Cancer diagnosis after emergency presentations in people with mental health and substance use conditions: a national cohort study.

BACKGROUND: Cancer survival and mortality outcomes for people with mental health and substance use conditions (MHSUC) are worse than for people without MHSUC, which may be partly explained by poorer access to timely and appropriate healthcare, from screening and diagnosis through to treatment and follow-up. Access and quality of healthcare can be evaluated by comparing the proportion of people who receive a cancer diagnosis following an acute or emergency hospital admission (emergency presentation) across different population groups: those diagnosed with cancer following an emergency presentation have lower survival. METHODS: National mental health service use datasets (2002-2018) were linked to national cancer registry and hospitalisation data (2006-2018), to create a study population of people aged 15 years and older with one of four cancer diagnoses: lung, prostate, breast and colorectal. The exposure group included people with a history of mental health/addiction service contact within the five years before cancer diagnosis, with a subgroup of people with a diagnosis of bipolar disorder, schizophrenia or psychotic disorders. Marginal standardised rates were used to compare emergency presentations (hospital admission within 30 days of cancer diagnosis) in the exposure and comparison groups, adjusted for age, gender (for lung and colorectal cancers), ethnicity, area deprivation and stage at diagnosis. RESULTS: For all four cancers, the rates of emergency presentation in the fully adjusted models were significantly higher in people with a history of mental health/addiction service use than people without (lung cancer, RR 1.19, 95% CI 1.13, 1.24; prostate cancer RR 1.69, 95% CI 1.44, 1.93; breast cancer RR 1.42, 95% CI 1.14, 1.69; colorectal cancer 1.31, 95% CI 1.22, 1.39). Rates were substantially higher in those with a diagnosis of schizophrenia, bipolar disorder or psychotic disorders. CONCLUSIONS: Implementing pathways for earlier detection and diagnosis of cancers in people with MHSUC could reduce the rates of emergency presentation, with improved cancer survival outcomes. All health services, including cancer screening programmes, primary and secondary care, have a responsibility to ensure equitable access to healthcare for people with MHSUC.

Mortality after release from incarceration in New Zealand by gender: A national record linkage study.

Background: People who enter and leave places of incarceration experience considerable health inequities and are at increased risk of premature death compared to the general population. Causes of premature death in this population vary markedly between countries and so country-specific information is needed. Additionally, there is a lack of large population-based studies which can disaggregate mortality risk based on person and incarceration factors. This study is the first examination of mortality in the period following release from incarceration in New Zealand. Methods: We linked deidentified administrative data on incarceration and release between 1 January 1998 and 31 December 2016 with national mortality data for the same period to examine mortality after release in those who had been incarcerated for at least 1 day. Age standardised mortality rates and mortality ratios compared to the general New Zealand population were calculated separately for men and women, for releases from remand compared with prison, and by cause of death and time since release. Results: 90,195 individuals (13% women, 49% Maori) were followed up for 9.4 years after release from incarceration, with 4,764 deaths over the follow-up period. The overall standardised mortality ratio was 3.3 (95% CI 3.2, 3.4) compared to the general population, and higher for women (3.8) than men (2.7). The most common causes of death were cardiovascular disease, cancer and suicide. Rates of death were similar following release from remand versus prison, however suicide rates were highest following release from remand. Regardless of the type of incarceration, mortality was highest in the first month after release. Conclusion: Experience of incarceration in New Zealand is associated with high rates of mortality from both chronic conditions and external causes. There are urgent policy imperatives to recognise and actively address the increased health and mortality risks faced by people released from New Zealand prisons.

Prescribing Smartphone Apps for Physical Activity Promotion in Primary Care: Modeling Study of Health Gain and Cost Savings.

BACKGROUND: Inadequate physical activity is a substantial cause of health loss worldwide, and this loss is attributable to diseases such as coronary heart disease, diabetes, stroke, and certain forms of cancer. OBJECTIVE: This study aims to assess the potential impact of the prescription of smartphone apps in primary care settings on physical activity levels, health gains (in quality-adjusted life years [QALYs]), and health system costs in New Zealand (NZ). METHODS: A proportional multistate lifetable model was used to estimate the change in physical activity levels and predict the resultant health gains in QALYs and health system costs over the remaining life span of the NZ population alive in 2011 at a 3% discount rate. RESULTS: The modeled intervention resulted in an estimated 430 QALYs gained (95% uncertainty interval 320-550), with net cost savings of 2011 NZ $2.2 million (2011 US $1.5 million) over the remaining life span of the 2011 NZ population. On a per capita basis, QALY gains were generally larger in women than in men and larger in Maori than in non-Maori. The health impact and cost-effectiveness of the intervention were highly sensitive to assumptions on intervention uptake and decay. For example, the scenario analysis with the largest benefits, which assumed a 5-year maintenance of additional physical activity levels, delivered 1750 QALYs and 2011 NZ $22.5 million (2011 US $15.1 million) in cost savings. CONCLUSIONS: The prescription of smartphone apps for promoting physical activity in primary care settings is likely to generate modest health gains and cost savings at the population level in this high-income country. Such gains may increase with ongoing improvements in app design and increased health worker promotion of the apps to patients.

Health Gain, Cost Impacts, and Cost-Effectiveness of a Mass Media Campaign to Promote Smartphone Apps for Physical Activity: Modeling Study.

BACKGROUND: Physical activity smartphone apps are a promising strategy to increase population physical activity, but it is unclear whether government mass media campaigns to promote these apps would be a cost-effective use of public funds. OBJECTIVE: We aimed to estimate the health impacts, costs, and cost-effectiveness of a one-off national mass media campaign to promote the use of physical activity apps. METHODS: We used an established multistate life table model to estimate the lifetime health gains (in quality-adjusted life years [QALYs]) that would accrue if New Zealand adults were exposed to a one-off national mass media campaign to promote physical activity app use, with a 1-year impact on physical activity, compared to business-as-usual. A health-system perspective was used to assess cost-effectiveness. and a 3% discount rate was applied to future health gains and health system costs. RESULTS: The modeled intervention resulted in 28 QALYs (95% uncertainty interval [UI] 8-72) gained at a cost of NZ $81,000/QALY (2018 US $59,500; 95% UI 17,000-345,000), over the remaining life course of the 2011 New Zealand population. The intervention had a low probability (20%) of being cost-effective at a cost-effectiveness threshold of NZ $45,000 (US $32,900) per QALY. The health impact and cost-effectiveness of the intervention were highly sensitive to assumptions around the maintenance of physical activity behaviors beyond the duration of the intervention. CONCLUSIONS: A mass media campaign to promote smartphone apps for physical activity is unlikely to generate much health gain or be cost-effective at the population level. Other investments to promote physical activity, particularly those that result in sustained behavior change, are likely to have greater health impacts.

Can administrative health utilisation data provide an accurate diabetes prevalence estimate for a geographical region?

AIM: To validate the New Zealand Ministry of Health (MoH) Virtual Diabetes Register (VDR) using longitudinal laboratory results and to develop an improved algorithm for estimating diabetes prevalence at a population level. METHODS: The assigned diabetes status of individuals based on the 2014 version of the MoH VDR is compared to the diabetes status based on the laboratory results stored in the Auckland regional laboratory result repository (TestSafe) using the New Zealand diabetes diagnostic criteria. The existing VDR algorithm is refined by reviewing the sensitivity and positive predictive value of the each of the VDR algorithm rules individually and as a combination. RESULTS: The diabetes prevalence estimate based on the original 2014 MoH VDR was 17% higher (n = 108,505) than the corresponding TestSafe prevalence estimate (n = 92,707). Compared to the diabetes prevalence based on TestSafe, the original VDR has a sensitivity of 89%, specificity of 96%, positive predictive value of 76% and negative predictive value of 98%. The modified VDR algorithm has improved the positive predictive value by 6.1% and the specificity by 1.4% with modest reductions in sensitivity of 2.2% and negative predictive value of 0.3%. At an aggregated level the overall diabetes prevalence estimated by the modified VDR is 5.7% higher than the corresponding estimate based on TestSafe. CONCLUSION: The Ministry of Health Virtual Diabetes Register algorithm has been refined to provide a more accurate diabetes prevalence estimate at a population level. The comparison highlights the potential value of a national population long term condition register constructed from both laboratory results and administrative data.