title: Efficacy of an incentive intervention on secondary prophylaxis for young people with rheumatic fever: a multiple baseline study

authors: Oetzel, John G.

subjects: Science & Technology

abstract: Background
Acute rheumatic fever in New Zealand persists and is a barometer of equity as its burden almost exclusively falls on Māori and Pacific Island populations. The primary objective of this study is to determine whether an incentive programme will result in increased secondary prophylaxis injections over a one-year period compared to a baseline period prior to the intervention.

Methods
The evaluation used a multiple baseline study to determine whether an incentive consisting of a mobile phone and monthly “top-up” (for data/calls) resulted in increased injections, increased texts/calls with nurses, reduced number of visits to get a successful injection, less medicine wasted, and increased nurse satisfaction. Participants were 77 young people (aged 14–21) on an acute rheumatic fever registry in Waikato region, New Zealand classified as either fully adherent (all injections received and no more than one late) or partially adherent based on injections at baseline.

Results
There was a sharp increase in injections for intermittent patients post-intervention and then a slight decrease overtime, while fully adherent patients maintained their high rate of injections (p = .003). A similar pattern for nurse satisfaction emerged (p = .001). The number of calls/texts increased for all patients (p = .003). The number of visits went down for partially adherent patients and up for fully adherent patients (p = .012). The overall incremental cost-effectiveness was $989 per extra successful injection although costs increased sharply toward the end of the intervention.

Conclusions
Incentivising secondary prophylaxis appears to have a strong impact for partially adherent patients, particularly during the early periods following the initiation of the intervention. Enhancing communication with patients who returned to care may result in more sustainable adherence.

Trial registration
Retrospectively registered: Australia New Zealand Clinical Trials Registry ACTRN12618001150235, 12 July 2018.

text: Efficacy of an incentive intervention on secondary prophylaxis for young people with rheumatic fever: a multiple baseline study Background
Acute rheumatic fever in New Zealand persists and is a barometer of equity as its burden almost exclusively falls on Māori and Pacific Island populations. The primary objective of this study is to determine whether an incentive programme will result in increased secondary prophylaxis injections over a one-year period compared to a baseline period prior to the intervention.

Methods
The evaluation used a multiple baseline study to determine whether an incentive consisting of a mobile phone and monthly “top-up” (for data/calls) resulted in increased injections, increased texts/calls with nurses, reduced number of visits to get a successful injection, less medicine wasted, and increased nurse satisfaction. Participants were 77 young people (aged 14–21) on an acute rheumatic fever registry in Waikato region, New Zealand classified as either fully adherent (all injections received and no more than one late) or partially adherent based on injections at baseline.

Results
There was a sharp increase in injections for intermittent patients post-intervention and then a slight decrease overtime, while fully adherent patients maintained their high rate of injections (p = .003). A similar pattern for nurse satisfaction emerged (p = .001). The number of calls/texts increased for all patients (p = .003). The number of visits went down for partially adherent patients and up for fully adherent patients (p = .012). The overall incremental cost-effectiveness was $989 per extra successful injection although costs increased sharply toward the end of the intervention.

Conclusions
Incentivising secondary prophylaxis appears to have a strong impact for partially adherent patients, particularly during the early periods following the initiation of the intervention. Enhancing communication with patients who returned to care may result in more sustainable adherence.

Trial registration
Retrospectively registered: Australia New Zealand Clinical Trials Registry ACTRN12618001150235, 12 July 2018.

year: 2019

title: The spatial equity and sustainability of general practitioner services: A mixed methods analysis of the Waikato DHB region

authors: Whitehead, Jesse

subjects: spatial equity

abstract: The New Zealand Primary Health Care Strategy states that quality primary health care is the first level of contact with the health system and should be universally accessible. Effective primary health care is an essential component of health systems, and is associated with more equitable distributions of health outcomes. However, not all New Zealanders have ready access to primary health care. For instance, adult residents of the Waikato region, and in particular Māori, have higher levels of unmet need for primay care than others. Improving the spatial equity of health services is a key step in achieving health equity. Health systems should contribute to achieving health equity and maintaining sustainable and equitable services into the future. 

This thesis research examines the spatial equity and sustainability of general practitioner (GP) services in the Waikato DHB region, using a mixed-methods approach to identify not only where inequities exist, but why they occur. A conceptual framework establishes a foundation for examining spatial equity and sustainability in New Zealand. Next, a systematic literature review identifies common definitions and measures of spatial equity. Primary Health Organisation (PHO) enrolment data is used to examine patterns of patient enrolment at GP services, and a range of health needs indicators were assessed for their suitability in the New Zealand primary care context. These findings inform the development of a Geographic Information Systems (GIS) model of spatial accessibility that is tailored to the Waikato District Health Board (DHB) context. The GIS model is then used, in combination with in-depth qualitative interviews, to examine the spatial equity and sustainability of GP services in the Waikato DHB region. 

Key findings include that spatial equity is commonly defined as a ‘need-based distribution of resources’, which can be quantified using a range of statistical and geospatial measures and techniques. PHO enrolment analysis revealed that most patients do not enrol with their closest service, and that the size of the ‘catchment area’ served by GP clinics varies with rurality. Analysis of indicators of health need suggest that ‘Ambulatory Sensitive Hospitalisations’ are a robust indicator; however, area-level socioeconomic deprivation is also strongly associated with other indicators of need and data is more widely available to researchers. Mixed-methods analysis suggests that GP services are not distributed equitably within the Waikato DHB region and that key barriers to access include the affordability, appropriateness, and availability of services. New Zealand’s history of colonisation and discrimination are identified as fundamental drivers of health inequity. Furthermore, population growth and ageing suggest that current levels of access to GP services are unlikely to be maintained in the future, while participants identify key economic, professional, organisation, and social dimensions that influence service sustainability in New Zealand.

text: The spatial equity and sustainability of general practitioner services: A mixed methods analysis of the Waikato DHB region The New Zealand Primary Health Care Strategy states that quality primary health care is the first level of contact with the health system and should be universally accessible. Effective primary health care is an essential component of health systems, and is associated with more equitable distributions of health outcomes. However, not all New Zealanders have ready access to primary health care. For instance, adult residents of the Waikato region, and in particular Māori, have higher levels of unmet need for primay care than others. Improving the spatial equity of health services is a key step in achieving health equity. Health systems should contribute to achieving health equity and maintaining sustainable and equitable services into the future. 

This thesis research examines the spatial equity and sustainability of general practitioner (GP) services in the Waikato DHB region, using a mixed-methods approach to identify not only where inequities exist, but why they occur. A conceptual framework establishes a foundation for examining spatial equity and sustainability in New Zealand. Next, a systematic literature review identifies common definitions and measures of spatial equity. Primary Health Organisation (PHO) enrolment data is used to examine patterns of patient enrolment at GP services, and a range of health needs indicators were assessed for their suitability in the New Zealand primary care context. These findings inform the development of a Geographic Information Systems (GIS) model of spatial accessibility that is tailored to the Waikato District Health Board (DHB) context. The GIS model is then used, in combination with in-depth qualitative interviews, to examine the spatial equity and sustainability of GP services in the Waikato DHB region. 

Key findings include that spatial equity is commonly defined as a ‘need-based distribution of resources’, which can be quantified using a range of statistical and geospatial measures and techniques. PHO enrolment analysis revealed that most patients do not enrol with their closest service, and that the size of the ‘catchment area’ served by GP clinics varies with rurality. Analysis of indicators of health need suggest that ‘Ambulatory Sensitive Hospitalisations’ are a robust indicator; however, area-level socioeconomic deprivation is also strongly associated with other indicators of need and data is more widely available to researchers. Mixed-methods analysis suggests that GP services are not distributed equitably within the Waikato DHB region and that key barriers to access include the affordability, appropriateness, and availability of services. New Zealand’s history of colonisation and discrimination are identified as fundamental drivers of health inequity. Furthermore, population growth and ageing suggest that current levels of access to GP services are unlikely to be maintained in the future, while participants identify key economic, professional, organisation, and social dimensions that influence service sustainability in New Zealand.

year: 2020

title: The PIN-domain ribonucleases and the prokaryotic VapBC toxin–antitoxin array

authors: Arcus, Vickery L.

subjects: growth regulation

abstract: The PIN-domains are small proteins of ∼130 amino acids that are found in bacteria, archaea and eukaryotes and are defined by a group of three strictly conserved acidic amino acids. The conserved three-dimensional structures of the PIN-domains cluster these acidic residues in an enzymatic active site. PIN-domains cleave single-stranded RNA in a sequence-specific, Mg²⁺- or Mg²⁺- dependent manner. These ribonucleases are toxic to the cells which express them and to offset this toxicity, they are co-expressed with tight binding protein inhibitors. The genes encoding these two proteins are adjacent in the genome of all prokaryotic organisms where they are found. This sequential arrangement of inhibitor-RNAse genes conforms to that of the so-called toxin–antitoxin (TA) modules and the PIN-domain TAs have been named VapBC TAs (virulence associated proteins, VapB is the inhibitor which contains a transcription factor domain and VapC is the PIN-domain ribonuclease). The presence of large numbers of vapBC loci in disparate prokaryotes has motivated many researchers to investigate their biochemical and biological functions. For example, the devastating human pathogen Mycobacterium tuberculosis has 45 vapBC loci encoded in its genome whereas its non-pathogenic relative, Mycobacterium smegmatis has just one vapBC operon. On another branch of the prokaryotic tree, the nitrogen-fixing symbiont of legumes, Sinorhizobium meliloti has 21 vapBC loci and at least one of these loci have been implicated in the regulation of growth in the plant nodule. A range of biological functions has been suggested for these operons and this review sets out to survey the PIN-domains and summarise the current knowledge about the vapBC TA systems and their roles in diverse bacteria.

text: The PIN-domain ribonucleases and the prokaryotic VapBC toxin–antitoxin array The PIN-domains are small proteins of ∼130 amino acids that are found in bacteria, archaea and eukaryotes and are defined by a group of three strictly conserved acidic amino acids. The conserved three-dimensional structures of the PIN-domains cluster these acidic residues in an enzymatic active site. PIN-domains cleave single-stranded RNA in a sequence-specific, Mg²⁺- or Mg²⁺- dependent manner. These ribonucleases are toxic to the cells which express them and to offset this toxicity, they are co-expressed with tight binding protein inhibitors. The genes encoding these two proteins are adjacent in the genome of all prokaryotic organisms where they are found. This sequential arrangement of inhibitor-RNAse genes conforms to that of the so-called toxin–antitoxin (TA) modules and the PIN-domain TAs have been named VapBC TAs (virulence associated proteins, VapB is the inhibitor which contains a transcription factor domain and VapC is the PIN-domain ribonuclease). The presence of large numbers of vapBC loci in disparate prokaryotes has motivated many researchers to investigate their biochemical and biological functions. For example, the devastating human pathogen Mycobacterium tuberculosis has 45 vapBC loci encoded in its genome whereas its non-pathogenic relative, Mycobacterium smegmatis has just one vapBC operon. On another branch of the prokaryotic tree, the nitrogen-fixing symbiont of legumes, Sinorhizobium meliloti has 21 vapBC loci and at least one of these loci have been implicated in the regulation of growth in the plant nodule. A range of biological functions has been suggested for these operons and this review sets out to survey the PIN-domains and summarise the current knowledge about the vapBC TA systems and their roles in diverse bacteria.

year: 2010