Outcome measures for Māori with non-traumatic dental presentations: a retrospective observational study and Kaupapa Māori approach examining emergency department inequities

In Aotearoa New Zealand, Māori experience higher unmet dental need, lower access to primary dental care and increased dependence on acute dental care.^1–3 Oral health inequities lead individuals to utilise emergency departments (EDs) for toothaches, dental abscesses and other conditions termed non-traumatic dental presentations (NTDP). Of NTDP, Māori are disproportionately over-represented compared to non-Māori.^3–5 Despite nearly 3 decades of healthcare professionals working towards oral health equity, Māori continue to face persistent adverse oral health outcomes, violating rights enshrined in Te Tiriti o Waitangi.^2,6 The Manatū Hauora – Ministry of Health Māori Action Plan, Whakamaua, strategically addresses these issues, emphasising the auditing of acute inpatient services as a crucial indicator of healthcare system equity.⁷

Systemic bias and structural racism are underlying causes of ethnic health inequities that contribute to individuals utilising acute services to access healthcare in Aotearoa New Zealand.⁸ Unfortunately, EDs are complex environments operating under time and resource constraints that pose challenges to delivering high-quality and equitable care to diverse populations. Clinicians are susceptible to unconscious biases, such as racial bias and stereotyping, which can be heightened in this environment due to factors such as overcrowding, variability of patient acuity and flow, and cognitive load.⁹ Despite high ED utilisation by Māori, few studies have examined ethnic disparities in emergency care in Aotearoa New Zealand. A study by Curtis et al. demonstrated that, despite some positive ED process measures, non-Māori received faster triage, had lower mortality within 10 days of departure and lower rates of repeat presentations compared to Māori attending ED.¹⁰ Another study by Prisk et al. found that non-Māori were more likely to receive investigations, go to observation areas and were less likely to be discharged or self-discharge than Māori.¹¹

The Australasian College for Emergency Medicine (ACEM) has recently released Te Rautaki Manaaki Mana to promote equity for Māori within EDs in Aotearoa.¹² The strategy aims to guide clinicians in achieving health equity in EDs by advocating for research that is relevant, safe and responsive to Māori, and incorporates Kaupapa Māori values and methodologies. Kaupapa Māori methodology includes rangatiratanga (Māori research leadership), acknowledgement of mātauranga Māori (Māori knowledge and worldview), positioning Māori at the centre of research objectives and adopting a structural determinants approach to address issues of power, racism and privilege.¹³ Several frameworks exist for researchers to utilise to promote equitable research practices.^2,13,14 Failing to embrace research methods that acknowledge the adverse impacts of colonisation perpetuates health inequities.¹³

The present study aims to assess the equity of care received by patients with NTDP at Christchurch ED by comparing demographic variables and outcomes measures between Māori and non-Māori. The study employs a Kaupapa Māori approach and framework to describe findings.

Tikanga (methods)

Positionality statement

This study recognises Te Ao Māori principles and Māori-centred analysis frameworks reflected in: rangatiratanga (Māori research leadership), undertaking Māori:non-Māori comparisons, maximisation of statistical power to quantitatively examine Māori:non-Māori inequities, and use of conceptual frameworks that enhance the reporting of Indigenous health research.^13,14 Our discussion is presented through a Kaupapa Māori framework previously utilised to explore oral health in Aotearoa New Zealand through the following criteria: whakapapa (lineage), whakakotahitanga (unity), whakawhānuitanga (diversity), whakawhanaungatanga (relationships), whakapakari (capacity building), rangatiratanga (leadership) and māramatanga (enlightenment).²

The first author SC-D is Māori (Ngāi Tahu), and this research involves TH (Ngāi Tahu and Ngāti Mutunga o Wharekauri), a senior Māori academic with expertise in Kaupapa Māori research methods. SC-D confirmed authorship with TH and built in a feedback mechanism that ensured that the research remained focussed on Kaupapa principles such as Māori advancement. The remaining authors are non-Indigenous authors with clinical and statistical expertise who have been involved in previous studies incorporating Kaupapa Māori approaches. The authors are academically and clinically interested by this topic for the following reasons: SC-D/TH are Kaupapa Māori researchers who share a vested interest in equitable health outcomes for Māori, and CF/LJ/AM (Pākehā, Tangata Tiriti) are dedicated to reducing inequities in oral health and ED care.

Study design

A retrospective observational study was conducted assessing NTDP presenting to Christchurch Hospital ED over a 2-year period between 1 January 2019 and 31 December 2020.

Setting

Christchurch Hospital is a tertiary-level hospital located in Canterbury, Aotearoa New Zealand, serving a population of approximately 580,000. The hospital’s ED is the primary acute referral centre in the region, with over 100,000 presentations annually.¹⁵ Patients with NTDP are solely managed by medical doctors and ED staff, unless they have significant facial swelling or systemic concern requiring acute referral to the Oral and Maxillofacial Service (OMS).

In Aotearoa New Zealand, publicly funded health and disability services are available to those who meet the eligibility criteria, and basic oral health services are provided for free until the age of 18. Thereafter, most primary dental care for adults is limited and primarily through private, user-pays dental services. The hospital-based dental service provides limited non-acute services during working hours, such as “relief-of-pain” services (e.g., simple extractions) for New Zealanders on incomes under an income threshold, and these services must be booked in advance.

Participants

Patients with arrival complaints or discharge diagnoses of “toothache”, “dental pain”, “facial swelling” or “dental abscess” were included. Patients were excluded if presentations were not related to NTDP, patients left before being seen by a doctor, or were missing documentation.

Data collection

Data were extracted from Christchurch Hospital’s electronic medical record system. Demographics and outcome variables were collected, including New Zealand Index of Deprivation (NZDep)¹⁶ (area-based measure of socio-economic deprivation from 1–10, 1 being the least deprived), triage code (1–5, 1 being the most urgent), ED length of stay (hours), time to be seen by doctor (minutes), admission to hospital from ED (admitted or discharged) and hospital length of stay if admitted (days).

Data analysis

Data underwent descriptive statistical analysis with IBM SPSS Statistics (Version 28.0). The normality of the continuous variables was assessed by inspecting histograms and performing Shapiro–Wilk tests. Non-parametric tests (Kruskal–Wallace) were used for continuous variables or Fisher’s tests for any cell with zero in it. Data not normally distributed were presented with median and interquartile range (IQR).

Non-standard output groupings were used in our results, implementing a super-aggregate level 0 grouping method when stratifying ethnicity. Ethnicity was prioritised as Māori, NZ European, Pacific peoples and Other ethnicities to maximise statistical power. Māori ethnicity is used as the reference category instead of NZ European.

Raw- and age-standardised incidence rates per 100,000 were calculated for Māori, Pacific peoples, NZ European and all other ethnicities. The age distribution of the 2001 Census Māori population data was used as the index for standardising these ethnic groups as per the Manatū Hauora – Ministry of Health recommendations for age standardisation.^17,18 Age-standardised incidences and standard errors were calculated using the method published by Bray and Ferlay.¹⁹ In controlling data for NZDep, for discrete data, binary logistic regression was used, and for continuous, a general linear model was used, with Māori as the reference group. A univariate coefficient and p-value was reported, as well as a multivariate coefficient controlling for deprivation.

Ethics

Ethical approval under the Minimal Risk Health Research University of Otago Human Ethics Application (HD21/032) was granted. In addition to ethical approval (RO#22070), locality authorisation and Māori consultation (#220429) were undertaken. The project was consequently approved by both the hospital and the regional University of Otago Māori Health Advancement Review Panel.

Whakarite (results)

Over the 2-year study period, there were a total of 2,034 presentations, which included 550 (27.0%) Māori, 1,211 (59.5%) NZ Europeans, 141 (6.9%) Pacific peoples and 132 (6.5%) Other ethnicities.

View Table 1–2, Figure 1–3.

Discrete data is shown in Table 1. Compared to the Census data, NZ European (59.5% vs 82.43%) and Other (6.5% vs 13.7%) ethnicities were under-represented compared to Māori (27.0% vs 9.4%) and Pacific peoples (6.9% vs 3.2%). Among the patients studied, there was a similar percentage between male and female Māori and Pacific peoples, while males were over-represented in NZ European ethnicities (57.2%) and Other ethnicities (57.6%). During the study period, a total of 103 admissions were recorded for NTDP, which included 33 (31.1%) Māori, 5 (5%) Pacific peoples, 57 (55.3%) NZ European and 9 (64%) Other ethnicities.

The NZDep distribution by ethnicity is shown in Figure 1. The distribution of NZDep was negatively skewed for all ethnic groups, with a median of 6 (IQR 4–8) and mode of 8. Most presentations were NZDep 7 and 8 (35%). The median NZDep score was less deprived for NZ European ethnicities (6, IQR 3–8) compared to Māori (7, IQR 4–8) and Pacific peoples (7, IQR 6–8).

Continuous data are shown in Table 2, where medians are favoured in each variable due to non-symmetrical value distributions. The median age of presentation is older for Pacific peoples (32), NZ European (32) and Other ethnicities (35) compared to the median age for Māori (28). A higher proportion of Pacific peoples (IQR 23–42), NZ European (IQR 25–45) and Other ethnicities (IQR 25–48) were older compared to Māori patients (IQR 23–34). The median triage score for Māori patients (4, IQR 3–4) was the same as the median triage for NZ European ethnicities (4, IQR 3–4) and Other ethnicities. Pacific peoples were triaged with lower urgency than both groups (4, IQR 4–4).

On average, Māori patients were seen by an ED doctor the fastest (45 minutes, CI 22–86), 11 minutes faster than NZ European ethnicities (56 minutes, CI 24–97), 9 minutes faster than Pacific peoples (54 minutes, CI 23–97) and 28 minutes faster than Other ethnicities (73 minutes, 30–123). There was no significant difference in the median ED length of stay across all groups (p=0.664). Of patients admitted, the median hospital length of stay in days was longer for Pacific peoples (3.8, IQR 1.8–3.9), NZ European (2.0, IQR 1.0–3.7) and Other ethnicities (1.4, 0.8–3.6) compared to Māori admissions (0.9, IQR 0.4–2.3).

Incidence of presentations per 100,000 population is presented in Figure 2. Where Māori were used as the reference population, NZ European (difference = 793.8, 95% CI=700.6–887.0) and Other (difference = 916.4, 95% CI=821.6–1011.3) had a lower incidence than Māori. The difference in incidence between Pacific peoples and Māori was not significant (difference = 105.3, 95% CI=-69.6–280.3).

Incidence of admissions per 100,000 population is presented in Figure 3. NZ European (difference = 49.5, 95% CI=25.8–73.3) and Other (difference = 51.5, 95% CI=27.1–75.9) had a lower incidence than Māori. The difference between Pacific peoples and Māori was not significant (difference = 28.6, 95% CI=-9.5–66.7).

Discrete and continuous outcome measures were controlled for NZDep (see Appendix) and found differences between ethnicities were not driven by deprivation.

Whakawhiti kōrero (discussion)

This study investigates the equity of care received by patients with NTDP at Christchurch ED by comparing demographic variables and outcomes measures between Māori and non-Māori.

Whakapapa (lineage)

The recognition of the past, where Māori have come from, have been and are going

This study found patient demographics and pre-admission variables were consistent with previous research on ED presentations for NTDP in Aotearoa New Zealand, with Māori being over-represented and of a younger median age.^3–5 These findings have not changed since they were reported in the New Zealand Oral Health Survey a decade ago.¹

Of presentations, Māori with NTDP were over three times more likely to present and over three times more likely to be admitted. However, following admission, NZ Europeans had a longer length of stay compared to Māori. While this difference in hospital length of stay could suggest that Māori patients present with lower severity of illness, a recent audit by Graham et al. suggests that Māori are referred to Christchurch Oral and Maxillofacial services at a rate almost four times higher than NZ Europeans, and there is no difference in the level of care required.²⁰ Compared to a similar study conducted in 2008–2009, these referral rates may suggest an increasing utilisation of hospital services and worsening of oral health inequity for Māori in this region.²¹ Another possibility is that Māori are discharged earlier, which may align with previous evidence that Māori do not receive adequate healthcare at initial presentation.^4,10 This study did not investigate repeat presentation or re-admission of patients; however, further investigation is required to understand this relationship.

Whakakotahitanga (unity)

A holistic approach to health improvement that is culturally valid, and which maximises coordination within the health sector and provides more effective services for Māori

It is important to acknowledge that health professional bias and institutional racism exist within acute care in hospitals and health systems in Aotearoa New Zealand to consider approaches to coordinate and improve health equity.¹⁰ NTDP are particularly susceptible to experience bias, given this group is most likely to present outside of regular working hours when clinicians may be fatigued.^5,22 In this study, some ED process measures for NTDP at this centre favoured Māori: Māori patients were triaged similarly and seen faster compared to other ethnicities. Shorter wait times for Māori aligns with the recently reported ED outcomes by Curtis et al., yet contrasts with other studies reporting ethnic bias in triage allocation favouring non-Māori.^9,10 This is encouraging given prolonged wait times have generally led to negative perceptions of acute care for Māori patients, who may question why they were not being seen and whether they made the right decision to seek care.²³

Whakawhānuitanga (diversity)

Recognising and catering for the diverse needs and aspirations of Māori individuals and collectives

The NZDep is an area-based measure of socio-economic deprivation in Aotearoa New Zealand.¹⁶ At Christchurch ED, most patients presenting with NTDP had deprivation indices of 7 or 8 (35%), contrasting with Waikato, where the highest proportion exhibits indices 9 or 10, indicating the highest deprivation.⁴ This divergence may stem partly from regional variations in service provision. For instance, Christchurch Hospital’s dental service offers subsidised relief-of-pain services to individuals eligible for a Community Services Card (CSC), redirecting those of highest deprivation from ED usage. Cost is by far the most prohibitive barrier to dental care, leading to deferral of primary care attendance and increased utilisation of ED services.^8,24 This stresses the importance of tailoring future interventions to regional data, acknowledging that different iwi, hapū and whānau may require different delivery approaches of oral health services.

These findings may suggest there exists a portion of patients presenting within index levels 7–8 that sit above the threshold for a CSC but may experience “in-work poverty”, for which Māori and Pacific peoples are most at risk.²⁵According to Smith et al., patients with low income, but above eligibility for a CSC and emergency care subsidy offered by Work and Income New Zealand (WINZ), face the greatest difficulty in accessing care.⁵ This gap in care is reflected in a qualitative study of Māori with type 2 diabetes, with participants feeling “penalised” for being employed when trying to access oral healthcare.²⁴

Whakawhanaungatanga (relationships)

The recognition of the many branches and associations, interactions and relations within and without Te Ao Māori

Māori oral health inequities arise from systemic failures in the provision of dental care. These failures are consequences of historical denial of Māori partnership and participation in the design of oral health policy and inequities in the social determinants of health.⁶ Despite public funding for dental care until age 18, inequities in childhood caries are already evident by age 5.⁶ Across all age groups, Māori adults have been shown to experience a poorer quality of life due to their oral health.⁶ Furthermore, recent analysis indicates that the uneven distribution of dental practices in Canterbury disproportionately affects utilisation of dental services, posing the greatest oral health risk to Māori adolescents.²⁶

Limited access to affordable and culturally responsive primary oral healthcare has led to a disproportionate dependence of Māori on sporadic or acute care.²⁷ Historically, due to limited WINZ grants, emergency dental care has often prioritised tooth extraction as the most viable solution, with EDs being inadequately equipped for treatments beyond symptomatic relief.⁵ This approach has continued to disadvantage Māori, perpetuating generational edentulism.^5,24 While the recently increased WINZ funding for low-income adults may increase access to additional relief-of-pain services, it does not encompass preventative care such as routine dental examinations. This increase does not address the need for improved access to primary oral healthcare for Māori.²⁸

Whakapakari (capacity building)

The recognition of the need for Māori institutions to continually grow and develop for the benefit of all

The recent partnership of the Dental Council New Zealand and Te Ao Mārama – The Māori Dental Association has led to the development of the National Māori Oral Health Equity Action Plan.²⁹ It demonstrates a commitment to a united oral health system, where all members must be held accountable for equity improvements for Māori. Future health policy must consider the Ministry of Health Māori Action Plan, Whakamaua, recognising oral health as integral to achieving holistic care for Māori.

Rangatiratanga (leadership)

Māori control over their own health improvement

Our findings reaffirm that oral health inequities disproportionately affect Māori. A restructure of the oral health system around Kaupapa Māori-focussed initiatives is needed, rather than increasing funding into historical structures that have under-served Māori.³⁰ The abolition of Te Aka Whai Ora—the Māori Health Authority—fails to demonstrate our health systems’ support for the coordination of Kaupapa Māori services and rangatiratanga through a “by Māori, for Māori” approach. Future oral health services must prioritise Māori–Crown partnerships to meet obligations enshrined in Te Tiriti o Waitangi and facilitate Māori decision-making throughout the health and disability system’s leadership and governance arrangements.⁷

Māramatanga (enlightenment)

The increase in knowledge and the application of that knowledge for a beneficial outcome

Although this study found some positive process markers for NTDP exist in the Christchurch ED, addressing inequitable oral health outcomes for Māori requires significant upstream change. These results may differ from other regions, and regular auditing of ethnic inequities within acute health services is crucial to achieve equity for Māori across Aotearoa New Zealand. Applications at regional and national levels should acknowledge that the final step of Kaupapa Māori research is transformational change. At a national level, development of frameworks such as Te Rautaki Manaaki Mana promote culturally safe and responsive healthcare for Māori in emergency care.¹²

Whaikaha (strengths)

This is the first study to investigate acute care outcomes related to NTDP for Māori patients utilising a Kaupapa Māori approach. This approach recognises that being Māori is not a risk factor for health disparities, but rather an indicator of an increased exposure to the impacts of colonisation and racism.¹³ Utilising a Kaupapa Māori approach is crucial to shifting the Western-dominated academic discourse on Hauora Māori.

Ngoi koretanga (limitations)

While NTDP are common hospital presentations, service provision varies by region. Before the establishment of Te Whatu Ora – Health New Zealand, district health boards had autonomy to provide relief-of-pain services, as seen in Canterbury. Regions lacking such services may have greater unmet dental needs and NTDP incidence. Furthermore, regional differences in ethnic composition may impact the generalisability of these findings. This study is retrospective in nature and the accuracy of data relies on self-identified ethnic and ED documentation. The electronic medical system utilised for data extraction only collects binary sex categorisation, and therefore this study fails to acknowledge the presentations of gender-diverse individuals. It also fails to capture important factors that may add to understanding NTDP, such as: patient experiences, reasons for attending ED over primary care and ED attendees who left before being seen.

Te whakamutunga (conclusion)

This study identifies inequitable presentation of Māori to Christchurch ED with NTDP. While ED outcomes measures were largely positive, differences in demographic variables indicate persisting upstream failures, specifically barriers to accessing primary oral healthcare and a paucity of Kaupapa Māori-focussed initiatives. Further action and accountability are required to reorient our oral health services to provide high-quality, equitable care for Māori.

View Appendix.