Impact of COVID-19 control on lung, breast, and colorectal pathological cancer diagnoses. A comparison between the Netherlands, Aotearoa New Zealand, and Northern Ireland.

BACKGROUND: The COVID-19 pandemic was managed in Aotearoa New Zealand (NZ) by a COVID-19 elimination policy, involving border closure and an initial national lockdown. This was different to most other countries including Northern Ireland (NI) and the Netherlands (NED). We quantify the effect of these policies on the diagnosis of three major cancers, comparing NZ with these two European countries. METHOD: Data from NED, NZ and NI population-based cancer registries were used to assess trends in all pathologically diagnosed (PD) lung, breast, and colorectal cancers from March to December 2020 (pandemic period) and compared to the similar pre-pandemic period (2017-2019). Trend data were also collated on COVID-19 cases and deaths per 100,000 in each population. RESULTS: Comparing the pre-pandemic period to the pandemic period there were statistically significant reductions in numbers of lung (↓23%) and colorectal (↓15%) PD cancers in NI and numbers of breast (↓18%) and colorectal cancer (↓18.5%) diagnosed in the NED. In NZ there was no significant change in the number of lung (↑10%) or breast cancers (↑0.2%) but a statistically significant increase in numbers of colorectal cancer diagnosed (↑5%). CONCLUSION: The impact of COVID-19 on cancer services was mitigated in NZ as services continued as usual reflecting minimal healthcare disruption and protected cancer services linked with the elimination approach adopted. The reduction in PD cases diagnosed in NED and NI were linked with higher COVID-19 rates and reflect societal restrictions which resulted in delayed patient presentation to primary and secondary care, disruption to screening and healthcare services as a result of COVID-19 infections on staff and the need to shift intensive care to COVID-19 patients. Reductions in PD cancers in NI and the NED and in particularly lung cancers in NI, highlight the need for targeted public health campaigns to identify and treat 'missing' patients. Protecting cancer services should be a priority in any future pandemic or systemic healthcare system disruption.

The impact of COVID-19 on lung cancer detection, diagnosis and treatment for Maori in Aotearoa New Zealand.

AIM: The purpose of this article is to examine disparities in the impact of the COVID-19 pandemic on access to lung cancer diagnosis and access to clinical services between Maori and non-Maori. METHODS: Using national-level data, we examined age-standardised lung cancer registrations, diagnostic procedures (bronchoscopy) and lung surgeries separately by ethnic group for the years 2018-2020, as well as patterns of stage of diagnosis. RESULTS: We found a trend toward a reduction in rates of lung cancer registration in Maori (but not non-Maori/non-Pacific) New Zealanders in 2020 compared to 2018 and 2019, but no apparent shift in the distribution of stage at diagnosis. We found a trend toward a reduction in rates of bronchoscopy for both Maori and non-Maori/non-Pacific patients, with the largest reduction observed for Maori. Rates of lung cancer surgery appeared to have reduced for Maori patients, although this was based on a small number of procedures. CONCLUSIONS: We observed disparities between Maori and non-Maori/non-Pacific patients in lung cancer registration and bronchoscopy as a result of the COVID-19 pandemic.

Maintaining cancer services during the COVID-19 pandemic: the Aotearoa New Zealand experience.

COVID-19 caused significant disruption to cancer services around the world. The health system in Aotearoa New Zealand has fared better than many other regions, with the country being successful, so far, in avoiding sustained community transmission. However, there was a significant initial disruption to services across the cancer continuum, resulting in a decrease in the number of new diagnoses of cancer in March and April 2020. Te Aho o Te Kahu, Aotearoa New Zealand's national Cancer Control Agency, coordinated a nationwide response to minimise the impact of COVID-19 on people with cancer. The response, outlined in this paper, included rapid clinical governance, a strong equity focus, development of national clinical guidance, utilising new ways of delivering care, identifying and addressing systems issues and close monitoring and reporting of the impact on cancer services. Diagnostic procedures and new cancer registrations increased in the months following the national lockdown, and the cumulative number of cancer registrations in 2020 surpassed the number of registrations in 2019 by the end of September. Cancer treatment services - surgery, medical oncology, radiation oncology and haematology - continued during the national COVID-19 lockdown in March and April 2020 and continued to be delivered at pre-COVID-19 volumes in the months since. We are cautiously optimistic that, in general, the COVID-19 pandemic does not appear to have increased inequities in cancer diagnosis and treatment for Maori in Aotearoa New Zealand.

The impact of the COVID-19 pandemic on cancer diagnosis and service access in New Zealand-a country pursuing COVID-19 elimination.

BACKGROUND: The COVID-19 pandemic has disrupted cancer services globally. New Zealand has pursued an elimination strategy to COVID-19, reducing (but not eliminating) this disruption. Early in the pandemic, our national Cancer Control Agency (Te Aho o Te Kahu) began monitoring and reporting on service access to inform national and regional decision-making. In this manuscript we use high-quality, national-level data to describe changes in cancer registrations, diagnosis and treatment over the course of New Zealand's response to COVID-19. METHODS: Data were sourced (2018-2020) from national collections, including cancer registrations, inpatient hospitalisations and outpatient events. Cancer registrations, diagnostic testing (gastrointestinal endoscopy), surgery (colorectal, lung and prostate surgeries), medical oncology access (first specialist appointments [FSAs] and intravenous chemotherapy attendances) and radiation oncology access (FSAs and megavoltage attendances) were extracted. Descriptive analyses of count data were performed, stratified by ethnicity (Indigenous Maori, Pacific Island, non-Maori/non-Pacific). FINDINGS: Compared to 2018-2019, there was a 40% decline in cancer registrations during New Zealand's national shutdown in March-April 2020, increasing back to pre-shutdown levels over subsequent months. While there was a sharp decline in endoscopies, pre-shutdown volumes were achieved again by August. The impact on cancer surgery and medical oncology has been minimal, but there has been an 8% year-to-date decrease in radiation therapy attendances. With the exception of lung cancer, there is no evidence that existing inequities in service access between ethnic groups have been exacerbated by COVID-19. INTERPRETATION: The impact of COVID-19 on cancer care in New Zealand has been largely mitigated. The New Zealand experience may provide other agencies or organisations with a sense of the impact of the COVID-19 pandemic on cancer services within a country that has actively pursued elimination of COVID-19. FUNDING: Data were provided by New Zealand's Ministry of Health, and analyses completed by Te Aho o Te Kahu staff.

Pill for this and a pill for that: A cross-sectional survey of use and understanding of medication among adults with multimorbidity.

OBJECTIVE: To understand the challenges managing medication use and knowledge of people living with multimorbidity. METHODS: A cross-sectional survey of 234 adults with multimorbidity, identified using retrospective hospital discharge data. Participants were recruited from two primary health organisations in New Zealand. RESULTS: Three quarters of participants (75%) were prescribed four or more medications, and one in four (27%) were prescribed eight or more medications. Participants reported knowing what their medications were for (88%, 95% CI 81.4-93.8) and when to take them (99%, 95% CI 97.5-99.9). However, over a fifth (22%, 95% CI 13.7-30.4) reported some problems managing multiple medications, and 40% (95% CI 30.2-50.2) reported a problem with side effects. CONCLUSION: The results highlight the need to consider how prescribing can be adapted for people with multimorbidity and move beyond the application of multiple disease-specific guidelines.

Effect of multimorbidity on health service utilisation and health care experiences.

INTRODUCTION Multimorbidity, the co-existence of two or more long-term conditions, is associated with poor quality of life, high health care costs and contributes to ethnic health inequality in New Zealand (NZ). Health care delivery remains largely focused on management of single diseases, creating major challenges for patients and clinicians. AIM To understand the experiences of people with multimorbidity in the NZ health care system. METHODS A questionnaire was sent to 758 people with multimorbidity from two primary health care organisations (PHOs). Outcomes were compared to general population estimates from the NZ Health Survey. RESULTS Participants (n = 234, 31% response rate) reported that their general practitioners (GPs) respected their opinions, involved them in decision-making and knew their medical history well. The main barriers to effective care were short GP appointments, availability and affordability of primary and secondary health care, and poor communication between clinicians. Access issues were higher than for the general population. DISCUSSION Participants generally had very positive opinions of primary care and their GP, but encountered structural issues with the health system that created barriers to effective care. These results support the value of ongoing changes to primary care models, with a focus on patient-centred care to address access and care coordination.

The impact of multimorbidity on people's lives: a cross-sectional survey.

AIMS: To describe the experiences of people living with multimorbidity in New Zealand. METHODS: We conducted a cross-sectional survey of adults with multimorbidity enrolled in two primary health organisations in New Zealand. Potential participants with multimorbidity were identified using retrospective hospital discharge data coded for long-term conditions. Sampling was stratified by ethnicity (Maori, Pacific and non-Maori/non-Pacific). Analysis was descriptive, with some responses compared to the general population estimates from the New Zealand Health Survey. RESULTS: A total of 234 participants completed the survey (mean age 65.2). Self-reported physical health was poor among the cohort: forty-one percent of participants reported only 'fair' or 'poor' general health, compared to 13.5% in the general population (age and sex standardised), with similar results for both self-reported mental health and physical health. Self-reported health was poorer for Maori and Pacific participants. The majority (70%) of those who were working reported their health had affected their productivity, while nearly 20% of participants reported financial difficulty in taking care of their health needs. CONCLUSIONS: These results emphasise the serious impact multimorbidity has on patients' health status compared to the general population. This research supports the development of holistic patient-centred care models designed to improve patient outcomes.

Epidemiology of multimorbidity in New Zealand: a cross-sectional study using national-level hospital and pharmaceutical data.

OBJECTIVES: To describe the prevalence of multimorbidity (presence of two or more long-term health conditions) in the New Zealand (NZ) population, and compare risk of health outcomes by multimorbidity status. DESIGN: Cross-sectional analysis for prevalence of multimorbidity, with 1-year prospective follow-up for health outcomes. SETTING: NZ general population using national-level routine health data on hospital discharges and pharmaceutical dispensing. PARTICIPANTS: All NZ adults (aged 18+, n=3 489 747) with an active National Health Index number at the index date (1 January 2014). OUTCOME MEASURES: Prevalence of multimorbidity was calculated using two data sources: prior routine hospital discharge data (61 ICD-10 coded diagnoses from the M3 multimorbidity index); and recent pharmaceutical dispensing records (30 conditions from the P3 multimorbidity index). METHODS: Prevalence of multimorbidity was calculated separately for the two data sources, stratified by age group, sex, ethnicity and socioeconomic deprivation, and age and sex standardised to the total population. One-year risk of poor health outcomes (mortality, ambulatory sensitive hospitalisation (ASH) and overnight hospital admission) was compared by multimorbidity status using logistic regression adjusted for confounders. RESULTS: Prevalence of multimorbidity was 7.9% using past hospital discharge data, and 27.9% using past pharmaceutical dispensing data. Prevalence increased with age, with a clear socioeconomic gradient and differences in prevalence by ethnicity. Age and sex standardised risk of 1-year mortality was 2.7% for those with multimorbidity (defined on hospital discharge data), and 0.5% for those without multimorbidity (age and sex-adjusted OR 4.8, 95% CI 4.7 to 5.0). Risk of ASH was also increased for those with multimorbidity (eg, pharmaceutical discharge definition: age and sex-standardised risk 6.2%, compared with 1.8% for those without multimorbidity; age and sex-adjusted OR 3.6, 95% CI 3.5 to 3.6). CONCLUSIONS: Multimorbidity is common in the NZ adult population, with disparities in who is affected. Providing for the needs of individuals with multimorbidity requires collaborative and coordinated work across the health sector.

Clinical guidelines: what happens when people have multiple conditions?

More people now live with multimorbidity than with a single long-term condition. Despite this, clinical guidelines remain focused on the management of individual conditions. When the treatment recommendations from multiple different disease-specific guidelines are combined for one individual it frequently leads to interactions between treatments, along with a high burden of treatment for patients. It is also recognised that people with multimorbidity are often excluded from the trials that generate the underlying evidence for these guidelines, and that treatment goals from guidelines often fail to align with patient goals. This viewpoint discusses the main issues with applying disease-specific guidelines to individuals with multiple long-term conditions, and presents a set of eight recommendations to improve care for people with multimorbidity in New Zealand.

A walking stick in one hand and a chainsaw in the other: patients' perspectives of living with multimorbidity.

AIMS: Multimorbidity is common, yet there are major gaps in research, particularly among younger and indigenous populations. This research aimed to understand patients' perspectives of living with multimorbidity. METHODS: A qualitative study of 61 people living with multimorbidity, 27 of whom were Maori and a third aged under 65, from urban and rural regions in New Zealand. Six focus groups and 14 interviews were conducted, recorded, transcribed and analysed. RESULTS: For many participants, living with multimorbidity disrupted their 'normal' lives, posing challenges in everyday activities such as eating and toileting, working and managing medications. Dealing with the health system posed challenges such as accessing appointments and having enough time in consultations. Cultural competency, good communication and continuity of care from healthcare providers were all valued. Participants had many recommendations to improve management, including a professional single point of contact to coordinate all specialist care. CONCLUSIONS: Living with multimorbidity is often challenging requiring people to manage their conditions while continuing to live their lives. This research suggests changes are needed in the health system in New Zealand and elsewhere to better manage multimorbidity thus improving patient's lives and reducing costs to the health sector and wider society.

Involving students in real-world research: a pilot study for teaching public health and research skills.

BACKGROUND: There is some evidence that medical students consider population health issues less important than other domains in the health sciences and attitudes to this field may become more negative as training progresses. A need to improve research skills among medical students has also been suggested. Therefore we piloted an integrative teaching exercise that combined teaching of research skills and public health, with real-world research. METHODS: Third year medical students at the University of Otago (Dunedin, New Zealand) filled in a questionnaire on their housing conditions and health. The students were given the results of the survey to discuss in a subsequent class. Student response to this teaching exercise was assessed using a Course Evaluation Questionnaire. RESULTS: Of the 210 students in the class, 136 completed the Course Evaluation Questionnaire (65%). A majority of those who responded (77%) greatly supported or supported the use of the survey and seminar discussion for future third year classes. Most (70%) thought that the session had made them more aware and concerned about societal problems, and 72% felt that they now had an improved understanding of the environmental determinants of health. Students liked the relevance and interaction of the session, but thought it could be improved by the inclusion of small group discussion. The findings of the students' housing and health were considered by the tutors to be of sufficient value to submit to a scientific journal and are now contributing to community action to improve student housing in the city. CONCLUSION: In this pilot study it was feasible to integrate medical student teaching with real-world research. A large majority of the students responded favourably to the teaching exercise and this was generally successful in raising the profile of public health and research. This approach to integrated teaching/research should be considered further in health sciences training and continue to be evaluated and refined.