ObjectivesTo understand health disparities in cardiovascular disease (CVD) in the indigenous Māori of New Zealand, diagnosed and undiagnosed CVD risk factors were compared in rural Māori in an area remote from health services with urban Māori and non-Māori in a city well served with health services.DesignProspective cohort study.SettingHauora Manawa is a cohort study of diagnosed and previously undiagnosed CVD, diabetes and risk factors, based on random selection from electoral rolls of the rural Wairoa District and Christchurch City, New Zealand.ParticipantsScreening clinics were attended by 252 rural Māori, 243 urban Māori and 256 urban non-Māori, aged 20–64 years.Main outcome measuresThe study documented personal and family medical history, blood pressure, anthropometrics, fasting lipids, insulin, glucose, HbA1c and urate to identify risk factors in common and those that differ among the three communities.ResultsMean age (SD) was 45.7 (11.5) versus 42.6 (11.2) versus 43.6 (11.5) years in rural Māori, urban Māori and non-Māori, respectively. Age-adjusted rates of diagnosed cardiac disease were not significantly different across the cohorts (7.5% vs 5.8% vs 2.8%, p=0.073). However, rural Māori had significantly higher levels of type-2 diabetes (10.7% vs 3.7% vs 2.4%, p<0.001), diagnosed hypertension (25.0% vs 14.9% vs 10.7%, p<0.001), treated dyslipidaemia (15.7% vs 7.1% vs 2.8%, p<0.001), current smoking (42.8% vs 30.5% vs 15.2%, p<0.001) and age-adjusted body mass index (30.7 (7.3) vs 29.1 (6.4) vs 26.1 (4.5) kg/m2, p<0.001). Similarly high rates of previously undocumented elevated blood pressure (22.2% vs 23.5% vs 17.6%, p=0.235) and high cholesterol (42.1% vs 54.3% vs 42.2%, p=0.008) were observed across all cohorts.ConclusionsSupporting integrated rural healthcare to provide screening and management of CVD risk factors would reduce health disparities in this indigenous population.

Objective: To report the processes and protocols that were developed in the design and implementation of the Hauora Manawa Project, a cohort study of heart disease in New Zealand and to report the participation at baseline. Methods: This study utilised application of a Kaupapa Māori Methodology in gaining tribal and health community engagement, design of the project and random selection of participants from territorial electoral rolls, to obtain three cohorts: rural Māori, urban Māori and urban non‐Māori. Logistic regression was used to model response rates. Results: Time invested in gaining tribal and health community engagement assisted in the development and design of clear protocols and processes for the study. Response rates were 57.6%, 48.3% and 57.2%. Co‐operation rates (participation among those with whom contact was established) were 74.7%, 66.6% and 71.4%. Conclusions: Use of electoral rolls enables straightforward sampling but results in low response rates because electors have moved. Co‐operation rates highlight the acceptability of this research project to the participants; they indicate the strength of Kaupapa Māori Methodologies in engaging Māori participants and community. Implications: This study provides a model for conducting clinical/biomedical research projects that are compatible with cultural protocols and methodologies, in which the primary aim of the research was Māori health gain.

The cost-effectiveness of hepatitis C virus (HCV) anti-viral therapy for injecting drug users (IDUs) on methadone maintenance is important because the majority have chronic infections that remain untreated. Cost-effectiveness analysis examines the costs of treatment compared with the benefits, which in this study are defined as savings in life. The cost-effectiveness of treatment for HCV infection is investigated for Mäori and non-Mäori IDUs on methadone maintenance therapy (MMT) in New Zealand. Markov models are used to model cohorts of IDUs, changes in their health states and the effects of MMT and anti-viral therapy on morbidity and mortality. Comparisons were made between conventional combination therapy (COT) and combination therapy with pegylated interferon. Sensitivity analysis is used to model cost-effectiveness of treatment under varying assumptions of progression of liver disease and compliance with treatment. The cost-effectiveness of MMT alone was estimated at 25397 dollars per life year saved (LYS) for non-Mäori men and 25035 dollars for non-Mäori women IDUs (costs and benefits discounted at 3%). The incremental effects of providing COT to all eligible patients were to save extra years of life, as well as to involve additional costs of anti-viral therapy. Analysis of both the incremental costs and benefits showed that a policy of providing COT to all patients meeting treatment criteria would have similar cost-effectiveness to MMT alone. Costs per LYS were estimated to be lower for Mäori for both men and women, reflecting ethnic differences in mortality. Cost-effectiveness was found to improve if the average age of stabilizing on MMT could be lowered by 5 years from the current average age of 31 years to age 26. Cost-effectiveness of the new treatment with pegylated interferon and ribavirin was found to be similar to that of COT because the increased LYS were offset by expected higher costs of the new pharmaceuticals. Sensitivity analysis showed that anti-viral treatment remained cost-effective under varying assumptions of the rate of disease progression and compliance with treatment.

Māori are the indigenous people of New Zealand (NZ), comprising approximately 15% of the national population. A major disparity exists between Māori and non-Māori in cardiovascular mortality, which remains the leading cause of premature death and disability in New Zealand.1,2 Furthermore, recent health statistics indicate that those living in rural areas are worse off than urban New Zealanders, including for prevalence of ischaemic heart disease.3 Rural Māori have a shorter life expectancy than urban Māori, with 1.2 years difference for women and 1.5 years difference for men. 3 The combination of resource accessibility and ethnic disparities may additionally disadvantage rural Māori communities with respect to health outcomes.Recent data on cardiovascular disease (CVD) and its risk factors in Māori has been obtained from mortality or hospital statistics, 1,4 from diagnoses in general practice, 5 and in urban Auckland communities, 6-10 but we lack information about the state of Māori cardiovascular health in rural communities. In addition, disease rates and risk factors in indigenous population groups may be underestimated if these groups do not have equivalent access to health care or CVD screening. This underestimation will occur in studies based on clinical databases. It will also occur in population studies that rely on self-report of doctor-diagnosed conditions, such as the New Zealand Health Survey. Results: Mean age of participants (n=252) was 45.7±0.7, 8% reported a history of cardiac disease, 43% were current smokers, 22% had a healthy BMI, 30% were overweight and 48% obese.Hypertension was previously diagnosed in 25%; an additional 22% were hypertensive at screening. Dyslipidaemia was previously diagnosed in 14% and an additional 43% were dyslipidaemic at screening. Type-2 diabetes was previously diagnosed in 11%. Glycaemic control was achieved in only 21% of those with type-2 diabetes.Blood pressure and cholesterol were above recommended targets in more than half of those with diagnosed CVD risk factors. Conclusions

This paper estimates future health service costs of the current practice in New Zealand of not funding treatment of hepatitis C virus (HCV) infections. Costs are estimated separately for Māori and non-Māori, male and female IDUs. Markov modelling is used to track the infection and progression of HCV to severe liver disease and death, and accumulated costs are estimated for the life of the cohort. Upper and lower estimates of costs are calculated based on different assumptions of the rate of progression of HCV to more severe liver disease. Costs are estimated at dollars 24.6 million per 1000 non-Māori men IDUs (discounted at 3%), under progression assumptions based on liver clinic studies, compared with dollars 10.3 million per 1000 using lower rates of progression based on community studies. Similarly, corresponding costs for non-Māori women are estimated at dollars 27.6 million and $11.2 million per 1000 IDUs. Costs for women are higher because their greater life expectancy is associated with more cases of liver cirrhosis (LC) at older ages. Future costs for Māori are lower than non-Māori, because Māori are more likely to die at younger ages and hence fewer progress to more advanced liver disease. The current situation in New Zealand of not treating HCV infections will result in considerable future costs as some people with HCV progress to more severe liver disease. Provisional estimates are that the accumulated costs of HCV-related liver disease for all IDUs currently infected will be between dollars 166 million at lower rates of disease progression (discounted at 3%) to dollars 400 million at upper rates. Some of the associated morbidity and mortality could have been avoided if the HCV infections had been treated.