INTRODUCTION:The timely identification of acute deterioration in people living in residential aged care is critical to reducing rates of resident morbidity and mortality. However, residents often present with atypical or nonspecific presentations that make this difficult. This study aimed to quantify the strength of the relationship between the indicators acute deterioration reported in the literature and morbidity and mortality. METHOD:A retrospective cohort study using routinely collected health data. A single dependant acute deterioration variable (emergency department presentation or hospital admission or death within 7 days of the last completed international resident assessment instrument long-term care facility (interRAI-LTCF) assessment) was correlated with indicators of acute deterioration reported in the literature and available in interRAI-LTCF. Univariate and multivariate logistic regression analysis evaluated this association. RESULTS:Nine variables were independently associated with acute deterioration. These were being 'largely asleep or unresponsive' odds ratio (OR): 7.95, 95% CI: 4.72-13.39, p < 0.001, 'easily distracted' (OR: 1.78, 95% CI: 1.28-2.49, p < 0.001), eating 'one or fewer meals a day' (OR: 2.13, 95% CI: 1.67-2.73, p < 0.001), reduced activities of daily living (OR: 2.06, 95% CI: 1.11-3.82, p = 0.02) inability to complete toilet transfer (OR: 1.95, 95% CI: 1.24-3.03, p = 0.004), 'dyspnoea; at rest' (OR: 1.81, 95% CI: 1.32-2.49, p < 0.001), 'two or more falls in 30 days' (OR: 1.53, 95% CI: 1.15-2.03, p = 0.003), peripheral oedema (OR: 1.37, 95 CI: 1.07-1.77, p = 0.014) and daily pain (OR: 1.37, 95% CI: 1.05-1.77, p = 0.019). CONCLUSION:Presenting with one of nine variables made residents between 1.4 and 8 times more likely to be experiencing acute deterioration than others living in the facility. The monitoring the resident for these variables by healthcare assistants could support the timely identification of acute deterioration. TRIAL REGISTRATION:Not applicable.

Abstract Background: The timely identification of acute deterioration in people living in residential aged care is critical to avoiding or reducing rates of adverse events such as Emergency Department (ED) presentation or hospitalisation or death. This task is difficult as advanced age, multiple morbidity and frailty cause atypical or non-specific presentations of ill health. This study aimed to quantify the association between clinical indicators of acute deterioration reported in the literature and adverse events in his population. Method: A retrospective cohort study using routinely collected health data. The cohort (n=5238) were aged 65 years or older in their last year of life and had an interRAI-LTCF assessment completed (I January to 31 December 2015). InterRAI-LTCF variables were matched with clinical indicators of acute deterioration reported in the literature. Univariate and multivariate logistic regression tested the association between those variables and ED presentation, hospitalisation or death 7 days or less from last completed interRAI-LTCF assessment. Results: Nine clinical indicators, from four health domains were independently associated with acute deterioration. Cognitive indicators were being ‘largely asleep or unresponsive’odds ratio (OR) 7.95 95% CI 4.72-13.39, p<.001 and being ‘easily distracted; different to usual’ (OR 1.78 95% CI 1.28-2.49, p<.001). In the behavioural domain, eating ‘one or fewer meals a day’ (OR 2.13 95% CI 1.67-2.73, p<.001) and functional domain, a decline in activities of daily living status (OR 2.06 95% CI 1.11-3.82, p = .02) and not transferring to the toilet in the last three days (OR 1.95 95% CI 1.24-3.03, p = .004) were significant. Physical domain indicators were ‘dyspnoea; at rest’ (OR 1.81 5% CI 1.32-2.49, p<.001), ‘two or more falls in last 30 days’ (OR 1.53 95% CI 1.15-2.03, p = .003), daily peripheral oedema (OR 1.37 95 CI 1.07-1.77, p = .014) and daily pain (OR 1.37 95% CI 1.05-1.77, p = .019). Conclusion and implication: Clinical indicators of acute deterioration reported in the literature are significantly associated with adverse events. This evidence is a first step towards the future development of tools to support residential aged care staff with the identification of acute deterioration.

PURPOSE:Pain is among the most common and consequential symptoms of cancer, particularly in the context of lung cancer. Māori have extremely high rates of lung cancer, and there is evidence that Māori patients with lung cancer are less likely to receive curative treatment and more likely to receive palliative treatment and to wait longer for their treatment than non-Māori New Zealanders. The extent to which Māori patients with lung cancer are also less likely to have access to pain medicines as part of their supportive care remains unclear. METHODS:Using national-level Cancer Registry and linked health records, we describe access to subsidized pain medicines among patients with lung cancer diagnosed over the decade spanning 2007-2016 and compare access between Māori and non-Māori patients. Descriptive and logistic regression methods were used to compare access between ethnic groups. RESULTS:We observed that the majority of patients with lung cancer are accessing some form of pain medicine and there do not appear to be strong differences between Māori and non-Māori in terms of overall access or the type of pain medicine dispensed. However, Māori patients appeared more likely than non-Māori to first access pain medicines within 2 weeks before their death and commensurately less likely to access them more than 24 weeks before death. CONCLUSION:Given the plausibility that there are differences in first access to pain medicines (particularly opioid medicines) among Māori approaching end of life, further investigation of the factors contributing to this disparity is required.

South Africa's apartheid history of legislated discrimination on the basis of race has left a legacy of massive income inequalities–with, at 0.63 in 2011, one of the highest Gini coefficients in the world (World Bank, 2017)–and inequalities in access to social services. It has also left an indelible imprint on the health sector, where private health insurance was developed to serve white workers, whereas the public health sector served the majority black population and lower-income whites.‹ The use of the terms African, Coloured, Indian (and the combined group black) and white indicates a statutory stratification of the South African population in terms of the former Population Registration Act. The use of these terms does not imply the legitimacy of this racist terminology, but is necessary for highlighting the impact of former apartheid policies on the health system.› Since the first democratic elections in 1994, there has been considerable commitment to addressing these inequalities. However, progress has been limited: income inequalities have in fact been growing and inequalities within the health sector are increasingly related to class rather than race.

OBJECTIVES:To explore how interRAI assessments could be used to identify opportunities to integrate palliative care into a plan of care.METHODS:A population-based, cross-sectional design using unique identifiers to link deaths with a national interRAI database. Data were analysed using logistic regression models and chi-square tests.RESULTS:A total of 4869 people died over a 12-month period in one district health board area; 50.9% (n = 2478) received one or more interRAI assessments in the year before death. Diagnosis impacted on the type and timing of interRAI assessments and the recognition of end-stage disease.CONCLUSION:People in the last year of life experience frequent interRAI assessments. There are opportunities to identify people who might benefit from a palliative care approach. Future research is needed to understand how interRAI assessors can be supported in the application of assessment items related to palliative care.

Background Little is known about the quality of end of life care in long-term care (LTC) for residents with different diagnostic trajectories. The aim of this study was to compare symptoms before death in LTC for those with cancer, dementia or chronic illness. Methods After-death prospective staff survey of resident deaths with random cluster sampling in 61 representative LTC facilities across New Zealand (3709 beds). Deaths ( n = 286) were studied over 3 months in each facility. Standardised questionnaires - Symptom Management (SM-EOLD) and Comfort Assessment in End of life with Dementia (CAD-EOLD) - were administered to staff after the resident’s death. Results Primary diagnoses at the time of death were dementia (49%), chronic illness (30%), cancer (17%), and dementia and cancer (4%). Residents with cancer had more community hospice involvement (30%) than those with chronic illness (12%) or dementia (5%). There was no difference in mean SM-EOLD in the last month of life by diagnosis (cancer 26.9 (8.6), dementia 26.5(8.2), chronic illness 26.9(8.6). Planned contrast analyses of individual items found people with dementia had more pain and those with cancer had less anxiety. There was no difference in mean CAD-EOLD scores in the week before death by diagnosis (total sample 33.7(SD 5.2), dementia 34.4(SD 5.2), chronic illness 33.0(SD 5.1), cancer 33.3(5.1)). Planned contrast analyses showed significantly more physical symptoms for those with dementia and chronic illness in the last month of life than those with cancer. Conclusions Overall, symptoms in the last week and month of life did not vary by diagnosis. However, sub-group planned contrast analyses found those with dementia and chronic illness experienced more physical distress during the last weeks and months of life than those with cancer. These results highlight the complex nature of LTC end of life care that requires an integrated gerontology/palliative care approach.

Abstract Introduction Staff in residential aged care (RAC) face increasing exposure to death and dying provoking coping-related responses. This study reports on research exploring the role of religious/spiritual belief in staff coping with death and dying in RAC homes. Method Utilising a mixed methods, concurrent triangulation design, data from interviews and questionnaires with 113 RAC staff were analysed to explore the relationship between staff members’ religious/spiritual beliefs and coping with resident deaths within the context of 50 RAC facilities. Results Participants appeared to have distinctly different experiences of the role of religious/spiritual beliefs in their attitudes toward death and dying – as reflected linguistically in how they described it. Strong religious/spiritual influence and religious affiliation were associated with lower scores for burnout. Level of religious/spiritual influence does make a difference in the strategies employed by staff in coping with death and dying. Conclusion Given the potential benefits associated with religious/spiritual beliefs, RAC facility management would be well advised to foster a workplace culture that supports and encourages spiritual/religious expression among facility staff. Greater understanding of the role of religious/spiritual beliefs in helping staff to make sense of the end-of-life experience can provide the basis for the development of staff supports enabling both improved staff well-being and resident end-of-life care.

AIMS:We aimed to: (i) update previous health system cost estimates (Blakely et al NZMJ 2014;127(1393)) using updated costing data and more refined methods; and (ii) provide context around current developments in the improved networking of health information systems in New Zealand.METHODS:As per our previous work, national health event data were linked for hospitalisations, inpatient procedures, outpatient events, pharmaceuticals, laboratory tests, and primary care consultations for the whole country. For each health event a cost was assigned. Health expenditure by sex and age, and proximity to death (last 6 or 12 months of life), was then calculated.RESULTS:The updated and more accurate method allocated lower amounts of total public health expenditure than the previous work: $6.1, $6.0 and $6.7 billion dollars (inflation-adjusted to 2011 NZ$) in 2007/08, 2008/09 and 2009/10 financial years, respectively. But the latter is still only 52% of total health system costs ($6.7/$12.98 billion). Health system costs for people not within six months of death were similar to the previous work, except for being reduced in the most elderly age groups (range: $495 per person-year in 10-14 year old females; to $5,239 per person-year in 85-89 year old males). Costs in the last six months of life remained highly variable by age group (by a factor of 14 and being maximal at $23,400 or more among 1-4 year olds). The proportion of cumulative health expenditure in the last year of life declined with increasing age of death: eg, 47%, 25%, 13% and 6% for individuals aged 40, 70, 80 and 90 respectively.CONCLUSIONS:Health system costs vary markedly across the life course, and are skewed to the last year of life. This analysis has benefited from quality improvements in cost data and method refinements, but further improvements in coming years are likely. This is particularly so with access to additional data sources, and with the move towards better integration of "big data" in the New Zealand health sector.

Objectives: In New Zealand (NZ), place of death among decedents aged 65+ years has been reported as residential aged care (RAC, 38%), acute hospital (34%) or elsewhere (28%). However, lifetime risk of use of RAC (or nursing homes) is unknown. A simple method of estimation is demonstrated for NZ and Australia, with comparisons to other countries. Methods: Deaths of RAC residents in acute hospitals were estimated for NZ from four separate studies and added to deaths occurring in RAC, to derive the likelihood of using RAC after age 65 years. Academic and other sources were searched for comparative reports. Results: An estimated 18% of RAC residents died in acute hospital in NZ. When added to those who died in RAC, the proportion using RAC for late-life care was estimated at over 47% (66% if aged 85+ years). Of 12 US reports, the median report was 41%. Elsewhere, Finland was 47%, UK 28%, Australia 34% to 53%, and Germany 22% & 26%. Conclusions: Simple estimation using existing data demonstrates that RAC in late life is common. Implications: Late-life care services will continue to evolve. Monitoring RAC utilisation is necessary for informed debate about palliative care provision in RAC, use of hospital by RAC residents and for planning and policy setting.

AIMS Health expenditure increases with age, but some of this increase is due to costs proximal to death. We used linked health datasets (HealthTracker) to determine health expenditure by proximity to death. We then determined the impact on future health expenditure projections of accounting for proximity to death in costs. METHODS 2007 to 2009 national health event data were linked for hospitalisations, inpatient procedures, outpatient events, pharmaceuticals, laboratory tests, and primary care consultations. Each event was assigned a cost. Health expenditure by sex, age and whether in last 6 or 12 months of life or not were calculated. Future health expenditure trends were then estimated for the Statistics New Zealand median projection population counts, with 2010-12 mortality rates reducing by 2% per annum into the future. RESULTS A total of $8.1, $8.8 and $9.2 billion dollars (inflation-adjusted to 2011 NZ$) was allocated to individual health events in HealthTracker in 2007, 2008 and 2009, respectively. Citizen costs for people not within 6 months of death ranged from $498 per person-year (10-14 year old females) to $6900 per person-year (90-94 year old males). Per person-year costs in the last 6 months of life were 10-fold higher on average, being maximal at $30,000 or more among infants and the older elderly (80+ years). Similar patterns were apparent for costs within 12 months of death. For people hypothetically exposed to these 2007-09 health system costs over their full life, the cumulative costs for a person dying at age 70 years was $113,000, and doubled to $223,000 for a person dying at age 90. The proportion of cumulative health expenditure in the last year of life declined with increasing age of death: e.g. 24%, 13% and 10% for someone aged 40, 70 and 90 respectively. Projections of future health system expenditure were overestimated by 2.3% to 3.5% in 2041 when not accounting for proximity to death in costs. CONCLUSIONS New Zealand is fortunate to have access to rich data on health system costs. The age-specific health system costs per citizen we have calculated can be used in health expenditure projections, for cost-effectiveness analyses, and for considering how public health expenditure is distributed across the life course.

Background. Human dendritic cell-specific intracellular adhesion molecule-3 (ICAM3)-grabbing non-integrin (DC-SIGN) is a mannose-binding lectin that initiates interaction between dendritic cells and resting T-lymphocytes. DC-SIGN is highly expressed in placental tissue on dendritic cells and Hofbauer cells, and it is suggested that HIV may become adsorbed to DC-SIGN on Hofbauer cells as part of the mechanism of mother-to-child HIV transmission. A possible mechanism of transfer of the virus from the Hofbauer cells to the fetus is the subsequent adsorption to DC-SIGN-related molecules (DC-SIGNRs), present on immediately adjacent capillary vascular endothelium. However, data on DC-SIGN and DC-SIGNR expression in the placenta are few. Methods. Forty term placentas from HIV-positive mothers and 21 term placentas from HIV-negative mothers underwent immunohistochemistry staining for DC-SIGN and DC-SIGNR expression. Five random sets of 10 villi were assessed, and the average number of positive cells were counted in each case. In addition, where possible, maternal and cord blood viral loads and maternal CD4+ counts were performed in the HIV-positive group only. Results. The median maternal CD4+ count was 377 cells/µl and 27% of participants had undetectable viral loads; the median detectable viral load was 3.72 log. Most (97%) of the cord bloods tested in infants from HIV-positive mothers had lower than detectable viral loads. HIV-positive cases had significantly greater expression of both DC-SIGNRs (median values in HIV-positive cases, 14.5 positive cells/10 villi (pc/10villi), compared with 11 pc/10villi in HIV-negative cases, p=0.020) and DC-SIGN (median value in HIV-positive cases, 26.5 pc/10villi, compared with 23 pc/10villi in HIV-negative cases, p=0.037). DC-SIGNR expression was also noted in Hofbauer cells and decidual macrophages in addition to endothelium (reported currently). There was no difference in expression of DC-SIGN and DC-SIGNRs in patients with or without chorioamnionitis, but there was an inverse relationship between DC-SIGN and DC-SIGNR expression and maternal CD4+ counts in HIV-positive cases. Conclusion. Both DC-SIGN and DC-SIGNR expression were higher in placentas from HIV-positive mothers compared with HIV-negative cases. These lectins may be potential new therapeutic targets for preventing vertical transmission of HIV.

Diffuse large B cell lymphoma (DLBCL) and plasmablastic lymphoma (PBL) represent aggressive non-Hodgkin lymphomas, particularly in the setting of HIV infection. Since the introduction of highly active antiretroviral therapy (HAART), recent studies have documented improved survival outcome in patients with AIDS-related lymphomas. This study contributes a South African perspective by correlating the HIV status and prognosis of DLBCL and PBL with differentiation profiles assessed by immunophenotyping. Analysis of the morphologic, immunophenotypic and clinicopathologic features of 52 cases of DLBCL and 9 cases of de novo PBL was performed. The overall survival of patients with PBL was poorer than that of DLBCL (logrank p value 0.002). Despite HAART, the overall survival with DLBCL and HIV infection was significantly poorer than HIV negative patients with DLBCL (p value <0.001). Profound immunosuppression was evident in the HIV positive group as the mean CD4 count was 151 cells/mm(3) in DLBCL and 61 cells/mm(3) in PBL. HIV positive patients were significantly younger at presentation with greater likelihood of extranodal lymphoma. When Hans' and Muris' algorithmic stratification of DLBCL were applied, no statistical significance was demonstrated (p values 0.188 and 0.399 respectively). However, when Bcl-2 expression occurred in germinal center-type DLBCL (Hans' defined), improved survival was conferred by the germinal center immunophenotype (p value 0.007). The study demonstrates that DLBCL and PBL have significant potential for aggressive behaviour and poor outcome in the setting of profound immunosuppression due to HIV infection. Further studies are required to assess the effect of targeted-immunotherapy (Rituximab) in combination with recent amendment of the South African national antiretroviral treatment guidelines which has created tremendous potential for improved survival in patients with AIDS-related non-Hodgkin B-cell lymphomas.

A National Health Insurance system has been proposed for South Africa and two of the seven guiding principles are that there be social solidarity and equity. These will require both risk cross-subsidies and income cross-subsidies to be engineered into the health care financing system. This paper considers the need for risk adjustment at a provincial level using at least age, gender and HIV prevalence. The proposed single purchaser model with 52 purchasing districts is shown to be problematic. An alternative multiple purchaser model is proposed which includes existing health funds and employer-based health care arrangements. The role of risk adjustment is described at various levels of the system and it is demonstrated that equity and social solidarity can be achieved in a multiple purchaser system.

In this chapter, private sector stakeholders are identified and categorised according to their respective roles in revenue collection, pooling, purchasing and delivery of health care. Representatives of key stakeholder organisations were contacted to elicit information on their organisation's responses to NHI and a desktop search was conducted. An overview of the key concerns of and arguments raised by the private sector regarding the rationale for reform, the goals of reform, the reform process as well as responses to the various ANC proposals are provided. The various models and proposals that the private sector have mooted in response to the NHI proposals are set out, and the role that the private sector could play in a future mandatory system is considered. It is clear that the debate cannot be clearly defined in the absence of official government policy. Concerns about the lack of consultation and transparency have been broadly expressed. However, it is clear that there remains substantial goodwill from all stakeholders to see reform and to participate in the reforms. Statements from stakeholders reveal a commitment to the goals of achieving universal access to quality health care for all South Africans as well as a commitment to open engagement and debate.

South Africa intends implementing major reforms in the financing of healthcare. Free market reforms in private health insurance in the late 1980s have been reversed by the new democratic government since 1994 with the re-introduction of open enrolment, community rating and minimum benefits. A system of national health insurance with income cross-subsidies, risk-adjusted payments and mandatory membership has been envisaged in policy papers since 1994. Subsequent work has seen the design of a Risk Equalisation Fund intended to operate between competing private health insurance funds. The paper outlines the South African health system and describes the risk equalisation formula that has been developed. The risk factors are age, gender, maternity events, numbers with certain chronic diseases and numbers with multiple chronic diseases. The Risk Equalisation Fund has been operating in shadow mode since 2005 with data being collected but no money changing hands. The South African experience of risk equalisation is of wider interest as it demonstrates an attempt to introduce more solidarity into a small but highly competitive private insurance market. The measures taken to combat over-reporting of chronic disease should be useful for countries or funders considering adding chronic disease to their risk equalisation formulae.