The first priority area identified and endorsed by the DHBRF Governance Group was Chronic Care. An RFP was released in 2006 and a research provider was contracted to begin in February 2007.

Chronic illness is the leading cause of illness and death in New Zealand. Maori and Pacific peoples experience higher levels of chronic disease and at an earlier stage in life. Internationally there is recognition of the importance of a systems approach to health care to ensure improved outcomes. The aim of this study is to review the New Zealand and international literature for effective interventions that improve outcomes and will reduce inequalities particularly for Maori and Pacific peoples. The study will also identify local initiatives by surveying all 21 District Health Boards. It will then evaluate a sample of initiatives to identify the critical components that are needed for achieving successful outcomes for people with chronic disease. Finally with the health of an expert advisory group, a workbook will be produced that will guide DHBs to key interventions for improving care for people with respiratory and heart disease.

Principal Investigator: Professor Martin Connolly
Auckland UniServices, University of Auckland
18 months, $600,000

The second RFP to be released focuses on improving access to primary care, medications and diagnostic services for vulnerable populations. The aim of the project is to enhance service delivery and in turn have the potential to reduce inequalities. An RFP was released in February 2007 and a research provider was contracted in August 2007.

The project will determine which initiatives have been successful and why. The final result will be a toolkit for generalisable implementation by DHBs. The research team have formed collaborations with a number of DHBs, PHOs and other health poviders to ensure the research results have national utility.

Principal Investigator: Dr Barry Gribben
CGB Health Research Limited
32 months, $1,479,670

The third project to be funded aims to use a translational approach to research, to develop an evidence based, sustainable system framework for primary health care (PMH), that builds on and strengthens existing capacities and capabilities, and can be implemented in a range of New Zealand settings. A research provider was contracted in February 2009.

The research will look at what do DHB's, PHO's, NGO's and other organisations need to do to provide quality appropriate mental heath care, ranging from mental health promotion to treatment of disorders in the primary care setting.

The process will engage key stakeholders in the participative development of the framework, based on the principles of Participatory Action Research.

A critical aspect of the project is useful broader-based engagement with communities of interest. In particular Pasifika, mental health consumers and other stakeholders such as NGO's by using the local stakeholder networks of our research partners, as opposed to having a 'representative' of each on the research team.

Principal Investigator: Dr Sunny Collings
University of Otago, in partnership with Synergia.
18 months, $999,632

This initiative seeks to fund projects that improve the health of New Zealander's through reducing the impact or incidence of cardiovascular disease, diabetes and/or obesity. It aims to do this through funding short term, translational research projects in one or all of these areas. The first round was run in late 2008, with seven research providers selected in December 2008. A second round of the RFP was completed in July 2009, and eight research providers were selected. Below are the projects selected for funding in both rounds.

This project is a prospective intervention study involving individuals at-risk of having further cardiovascular events or developing Type 2 Diabetes Mellitus. Those people with acute coronary syndrome and hyperglycaemia are identified as at-risk individuals. The proposed study will involve two groups. Group A is the control and the subjects will receive primary and secondary healthcare as per normal. Group B is the intervention and participants will receive normal secondary care but a more structured and focused link with primary healthcare. The intervention will involve regular check-ups over a 9 month period and a comprehensive package of education, diet and exercise from the primary health care services. The aim of this study is to optimise and co-ordinate the resources that are already present in the healthcare sector to provide a more strategic focus on the at-risk groups and to ultimately reduce the incidence of further cardiac events and development of type 2 diabetes.

This project is led by Dr Jeremy Krebs, Department of Endocrinology, Capital & Coast District Health Board
12 months, $102,855

Type 2 diabetes affects 200 000 New Zealanders. Maori and Pacific populations have higher rates and related complications. Tight control of glucose and blood pressure reduces the rates of complications and underpins the management of diabetes. International evidence demonstrates that group-based self-management education facilitates improved glucose control, better understanding of disease and quality of life. These programmes have been developed in particular population, cultural and social contexts. New Zealand must develop an efficacious and cost-effective education programme that meets the specific needs of our population. This must be deliverable in primary care, meet the needs of Maori and Pacific and be developed in partnership with them. In this proposal a broad partnership between Secondary care, PHOs, Maori and Pacific stakeholders and University, reviews existing evidence-based programmes and develops a NZ equivalent including distinct Maori and Pacific components. The programme will be piloted and revised accordingly. It will then be tested in primary care environments in Wellington and Dunedin, including Maori and Pacific providers.

This project is led by Dr Jeremy Krebs Dr Jeremy Krebs, Department of Endocrinology, Capital & Coast District Health Board
12 months, $133,772

Decreasing diabetes foot and limb complications among Maori is a priority. Prior research found that informed supportive whanau contexts are essential for ensuring and maintaining change. This research will translate those findings into an appropriate programme. This programme will work with people who have diabetes and their whanau, using a multi-method design, within a Maori theoretical framework. In collaboration with a facilitator from the Taranaki PHO, six Maori with diabetes and their whanau (N= approx 60) will develop their own plans for supporting preventive foot health. Evaluation will assess the effectiveness of the program in reducing the impact and incidence of diabetes related foot pathology in the participants with diabetes and ensuring a supportive family context. This will inform policy at a national level about the effectiveness of a program designed by and with whanau rather than for an individual. It will inform national strategies about processes that work in the regional DHB delivery of preventive health.

This project is led by Dr Lisa Ferguson, Taupua Waiora, Centre for Maori Health Research, AUT University
12 months, $98,355

Bariatric surgery is a safe and effective method of delivering marked long-term weight reduction and a dramatic improvement in diabetes control. However, it is not without its own side-effects and recipients may still regain the lost-weight if a commitment to lifestyle changes is not maintained. The aim of the current study is to investigate whether intensive pre- and post-operative counselling and support of morbidly-obese diabetic subjects will provide a better outcome than standard care. A cohort of patients with type 2 diabetes and morbid obesity (BMI=35) will be randomised to receive a "wrap around" regimen comprising intensive psychological assessment/counselling, cultural support , intensive dietetic assessment/counselling and an exercise programme or standard guideline-based based care in a 1:1 ratio. All participants will undergo a bariatric surgery procedure 6-months after randomisation. The total duration of follow-up is 18 months (i.e. 6-months pre-surgery and 12-months post-surgery). Principle outcome measures include change in BMI, HbA1c, blood pressure, fasting lipid levels, resting pulmonary function and quality of life. If the study is successful, this could lead to a new health strategy where the very obese diabetic patient is offered an effective weight reduction treatment and the possibility of avoiding the worst scourges of long-term diabetes.

This project is led by Dr Brandon Orr-Walker, Middlemore Hospital, Counties Manukau District Health Board.
12 months, $76,509

Specialist diabetes services are currently delivered by diabetologists through the conventional outpatient clinic. Because of the demand on this service waiting times for people with diabetes referred by their GP can be considerable. The aim of this study is to examine the impact of providing a virtual (telephone) clinic for general practitioners and practise nurses. All referrals made to the diabetes service will be answered by way of direct telephone contact with the referrer by one of the four diabetes specialists at Dunedin Hospital. The aim will be to provide the advice that the primary care worker requires to care for the patient in the community without the patient having to come to the diabetes outpatient clinic. We will also be able to provide advice for primary care workers who telephone the service at this time. We will determine the effectiveness of this service by comparing the number of patients seen in the outpatient clinic in the 6 months prior to and after the virtual clinic is established.

This project is led by Associate Professor Patrick Manning, Endocrinology, Otago District Health Board.
12 months, $11,500

This research will build on a national CVD dynamic simulation model to explore how it can be translated to the specific local context of Counties Manukau. We will partner with local DHB and PHO experts to identify: local priority questions that might be addressed by the model; where local data is available to apply within the national model; to quantify local changes in service during the time of the study and determine whether the model accurately reflects the effects of these changes on the system of cardiovascular services in Counties Manukau. By involving local experts we expect to transfer knowledge of how to use these tools, and assess whether these experts consider this modelling process will help refine local decision making and therefore improve delivery of services within the available resources.

This project is led by Dr Allan Moffitt, Primary Care Development, Counties Manukau District Health Board.
12 months, $104,462

We plan to take an in depth look at how those with diabetic eye disease referred to and seen in hospital eye departments across the country in an effort to identify what practices make an efficient referral service (measured by meeting the national guidelines) so that these practices might be adopted by other services to improve efficiency and health outcomes for patients. Blindness as a result of diabetes when managed appropriately is almost entirely preventable. This will take the form of a cross-sectional analysis or audit. We anticipate that this will take six months to do; and that we will need to look at quite a number of the different eye clinics around the country in order to identify trends that are applicable to our different target populations (Maori, Non Maori, Pacific Islanders as well as younger and older populations).

This project is led by Dr Edward Hutchins, Ophthalmology Section, University of Otago Dunedin School of Medicine.
8 months, $103,030

Objective: To determine whether blood sugar tests in early pregnancy will detect women with undiagnosed diabetes.

Methods: Blood tests for diabetes will be included with the first antenatal bloods. Women with a positive result will be offered a further test to confirm diabetes and be given treatment as necessary.

Impact: Diabetes may go undetected for several years. In pregnancy, untreated maternal diabetes can cause problems for the baby including birth defects, delayed lung development, and obesity. Currently, women are offered testing for gestational (pregnancy) diabetes at 24-28 weeks of pregnancy. This means that women with undiagnosed pre-existing diabetes remain unrecognised until late pregnancy when treatment may be much less effective in reducing adverse pregnancy outcomes. Detection and prompt treatment of pre-existing diabetes in early pregnancy can reduce potential immediate and long-term harm to the baby and have a positive impact on maternal health.

This project is led by by Dr Ruth Hughes, Canterbury District Health Board.
12 months, $124,220

In February 2009 the Waikato Heart Failure group received funding for a community-based integrated heart failure service. We wish to investigate the impact of this new service on patient outcomes. This is an observational (comparative) study looking at a quality improvement intervention.

We wish to: Improve detection of heart failure; identify any inequalities; provide better local access to diagnostics and specialist care; and, to improve communication between primary and secondary care providers, and health providers and patients.

Once completed we will have relevant estimates of the numbers with and severity of heart failure against agreed guidelines, relevant risk factors, and a basis for early diagnosis and intervention. The service (intervention) will be evaluated to show whether it has led to an improvement in diagnosis and management of heart failure. It will inform national strategies about processes that work for timely diagnosis and management of heart failure in primary care.

This project is led by Dr Anita Bell, Waikato District Health Board.
12 months, $118,304

We propose to evaluate the utility of a cough reflex test for reducing pneumonia in acute stroke patients. All stroke patients referred for swallowing evaluation in a 9 month period will be approached for participation in the study.

Consenting participants will be randomly assigned to either a 1) standard evaluation group or 2) standard evaluation with inclusion of cough reflex testing. For those in the experimental group, concentrations of inhaled, nebulised citric acid will be administered to assess cough response and results will contribute to usual clinical decision making. Outcomes for both groups will be measured by pneumonia rates by 3 months post discharge and other clinical indices of swallowing impairment.

If successful in reducing morbidities associated with acute stroke, this test can be easily implemented by clinicians without significant cost or resources and consequently reduce the impact of diabetes, cardiovascular disease and obesity on health status and quality of life.

This project is led by Ms Helen McLauchlan, Counties Manukau District Health Board.
12 months, $91,500

This research will build on a national cardiovascular dynamic simulation model to explore how it can be translated to a the specific regional context of Hawke's Bay. We will partner with local experts to identify: Local priority questions that might be addressed by the model; where local data is available, or not, to apply within the national model; to quantify local changes in service during the time of the study and determine whether the model accurately reflects the effects of these changes on the system of cardiovascular services in Hawke's Bay. By involving local experts we expect to transfer knowledge of how to use these tools, and assess whether these experts consider this modelling process will help refine local decision making and therefore improve delivery of services within the available resources.

A parallel application from Counties Manukau DHB will enable triangulation between a national perspective and two distinctly different regions.

This project is led by Mrs Dianne Keip, Bay District Health Board.
12 months, $27,900

This study will evaluate whether a new developed, non-invasive skin test is effective for screening for diabetes in the community and also for identifying patients with diabetes at increased risk of developing the serious vascular complications associated with the disorder. The test involves ultraviolet measurement of the fluorescence intensity of proteins in the skin.

The proposed study represents the final clinical phase of a series of studies that will validate and calibrate the method in both diabetic and non-diabetic people. The study will involve placement of the portable fluorescent measuring device in primary healthcare settings and also in hospital diabetes out-patient clinics. The ability of the skin test to identify subjects with undiagnosed diabetes and/or diabetic patients at increased vascular risk will be compared against currently used standard procedures. Depending on the outcome of these comparisons, it is possible this simple and inexpensive skin test may improve the ability to screen and monitor diabetes in the community.

This project is led by by Dr Brett Shand, Canterbury District Health Board.
12 months, $108,232

Diabetes is present in 10-15% of patients admitted to hospital in New Zealand; about one in six of people with diabetes are admitted each year. Their stay in hospital is roughly doubled compared with non-diabetic patients. Our aim is to try three models of care delivery to see if they can reduce length of stay and/or improve quality of care. We will trial the methods below with teams involving specialist nurses and doctors, over an eight month period:

Proactive - Daily ward visits/phone calls to identify patients and arrange treatment. Reactive - Rapid responses to ward-initiated referrals. Electronic - Immediate email notification of all admissions, then prioritising.

Measures will include time from admission to discharge, nursing staff time, quality of care and patient/staff satisfaction surveys. A positive result would allow shorter stays and better care for patients, with major savings of beds and costs for DHBs.

This project is led by Dr Paul Drury, Auckland District Health Board.
12 months, $148,110

Programmes aimed at the management and treatments of obesity in the general child population are often not appropriate for children with disability. The objective of this research is to evaluate the effectiveness and appropriateness of the modified Mind Exercise Nutrition… Do it! (MEND) pilot programme used by the Auckland District Health Board as a way of addressing the health issue of obesity in children with disability.

The MEND pilot programme will be evaluated through the use of the Framework for Programme Evaluation in Public Health (Centres for Disease Control and Prevention, 1999) which includes engaging stakeholders; description and evaluation of the program; gathering credible evidence and conclusions; and dissemination of the findings. Identification of successful interventions and effective service delivery to manage obesity, increase physical activity, improve nutrition and contribute to well being are critical to address the health issues (both present and future) of children and families with disability.

This project is led by Mrs Madeleine Sands, Auckland District Health Board.
12 months, $78,435

Traditionally low intensity ‘fat burning’ endurance training (LIET), for example walking or jogging, has been prescribed for those at-risk of developing type 2 diabetes and cardiovascular disease (CVD). This type of exercise has met with limited risk factor reduction and exercise adherence success. Recent research suggests high intensity exercise (HIIT) or combined high and lower intensity exercise (MIXT) may provide a time efficient method for improving risk factor reduction and exercise adherence. Our objective is to examine whether these findings can translate to populations at-risk of diabetes and cardiovascular disease in an Aotearoa/New Zealand context. In the first 12 week phase of the research translation of HIIT and MIXT to at-risk populations will be examined and in the second 6 month phase the exercise interventions will be adapted to match those readily available to participants in their local area. Changes in risk factors will be assessed along with exercise adherence.

This project is led by Dr Helen Lunt, Canterbury District Health Board.
12 months, $161,699

The most recent project to be contracted under the DHBRF focuses on reducing cancer (mortality and morbidity) through the detection and management of cancer to improve quality of cancer care services for people in primary care. An RFP was released in 2008 and a research provider was contracted to begin in June 2009.

Lung cancer is the leading cause of cancer deaths in New Zealand, and its poor prognosis is largely attributed to late diagnosis.

The study aims to identify barriers, especially for Maori and Pacific peoples, to timely diagnosis and appropriate initial cancer care, and to recommend service change to facilitate diagnosis and coordinated care.

A stocktake of primary care services and documentation of the lung cancer patient’s journey from presentation to primary care until the first specialist assessment will be performed in three Primary Health Organisations in greater Auckland. Reasons for not attending appointments and initial presentation to secondary care via the emergency department will be explored by interviews and focus groups.

Improved understanding of the barriers to early diagnosis and recommendations for service modification to better meet community needs and expectations have the potential to result in earlier diagnosis, improving quality of life and survival for people with lung cancer.

Principal investigator: Dr Wendy Stevens
University of Auckland, Northern DHB Support Agency Limited.
36 months, $1,176,789