Does the National Bariatric Prioritization Tool predict health outcomes?

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 Maori 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 Maori 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.

Development of the national bariatric prioritization tool in Aotearoa New Zealand.

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.

Cost analysis of index versus delayed cholecystectomy for acute cholecystitis in a New Zealand Provincial Centre.

BACKGROUND: Evidence suggests index cholecystectomy (IC) in patients with acute cholecystitis is safe, has decreased hospital stay and is cheaper than delayed cholecystectomy (DC). Costs of cholecystectomy have not previously been investigated in New Zealand. The aim of this study was to compare cost of IC with DC for patients with acute cholecystitis. METHODS: A retrospective analysis of adults admitted to Northland hospitals with acute cholecystitis between 1 January 2015 and 31 December 2019 who underwent subsequent cholecystectomy, was performed. Actual patient-level costs were utilized for cost comparison between IC and DC. Factors associated with increased costs were assessed using multivariate analysis. RESULTS: Two hundred and eleven patients were included in the study; 72 (34%) underwent IC and 139 (65%) DC. There was no significant difference in total cost for IC ($12 767) versus DC ($12 029) (p = 0.192); this persisted on multivariate analysis. Patients having IC had more severe cholecystitis, and 90-day representation rate following DC was 35%. Costs were increased by severity of cholecystitis, age, American Society of Anesthesiology score (ASA) and travel distance. CONCLUSION: This study showed there is no significant difference in cost between IC and DC for patients with acute cholecystitis in Northland, New Zealand. Severity, increasing age, ASA and travel distance were drivers of costs. To recognize the cost benefits of IC, it is likely that increased rates of IC are needed.

Development of the General surgery prioritisation tool implemented in New Zealand in 2018.

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.

Management of coronary artery disease in patients on dialysis.

AIMS: Coronary artery disease is common in patients with end-stage renal failure (ESRF). However, there is little evidence that revascularisation improves outcomes, compared with medical management. This study assessed survival and cardiovascular outcomes in patients with ESRF undergoing coronary angiography and then having coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI) or medical management. METHODS: Survival and major adverse cardiac events (MACE) were examined in all patients with ESRF who underwent coronary angiography at Auckland City Hospital between 2003 and 2012. Outcomes of patients who underwent revascularisation (CABG or PCI) were compared with those managed medically. RESULTS: Two hundred and eighty-eight patients with ESRF had a total of 382 diagnostic coronary angiograms. Ninety-one (32%) patients underwent revascularisation (61 PCI, 30 CABG), with the other 197 (68%) treated medically or requiring no specific cardiac treatment. The median survival was 3.3 (IQR 2.1-5.3) years in patients undergoing CABG, 2.9 (IQR 1.5-5.4) years in patients treated with PCI and 2.9 (IQR 1.3-5.5) years in patients managed medically. There was no significant difference in survival between treatment modalities in the entire cohort, nor in the 108 patients with triple vessel disease. Similarly, there was no difference in the incidence of major adverse cardiac events, comparing medical management with revascularisation. CONCLUSION: There was no apparent survival advantage with revascularisation by either CABG or PCI, compared with medical management, in patients with ESRF undergoing coronary angiography. This study confirms the poor prognosis of patients with ESRF and coronary disease. Observational studies cannot control for all potential confounders; randomised trial data are needed to guide optimal management of this high-risk patient cohort.