Management of type 2 diabetes in New Zealand: a scoping review of interventions with measurable clinical outcomes.

OBJECTIVE: This review aimed to assess the effectiveness of interventions for type 2 diabetes (T2D) management in New Zealand on clinical outcomes, and explore the factors impacting their feasibility and acceptability. STUDY DESIGN: Scoping review. METHODS: Three databases (PubMed, Web of Science and Scopus) were searched between January 2000 and July 2023. Reference lists of included studies were hand searched to identify additional articles. RESULTS: The search yielded 550 publications, of which 11 were included in the final review. Most interventions (n = 10) focussed on education and seven were delivered by health professionals. Supporting factors for interventions included clinical/peer support (n = 8) and whanau (family) involvement (n = 6). Hindering factors included non-adherence (n = 4) and high drop-out (n = 4). Most studies reported modest improvement in HbA1c and weight at six months, but minimal change in HbA1c, weight, lipids, renal profile, and blood pressure by two years. CONCLUSION: Future interventions should involve culturally appropriate approaches to improve engagement and acceptability while addressing lifestyle and medication adherence for T2D management. T2D interventions not widely disseminated via academic channels need to be further identified.

Key factors in the decision-making process for mastectomy alone or breast reconstruction: A qualitative analysis.

Breast cancer is the most common cancer to affect New Zealand women. Women diagnosed face several decisions regarding surgical treatment, including whether to undergo lumpectomy, mastectomy, or breast reconstruction. Reconstructive surgery adds an additional layer of complexity, with several reconstructive options, each associated with differing surgical and recovery times. Furthermore, surgical decisions are often made under time-pressure and significant diagnostic distress, therefore provision of good information to support decision-making is crucial to adequately inform women of their options. We interviewed 24 women who had undergone breast surgery within the preceding 12 months to assess the key factors leading to their decision to opt for their chosen surgical procedure. Interviews revealed that decision-making was complex and involved multiple factors. Women were ultimately confronted with assessing feminine identity versus survival. Whether opting for breast reconstruction or not, women were fearful of what surgery would involve and how their reconstructed breast or mastectomy scar might look following surgery. Shared decision-making between patient and clinician can mitigate this fear and provide women with a sense of autonomy over their health decisions. Provision of visual depictions of surgical outcomes was not routinely provided to those interviewed but was expressed as important to help women manage surgical expectations. Therefore our findings support the multi-modal presentation of diagnostic and treatment information to support decision-making. Likewise, women reported feeling unsupported in their decision not to undergo breast reconstruction, suggesting a need to develop resources to provide women with positive discussions about 'going flat'.

A policy of day-case sinonasal surgery is safe, well tolerated and cost-effective.

OBJECTIVE: Practices vary regarding the timing of discharge after sinonasal surgery. This study aimed to examine the cost-effectiveness of same-day discharge compared to next-day discharge after sinonasal surgery. METHODS: A retrospective single-surgeon audit of sinonasal surgery over a 12-month period was performed. Demographic and clinical details, including distance travelled home, timing of discharge, hospital re-presentation, and complications, were collected and compared between the same-day discharge and next-day discharge groups. A cost-effectiveness analysis was performed. RESULTS: A total of 181 patients were identified; 117 underwent day-case surgery, of which 6 re-presented to the emergency department. Sixty-four patients stayed overnight after surgery, and six of those patients re-presented to the emergency department. The per patient cost was $3262 for day-case sinonasal surgery and $5050 for those admitted overnight after surgery (p < 0.001). CONCLUSION: Routine same-day discharge after sinonasal surgery is achievable, safe and cost-effective.

Community engagement in general practice: a qualitative study.

BACKGROUND Community engagement is believed to be an important component of quality primary health care. We aimed to capture specific examples of community engagement by general practices, and to understand the barriers that prevent engagement. METHODS We conducted 20 distinct interviews with 31 key informants from general practice and the wider community. The interviews were semi-structured around key relevant topics and were analysed thematically. RESULTS Key themes identified from the interview transcripts included an understanding of 'community', examples of community engagement and the perceived benefits and barriers to community-engaged general practice. We particularly explored aspects of community engagement with Maori. CONCLUSIONS General practices in the study do not think in terms of communities, and they do not have a systematic framework for engagement. Although local champions have generated some great initiatives, most practices seemed to lack a conceptual framework for engagement: who to engage with, how to engage with them, and how to evaluate the results of the engagement.

The prevalence of diabetic foot disease in the Waikato region.

AIM: The aim of this study was to establish the prevalence of diabetic foot disease by utilising the retinal eye screening register in the Waikato region of New Zealand. Understanding both the prevalence and the degree of foot disease across the general diabetes population will help to determine what podiatry services are required for people with diabetes. METHOD: 2192 people aged 15years and over, who attended the Waikato Regional Diabetes Service mobile retinal photo screening service for the six-month period between May and November 2014, consented to a foot screen including testing for sensation and pedal pulses. A digital image was taken of the dorsal and plantar aspect of each foot for review by a registered Podiatrist. RESULTS: Thirteen percent of the study sample was identified as having a high-risk foot including active foot complications. 65% were categorised as low risk and a further 22% at moderate risk of diabetic foot disease. Factors identified as significant included age, type of diabetes, duration of diabetes, and smoking. These factors placed people at greater risk of diabetic foot disease. CONCLUSION: A significant number of people with diabetes are at risk of diabetic foot disease. This study has highlighted the need for targeted podiatry services to address diabetic foot disease.

Investigations and referral for suspected cancer in primary care in New Zealand-A survey linked to the International Cancer Benchmarking Partnership.

A national internet-based survey of New Zealand (NZ) primary care physicians (n = 192) used the survey instrument developed by the International Cancer Benchmarking Partnership (ICBP). Practitioners were recruited by a range of methods assisted by NZ general practice networks and contacts. Compared to 11 other ICBP jurisdictions, direct access to diagnostic tests was more limited and took more time than in most other areas; the average wait for a test to be done and reported was 3.0 weeks for X-rays and 8.0 for ultrasound, compared to ICBP averages of 1.6 and 4.7 weeks respectively. Forty-five per cent of respondents could get specialist advice within 48 hr. Sixty-six per cent were aware of NZ guidelines for cancer in primary care, and of those 44% consulted them sometimes or often. Access to tests was greater, and time required much less, in the private than the public care system. NZ respondents each answered two of five clinical vignettes, with results similar to other ICBP areas. The survey also included general practice trainees (N = 42); their results were similar to the main group. The results suggest that improvements in prompt access to diagnostic tests and referrals for suspected cancer need to be given priority in NZ.

Breast cancer inequities between Maori and non-Maori women in Aotearoa/New Zealand.

Maori women have one of the highest incidences of breast cancer in the world. This high incidence is generally unexplained although higher rates of obesity and alcohol intake are modifiable risk factors that may be important. Maori women are less likely to attend mammographic breast screening and are likely to be diagnosed with more advanced disease. This is one of the reasons for the excess mortality. Another factor is differences in the treatment pathway. Maori women are more likely to experience delay in receiving treatment, are less likely to receive radiotherapy, are more likely to be treated with a mastectomy and are less likely to adhere to long-term adjuvant endocrine therapy. However, genetic factors in Maori women do not seem to impact significantly on mortality. This review looks at the inequity between Maori and non-Maori women and addresses the causes. It proposes ways of reducing inequity through primary prevention, increased participation in breast screening and greater standardisation of the treatment pathway for women newly diagnosed with breast cancer. We believe that health system improvements will decrease barriers to health care participation for Maori women and suggest that further research into identifying and modifying obstacles within health systems is required.

Differences in survival between Maori and New Zealand Europeans with prostate cancer.

This study aims to examine the survival disparity between Maori men and New Zealand (NZ) Europeans diagnosed with prostate cancer. We identified men aged 40+ years in the Midland Cancer Network region registered with prostate cancer in 2007-2010 in the Cancer Registry. Data were extracted from patient notes of all Maori men and a sample of NZ Europeans. The survival disparity between Maori men and Europeans was estimated by the Kaplan-Meier method and Cox proportional-hazards regression models after adjusting for other factors. This study included 535 men with prostate cancer (135 Maori men and 400 Europeans). The 5-year cancer-specific survival was 98.6% for men diagnosed with localised cancer, 88.8% for locally advanced disease and 19.1% for metastatic cancer. The all-cause survival and the cancer-specific survival were both significantly poorer for Maori men than for NZ Europeans (log rank test: P = 0.004, 0.006 respectively). The hazard ratio of cancer-specific survival for Maori men was 2.01 (95% CI: 1.21-3.36) compared with NZ Europeans. Maori men with prostate cancer had poorer all-cause survival and cancer-specific survival than NZ Europeans. Maori men were at risk of having more advanced disease at diagnosis, which explains most of the survival inequity between Maori men and NZ Europeans.

Risk factors associated with mortality from breast cancer in Waikato, New Zealand: a case-control study.

OBJECTIVES: The aim of this study is to identify key characteristics associated with mortality from breast cancer among women with newly diagnosed breast cancer in New Zealand (NZ). STUDY DESIGN: Case-control study. METHODS: All primary breast cancers diagnosed between 01/01/2002 and 31/12/2010 in Waikato, NZ, were identified from the Waikato Breast Cancer Register. A total of 258 breast cancer deaths were identified from 1767 invasive cancers diagnosed over this period. RESULTS: Breast cancer deaths (n = 246) were compared with an age and year of diagnosis matched control group (n = 652) who were alive at the time of the death of the corresponding case and subsequently did not die from breast cancer. Diagnosis through symptomatic presentation, advanced stage, higher grade, absent hormone receptors (i.e. oestrogen and progesterone) and HER-2 amplification were associated with significantly higher risks of breast cancer mortality in bivariate analysis. Tumour stage, grade and hormone receptor status remained significant in the multivariable model, while mode of detection and HER-2 status were non-significant. In the bivariate analysis, Maori women had a higher risk of breast cancer mortality compared to NZ European women (OR 1.34) which was statistically non-significant. However in the adjusted model, risk of mortality was lower for Maori compared to NZ European women, although this was not significant statistically (OR 0.85). CONCLUSIONS: Mortality pattern from breast cancer in this study were associated with established risk factors. Ethnic inequity in breast cancer mortality in NZ appears to be largely attributable to delay in diagnosis and tumour related factors. Further research in a larger cohort is needed to identify the full impact of these factors on ethnic inequity in breast cancer mortality.

Prostate cancer incidence and mortality in rural men--a systematic review of the literature.

INTRODUCTION: Prostate cancer is a common health problem in men worldwide. This systematic review has been undertaken to determine if there are differences in incidence of and mortality from prostate cancer between rural and urban men. The understanding of geographical patterns of prostate cancer incidence and mortality is necessary in order to identify and assess any disparities between rural and urban residents in gaining access to healthcare services, such as screening, diagnosis and treatment. METHODS: Medline, CINAHL and Embase were searched using relevant mesh phrases, such as 'prostate cancer incidence rural' or 'prostatic neoplasms mortality rural'. Secondary literature and reports not published in peer-reviewed journals were included if inclusion criteria had been met. The following inclusion criteria were applied: cohort (population-based study) of adult men, diagnosis of prostate cancer, comparing rural and urban groups, and incidence or mortality with available statistical parameters as outcome. RESULTS: In total, 25 studies were found to fit the inclusion criteria. Sixteen cohort studies were identified that examined incidence of prostate cancer in rural and urban populations, while 18 studies focused on mortality. Nine of these publications discussed both aspects. Twenty of these studies were published in scientific journals, while five were reports identified through secondary literature search. Prostate cancer incidence was found to be higher in urban men, while mortality patterns seemed to vary to some degree depending on different definitions of rural/urban groups, as well as on variations in demographic factors and study periods. There is evidence, however, that after prostate-specific antigen testing was introduced death rates tended to be higher in rural men with prostate cancer. CONCLUSIONS: The review of the literature showed that in spite of inconsistent definitions of rural/urban categories among studies the majority reported higher incidence rates in urban men. This finding suggests that rural men are less likely to be screened and less likely to be subsequently diagnosed with prostate cancer. Although mortality patterns tended to be heterogeneous, there was some evidence that rural residents with prostate cancer experience higher death rates. It would be beneficial if future studies take into consideration factors such as stage at initial diagnosis, ethnicity, and socioeconomic and health status when assessing differences in cancer outcomes. Few studies in this review accounted for one or more of these variables, although there are indications that they contribute to differences in prostate cancer incidence and mortality between rural and urban populations.

Ethnic differences in the natural progression of nephropathy among diabetes patients in New Zealand: hospital admission rate for renal complications, and incidence of end-stage renal disease and renal death.

AIMS/HYPOTHESIS: We estimated the incidence of chronic renal failure, the incidence of end-stage renal disease (ESRD) and renal mortality rates among New Zealand European and Maori patients with diabetes and estimated the ethnic difference in the risk of developing renal failure. METHODS: A renal complication-free cohort of adult diabetes patients registered with Waikato regional diabetes service, diagnosed with diabetes before 2003, were retrospectively followed for 4 years. Events of interest were renal hospital admission, ESRD and death coded with renal disease. Incidences of renal hospital admission, ESRD and death from renal disease were calculated for NZ Europeans and Maori patients with diabetes. Ethnic and sex differences in the risks of these renal outcomes were estimated using a Cox proportional hazards model. RESULTS: Of the 7,900 patients followed up, 116 (1.5%) had a renal admission, 42 (0.5%) started dialysis/transplantation and 21 (0.27%) died from renal disease. Maori diabetes patients had significantly higher incidences of dialysis or transplantation and rates of renal admission and renal death. Adjusted hazard ratios indicate that, compared with NZ Europeans with diabetes, Maori diabetes patients had a significantly higher risk of ESRD, renal admission and renal death (46-fold, seven-fold and four-fold increases, respectively). Maori patients progressed at a significantly faster rate from first hospital admission for chronic renal disease to ESRD. CONCLUSIONS/INTERPRETATION: There were huge ethnic disparities in outcomes from renal disease. Screening for early kidney disease among Maori diabetes patients, intensive management of risk factors and further research on the aetiology of renal disease among Maoris is recommended.

Prevalence of diabetes in New Zealand general practice: the influence of ethnicity and social deprivation.

BACKGROUND: The prevalence of diagnosed diabetes among different ethnic groups and the influence of deprivation on the prevalence of diabetes among Maori and New Zealand Europeans was investigated. METHODS: This was a cross-sectional survey on all patients registered with 10 practices in the Rotorua General Practice Group on 1 July 2007. Patients diagnosed with diabetes were identified though diagnostic codes for diabetes, prescriptions for diabetes medications and laboratory tests for glycosylated haemoglobin (HbA(1c)). Prevalence of diabetes by ethnicity, age group, gender and NZDep2001 quintiles was calculated. Adjusted ORs for the risk of diabetes were obtained from logistic regression analysis. RESULTS: Of the 45 500 patients registered, 1819 had been diagnosed with diabetes mellitus. In the 40+ age groups, the prevalence of diabetes in Maori and Pacific people was around three times that in Europeans. With increasing deprivation, the age-standardised prevalence of diagnosed diabetes increased among European males (2.7-5.0%) and females (2.1-3.1%). However, the prevalence of diabetes was highest among the least deprived Maori (males 9.7%, females 6.2%). The adjusted risk of diabetes for the most deprived Maori is not significantly different from that for the least deprived Maori. The most deprived Europeans had nearly twice the risk of having diabetes than the least deprived Europeans. CONCLUSIONS: Although the rising prevalence of diabetes with increasing deprivation among Europeans shows a similar trend to results from national and international studies, the trend among Maori seems to be different because the least deprived are equally at risk of diabetes. Diabetes interventions aimed at Maori should be tailor-made to include the least deprived groups.

Risk of myocardial infarction in men and women with type 2 diabetes in the UK: a cohort study using the General Practice Research Database.

AIMS/HYPOTHESIS: Our primary aim was to establish reliable and generalisable estimates of the risk of myocardial infarction (MI) for men and women with type 2 diabetes in the UK compared with people without diabetes. Our secondary aim was to investigate how the MI risk associated with diabetes differs between men and women. METHODS: A cohort study using the General Practice Research Database (1992-1999) was carried out, selecting 40,727 patients with type 2 diabetes and 194,913 age and sex-matched patients without diabetes. Rates of MI in men and women with and without diabetes were derived, as were hazard ratios for MI adjusted for known risk factors. RESULTS: The rate of MI in men with type 2 diabetes was 19.74 (95% CI 18.83-20.69) per 1,000 person-years compared with 16.18 (95% CI 15.33-17.08) per 1,000 person-years in women with type 2 diabetes. The overall adjusted relative risk of MI in diabetes versus no diabetes was 2.13 (95% CI 2.01-2.26) in men and 2.95 (95% CI 2.75-3.17) in women and decreased with age in both sexes. Women with type 2 diabetes aged 35 to 54 years were at almost five times the risk of MI compared with women of the same age without diabetes (HR 4.86 [95% CI 2.78-8.51]). CONCLUSIONS/INTERPRETATION: This study has demonstrated that women with type 2 diabetes are at a much greater relative risk of MI than men even when adjusted for risk factors.

Risk of stroke in people with type 2 diabetes in the UK: a study using the General Practice Research Database.

AIMS/HYPOTHESIS: Risk estimates for stroke in patients with diabetes vary. We sought to obtain reliable risk estimates for stroke and the association with diabetes, comorbidity and lifestyle in a large cohort of type 2 diabetic patients in the UK. MATERIALS AND METHODS: Using the General Practice Research Database, we identified all patients who had type 2 diabetes and were aged 35 to 89 years on 1 January 1992. We also identified five comparison subjects without diabetes and of the same age and sex. Hazard ratios (HRs) for stroke between January 1992 and October 1999 were calculated, and the association with age, sex, body mass index, smoking, hypertension, atrial fibrillation and duration of diabetes was investigated. RESULTS: The absolute rate of stroke was 11.91 per 1,000 person-years (95% CI 11.41-12.43) in people with diabetes (n = 41,799) and 5.55 per 1,000 person-years (95% CI 5.40-5.70) in the comparison group (n = 202,733). The age-adjusted HR for stroke in type 2 diabetic compared with non-diabetic subjects was 2.19 (95% CI 2.09-2.32) overall, 2.08 (95% CI 1.94-2.24) in men and 2.32 (95% CI 2.16-2.49) in women. The increase in risk attributable to diabetes was highest among young women (HR 8.18; 95% CI 4.31-15.51) and decreased with age. No investigated comorbidity or lifestyle characteristic emerged as a major contributor to risk of stroke. CONCLUSIONS/INTERPRETATION: This study provides risk estimates for stroke for an unselected population from UK general practice. Patients with type 2 diabetes were at an increased risk of stroke, which decreased with age and was higher in women. Additional risk factors for stroke in type 2 diabetic patients included duration of diabetes, smoking, obesity, atrial fibrillation and hypertension.

Risk of colorectal cancer in general practice patients presenting with rectal bleeding, change in bowel habit or anaemia.

The aim was to use data routinely collected in general practice to assess the absolute risk of colorectal cancer in patients newly presenting to their general practitioner (GP) with relevant symptoms. Three cohorts were identified from patients attending a sample of UK general practices. Patients with new symptoms of rectal bleeding, changes in bowel habit or anaemia were identified, and their incident rate for colorectal cancer and the positive predictive value (PPV) of each symptom in the following 12 months were calculated by age and gender. The total population over the age of 40 years was 2.8 million, and 9143 incident cases of colorectal cancer were identified. A total of 67,164 patients (28% men) were identified with anaemia, 27,524 (40% men) with changes in bowel habit and 44,741 (48% men) with rectal bleeding. For each cohort, the absolute risk rose with increasing age, and men were twice as likely to develop colorectal cancer. The PPV for developing colorectal cancer in the subsequent 12 months in those aged 60-69 years with anaemia was 3.02% for men, 1.38% for women; with changes in bowel habit 6.89% for men, 2.42% for women; and with rectal bleeding was 5.99% for men, 3.50% for women. A combination of any two signs and symptoms doubled the risk of an underlying cancer. In UK general practice, men are less likely to present with symptoms and signs of colorectal cancer compared with women, but after investigation are much more likely to have a colorectal cancer diagnosed. This should be taken into account in guidelines for referral.

A semantically enabled formalism for the knowledge management of Parkinson's disease.

Bio-ontology is a formal representation of biological concepts that is used in the interchange of communication between computers and humans alike. They can then be used in the formulation and retrieval of knowledge. In developing a knowledge-based system for Parkinson's Disease, a procedure of knowledge map was used to capture and harness the intellectual resources of an organization, and new paradigms for knowledge mapping were also formulated. Knowledge bases for symptoms and drugs, physiotherapy, speech and language therapy, and dieting that affect patient care were developed. Finally, the knowledge bases were merged to form a single central repository of knowledge base.

Mortality in people with type 2 diabetes in the UK.

AIMS: Under-reporting of diabetes on death certificates contributes to the unreliable estimates of mortality as a result of diabetes. The influence of obesity on mortality in Type 2 diabetes is not well documented. We aimed to study mortality from diabetes and the influence of obesity on mortality in Type 2 diabetes in a large cohort selected from the General Practice Research Database (GPRD). Methods A cohort of 44 230 patients aged 35-89 years in 1992 with Type 2 diabetes was identified. A comparison group matched by year of birth and sex with no record of diabetes at any time was identified (219 797). Hazards ratios (HRs) for all-cause mortality during the period January 1992 to October 1999 were calculated using the Cox Proportional Hazards Model. The effects of body mass index (BMI), smoking and duration of diabetes on all-cause mortality amongst people with diabetes was assessed (n = 28 725). Results The HR for all-cause mortality in Type 2 diabetes compared with no diabetes was 1.93 (95% CI 1.89-1.97), in men 1.77 (1.72-1.83) and in women 2.13 (2.06-2.20). The HR decreased with increasing age. In the multivariate analysis in diabetes only, the HR for all-cause mortality amongst smokers was 1.50 (1.41-1.61). Using BMI 20-24 kg/m(2) as the reference range, for those with a BMI 35-54 kg/m(2) the HR was 1.43 (1.28-1.59) and for those with a BMI 15-19 kg/m(2) the HR was 1.38 (1.18-1.61). CONCLUSIONS: Patients with Type 2 diabetes have almost double the mortality rate compared with those without. The relative risk decreases with age. In people with Type 2 diabetes, obesity and smoking both contribute to the risk of all-cause mortality, supporting doctrines to stop smoking and lose weight.

Emergency management of diabetes and hypoglycaemia.

OBJECTIVE: Hypoglycaemia is the commonest diabetic emergency and is associated with considerable morbidity and mortality. This study looked at the use of the emergency services by people with diabetes, with particular reference to hypoglycaemia. METHOD: Data were collected on all attendances related to diabetes at accident and emergency departments at two district general hospitals in Surrey, UK, over a one year period. RESULTS: Hypoglycaemia was the commonest reason for attendance at accident and emergency. The management of hypoglycaemia was variable, the most frequent method of treatment being intramuscular glucagon administered by the ambulance service. Ninety per cent of patients with hypoglycaemia were either discharged or self-discharged from the accident and emergency department, and half of these patients had no follow up arranged. CONCLUSIONS: Hypoglycaemia is the commonest diabetic emergency and current management is suboptimal. Standardised protocols and better education of healthcare professionals and patients are required.

All-cause mortality rates in patients with type 1 diabetes mellitus compared with a non-diabetic population from the UK general practice research database, 1992-1999.

AIMS/HYPOTHESIS: We compiled up to date estimates of the absolute and relative risk of all-cause mortality in patients with type 1 diabetes in the UK. MATERIALS AND METHODS: We selected patients with type 1 diabetes (n=7,713), and for each of these diabetic subjects five age- and sex-matched control subjects without diabetes (n=38,518) from the General Practice Research Database (GPRD). Baseline was 1 January 1992; subjects were followed until 1999. The GPRD is a large primary-care database containing morbidity and mortality data of a large sample representative of the UK population. Deaths occurring in the follow-up period were identified. RESULTS: The study comprised 208,178 person-years of follow-up. The prevalence of type 1 diabetes was 2.15/1,000 subjects in 1992 (mean age 33 years, SD 15). Annual mortality rates were 8.0 per 1,000 person-years (95% CI 7.2-8.9) in type 1 diabetic subjects compared with 2.4 per 1,000 person-years (95% CI 2.2-2.6) in those without diabetes (hazard ratio [HR]=3.7, 95% CI 3.2-4.3). The increased mortality rates in patients with type 1 diabetes were apparent across all age-bands. The HR was higher in women (HR=4.5, 95% CI 3.5-5.6 compared with non-diabetic women) than men (HR=3.3, 95% CI 2.7-4.0), such that the sex difference (p<0.0001) in mortality in the non-diabetic population was abolished (p=0.3) in the type 1 diabetic patients. The predominant cause of death in patients with type 1 diabetes was cardiovascular disease. CONCLUSIONS/INTERPRETATION: Despite advances in care, UK mortality rates in the past decade continue to be much greater in patients with type 1 diabetes than in those without diabetes.

Prehospital trauma management: a national study of paramedic activities.

OBJECTIVES: The benefits of prehospital trauma management remain controversial. This study aimed to compare the processes of care and outcomes of trauma patients treated by paramedics, who are trained in advanced prehospital trauma care, with those treated by ambulance technicians. METHODS: A six year prospective study was conducted of adult trauma patients attended to by the Scottish Ambulance Service and subsequently admitted to hospital. Prehospital times, interventions, triage, and outcomes were compared between patients treated by paramedics and those treated by technicians. RESULTS: Paramedics attended more severely injured patients (16.5% versus 13.9%, p<0.001); they attended a higher proportion of patients with penetrating trauma (6.6% versus 5.7%, p = 0.014) and had longer prehospital times. Patients managed by paramedics were more likely to be taken to the intensive care unit, operating theatre or mortuary, (11.2% versus 7.8%, p<0.001) and had higher crude mortality rates (5.3% versus 4.5%, p = 0.07). However, no difference in mortality between the two groups was noted when corrected for age, Glasgow coma score and injury severity score. CONCLUSIONS: This large scale national study shows that paramedics show good triage skills and clinical judgement when managing trauma patients. However, the value of the individual interventions they perform could not be ascertained. Further controlled trials are necessary to determine the true benefits of advanced prehospital trauma life support.