Analysis of skin condition emergency department outcomes via the free Healthline service from Whakarongorau Aotearoa

Skin conditions are known to disproportionately affect Māori and Pasifika,¹ children under 4, and New Zealanders living in more deprived areas of Aotearoa New Zealand.² The higher prevalence of skin diseases among Māori and Pasifika in Aotearoa New Zealand and other Indigenous groups around the world has been linked to many factors, including the impact of socio-economic factors, inadequate and overcrowded housing, lack of access to primary healthcare,^3,4 poverty, health literacy³ and the historical effects of colonisation.^5,6

The risks of untreated skin conditions include secondary infection by Staphylococcus aureus and Streptococcus pyogenes (group A streptococcus; GAS), which can lead to cellulitis, bacteraemia and osteomyelitis.⁷ Researchers have reported robust evidence linking a GAS-positive throat or skin swab to the subsequent triggering of acute rheumatic fever (ARF), particularly in vulnerable Indigenous communities.⁸ In an Auckland analysis of laboratory skin swabs, Māori and Pasifika under 20 years of age had considerably higher GAS detected than in European and other ethnicities.⁹ Māori and Pasifika in Aotearoa New Zealand have some of the highest rates of rheumatic fever in the world.¹⁰

The aim of this research was to understand the utilisation of the Whakarongorau Aotearoa | New Zealand Telehealth Services’ free 24/7 Healthline service for skin conditions, with a specific interest in whether Māori and Pasifika were utilising the service and their subsequent call outcomes. This study aimed to analyse the outcomes of skin condition calls made through Healthline and investigate which service users were advised to go to emergency departments (EDs; within the recommended 6 hours).  

Methods

Whakarongorau Aotearoa is a government-funded, free-to-use, 24 hours a day, 7 days a week health advice and support service accessible via phone, text, email and web chat.¹¹ Whakarongorau Aotearoa and its services are supported by trained professionals, including medical doctors, nurses, paramedics, psychologists, counsellors and other health personnel.¹² In 2022, Whakarongorau Aotearoa had 725,661 contacts (464,631 unique contacts), i.e., approximately one in 11 people in Aotearoa New Zealand.¹³ Healthline call handlers have access to the Odyssey clinical decision support tool to support their decision making in advising a service user during a call. These clinicians can also ask for an image to be uploaded (by the service user) to support their decision.

Whakarongorau Aotearoa’s Healthline service is not a diagnostic service; rather it is a triage line, meaning they are not responsible for diagnosing a service user’s symptoms but in recommending a service user on where to go to receive the appropriate treatment. A service user’s outcome depends on their symptoms, the time of day, where they are located and how far away they are to the nearest primary care service. It is also factored in whether a service user states they cannot afford a particular service, for example an after-hours clinic. If a service user calls in after-hours i.e., after 6 pm, their only options for care within 12 hours are an urgent care clinic or an ED.  

Service user data are collected during the call with Whakarongorau for clinical audit and quality improvement. Service users are made aware that their calls are being recorded (before the call begins) and can choose to remain anonymous without impacting the call outcome. All data is stored securely on a Whakarongorau device (in compliance with the Health Information Privacy Code 2020 and the Privacy Act 2020).^14,15 Data are provided for research purposes in an aggregated de-identifiable form. As the data are de-identifiable, there is minimal risk of breaking service user confidentiality. Data from service users were collected between 1 January 2019 to 31 December 2022 from the skin condition dataset, a subset of the broader Healthline database. This research project was approved by the Auckland University of Technology Ethics Committee (AUTEC) (23/28). STROBE Guidelines were followed (see Appendix A).¹⁶

Participants

Participants were service users who called the free Healthline service seeking advice about skin conditions in 2019 through to the end of 2022. The skin condition subset of Healthline data is comprised of specific skin symptoms, including: skin rash, skin allergy symptoms, measles rash, lump(s), skin/tissue problems, itching, hives, nappy rash, skin irritation, eczema, cold sores, impetigo, dry skin, spot on the skin, “slapped cheek” disease, flea bites, phlebitis, acne, dermatitis, cradle cap, scratching, nettle rash, Seborrhoeic dermatitis and tinea (ringworm).

Variables

De-identified data were provided for age group, ethnicity group and residential district. The Whakarongorau system allows for multiple ethnicities to be recorded for any individual who identifies with more than one ethnic group; however, only one “prioritised” ethnicity is used in this study.¹⁷  

Call outcomes through Healthline are the advice given by a Healthline call handler to a service user regarding their symptoms. This includes the most acute outcome, “111 Emergency”, where an ambulance is called for the service user, to the least acute outcome, “Self Care”, where a service user can manage their symptoms at home and to call back if they have further concerns (this outcome includes general health information; see Appendix B for more information). ED outcomes in this research include the recommendation of a service user to go to ED (within 6 hours); this research does not show whether a service user turned up to an ED.

Data sources

Deprivation data were used in this research to investigate possible correlations with ED outcome data using regression analysis. These deprivation data were accessed from The University of Auckland’s School of Population Health Research (2018) (see Appendix C).¹⁸

Study size

Between 2019 and the end of 2022, 61,876 skin condition calls were recorded through the Healthline service: 19,809 in 2019; 13,771 in 2020; 14,105 in 2021; and 14,191 in 2022.  

Statistical methods

R and RStudio were used to conduct statistical data analysis using significance tests (including Chi-squared tests, ANOVA, regression analysis and t-Tests). Differences with p-value (p) <0.05 were deemed statistically significant.¹⁹ Graphical representations of data were made using Microsoft Excel. “Unknown” or anonymous data were included in this research.

Results

Between the start of 2019 and the end of 2022, 1,414,664 calls were recorded through the free 24/7 Healthline service, with 4.4% of these regarding skin conditions (61,876 calls). A total of 188,231 calls (13.3%) through Healthline resulted in an ED outcome recommendation, whereas for skin condition calls, 3,294 calls (5.3% of skin condition calls) resulted in an ED outcome. Outcomes resulting in a “111 Emergency” and requiring an ambulance were 0.7% for skin condition calls (406) and 3.7% for total Healthline calls (52,408) (see Appendix B). Skin condition calls peaked on Sundays every year and between 6 and 7 pm each day (see Appendix D).

ED outcome by ethnicity

Skin condition ED outcomes were further investigated by ethnicity group.

View Figures 1–4.

Over 4 years (2019–2022), there were 3,294 ED outcomes (5.3%) for skin condition calls through Healthline. Of the ED outcome skin condition calls, 29% identified as Māori (942; Figure 1), a significantly higher proportion than the stated proportion of Māori in the Aotearoa New Zealand population (17% Māori, p<0.0001).²⁰ This is also statistically higher than the proportion of Māori calling into Healthline regarding a skin condition (23.6% Māori or 14,572 calls, p<0.0001). Additionally, European (53.6% or 1,766 ED outcomes), Pasifika (6.2% or 203) and Asian (2.6% or 86) ethnicity groups were under-represented in the ED outcome for skin conditions than their respective Aotearoa New Zealand population demographics (p<0.0001).²⁰ However, the proportion of Pasifika calling regarding a skin condition is not statistically different from their ED outcomes (5.9% Pasifika or 3,648 calls, p=0.552).

ED outcome by age and ethnicity

The highest number of skin condition calls were regarding service users aged under 12 years of age. This age group had 33,710 calls documented (54% of calls). The proportion of each ethnicity by age group for skin condition ED outcomes are shown in Figure 2 (see also Appendix F). This table includes four age groups: 0–12 years, 13–34 years, 35–64 years and 65+ years.

The distribution of recommended ED outcomes by ethnicity and age group is shown in Figure 2. All ethnicity groups had their highest number of ED outcomes for service users aged 12 years and under. Māori have a high proportion of service users aged 12 years and under, with 37% of this group identifying as Māori (942 ED outcomes; Figure 2). The highest age group for Māori and Pasifika ED outcomes were service users aged between 3 and 5 years old, with 208 and 46 ED outcomes, respectively.  

ED outcome by district

ED outcomes by Aotearoa New Zealand district (per 10,000 people) were investigated, shown in Figure 3 (see also Appendix G).

The highest proportion of ED outcomes per capita came from the Wairarapa district, with 5.49 ED outcomes per 10,000 people. The second highest was the West Coast district, with 4.28 ED outcomes per 10,000 people, the smallest district in Aotearoa New Zealand (~32,700).²¹ The lowest ED outcomes per capita were from Waitematā district, the largest district in New Zealand (~633,500).²¹ All the district population sizes are available in Appendix G, Table 5. Wairarapa, West Coast, Taranaki, and South Canterbury districts had significantly higher ED outcomes than the overall Aotearoa New Zealand average (p<0.005). All of these regions have smaller Aotearoa New Zealand populations (shown in Figure 3 in blue font).

The overall highest skin condition ED outcomes in 2022 were from Canterbury (103 ED outcomes) and Waikato (95). The highest number of skin condition calls (all outcomes) were from Canterbury, with 2,147. However, the highest number of calls per capita came from Wairarapa, with 49.8 calls per 10,000 people. This was significantly higher than the average of 33.4 calls per 10,000 people (p<0.0001).

ED outcome by district deprivation

Figure 4 shows the relationship between skin condition ED outcomes and overall district deprivation.

The 2018 New Zealand Index of Multiple Deprivation (IMD18) data were used to investigate a relationship between district deprivation and skin condition ED outcomes.¹⁸ Education district deprivation proved the highest correlation with district ED outcomes, with an R² value of 0.897. Regression analysis further demonstrated a linear relationship between the two variables (p<0.0005). “Access to services” (including health services) and “Overall” district deprivation (Figure 4) also correlated with district ED outcomes (p<0.005, and p<0.05, respectively), but to a lesser significance (see Appendix H). Interestingly, no significant correlation was found between health deprivation and the results of this research. A positive correlation was proven between ED outcomes (per capita) and smaller district population sizes, with an R² value of 0.895. Regression analysis further proved a linear relationship between the two variables (p<0.0005).  

In 2022, service users living in rural areas made up 20.3% of skin condition ED outcomes, and urban users were 79.7%. The proportion of rural ED outcomes is statistically higher when compared to their Aotearoa New Zealand demographic (16.3%) (p<0.001).²² This further strengthens our finding that more deprived service users correlate with higher skin condition ED outcomes (see Appendix I).

Discussion

Māori are over-represented for skin condition calls with the recommended outcome of attendance at ED within 6 hours. This is not unexpected as Māori are known to be over-represented in ED data. However, this over-representation is not seen in Pasifika Healthline data, when Pasifika are known to have high presentations of severe infectious skin conditions at EDs across Aotearoa New Zealand. This suggests that Pasifika are not using the Healthline service before presenting at ED with severe skin conditions, whereas Māori are. From the results we can hypothesise that Pasifika have competing social demands and may not be aware of how serious a skin condition can become if it turns septic. Alternatively, Pasifika may prefer to use in-person primary care or ED services rather than a virtual telehealth service. Our finding is important as it suggests there should be more targeted support and advertisement to Pasifika communities to ensure they are aware of the free 24/7 service.

Younger Māori (≤12 years old) are especially affected in this ED outcome data, which correlates with the larger younger population observed in Māori. Māori are associated with a shorter life expectancy (male = 73.4 years and female = 77.1 years) than NZ Europeans (81 and 84.5 years) and the overall Aotearoa New Zealand average (80 and 83.5 years).²³ Skin conditions are very common for the under 2-year-old age group, with infection occurring much quicker than other age groups. Māori and Pasifika both have larger young populations, meaning they are more likely to have skin conditions, leading to higher rates of infections. Another explanation for this age group having the highest ED outcomes is increased precautions taken due to awareness that neonates and young children have under-developed and immature immune systems, meaning a minor infection can be life threatening.²⁴

A high proportion of Māori (18% of the Māori population),²² unlike Pasifika, live in rural areas around Aotearoa New Zealand, which corresponds with decreased access to health services. This study shows that Wairarapa and West Coast had the highest ED outcomes per capita; these are two rural districts with small populations. Both districts ranked poorly for access to services (including education).¹⁹ Urgent care is not an option in rural areas, making ED a service user’s only option after hours. ED is also the only option (during the day) when general practitioner (GP) appointments are not available in the near future. It should be noted that although Māori and rural districts are over-represented in this data, it is a good result that they are aware of and using the free Healthline service to seek advice and help.

Previous literature has detailed factors contributing to more severe skin conditions, including the overcrowding of unsuitable housing (mouldy and damp housing), lower socio-economic status and the inability to afford a GP appointment or other preventative care before the hospital.⁴ In Aotearoa New Zealand, healthcare is free for under 14-year-olds; however, one study identified that while patients might try to make an appointment to see a doctor, the most frequently named reason they don’t is that they often cannot get an appointment.²⁵ Yeoh et al.⁷ proposed the idea of skin conditions (specifically scabies and impetigo) becoming normalised in communities where the prevalence was high and it was assumed the condition would resolve itself.⁷ Jeffreys et al.²⁶ found that cost, time and lack of transport were essential factors regarding the severity of skin conditions.²⁶ This is further complicated in rural areas, where patients must travel further to reach healthcare.²⁷  

From the results of our research, it appears that access to services (especially education) is an important factor in preventing skin conditions from getting to the stage of needing hospitalisation. In Aotearoa New Zealand, access to nurses is available, free of charge, to students throughout the school day regarding any health concerns or requests for information. As a result, students do not have to travel elsewhere for healthcare or miss school for an appointment. This eliminates the cost, time and lack of transport, a factor communicated by Jeffreys et al.,²⁶ and the lack of access to services in rural areas by Norris et al.²⁷ Education also provides an essential service by teachers, as if they see a student with a skin condition (or another health issue), they can inform the nurse and parents about getting it looked at by a healthcare professional.  

Limitations

This research's limitations include the prioritised ethnicity data of Whakarongorau service users, which could result in certain ethnic groups being under-represented in the data. There is also the issue surrounding anonymous service users and the lack of information surrounding these users, resulting in once again certain ethnic groups being under-represented. It is, however, a right of Whakarongorau service users to remain anonymous without impacting the outcome of their call.  

Future research

With the introduction of the new Māori pathway in Healthline (launched Dec 2022), 2023 data will be of particular interest to determine whether skin condition outcomes for Māori differ from previous years. This research suggests the benefit of having a Māori pathway and potentially a Pasifika pathway in Healthline to increase access to health services for Māori and Pasifika and improve their health outcomes.  

Conclusion

This study has shown that Māori and those living in more rural areas are over-represented in skin condition ED outcome calls through the Healthline service. The reasonings proposed in this paper for these findings are due to the inaccessibility and unaffordability of health services. It should be acknowledged that other underlying contributing factors impact Māori health (not discussed in this paper), such as marginalisation. It is, however, a positive result that these groups are using the Healthline service. More concerningly, Pasifika Healthline ED outcome data do not match the high numbers of Pasifika presenting at ED with severe skin conditions. Skin conditions are linked to life-threatening diseases, including invasive GAS and rheumatic fever. Early access to the Healthline service could increase health literacy and perhaps prevent skin conditions from deteriorating into more serious diseases. This paper will help inform Whakarongorau to implement a strategy for supporting Pasifika with skin conditions, as well as further support the Healthline Māori pathway.

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View Appendices.