of obesity and weight loss; access to bariatric surgery; Māori advocacy and framing of Māori. Of the five themes, access to bariatric surgery and attitudes towards bariatric surgery were most prevalent. Māori advocacy was another common theme that arose largely due to the support of public funding of bariatric surgery championed by Dame Tariana Turia. Aside from this, narratives describing equity of bariatric surgery provision and equitable outcomes following bariatric surgery for Māori were sparse., Conclusion: There was limited reporting on Māori health inequalities and equitable access to publicly funded bariatric surgery in New Zealand. We argue that this lack of coverage may work against addressing disparities in obesity prevalence and access to publicly funded bariatric surgery for Māori in New Zealand., Competing Interests: Nil.

Background: Publicly funded bariatric surgery in New Zealand (NZ) is steadily on the rise to meet the obesity epidemic. Ethnic disparities in obesity rates exist in NZ with Māori and Pacific people having three to five times higher rates than all other ethnic groups within NZ. Ethnic disparities in rates of bariatric surgery have been reported internationally. This research sought to describe rates of publically funded bariatric surgery by self-identified ethnicity in NZ., Methods: Using reported census and hospitalization discharge data from Statistics NZ and the NZ Ministry of Health, we calculated estimate rates of publicly funded bariatric surgery in the morbidly obese population from June 2009 to July 2014., Results: The average number of publicly funded bariatric procedures performed per 1000 morbidly obese patients from June 2009 to July 2014 was 3.0 for European, 1.4 for Māori and 0.7 for Pacific ethnicities., Conclusion: While these data should be interpreted cautiously due to data limitations, the estimated rates may indicate that bariatric services are currently being provided inequitably across the major ethnic groups within NZ. We suggest that further studies should be performed to explore potential patient, healthcare provider and system-level factors that may contribute to ethnic disparities in the rates of publicly funded bariatric surgery in NZ., (© 2017 Royal Australasian College of Surgeons.)

Background: Although many clinical prediction rules (CPRs) for appendicitis exist, none have been developed for a New Zealand population presenting with right iliac fossa (RIF) pain. The aim of this study was to derive and validate an appendicitis CPR for our population., Method: This is a retrospective review of all patients from December 2010 to February 2012 of at least 15 years of age presenting to the general surgery service with RIF pain. Patient data were divided into derivation and validation groups. Univariate and multiple regression analyses identified significant predictors of appendicitis which were used to construct a CPR. A retrospective validation study was then performed and the CPR was refined accordingly. Finally, the accuracy of the CPR was tested., Results: The final components of the new CPR, the APPEND score, were Anorexia, migratory Pain, local Peritonism, Elevated C-reactive protein, Neutrophilia and male gender (Dude). This CPR has an area under the receiver operating characteristic curve of 0.84. The CPR can stratify patients into low, intermediate and high-risk groups which may standardize patient care and reduce the negative appendicectomy rate., Conclusion: A new CPR for predicting appendicitis, in patients presenting with RIF pain, has been derived and validated for use in our population. A prospective study to further evaluate its performance is required., (© 2017 Royal Australasian College of Surgeons.)

Aims: Communication failures in healthcare are frequent and linked to adverse events and treatment errors. Simulation-based team training has been proposed to address this. We aimed to explore the feasibility of a simulation-based course for all members of the operating room (OR) team, and to evaluate its effectiveness., Methods: Members of experienced OR teams were invited to participate in three simulated clinical events using an integrated surgical and anesthesia model. We collected information on costs, Behavioural Marker of Risk Index (BMRI) (a measure of team information sharing) and participants' educational gains., Results: We successfully recruited 20 full OR teams. Set up costs were NZ$50,000. Running costs per course were NZ$4,000, excluding staff. Most participants rated the course highly. BMRI improved significantly (P = 0.04) and thematic analysis identified educational gains for participants., Conclusion: We demonstrated feasibility of multidisciplinary simulation-based training for surgeons, anesthetists, nurses and anaesthetic technicians. The course showed evidence of participant learning and we obtained useful information on cost. There is considerable potential to extend this type of team-based simulation to improve the performance of OR teams and increase safety for surgical patients.

Background: Laparoscopic sleeve gastrectomy (LSG) is increasingly used as a single-stage bariatric procedure. However, its safety and efficacy in super-obese patients (body mass index [BMI] > 50 kg/m(2)) is less well defined. This series reports on 400 consecutive patients who underwent LSG at our institution, to evaluate safety and efficacy in the super-obese., Materials and Methods: We performed a retrospective review of prospectively collected data on 400 consecutive patients who underwent LSG at our institution. We analyzed baseline demographic data, median length of hospital stay, complications, length of follow-up, weight loss, and comorbidity resolution. We graded complications according to the Clavien-Dindo classification system. We classified patients as super-obese and non-super-obese and compared outcomes between groups. We used the two-tailed t-test and Fisher's exact test as necessary., Results: There were 400 patients, 291 of whom were female (73%). The mean age was 44 y (standard deviation [SD] ± 9 y). The mean preoperative weight and BMI were 140 kg (SD ± 31 kg) and 49 kg/m(2) (SD ± 9 kg/m(2)), respectively. There were 67 complications (16%) in total. The major complication rate was 7.2%, with one recorded death. The median length of hospital stay was 3 d, and the mean follow-up period was 1 y. A total of 170 patients (43%) were super-obese, with a mean preoperative BMI of 56 kg/m(2) (SD ± 5 kg/m(2)). The mean absolute weight loss (59 versus 36.7 kg; P < 0.01) and percentage excess weight loss (58.9% versus 45.9%; P < 0.01) was significantly higher in the super-obese. The mean postoperative BMI for super-obese patients was 38.9 kg/m(2). There was no difference between groups in the incidence of major complications (8.2% versus 6.5%; P = 0.56)., Conclusion: Laparoscopic sleeve gastrectomy is safe and effective in the super-obese, with acceptable weight loss and no increase in the major complication rate., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Aims: This paper describes the rationale and methodology of a study assessing the reliability of tools for clinical prioritisation (Clinical Priority Assessment Criteria [CPAC]) of patients for elective surgery in New Zealand., Methods: Surgeons from three specialties (general, vascular, and orthopaedic surgery) completed a computerised evaluation rating clinical vignettes across a range of diagnoses using several priority tools. The study design is described and an outline of the individual tool development and definitions is given., Results: Of the 124 surgeons that participated in this study, 48% (60) were general surgeons, 21% (26) were vascular surgeons and 31% (38) were orthopaedic surgeons. The response rates in the first phase of data collection were 67%, 79%, and 63% for general, vascular, and orthopaedic surgery respectively. Completion rates were high with 100%, 93%, and 98% of the same groupings of surgeons completing the first round evaluations. A further 77% to 89% of the participants from the first round also completed the re-test evaluation., Conclusion: This study indicates that assessment of the reliability of CPAC tools currently in use in New Zealand is feasible using a vignette-based approach. In the future, study designs that allow for some face-to-face contact may be preferable for achieving optimal response and completion rates among surgeons. Further work from this study will focus on the individual results for each specialty and examining whether altering ethnicity status in vignettes had any effect on scoring behaviour.

Background: To assess the presentation, management and risk factors for mortality in necrotizing fasciitis at Middlemore Hospital in South Auckland, New Zealand., Methods: A retrospective review of the medical records of patients presenting to Middlemore Hospital over a 6-year period (1997-2002) with a diagnosis of necrotizing fasciitis., Results: Forty eight patients were identified. There were 27 men and 21 women whose age ranged from 19 to 80 years (median 51 years) at presentation. Maori and Pacific Islanders accounted for 64% of total admissions despite making up only 31% of the referral population. Streptococcus Pyogenes was the most common bacterial isolate (54%). 31% of patients had polymicrobial infections. Sixty-two per cent of cases involved extremities. The median number of operations and length of stay were 4 and 31 days, respectively. Overall mortality was 29%. In multivariate analysis, delay in surgical intervention (P = 0.015) and diabetes mellitus (P = 0.023) were found to be associated with increased mortality. Ethnicity, sex, type of pathogen, site of infection and increasing age did not affect mortality., Conclusion: Necrotizing fasciitis remains a significant problem in our community especially in the Maori and Pacific population. Early surgical debridement decreases mortality rates.

Background: The introduction of health reforms in New Zealand included the setting of an arbitrary waiting time threshold of 6 months for surgery. The aim of the present study was to investigate the differences in waiting times for different diagnoses in elective general surgery, and the interplay between diagnoses and waiting time thresholds., Methods: A survival curve analysis of 918 patients placed on the elective general surgical waiting lists was conducted. This was undertaken in a tertiary level hospital in New Zealand before the implementation of the waiting time thresholds. The difference between diagnoses of time waited for elective surgery (plotted on survival curves), and hazard function for patients waiting at 180, 360 and 540 days, was investigated., Results: Survival curves for malignancy, cholelithiasis, hernias and anorectal disease were different on log-rank test (P < 0.001). Those with a diagnosis of malignancy show that at 180 days the hazard function was 0.0049 but by 360 days had dropped to zero. With hernias and anorectal disease, the drop to zero appeared to be delayed until 540 days; however, the confidence intervals at 360 days included zero. In the case of cholelithiasis, the hazard functions indicate surgery occurring until 540 days., Conclusions: There are different waiting time thresholds for different surgical illnesses. Setting a universal waiting time for elective surgery is not supported.