MidCentral District Health Board Rheumatic Fever Prevention Plan. October 2013

Transcription

1 MidCentral District Health Board Rheumatic Fever Prevention Plan October 2013

2 Contents Section 1: Introduction Executive summary Purpose... 5 Section 2: Overview of acute rheumatic fever in MidCentral DHB Geography The MidCentral DHB population Acute rheumatic fever disease burden Government targets Commitment statement... 9 Section 3: Quick and effective treatment of Group A streptococcal (GAS) throat infections Appropriate use of NZ sore throat management guidelines by primary care health professionals Ensuring treatment compliance Interventions to improve access Section 4: Effective follow-up of identified rheumatic fever cases Administration of antibiotics for secondary prevention Notification of confirmed cases to local Medical Officer of Health Known risk factors and system failure points Appendices Appendix 1: Acute rheumatic fever initial hospitalisation criteria MidCentral DHB Rheumatic Fever Prevention Plan Page 2

3 Section 1: Introduction 1.1 Executive summary The incidence of acute rheumatic fever in the MidCentral District Health Board (DHB) area is relatively low when compared to other District Health Boards in New Zealand. The MidCentral DHB rheumatic fever prevention plan expresses a commitment by MidCentral DHB to maintain a low incidence of acute rheumatic fever in the MidCentral DHB population and to ensure any cases that do occur are managed effectively according to evidence-based best practice. The plan provides an overview of the burden of rheumatic fever in the MidCentral DHB population followed by two sections describing the actions that will be taken by MidCentral DHB to meet the commitments expressed in this plan. The content of the two action sections are summarised in Tables 1 and 2 below. Table 1: Summary of planned activities to ensure quick and effective treatment of Group A streptococcal (GAS) throat infections Ref Work programme Actions Indicators 1 Section 3 - Quick and effective treatment of Group A streptococcal (GAS) throat infections 3.1 Appropriate use of NZ sore throat management guidelines by primary care health professionals Provider education Delivery of targeted education to primary care health professionals Map of Medicine/Clinical Collaborative Pathways Development of sore throat management pathway 3.2 Ensuring treatment compliance Collaboration with community pharmacists Promotion of active interactions between patients and pharmacists to facilitate access to treatment and improve antibiotic adherence Evidence-based promotion of simple treatment Delivery of targeted education to primary care health regimes professionals 3.3 Interventions to improve access Improving health literacy Delivery of appropriate health promotion messages to children/young adults and whānau Financial assistance/alternative pathways of care for people with low incomes Raise awareness of financial assistance options to attend primary health care services among whānau and health professionals Increased throat swab testing Increased proportion of antibiotics dispensed for sore throats are prescribed in accordance with national guidelines Maintenance/reduction of acute rheumatic fever initial hospitalisations Increased proportion of antibiotics dispensed for sore throats are prescribed in accordance with simplest recommended regime Maintenance/reduction of acute rheumatic fever initial hospitalisations 1 Progress towards specific indicators will be applicable from the time that relevant actions are implemented. Specific indicator targets may be further defined when additional data are available. MidCentral DHB Rheumatic Fever Prevention Plan Page 3

4 Table 2: Summary of planned activities to ensure effective follow-up of identified rheumatic fever cases Ref Work programme Actions Indicators 2 Section 4: Effective follow-up of identified rheumatic fever cases 4.1 Administration of antibiotics for secondary prevention Investigation of current local processes Review of rheumatic fever register and secondary prophylaxis protocol Actions to ensure timely antibiotic prophylaxis Modification of register, protocols and care pathways as necessary 4.2 Notification of confirmed cases to local Medical Officer of Health Maintenance/reduction of acute rheumatic fever recurrences All cases receive monthly antibiotics not more than 5 days after the due date Investigation of current local processes Review of local notification and admission data All cases are notified to the Medical Officer of Actions to ensure complete and timely notifications Modification of local processes as necessary to improve notifications Health within 7 days of hospital admission 4.3 Known risk factors and system failure points Identification of risk factors and system failure points Review of previous acute rheumatic fever cases and development of a supplementary survey to identify risk factors in new cases Maintenance/reduction of acute rheumatic fever initial hospitalisations Actions to reduce the impact of known risk factors and system failure points Development of strategies to modify the impact of known risk factors and system failure points as necessary 2 Progress towards specific indicators will be applicable from the time that relevant actions are implemented. Specific indicator targets may be further defined when additional data are available. MidCentral DHB Rheumatic Fever Prevention Plan Page 4

5 1.2 Purpose The incidence of rheumatic fever is much higher in New Zealand than in other comparable countries. Rheumatic fever is unevenly distributed in New Zealand it occurs mainly in the North Island, is strongly correlated with poor socio-economic status, and disproportionately affects Māori and Pacific people. Approximately 70 percent of cases occur in primary and intermediate school-aged children and there has been an increasing trend in the incidence of rheumatic fever in New Zealand over recent years. One of the Government s key results areas for Better Public Services is the reduction of the incidence of rheumatic fever by 2017 by two-thirds. All DHB annual plans identified the development of a Rheumatic Fever Prevention Plan by 20 October 2013 as a key activity for the 2013/2014 year. The Rheumatic Fever Prevention Plan will identify MidCentral DHB s approach and commitment to delivering a range of actions which will contribute to achieving their rheumatic fever target. This document describes the current burden of acute rheumatic fever in the MidCentral DHB area and the activities that MidCentral DHB will undertake to reduce the incidence of rheumatic fever. The Rheumatic Fever Prevention Plan covers the period from 20 October 2013 to 30 June MidCentral DHB Rheumatic Fever Prevention Plan Page 5

6 Section 2: Overview of acute rheumatic fever in MidCentral DHB 2.1 Geography The area for which the MidCentral DHB has responsibility is based on territorial authority and ward boundaries and includes: Manawatu District, Palmerston North City, Tararua District, Horowhenua District, and Kapiti District (Otaki Ward). 2.2 The MidCentral DHB population The MidCentral District Health Board serves a population of approximately 170,200 people (2013/14 estimate). The MidCentral DHB population tends to be similar to the NZ population in general, but with a slightly higher proportion of older people and people living in communities with the most deprived NZDep2006 scores as compared to the national average. The MidCentral DHB population has a similar proportion of Māori and a lower proportion of Pacific people when compared to the NZ population /2014 population estimates from Ministry of Health website. Available at: Accessed 1 Oct MidCentral DHB Rheumatic Fever Prevention Plan Page 6

7 3-year average ARF hospitalisation rate per 100,000 total population 2.3 Acute rheumatic fever disease burden Acute rheumatic fever incidence 4 in the MidCentral DHB area is relatively low when compared to other District Health Boards. Table 3 shows the number of initial hospitalisations for acute rheumatic fever in the MidCentral DHB area since July Table 3: Acute rheumatic fever hospitalisations in MidCentral DHB (July 2002-June 2013) Year Number of initial hospitalisations 2002/ / / / / / / / cases = 2.67 cases/year 2010/11 3 Annual rate = 1.6 cases per 2011/ ,000 total population 2012/13 1 Total 25 For the three year period from July 2009 to June 2012 there were 8 new cases of acute rheumatic fever, or approximately 3 cases per year in the MidCentral DHB area. The average annual incidence rate during this three year period was 1.6 cases per 100,000 total population in the MidCentral DHB area. Figure 1 shows the average annual acute rheumatic fever hospitalisation rates for all New Zealand DHBs (all cases in South Island DHBs are combined and represented by the Southern region data point). Figure 1: Average annual acute rheumatic fever hospitalisation rate (per 100,000) in New Zealand District Health Boards (July 2009-June 2012) The average annual incidence of acute rheumatic fever is lower in the MidCentral DHB area than in the Central region as a whole (3.2 cases per 100,000 total population) and is also lower than in New Zealand (4.0 cases per 100,000 total population) Disease burden by age District Health Board Acute rheumatic fever occurs most commonly in school-aged children. Table 4 shows the number of initial hospitalisations and the average annual incidence rate by age for acute rheumatic fever in the MidCentral DHB area since July It can be seen that almost all of the cases (96%) during this time period occurred in children and young adults aged less than 20 years. 4 Acute rheumatic fever initial hospitalisations are used as the measure of incidence of acute rheumatic fever and the criteria for these hospitalisations are outlined in Appendix 1. MidCentral DHB Rheumatic Fever Prevention Plan Page 7

8 Table 4: Number of ARF hospitalisations and average annual incidence rate by age (July 2002 June 2013) Age at admission Number of ARF initial hospitalisations Annual incidence rate (per 100,000 population by age*) <5 years years years years years years and over 0 0 Total * using Census 2006 population counts (by age) as denominator Disease burden by ethnicity Acute rheumatic fever disproportionately affects Māori and Pacific people in New Zealand. Table 5 shows the number of initial hospitalisations and the average annual incidence rate by ethnicity for acute rheumatic fever in the MidCentral DHB area since July Table 5: Number of ARF hospitalisations and average annual incidence rate by ethnicity 5 (July 2002 June 2013) Ethnicity Number of ARF initial Annual incidence rate (per 100,000 hospitalisations population by ethnicity*) NZ European NZ Māori Pacific Other 0 0 Total * using Census 2006 population counts (by ethnicity) as denominator The majority of acute rheumatic fever cases (68%) in the MidCentral DHB area between July 2002 and June 2013 occurred in children and young adults of Māori ethnicity. Slightly less than one-quarter (24%) of acute rheumatic fever hospitalisations occurred in Pacific peoples over the same time period. The annual incidence rates by ethnicity in the MidCentral DHB area are consistent with the national pattern of disproportionate burden of disease for Māori and Pacific people Disease burden by deprivation Acute rheumatic fever is strongly associated with poor socioeconomic status. Table 6 shows the number of initial hospitalisations by deprivation for acute rheumatic fever in the MidCentral DHB area since July Table 6: Number of ARF hospitalisations by deprivation (July 2002 June 2013) based on residential address at time of admission* NZDep2006 decile Number of ARF initial hospitalisations Decile 1 least deprived 0 Decile 2 0 Decile 3 1 Decile 4 0 Decile 5 2 Decile 6 1 Decile 7 1 Decile 8 4 Decile 9 8 Decile 10 most deprived 7 Total 24 *No address information available for 1 case More than three-quarters (79%) of all acute rheumatic fever hospitalisations in the MidCentral DHB area occurred in people living in communities that belong to the 30% of New Zealand neighbourhoods 6 with the most deprived NZDep2006 scores. 5 NZ Census 2006 uses grouped total responses for ethnic group. This includes all of the people who stated each ethnic group, whether as their only ethnic group or as one of several ethnic groups. Where a person reported more than one ethnic group, they have been counted in each applicable group. 6 Census small areas belonging to deciles 8, 9 & 10 in NZDep2006 MidCentral DHB Rheumatic Fever Prevention Plan Page 8

9 2.3.4 Disease burden by territorial authority area Table 7 shows the geographical distribution of acute rheumatic fever cases by territorial authority in the MidCentral DHB area since July Table 7: Number of ARF hospitalisations by territorial authority (July 2002 June 2013) based on residential address at time of admission* Territorial Authority Number of ARF initial hospitalisations Horowhenua District 7 Kapiti Coast District (Otaki Ward only) 1 Manawatu District 0 Palmerston North City 14 Tararua District 2 Total 24 *No address information available for 1 case Almost 60% of cases occurred in the Palmerston North City area and a further 30% of cases occurred in the Horowhenua District over the last 11 years. When population size is adjusted for this equates to an annual rate of 1.6 cases per 100,000 in Palmerston North City and 2.0 cases per 100,000 in Horowhenua. 2.4 Government targets The New Zealand Government is committed to reducing the incidence of acute rheumatic fever by two-thirds by June The targets for annual number of cases and annual incidence rates for the MidCentral DHB area during the next four years are summarised in Table 8. Table 8: Acute rheumatic fever initial hospitalisation average annual target numbers and rates for MidCentral DHB, 2012/13 to 2016/17 Annual number of cases Annual incidence rate (per 100,000) 2009/ /12 Baseline rate (3-yr average) 2012/13 target: Remain at baseline level 2.5 Commitment statement 2013/14 target: 10% reduction from baseline 2014/15 target: 40% reduction from baseline 2015 /16 target: 55% reduction from baseline 2016/17 target: 2/3 reduction from baseline MidCentral DHB is dedicated to achieving the Government targets and maintaining a low incidence of acute rheumatic fever hospitalisations to improve health outcomes for the MidCentral DHB population, especially children and young adults. MidCentral DHB acknowledges the disproportionate burden of acute rheumatic fever experienced by Māori, Pacific and the most socioeconomically disadvantaged people within our communities, and is committed to an equity focussed approach to reduce health inequalities occurring as a result of acute rheumatic fever in the MidCentral DHB area. MidCentral DHB Rheumatic Fever Prevention Plan Page 9

10 Section 3: Quick and effective treatment of Group A streptococcal (GAS) throat infections MidCentral DHB supports evidence-based, best practice management of sore throats through high quality, responsive primary health care services. Engagement with local primary care stakeholders, development of a shared understanding of the burden of rheumatic fever in the MidCentral DHB area, and collaborative development of strategies consistent with national clinical guidelines and health promotion approaches will ensure that service improvements are locally relevant and underpinned by sound evidence. 3.1 Appropriate use of NZ sore throat management guidelines 7 by primary care health professionals Provider education MidCentral DHB, in collaboration with Central Primary Health Organisation and other primary care providers/organisations, will undertake a targeted educational strategy to improve the management of sore throats by primary care health professionals in MidCentral DHB communities. This will be achieved through the following activities: Communication and engagement with key primary care stakeholder groups including Central Primary Health Organisation and local Māori health service providers 8 Identification and prioritisation of target groups of primary care heath professionals Development and staged delivery of learning opportunities to the identified groups of health professionals with a focus on relevance to their role within the primary care sector and covering important 7 The National Heart Foundation is currently reviewing and updating the 2006 Sore Throat Management Guidelines. These guidelines are due to be released by the end of 2013 on the National Heart Foundation website. 8 There are no Pacific health service providers in the MidCentral DHB area. aspects of history and triage (identifying high risk children at point of first contact), diagnostic testing (throat swabbing), and best practice, evidence-based treatment decisions Map of Medicine/Clinical Collaborative Pathways MidCentral DHB has invested in Map of Medicine as a tool for developing collaborative clinical care pathways to improve patient outcomes through enhanced referral processes and a seamless patient health care experience across primary and secondary care. MidCentral DHB will utilise the Map of Medicine to develop a localised collaborative clinical pathway for sore throat management and this will be undertaken following the release of the revised national sore throat management guidelines which are expected in December The Map of Medicine clinical pathway will provide primary care health professionals with rapid access to the most up-to-date, evidence based, and locally relevant guidance to improve the triage, diagnosis and treatment of sore throats. This strategy complements the provider education outlined in Section and offers frontline health professionals with ongoing access to clinical decision support consistent with local need at the point of care Measuring progress The success of activities to improve awareness and utilisation of the New Zealand sore throat management guidelines by primary care health professionals will be measured by conducting audits of clinical practice before and after the interventions are implemented. It is proposed that the following measures of clinical practice will be audited: Throat swab requests and results Antibiotic prescribing MidCentral DHB Rheumatic Fever Prevention Plan Page 10

11 Data collection for throat swabbing audits will be done in collaboration with MedLab Central and antibiotic prescribing audits will utilise available data from national pharmaceutical databases. It is recognised that there are some important limitations when undertaking audits of throat swabbing practices and antibiotic prescribing in a primary care setting. These limitations include: Not all children/young adults presenting to primary care with a clinically significant sore throat will have a throat swab taken. Empiric antibiotic treatment may be started without laboratory confirmation of GAS infection and this may result in an underestimation of the prevalence of GAS sore throats presenting to primary care. Not all antibiotic prescriptions for the management of sore throats will be dispensed. Pharmaceutical databases only capture information about dispensed medications and therefore the extent of antibiotic prescribing for sore throats presenting to primary care is likely to be underestimated. To assess whether antibiotics are being prescribed in accordance with the national guidelines, it must be assumed that the specific antibiotic regimes subject to the audit are being used exclusively for treatment of sore throats. 3.2 Ensuring treatment compliance Collaboration with community pharmacists Community pharmacists have a key role in promoting patient adherence with prescribed treatments at the point of dispensing. MidCentral DHB has an established collaborative relationship with the MidCentral Community Pharmacists Group (MCPG) and is committed to working together to enhance patient adherence with antibiotic treatments for sore throat management. This will be achieved through the following activities: Inclusion of pharmacists as a key target group for provider education (Section 3.1.1) Promotion of active interactions between pharmacists, children/young adults and whānau in a community pharmacy setting to appropriately identify and refer people with increased risk for medical assessment and treatment Promotion of active interactions between pharmacists, children/young adults and whānau to encourage adherence with dispensed antibiotic treatments for sore throats Evidence-based promotion of simple treatment regimes For short term treatment of acute conditions it is well recognised that patient medication adherence is correlated with the complexity of the treatment regime. Where there is sound evidence of effectiveness indicated in the most up-to-date national sore throat management guidelines, MidCentral DHB will promote use of the simplest recommended antibiotic regimes (such as once-daily dosing) to improve treatment compliance. This approach will be promoted as part of the provider education activities (Section 3.1.1) and will also be considered during the development of the Map of Medicine sore throat management pathway (Section 3.1.2) Measuring progress Measuring patient adherence with prescribed treatment regimes is problematic. Subjective patient surveys of treatment compliance are fraught with reporting biases and objective measures of adherence with short-course regimes are rarely available. The ultimate measure of effective management of sore throats in the context of this prevention plan, including compliance with prescribed antibiotic treatment, is the maintenance or reduction in incidence of acute rheumatic fever initial hospitalisations in the MidCentral DHB population. Increased utilisation of the simplest recommended antibiotic regimes for the treatment of sore throats may indicate a commitment by prescribers to MidCentral DHB Rheumatic Fever Prevention Plan Page 11

12 improve patient compliance and thus may demonstrate some success of activities to promote this approach in primary care. This can be measured during the clinical audit of antibiotic prescribing (Section 3.1.3). 3.3 Interventions to improve access Improving health literacy To ensure that children and young adults receive appropriate treatment for sore throats they must first seek health care for a condition that is commonly considered self-limiting and not requiring medical intervention. MidCentral DHB will support community health literacy about rheumatic fever and the importance of timely assessment of sore throats in children and young adults through a proactive health promotion approach. Activities to achieve this may include: Appropriate messages delivered in current school-based health promotion programmes, with a particular focus on low decile schools and in areas with high proportions of Māori and Pacific children Dissemination of suitable health promotion messages on DHB vehicles as mobile billboards Exploration of various communication tools such as social media, local youth health websites, text messaging, local radio advertising and school correspondence as possible mechanisms for delivering health promotion messages to children, young adults and their families/whānau Raising awareness of financial assistance options for people with low incomes As has been previously described, a considerable proportion of the disease burden associated with rheumatic fever is experienced by children and young adults living in areas of high socioeconomic deprivation. Financial barriers to accessing primary health care services are an important determinant of health in these communities. MidCentral DHB will support primary care health professionals to provide information to people with low incomes about available financial assistance options that may improve access to necessary primary care services. This will be achieved by raising awareness among primary care providers about currently available options for their patients to seek financial assistance through appropriate social services mechanisms. Information will be presented as part of the provider education activities (Section 3.1.1) and will also be considered during the development of the Map of Medicine sore throat management pathway (Section 3.1.2) Measuring progress Measuring improvement in access to primary health care services is challenging. It is often difficult to know the extent of unmet need (i.e. the proportion of people who do not access health care services despite having a need for care) and therefore assessing the success of interventions to address unmet need is complex. In the context of this rheumatic fever prevention plan, the ultimate measure of improved access to primary care for effective management of sore throats is the maintenance or reduction in the incidence of acute rheumatic fever initial hospitalisations in the MidCentral DHB population. MidCentral DHB Rheumatic Fever Prevention Plan Page 12

13 Section 4: Effective follow-up of identified rheumatic fever cases MidCentral DHB is committed to effective secondary prevention of acute rheumatic fever. Engagement with local providers of secondary prevention services, review of current secondary prevention processes, and collaborative development of enhanced secondary prevention strategies will ensure that service improvements are effective and consistent with local need. 4.1 Administration of antibiotics for secondary prevention Review of current local processes MidCentral DHB will undertake a review of local processes for secondary prevention of acute rheumatic fever to identify areas that could be enhanced to improve patient outcomes including ensuring that monthly antibiotics are given not more than 5 days after their due date. This will include review of the following: Local rheumatic fever antibiotic prophylaxis protocol Local rheumatic fever register to determine current adherence and timeliness of secondary prophylaxis A comparative review of local secondary prevention service provision for school aged children (currently delivered through Public Health) and school leavers (currently delivered through primary care) will also be undertaken to determine the effectiveness of these different approaches Actions to ensure timely antibiotic prophylaxis Following the review of local processes for secondary prevention, any areas of concern that are identified will be investigated by the Public Health Service and subsequent actions will be taken to improve the standard of care as necessary. This may include updating the rheumatic fever register processes and/or antibiotic prophylaxis protocols, or considering alternative pathways of care to enhance service delivery and outcomes for patients (e.g. delivery of secondary prevention for all patients, regardless of age, through a single consistent service provider pathway). Further regular reviews of the rheumatic fever register and secondary prevention protocols will be undertaken as a continuing quality assurance activity Measuring progress The success of secondary prevention of acute rheumatic fever in MidCentral DHB will be determined by: Maintenance or reduction in acute rheumatic fever recurrences Timely adherence with secondary prophylaxis (not more than 5 days after the due date) for all rheumatic fever cases as measured through a process of regular audit of the local rheumatic fever register 4.2 Notification of confirmed cases to local Medical Officer of Health Investigation of current local processes MidCentral DHB will undertake a review of local notification processes for confirmed acute rheumatic fever cases to identify areas that could be improved to ensure all cases are notified to the Medical Officer of Health within 7 days of hospital admission. This will include the following: Comparison of local notification and admission data to determine timeliness of notifications Collaboration with paediatric and general medical services to review processes for notification at the point of care MidCentral DHB Rheumatic Fever Prevention Plan Page 13

14 4.2.2 Actions to ensure complete and timely notifications Following the review of local processes for notification any areas of concern that are found will be investigated by the Public Health Service in collaboration with clinicians to identify mechanisms for improving the notification process. This may include updating current notification processes at the point of care, or considering alternatives that will facilitate simplified rapid notification of confirmed cases Measuring progress Progress towards accurate and timely notification (within 7 days of hospital admission) of all confirmed cases of acute rheumatic fever in MidCentral DHB will be measured by regular review and comparison of local EpiSurv notification data and hospital admission data to determine completeness and timeliness of notifications. 4.3 Known risk factors and system failure points Identification of known risk factors and system failure points MidCentral DHB will undertake an audit of all cases of acute rheumatic fever admitted since July 2002 to identify known risk factors and system failure points that may have contributed to these historic admissions. MidCentral DHB is also interested in examining risk factors associated with the development of acute rheumatic fever and subsequent adherence with secondary prophylaxis in new cases. Elevated risk is often associated with the broader determinants of health such as household crowding, socioeconomic status and access to primary health care services which are not commonly documented in clinical notes. To further investigate the association of known and suspected risk factors with acute rheumatic fever locally, a supplementary survey instrument will be developed to systematically collect information about potential risk factors from new cases Actions to reduce the impact of known risk factors and system failure points Following the case audit process any areas of concern that are found will be explored by the Public Health Service to identify potential opportunities to reduce the risk of new cases and the impact of risk factors and system failure points on rheumatic fever recurrence. Any actions taken will depend upon the specific issues discovered and the local context within which these aspects of patient care are operating. MidCentral DHB is supporting local initiatives to improve housing through a significant financial investment in the provision of heavily subsidised insulation for eligible homes in the MidCentral DHB area. Better housing and living conditions have far-reaching health benefits for residents and may contribute towards reducing the transmission of Group A streptococcal throat infections. MidCentral DHB is also currently providing financial and operational support to the Massey University School-Based Ventilation Study which aims to determine whether a ventilation system in schools has an impact on the prevalence of sore throats among school-aged children Measuring progress Progress towards reducing the impact of known risk factors and system failure points will be determined by maintenance or reduction in acute rheumatic fever initial hospitalisations. MidCentral DHB Rheumatic Fever Prevention Plan Page 14

15 Appendices Appendix 1: Acute rheumatic fever initial hospitalisation criteria The following criteria have been used to define acute rheumatic fever initial hospitalisations. ICD codes: Inclusions: Exclusions: Transfers: Timeframe: ICD-10-AM diagnosis codes: I00, I01, I02 (acute rheumatic fever) ICD 9 CM-A diagnosis codes: 390, 391, 392 (acute rheumatic fever) ICD-10-AM diagnosis codes: (chronic rheumatic heart disease) ICD 9 CM-A diagnosis codes: (chronic rheumatic heart disease) Principal diagnoses (acute rheumatic fever) only Overnight admissions Day-case admissions Previous acute rheumatic fever diagnosis (principal and additional) from 1998 Previous chronic rheumatic heart disease diagnosis (principal and additional) from 1988 New Zealand non-residents Transfers with a principal diagnosis of acute rheumatic fever are counted as one acute rheumatic fever hospitalisation episode Trends from 2002 onwards MidCentral DHB Rheumatic Fever Prevention Plan Page 15

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