Timothy Kenealy

Objective: To examine hospitalisations caused by diabetes‐related foot disease (DFD) at the largest tertiary hospital in Aotearoa New Zealand. Methods: We analysed hospital admission data for DFD‐caused hospitalisations from Auckland City Hospital (ACH), from 1 July 2014 to 30 June 2019, for people 15 years or older, using ICD10‐AM discharge codes and amputation procedure codes. DFD‐caused hospitalisations were defined where DFD was the principal reason for admission. Demographic variables and length of stay were also collected. Results: During the study period, out of the total 11,222 hospitalisations in persons with diabetes, 1605 (14.3%) were DFD‐caused hospitalisations, which included 265 (16.5%) minor amputations and 94 (5.9%) major amputations. There were a total of 71,033 hospital bed days in persons with diabetes, of which 16,992 (23.9%) hospital bed days were due to DFD. Median length of stay in days was 4 (IQR: 1–8) for persons with diabetes; 7 (3–14) for DFD‐caused hospitalisations, 13 (8–22) for minors and 17 (13–26) for major amputations. The DFD‐caused hospitalisation rate per 1000 persons with diabetes increased by 86% from 6.2 (95% CI: 5.2, 7.2) in 2014/15 to 11.5 (10.2, 12.8) in 2018/19 and combined minor and major amputation rates increased 82% from 1.1 (0.7, 1.5) to 2.0 (1.4, 2.5). The rate of first DFD‐caused hospitalisation was highest for Māori at 7.5 (5.8 9.5), followed by Pacific at 5.3 (4.5, 6.2) and lowest for European/Other at 3.7 (3.3, 4.1) per 1000 person‐years with diabetes. Conclusion: DFD‐caused hospitalisations and amputations made up nearly a quarter of all hospital bed days used by people with diabetes and nearly doubled over 5 years. The highest rates were found in adults of Māori and Pacific ethnicity. Most DFD‐caused hospitalisations did not involve amputations (78%). The high and increasing burden of DFD‐caused hospitalisations suggest surveillance could monitor necessary changes to preventative foot care services.

Aims/hypothesis: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are known to reduce cardiovascular and all-cause mortality in people with type 2 diabetes, but there are limited data regarding mortality outcomes in different ethnic groups (including Indigenous peoples). This study reports on mortality outcomes in a population in Aotearoa New Zealand (hereafter New Zealand) with type 2 diabetes, following the funded availability of the SGLT2i empagliflozin with prioritised access for Māori and Pacific people. Methods: Data were collected from primary care records for those aged 18–75 years with type 2 diabetes (Auckland/Waikato regions of New Zealand; February 2021 to December 2023; n =59,505). These data were linked to national medication-dispensing and mortality records for 2021–2024 via national health identifier numbers. Following propensity matching and Cox modelling for ethnicity, age, gender, medication use, baseline HbA _1c and cardiovascular and/or renal disease/risk (CVRD) status (yes/no), mortality rates were compared by ethnicity in those with and without CVRD and who did/did not initiate empagliflozin. This study was reported in accordance with the CONSIDER statement, used to strengthen the reporting of research involving Indigenous peoples. The study was funded by the Health Research Council of New Zealand. Results: Following matching, two groups of 12,792 individuals were identified. Annualised crude mortality (deaths per 1000 individuals per year) was higher in those not dispensed with SGLT2i than in those receiving SGLT2i (35.2 vs 13.1 in those with CVRD and 7.7 vs 3.6 in those without CVRD, respectively). After adjustment, the greatest difference in mortality with SGLT2i use was seen in Māori (HR 0.475; 95% CI 0.336, 0.672; p p p <0.001). Conclusions/interpretation: The protective effect of SGLT2i use on mortality appears to differ by ethnicity and is greater in Indigenous Māori and Pacific populations in New Zealand with type 2 diabetes. SGLT2i use in Indigenous and minority populations may support improved health equity.

Background/Objectives: Ethnic disparities in type 2 diabetes (T2D) outcomes remain a significant public health challenge in Aotearoa New Zealand (NZ), but are not accurately reported in large datasets. This cross-sectional study used linked regional health records to examine ethnic inequities in glycaemic control and achievement of clinical targets among adults with T2D in the Waikato and Auckland regions. Methods: A cross-sectional analysis was conducted on 57,734 adults aged 18–75 years with confirmed T2D enrolled in four Primary Healthcare Organisations. Clinical and sociodemographic data from February 2021 to December 2023 were linked via National Health Index numbers. Key outcomes included the percentage of patients at target for HbA1c, blood pressure, lipid profiles, renal and liver function tests. Logistic regression assessed associations between ethnicity, socioeconomic deprivation, and clinical target attainment. Results: The mean age was 56.5 ± 12.4 years, and 86.8% of the cohort were overweight or obese. Overall, only 46.3% achieved the HbA1c target (<53 mmol/mol) in their most recent test, with Māori (OR 1.35) and Pacific (OR 1.84) ethnicities, higher deprivation, obesity, and younger age independently associated with elevated HbA1c. Hypertension affected two-thirds of participants (71.9% above target), notably Asians and Pacific peoples. Māori and Pacific peoples had over twice the odds of renal impairment and were 2.5 times more likely to have elevated albumin-to-creatinine ratios. Abnormal liver function test decreased with age (OR ≤ 0.65), though Asians had over twice the odds of elevated ALT and AST compared to Europeans. Conclusions: Significant ethnic inequities exist in glycaemic and clinical target attainment among people with T2D in NZ. These findings highlight critical gaps in diabetes management and underscore the urgent need for targeted, equity-focused interventions addressing both socioeconomic and ethnic disparities to improve outcomes and reduce health inequities.

Background It has long been believed that antibiotics have no role in the treatment of common colds yet they are often prescribed in the belief that they may prevent secondary bacterial infections. Objectives To determine the efficacy of antibiotics compared with placebo for reducing general and specific nasopharyngeal symptoms of acute upper respiratory tract infections (URTIs) (common colds). To determine if antibiotics have any influence on the outcomes for acute purulent rhinitis and acute clear rhinitis lasting less than 10 days before the intervention. To determine whether there are significant adverse outcomes associated with antibiotic therapy for participants with a clinical diagnosis of acute URTI or acute purulent rhinitis. Search methods For this 2013 update we searched CENTRAL 2013, Issue 1, MEDLINE (March 2005 to February week 2, 2013), EMBASE (January 2010 to February 2013), CINAHL (2005 to February 2013), LILACS (2005 to February 2013) and Biosis Previews (2005 to February 2013). Selection criteria Randomised controlled trials (RCTs) comparing any antibiotic therapy against placebo in people with symptoms of acute upper respiratory tract infection for less than seven days, or acute purulent rhinitis less than 10 days in duration. Data collection and analysis Both review authors independently assessed trial quality and extracted data. Main results This updated review included 11 studies. Six studies contributed to one or more analyses related to the common cold, with up to 1047 participants. Five studies contributed to one or more analyses relating to purulent rhinitis, with up to 791 participants. One study contributed only to data on adverse events and one met the inclusion criteria but reported only summary statistics without providing any numerical data that could be included in the meta‐analyses. Interpretation of the combined data is limited because some studies included only children, or only adults, or only males; a wide range of antibiotics were used and outcomes were measured in different ways. There was a moderate risk of bias because of unreported methods details or because an unknown number of participants were likely to have chest or sinus infections. Participants receiving antibiotics for the common cold did no better in terms of lack of cure or persistence of symptoms than those on placebo (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.60 to 1.14, (random‐effects)), based on a pooled analysis of six trials with a total of 1147 participants. The RR of adverse effects in the antibiotic group was 1.8, 95% CI 1.01 to 3.21, (random‐effects). Adult participants had a significantly greater risk of adverse effects with antibiotics than with placebo (RR 2.62, 95% CI 1.32 to 5.18) (random‐effects) while there was no greater risk in children (RR 0.91, 95% CI 0.51 to 1.63). The pooled RR for persisting acute purulent rhinitis with antibiotics compared to placebo was 0.73 (95% CI 0.47 to 1.13) (random‐effects), based on four studies with 723 participants. There was an increase in adverse effects in the studies of antibiotics for acute purulent rhinitis (RR 1.46, 95% CI 1.10 to 1.94). Authors' conclusions There is no evidence of benefit from antibiotics for the common cold or for persisting acute purulent rhinitis in children or adults. There is evidence that antibiotics cause significant adverse effects in adults when given for the common cold and in all ages when given for acute purulent rhinitis. Routine use of antibiotics for these conditions is not recommended.

Most research on social support in diabetes management lacks detail on the specific behaviours involved. This narrative review identifies the types of social support behaviours that aid management of Type 2 diabetes. After searching five databases (62 included papers), we conducted a qualitative synthesis using a five-category taxonomy. Emotional and tangible support were most frequently reported, alongside social contact, belonging, and informational guidance. Emotional support included sharing experiences, feeling cared for, esteem support, and having someone available when needed. For care providers, key processes were building rapport, assessing needs, and offering both emotional and practical assistance. Some support, such as shared experiences, information, and belonging, may be ‘invisible,’ reducing the risk of obligation or dependency. Supportive behaviours that strengthen self-efficacy were especially beneficial for diabetes management. These findings provide a resource for designing interventions and guiding caregivers. Health services offering effective social support are more likely to improve diabetes outcomes.

Diabetes-related foot disease (DFD) includes neuropathy, ulceration, infection, gangrene and amputations. It increases the risk of hospitalisation, cardiovascular (CVD) events and premature death. 1,2 In 2023, about 323,700 people in Aotearoa New Zealand (NZ) were living with diabetes with the number forecast to rise by up to 90% by 2045. 3 Of these perhaps 13% were at high risk of developing or having a diabetic foot ulcer (DFU), and a further 22% were at moderate risk, based on the Scottish Intercollegiate Guidelines Network (SIGN) foot risk catergories. 4 More than 700 diabetes-related amputations occur annually in NZ with about one-third being major (above the ankle). 5 Māori are two-thirds more likely to undergo a major amputation than non-Māori. 6 The NZ estimated major amputation rate of 6.4 per 100,000 total population is double the rate for United Kingdom and approximately 1.7 times the rate for Australia. 7 The causal pathway from diabetes-related microvascular and macrovascular complications to DFD overlaps with well-established CVD risks. 8,9 Annual foot screening, integrated with CVD risk assessment, is key to identifying risk factors and foot abnormalities. 10 Foot screening takes about 1 minute, with checks for sensory, vascular, musculoskeletal, and dermatological changes that enable foot risk categorisation. 11 For those at increased risk the results can prompt treatment intensification and referral to preventive services. A Annual foot screening is an established component of diabetes care in NZ. We advocate for consistently capturing foot screening results and strategically using the data to enhance preventative foot care. Annual foot screening with standardised risk categorisation, data definitions and reporting could serve as an indicator to monitor DFD, helping health care providers, service planners, policymakers, and researchers identify individuals at risk, understand DFD prevalence, commission and monitor relevant foot services, and manage equitable outcomes. 12,13 At a patient level, it permits tracking of changes in foot health, enabling timely implementation of appropriate preventative care. 10 In the Northern Region of NZ two performance indicators have been introduced aiming to monitor the effectiveness of preventative DFD management. One monitors foot screening coverage, with a 90% target. The other reports the proportion of those people screened who have a recorded foot risk category (low, moderate, high, in-remission or active DFD) with a 100% target. While the value of standalone foot screening programmes can be debated 14 that is not what we are promoting. 15-17 Integrating annual foot screening into existing diabetes care pathways is recognised by international guidelines as the foundation for systematic multidisciplinary DFD care. 18,19 Prompt referral and early intervention alongside good risk factor management can prevent DFD-caused hospitalisations, amputations, and premature deaths, while preventative foot care services are associated with a decreased incidence of DFU and improved survival. 8,15,20,21 Conversely, delayed referral to specialist foot services is associated with increased DFU severity and related infections, more hospitalisations with extended stays, more revascularisations, and increased amputations. 22 In NZ, the Quality Standards for Diabetes Care 2020 expect people with diabetes to have annual foot screening with documented results. 23 Health care management and

Introduction: Management of type 2 diabetes (T2D) occurs predominantly in primary health care in Aotearoa New Zealand. Optimising the delivery of clinical diabetes management by upskilling healthcare professionals can reduce the strain on the healthcare system and improve patient care. Aim: This study aimed to qualitatively evaluate the importance of an education programme delivered by a non-physician diabetes specialist on nurses’ knowledge and confidence of T2D management in primary care. Methods: Semi-structured interviews with nurses enrolled in the programme for at least 6 months and their nurse leads across two clinics in the Waikato region were conducted to assess their confidence and knowledge in T2D management, as well as the acceptability of the programme. Transcripts were analysed using quantitative content analysis. Results: Four nurses and two nurse leads were interviewed, lasting between 15 and 60 min. Nurses reported improved knowledge of diabetes medications and interpreting clinical measures. Nurses also felt more confident in their communication skills with patients, advocating for their patients, and improved patient engagement. Further education was needed on administering diabetes medication, knowledge of medical devices such as continuous glucose monitoring, and understanding the pathophysiology of diabetes. Discussion: Self-efficacy and self-reported skills of nurses in T2D management improved following the diabetes mentoring programme. Further research is needed to assess quantitative clinical measures and whether the programme is effective in improving patient health outcomes.

Māori are over-represented in Aotearoa New Zealand morbidity and mortality statistics. Other populations with high health needs include Pacific peoples and those living with material deprivation. General practice has evolved into seven models of primary care: Traditional, Corporate, Health Care Home, Māori, Pacific, Trusts / Non-governmental organisations (Trust/NGOs) and District Health Board / Primary Care Organisations (DHB/PHO). We describe nurse work in relation to these models of care, populations with high health need and patient health outcomes. We conducted a cross-sectional study (at 30 September 2018) of data from national datasets and practices at patient level. Six primary outcome measures were selected because they could be improved by primary care: polypharmacy (≥ 65 years), glucose control testing in adults with diabetes, immunisations (at 6 months), ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances. Analysis adjusted for patient and practice characteristics. Nurse clinical time, and combined nurse, nurse practitioner and general practitioner clinical time, were substantially higher in Trust/NGO, Māori, and Pacific practices than in other models. Increased patient clinical complexity was associated with more clinical input and higher scores on all outcome measures. The highest rates of preventative care by nurses (cervical screening, cardiovascular risk assessment, depression screening, glucose control testing) were in Māori, Trust/NGO and Pacific practices. There was an eightfold difference, across models of care, in percentage of depression screening undertaken by nurses and a fivefold difference in cervical screening and glucose control testing. The highest rates of nurse consultations afterhours and with unenrolled patients, improving access, were in PHO/DHB, Pacific, Trust/NGO and Māori practices. Work not attributed to nurses in the practice records meant nurse work was underestimated to an unknown degree. Transferring work to nurses in Traditional, Health Care Home, and Corporate practices, would release general practitioner clinical time for other work. Worse patient health outcomes were associated with higher patient need and higher clinical input. It is plausible that there is insufficient clinical input to meet the degree of patient need. More practitioner clinical time is required, especially in practices with high volumes of complex patients.