Download Cardiac Services Plan for the Midland Region

C ARDIAC S ERVICES P LAN
FOR THE
M IDLAND R EGION
Prepared by:
Jan Barber,
Midland Regional Service Planner
Date:
February 2006
D
Midland Region Cardiac Services Plan - 2006
Acknowledgements:
Acknowledgment is made to the large number of individuals who have provided information and
assistance in the development of this document.
In particular the support and input of the following individuals is acknowledged:
Dr Gerry Devlin, Clinical Director Cardiology, Waikato DHB
Dr Jonathan Tisch, Cardiologist, Bay of Plenty DHB
Max Lynds, Operations Manager, Cardiology Services, Waikato Hospital
COPYRIGHT STATEMENT
The content of this document is protected by the Copyright Act 1994. The information provided on
behalf of the Midland District Health Boards, may be reproduced without further permission, subject
to the following conditions:
■ you must reproduce the material accurately, using the most recent version;
■ you must not use the material in a manner that is offensive, deceptive or
misleading; and
■ you must acknowledge the source and copyright status of the material.
Whilst every effort has been made to ensure its accuracy, the Midland District Health Boards will not
be liable for the provision of any incorrect or incomplete information.
The five District Health Boards that comprise the Midland group are Bay of Plenty, Lakes, Tairawhiti,
Taranaki, and Waikato.
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Midland Region Cardiac Services Plan - 2006
Table of Contents
List of Tables & Figures
5
1.
Executive Summary and Recommendations
7
2.
Background
15
3.
Ministry of Health / DHB Health Objectives and Guidelines
17
4.
5.
6.
7.
8.
9.
3.1.
New Zealand Health Strategies
17
3.2.
District Health Board - Cardiac Disease Objectives & Related Activities
18
3.3.
Cardiovascular Guidelines
24
Current Situation and Issues
28
4.1.
Demographics
28
4.2.
Cardiac Disease Data
29
4.3.
Current Clinical Cardiac Services
37
4.4.
Private Cardiac Services
38
Contracting and Funding
40
5.1.
DHB Agreements
40
5.2.
Outpatient Clinics
41
5.3.
DHB Expenditure on Cardiac Services
42
Primary Prevention of Cardiac Disease
45
6.1.
Health Promotion
45
6.2.
Identification and Management of ‘At Risk’ Individuals
48
Secondary Prevention
50
7.1.
Primary Care
50
7.2.
Secondary / Tertiary Services
52
7.3.
Revascularisation
74
7.4.
Cardiac Rehabilitation
81
Acute Coronary Syndrome
87
8.2.
Emergency Care
89
8.3.
Thrombolysis
92
8.4.
Primary Percutaneous Coronary Interventions
93
8.5.
Transport
94
Chronic Conditions
97
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Midland Region Cardiac Services Plan - 2006
10.
11.
12.
13.
14.
9.1.
Heart Failure
97
9.2.
Rheumatic Fever
101
Resources
104
10.1.
Equipment
104
10.2.
Workforce
107
10.3.
Systems
116
Service Co-ordination
118
11.1.
Patient Care Co-ordination
118
11.2.
Integrated Care
119
11.3.
Clinical Care Networks
120
District Health Board Cardiovascular Disease Strategies
122
12.1.
C&C DHB: Resource Allocation & Cardiovascular Resource Allocation 2004
122
12.2.
The Waitemata DHB Cardiovascular Action Plan 2003
125
12.3.
Hutt Valley DHB Cardiovascular Service Plan 2002
126
12.4.
The Canterbury Heart Health Strategy, September 2004
126
International Precedents
128
13.1.
United Kingdom
128
13.2.
Australia
129
13.3.
United States of America
129
Future Directions
131
14.1.
Non-invasive Imagining Technologies
131
14.2.
Genetic Screening
132
14.3.
Cellular Therapy to Treat Heart Disease
132
14.4.
Cardiac Surgery
132
15.
Appendices
134
16.
References
159
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Midland Region Cardiac Services Plan - 2006
List of Tables & Figures
LIST OF TABLES
Table 1
Midland DHB population and predicted changes
28
Table 2.
Cardiovascular rates of death per 100,000 population in New Zealand, 2000 and Australia 2001
29
Table 3
Death rates per 100,000 from CHD in New Zealand according to ethnicity and age, 2000.
30
Table 4.
Data by Midland DHB
30
Table 5
New Zealand health indicators for cardiac disease
31
Table 6
Potential changes in hospital admissions for coronary heart disease for all discharges – acute & sub-acute 33
Table 7
Predicted increase in prevalence of adult diabetes patients 1996 – 2011
34
Table 8
Relative contributions of variables to increase in diabetes prevalence 1996 – 2011
35
Table 9
Cardiothoracic surgical discharge ratio (weighted) 1995 – public and private, and 2000 – public only
36
Table 10
Barriers to care and solutions used in Māori primary care services
38
Table 11
Cardiac procedures undertaken at Mercy Hospital for Midland population
39
Table 12
Contract and actual volumes for cardiac service purchase units
40
Table 13
Cardiology first specialist assessments: subsequent attendance ratios
41
Table 14
Expenditure on cardiac services by Midland DHB 2004
42
Table 15
Cardiac services at Midland DHBs
52
Table 16
Percent cardiovascular heart disease admissions by Midland DHB of domicile, ethnicity, and gender
60
Table 17
BNP tests and cost by Midland DHB 2003 – 2005
65
Table 18
Predicted pacemaker implantations by Midland DHB domicile population
66
Table 19
Predicted number of electrophysiology screenings by Midland DHB domicile population
68
Table 20
Predicted number of ICD implants by Midland DHB domicile population
68
Table 21
Predicted cardiac catheterisation and angiography by Midland DHB domicile population
70
Table 22
CCU beds per Midland DHB, current and predicted per 100,000 population
73
Table 23
Standardised discharge ratios for Midland DHB, relative to a national mean of one
74
Table 24
Predicted percutaneous coronary interventions for the Midland region
75
Table 25
Waikato hospital outcomes for drug eluting stents, June 2002 – June 2004
77
Table 26
Number of Midland DHB domicile residents discharged from all hospitals, with case-weighted totals for
cardiothoracic surgery
78
Table 27 Actual treatment thresholds, discharges and standardised discharge ratios by cardiac unit for CABG and
angioplasty patients treated July 2002 – June 2003
79
Table 28 Number of patients discharged from DHB hospitals, for acute and elective cardiothoracic surgery
79
Table 29 Number of Midland DHB domicile residents discharged from all hospitals, for cardiothoracic surgery
80
Table 30 Predicted coronary artery bypass grafts for the Midland region 2006 – 2011
80
Table 31 Midland cardiac rehabilitation programmes
82
Table 32 Cardiac rehabilitation attendance data for selected programmes
83
Table 33 Predicted patient number for cardiac rehabilitation
85
Table 34 Acute rheumatic fever notifications 1995-2000
102
Table 35 Electrophysiology, defibrillation and pacing laboratory requirements
105
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Midland Region Cardiac Services Plan - 2006
LIST OF TABLES CONTINUED
Table 36 Coronary angiography and angioplasty laboratory requirements
105
Table 37 Total laboratory requirements for Midland region
105
Table 38 Tauranga Hospital catheter laboratory requirements with extended service
106
Table 39 Cardiac catheterisation laboratory capital cost 2002-03
106
Table 40 Midland DHB waiting times for cardiology first specialist assessments as at April 2005
109
Table 41 Cardiologist requirements for the Midland region
110
Table 42 Predicted cardiac catheter laboratory workforce requirements
112
Table 43
Predicted cardiac catheter laboratory workforce requirements – Option Two
113
Table 44
Cardiac rehabilitation nurses required at 1 per 225 patients
113
Table 45
Cardiac Surgeon recommendations for the Midland region
114
LIST OF FIGURES
Figure 1
Predicted population 65_plus by DHB 2001 – 2026
28
Figure 2
Ethnicity of DHB populations, 2001
29
Figure 3
Bay of Plenty DHB outpatient first specialist assessment waiting list 2003-04
41
Figure 4
Waikato hospital cardiology procedure waiting times as at June 2005
42
Figure 5
CVD expenditure by service, Australia, 2004
43
Figure 6
Estimated percent of cardiac services expenditure by Midland DHB
44
Figure 7
Number of days waited for transfer to Waikato Hospital from Midland facilities 2003-04
53
Figure 8
Ischaemic heart disease admissions by Midland DHB Of domicile and gender
60
Figure 9
Patients waiting for echocardiography at Bay of Plenty and Waikato DHBs as at June 2005
64
Figure 10 BNP test volume and cost by laboratory 2003-05 (extrapolation full year)
65
Figure 11 Waikato Hospital ablation waiting list as at June 2005
68
Figure 12 Waikato Hospital – angiography waiting list as at June 2005
69
Figure 13 Waikato Hospital stent use March – May 2005
77
Figure 14 Cardiac rehabilitation attendee by ethnicity percent for selected Midland DHB programmes
84
Figure 15 Acute Coronary Syndrome flow diagram
88
Figure 16 Heart failure admissions by ethnicity and DHB of domicile
98
Figure 17 Acute rheumatic fever hospital admissions by DHB of domicile
102
Figure 18 Acute rheumatic fever admissions 0-14 year olds per 100,000 population by DHB of domicile
103
Figure 19 Acute rheumatic fever hospital admissions per 100,000 population by ethnicity
103
Figure 20 Cardiologist per 100,000 population in 2000
109
Figure 21 The New Zealand Heart Foundation Heart Health Continuum
119
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Midland Region Cardiac Services Plan - 2006
1.
Executive Summary and Recommendations
EXECUTIVE SUMMARY
This service plan addresses current issues and opportunities for managing cardiac disease into the future for
the five Midland DHBs, Bay of Plenty, Lakes, Tairawhiti, Taranaki, and Waikato. The positive relationships
and the individual provider initiatives within the region provide building blocks for a collaborative approach to
determine the best way forward for services. This plan should be considered as a working document, as this
is a rapidly changing service with: new guidelines and workforce recommendations expected during 2006;
frequent research-based changes in best practice; as well as new technologies becoming available and
incorporated into routine practice on a regular basis.
Cardiology encompasses all aspects of the care of patients with heart disease. This service aims to meet
the need for comprehensive risk assessment and risk modification, involving medical treatment of symptoms
and disease by drugs, non-surgical intervention or surgery as appropriate. Midland adult patients access
these services through community, primary, secondary, and tertiary care services, available within the five
Midland DHBs. Quaternary services, such as heart transplant are provided by Auckland DHB.
Cardiac disease has a major impact on an individual's quality of life, including chronic pain or discomfort,
activity restriction, disability, and unemployment. Detailed data on mortality from cardiac disease is readily
available, however there is a lack of data on other critical health outcomes, such as incidence, prevalence
and quality of life, needed to plan and evaluate prevention and management interventions
Potential risks relating to cardiac disease for the Midland DHBs include:
■ Increasing prevalence of cardiac disease due to:
– Ageing population;
– Predicted increase in diabetes per annum:
♦
European 0.2%
♦
Māori 0.38%
♦
Pacific 0.4%
Noting that people with diabetes have double the risk of myocardial infarction, and a two – eight times
greater risk of heart failure, than those without diabetes;
–
–
–
Increasing obesity;
Better survival of acute episodes which can lead to further episodes, or chronic illness;
Predicted average increase in CHD hospitalisations:
♦
< 65 years – 3.3-3.6%;
♦
65–79 years – 1.1-2.1%;
♦
80+ years – 3.2-4.8%.
■ Current long waiting times for diagnostic tests and treatment due to staff and facility constraints.
E.g. as at June 2005
– FSA – most DHBs have 50+ patients waiting >6months;
– Echocardiography – Waikato & BoP >340 waiting 6 months;
– Angiography – Waikato 217 patients waiting up to 36 months;
– Angioplasty – Waikato elective procedures – 20% of total PCI;
– Electrophysiology – 73 patients waiting – 40 > six months.
■ Cardiac Surgery
– Increasing complexity;
– Currently only 30% of cardiac surgery is undertaken on an elective basis.
■ Systems issues:
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Midland Region Cardiac Services Plan - 2006
–
–
No agreed process for service development across providers or DHBs;
Systems do not currently allow for sharing of data across DHBs or providers (noting that planning
is in place for systems to allow this to occur within the next 3-5 years);
– Many providers develop own systems to collect data – some paper based;
– Difficult to monitor, audit and compare outcomes of interventions.
■ Affordability
– To prevent further, and manage current and future cardiac disease, DHBs will need to put
significant investment into the service.
– Cardiovascular disease is identified as a priority in the New Zealand Health Strategy but the level
of expected service has not been agreed at a national level. Midland DHBs have the opportunity to
agree appropriate service levels and determine options to manage services, for the future.
The outcomes of various studies show that lifestyle factors account for at least 50% of the decreasing
mortality from cardiac disease, with the most significant of these being smoking (30–48%) followed by
cholesterol and blood pressure (10-12%). The risk factors have been shown to be the same irrespective of
ethnicity, age, or gender. Medical interventions, including secondary prevention, treatment of myocardial
infarction, hypertension, heart failure, and angina, have been shown to decrease mortality rates by 42-46%.
Cardiac disease utilises a significant amount of acute care services and there is scope to prevent and
manage disease through targeted health promotion, risk assessment and management, and cost effective
secondary prevention strategies. Adequate medical and surgical management of cardiac disease patients is
crucial to improve survival and quality of life. Interventional procedures such as coronary artery bypass
grafting, angioplasty, and pacemaker implants, have been shown to improve the quality of life and decrease
illness and death for individuals with cardiac disease. These interventions, particularly revascularisation
strategies, in acute coronary syndromes are evidenced-based and are widely promulgated in international
guidelines as best practice.
Collaborative efforts by health service providers are required to provide the wide range of services that will
enhance the quality of life of individuals living with cardiac disease, as well as their families. Numerous
studies reveal a gap between evidence-based recommendations for patient management and actual
practice. While a variety of local programmes and quality assurance measures are being implemented or in
place, these do not provide data on any district or regional level to provide an understanding of actual
practice or outcomes of services.
Midland DHBs have the opportunity to build on the positive relationships established across the secondary
and tertiary cardiac service providers across the region. A pharmaceutical company sponsored meeting, led
by Waikato clinicians, has been held on an annual basis since 2002 and has resulted in the development of
regional protocols for a number of clinical services. Should the DHBs wish to foster this collaboration, there
is the potential to develop this initiative further, to encompass a collaborative approach across all sectors of
cardiac care services.
The World Health Organisation 2002 report indicates that cost effective interventions are available to halve
the CVD burden within five years. To ensure these interventions are utilised in the Midland region, it is
important that opportunities within the Midland DHBs are developed in the following areas:
■
■
■
■
Primary prevention;
Timely treatment of acutely ill individuals;
Secondary prevention including rehabilitation;
Support for the chronically ill.
Through:
■ Patient-centred services;
■ Acknowledgement of the role of intervention at primary, secondary and tertiary level care;
■ A multidisciplinary, multi-professional team approach;
■ Improved risk assessment and management;
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Midland Region Cardiac Services Plan - 2006
■
■
■
■
Service development and integration of evidence-based cost-effective clinical services;
Improved knowledge and education of consumers and service providers;
Addressing workforce issues;
Better information systems to identify, monitor and audit management.
This plan is based on international and New Zealand guidelines for best practice. It is acknowledged that
implementation of the plan will be undertaken with local factors taken into consideration. It is also
recognised that implementation will be dependent on the funding available. The cost to implement this plan
has not been developed but it is recognised that the cost may be greater than the revenue available and
prioritisation of the plan recommendations will be required.
The challenge for DHBs is to fund community and primary care services to prevent future growth in cardiac
disease, to identify and manage cardiac disease in the community, while ensuring that secondary and
tertiary services are able to provide a service that meets the needs of those with acute and chronic disease
in a timely way.
RECOMMENDATIONS
The high mortality rate and predicted increase in cardiac disease have significant implications for the
Midland region. There are a large number of guidelines and recommendations for the prevention and
management of cardiac disease but little evidence on the incidence, prevalence and impact of the disease in
the community. Many of the recommendations included in this service plan relate to better collaboration and
cooperation; however there is a need for investment to ensure services can be provided to meet current
need, as well as allowing service development, and improved data and audit systems. Once these tools are
in place, the ability for the Midland service to meet the needs of the changing population and to implement
rapidly changing best practice treatment options will be improved.
It is recommended that the Midland region agree specific targets and objectives. In choosing these it is
important to identify those that can be measured easily and in a timely fashion e.g. heart failure
hospitalisations. Mortality data is available but information is delayed and while important to understand
changes in mortality it will be several years before outcomes will be known. The United States targets and
objectives provide an indication of options for consideration.
To provide an indication on the level of resource the Cardiac Service Plan recommendations have been
broadly classified into:
1. General or systems changes that can be undertaken without significant resource implications;
2. Those that require some resource to undertake further analysis or to implement change;
3. Those that require one-off resource but with the potential for additional resources depending on the
outcome of the initial investigations;
4. Recommendations with significant resource implications.
It should be noted that these classifications do not provide any indication of priority based on
need, feasibility or impact, nor has cost-benefit been considered. A list of recommendations based
on health sector and service is included as Appendix 9.
1. General or systems changes
1.1. DHBs and PHOs should support national activities that reduce smoking rates, improve nutrition,
reduce obesity, and increase physical activity, in line with the New Zealand Healthy Eating Healthy
Action strategy.
1.2. PHOs should be encouraged to participate in intersectoral projects, and provide supportive
programmes, that focus on the priority health promotion activities.
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Midland Region Cardiac Services Plan - 2006
1.3. DHBs, PHOs, and other community providers should be encouraged to utilise the Heart
Foundation as a resource for information and potential support for programme development.
1.4. DHB funders should encourage PHO inclusion of secondary or tertiary general medicine or
cardiology input into the development of SIA and HP proposals to enable an integrated approach
to service development. Where this does not occur in the development phase, comment should
be sought from staff in the relevant speciality to ensure the proposal does not adversely affect the
hospital provider e.g. through a significant increase in referrals without the resource to manage
these.
1.5. Primary care continuing education programmes should include updates on CVD guidelines as a
regular component of education for relevant providers.
1.6. DHBs should consider the option for including specific measures from the CVD guidelines as PHO
performance indicators.
1.7. Drug eluting stents are not currently included in any ICD10 code and therefore there is no current
funding stream. Waikato DHB should raise the issue of funding for drug eluting stents at a
national level; the new technologies group is likely to be the appropriate forum.
Midland DHBs should agree a methodology for determining whether sharing costs for new
technologies, when these fall outside any national process, is appropriate.
2. Resource required to undertake further analysis, or implement change.
2.1. Consideration should be given to the establishment of local or district wide health promotion
steering groups, to enable the development of health promotion plans than support intersectoral
collaborative projects that target at risk groups, and provide a supportive environment to change
behaviour.
2.2. PHOs should consider options for improving education and compliance for patients with cardiac
disease.
2.3. PHOs should consider quality targets that identify specific measures against the CVD guidelines,
noting that CHD or CVD coding and/or register will be a critical component of this.
2.4. Chest pain units have been shown to improve patient care. It is recommended that an evaluation
of the chest pains units at Waikato and Tauranga Hospitals be undertaken within 12-months of
commencing operation, to determine the option for establishment of chest pain units at other
secondary care facilities across the region. Evaluation criteria should include effectiveness,
acceptability and cost-effectiveness data from before establishment (where available) and after,
such as:
proportion of patients with acute chest pain who are admitted to hospital;
length of stay of patients admitted with non-ischaemic pain (both ED and hospital);
■
the rate of adverse events within 30 days among those discharged;
■
patient related factors for health related quality of life and satisfaction with care.
2.5. A review of all diagnostic tests across the region should be undertaken with the view to agreeing a
means to ensure appropriate and equitable access into the future.
■
■
2.6. A full review of echocardiography across the region should be undertaken and a planned
approach to identify, update and replace equipment where necessary, to enable an agreed and
equitable level of access to echocardiography into the future. This should include access to
cardiologist reporting of all echos and medical supervision of the service.
The agreed level of access should be based on clinical criteria, together with access to
B-type-Natriuretic Peptide (BNP) testing, recognising the cost implications of the
decision for the DHBs.
2.7. DHB providers and PHOs should adopt the regional BNP guidelines and monitor the use of BNP
against these guidelines.
■
■
DHBs should consider options to review, or audit, the use of BNP testing against the
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Midland Region Cardiac Services Plan - 2006
regional guidelines.
2.8. The current number of cardiac care beds available in the region is inadequate for the throughput
of patients and current delays for diagnosis and treatment. Midland DHBs should undertake a
review to determine options for managing cardiac patient throughput, this should include
recommendations below for earlier discharge of patients home or to a facility closer to home.
Consideration should be given to extending the same day discharge programme,
following angioplasty, (currently to Hilda Ross facility at Waikato Hospital) for suitable
patients to a facility in the DHB of domicile, or home:
– Resource for this might include education, telephone follow-up, and access to
nursing and/or medical advice.
■
In addition, consideration should be given to earlier discharge of suitable cardiac
surgery patients to a hospital facility closer to their home.
– For this to occur patients would require access to care including, wound care and
physiotherapy as agreed with the Waikato Hospital cardiac surgery service.
2.9. In the absence of a New Zealand agreed standard, the Midland DHBs cardiologists, physicians,
and emergency medicine specialists should agree a standard time in which thrombolysis should
be administered to appropriate AMI patients – call-to-needle time and door-to-needle time.
■
Each facility should undertake regular audit of door-to-needle time against the agreed
criteria.
■
Each facility should undertake regular audit of call-to-needle time against the agreed
criteria.
2.10. Ambulance triage criteria for cardiac patients should be reviewed to ensure timely transfer to
treatment facility.
■
2.11. The Midland Region Public Health Units should ensure development of comprehensive rheumatic
fever registers, to record incident cases and track their follow-up.
2.12. Better collaboration, cooperation, and data would provide the opportunity for Midland DHBs to
agree specific objectives and targets in relation to decreasing the burden of cardiac disease.
There is insufficient publicly available data to measure all potential objectives; however, there is an
opportunity for PHOs to work with a clinical network and the DHBs to establish specific objectives
and targets that can be measured for their own population, or jointly through agreeing to share
data to allow for a “Midland approach”.
Objectives that could currently be agreed include:
Reduce hospitalisations of older adults with congestive heart failure as the principal
diagnosis. Target: 50% decrease in adults over 65 years between 2006 and 2011;
■
Improve the management of acute coronary syndrome. Target: 80% of all ACS
patients undergo angiography within 72 hours of admission by 2011.
Other options that would require data not currently collected at a DHB level include:
■
Increase the proportion of adults who call and receive early pre-hospital care and
treatment;
■
Reduce the proportion of adults with high blood pressure and increasing the proportion
of adults with high blood pressure whose blood pressure is under control;
■
Increase the proportion of adults with high blood pressure who are taking action (e.g.
losing weight, increasing physical activity, or reducing sodium intake) to help control
their blood pressure.
2.13. The current framework for health services does not lend itself to coordination and integration of
service delivery across sectors and in particular across District Health Boards. The number of
individuals and organisations involved in delivering cardiac services requiring education,
coordination, and integration, lends this service to the development of a regional clinical network.
An outline of a proposed network is included in this plan, with further detailed development options
occurring as a DHBNZ Management Action Programme (MAP) project.
■
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Midland Region Cardiac Services Plan - 2006
PHOs should be represented on any established Cardiac Clinical Network.
■
Patients cared for by a cardiologist compared with a general medical physician have
been shown to have a better longer-term survival rate. The most important factor
affecting survival has been identified as access to effective medication and therefore
the adherence to guidelines and protocols is vital for patient management. In a regional
service, it is critical to maintain a strong relationship between cardiologists and general
physicians to promote best practice for all patients.
3. Require one-off resource with the potential for additional resource needs depending on the
outcome of the initial investigations
■
3.1. It is recommended that there be a review of all Midland DHB phase I and phase II cardiac
rehabilitation programmes against the New Zealand Cardiac Rehabilitation Guidelines.
A regional coordination model should be developed for the delivery of cardiac
rehabilitation services that would provide programmes close to home and promote
access to cardiac rehabilitation in groups traditionally underrepresented; high quality
central data collection; the creation of a district or regional cardiac rehabilitation registry
to allow future planning, coordination, monitoring, and evaluation of services in Midland.
■
This model should include options for providing community or home-based
rehabilitation to ensure that all eligible patients (including rural, Māori, elderly and heart
failure patients) have access to cardiac rehabilitation.
■
DHBs should ensure heart failure patients have access to multidisciplinary cardiac
rehabilitation as part of the review of cardiac rehabilitation programmes in the districts.
Heart failure should be a specific component of the recommended review of cardiac
rehabilitation programmes.
■
A regional network of rehabilitation staff should be established to encourage peer
support and education activities.
3.2. DHBs should review palliative care options available for patients with end stage cardiac
conditions.
■
3.3. The Midland DHBs should review CPR training and access to AEDs and trained personnel in the
community, in particular in the rural areas when there may be delay for emergency first response.
3.4. A Midland region policy on access to first response services in the region should be developed.
The ECCT should be involved, if not responsible, for the development of this policy.
3.5. The Midland DHBs should undertake a review of the region to determine localities where access
to a facility providing thrombolysis is greater than one hour.
Community thrombolysis programmes should be rolled out to identified localities across
the region.
■
The option for Waikato coronary care unit receiving all ECGs should be considered.
■
The option for the NZ Rural Institute to hold the contract for community thrombolysis for
all DHBs in the Midland Region should be considered.
3.6. Treatment of ACS is a constantly and rapidly evolving field. The Cardiac Society, Ministry of
Health, and the New Zealand Guidelines Group have developed ACS guidelines for New Zealand.
These principles for the treatment of Acute Coronary Syndrome should be adopted for the Midland
Region:
■
■
■
■
■
Appropriate treatment in the community as early as possible (following symptom
development) where there may be delay in access to trained professionals;
Primary angioplasty is the treatment of choice for STEMI and should be undertaken
within 12 hours of the onset of symptoms when presenting to Waikato Hospital where
interventional facilities are available;
Where access to primary angioplasty is >3 hours from the onset of symptoms,
thrombolysis is the treatment of choice for STEMI;
Patients with contraindications to thrombolysis or failure of thrombolysis 45-60 minutes
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Midland Region Cardiac Services Plan - 2006
after administration, should be immediately transferred to Waikato Hospital for primary
or rescue angioplasty providing transport can be achieved expeditiously;
■
After thrombolysis, routine angiography (within 24 hours if possible) is a strategy
increasingly recommended in international guidelines, even if the patient is
asymptomatic and without demonstrable ischaemia. Note, this has significant
resourcing implications;
■
If an interventional facility is not available within 24 hours, patients who have received
successful thrombolysis, with evidence of spontaneous or inducible ischaemia prior to
discharge, should be referred for coronary angiography and revascularisation as
appropriate;
■
Patients with non-ST elevation acute coronary syndrome (Unstable angina and nonSTEMI) require further risk stratification.. A clear benefit from early angiography (<48
hours) and, when required, PCI, or CABG surgery has been reported only in the highrisk groups;
■
To enable appropriate treatment, an efficient and coordinated transport service across
the region is critical.
3.7. Monitoring the use of interventions and health services can provide information for planning and
evaluating health services to meet the changing needs of the population. To date, no database on
individuals with cardiac disease has been established to provide person specific data on the use
of interventions and health services. The Midland DHBs should agree the cardiac service needs
for region and ensure these are considered as a component of the overall region IT strategy.
This should include DHBs and Primary Health Organisations (PHO’s) jointly
determining the appropriate option for cost-effective use of available or new technology
to establish cardiovascular disease registers and data management
■
Regional implementation of the Picture Archiving and Communication Systems (PACS)
has identified cardiology as a service with a specific need to be included but the current
system being implemented does not include the specific cardiology requirements. This
should be recognised and the implications around time, cost and storage space for the
service, in particular Waikato cardiology, understood until a PACS solution can be
identified.
4. Recommendations with significant resource implications.
■
4.1. The Midland region cannot meet the current demand for diagnostic and treatment procedures with
the facilities and staffing available. Nor are the current treatment levels meeting best practice
recommendations. Midland DHBs should agree to work towards the recommended rates for
diagnostic and treatment procedures as identified, recognising the implications for catheter
laboratories and staffing which are identified in the resource section of this paper:
Angiography – 2.5 times the revascularisation volume
■
Electrophysiology – 250 pmp
■
Implantable cardioverter-defibrillators (ICD) – 200 pmp by 2006, 300 pmp by 2011;
■
Pacemakers – 550 pmp
The 2005 British Cardiac Society predictions should be noted and all predicted rates reviewed on
an annual basis.
■
4.2. The level of revascularisation procedures recommended is 1400 pmp PCI and 750 pmp CABG.
These should be adjusted, if required, to retain 2150 procedures per million population. Noting the
2005 British Cardiac Society is predicting 2200 – 3000 PCI and 700 CABG pmp per annum will be
required in the future.
4.3. At this time, patient safety, and the volume of PCI, and the resource and capital costs required to
establish an interventional service, leads to the recommendation that Waikato Hospital should
continue to provide all percutaneous revascularisation for the Midland region.
This
recommendation should be reviewed at a time when safety of treatment away from a cardiac
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Midland Region Cardiac Services Plan - 2006
surgery unit is acceptable, and there is a substantial increase in PCI or best practice requirement
for an increase in facilities providing the service within the region.
4.4. A coordinated approach to all cardiac transport is required and a regional review should be
undertaken to determine options for the future.
4.5. The Midland DHBs recognise the Midland ECCT air ambulance needs-analysis incorporates the
air ambulance service needs for cardiac patient transfer within the region.
The outlined air ambulance proposal included should be developed further as a joint
proposal that clearly identifies implications for the DHBs in relation to flight numbers
and costs, together with efficiencies and benefits for patient care.
■
An urgent recommendation for consideration is that Waikato DHB employs or identifies
two flight nurses – total 1FTE to be seconded to the air ambulance service for cardiac
transfers. That the remaining shifts be undertaken at Waikato Hospital to ensure
appropriate skills and training.
4.6. Waikato Hospital should plan for four cardiac catheter laboratories on site.
■
4.7. Tauranga Hospital should plan for one dedicated catheter laboratory to undertake cardiac
diagnostic angiography and pacemaker services for the Bay of Plenty. An option for
consideration, is for Tauranga to deliver elective services for the Lakes and Tairawhiti DHBs, this
would allow Waikato to focus on acute service delivery for all Midland DHBs.
4.8. That options identified to increase cardiac catheter laboratory services be considered to ensure
appropriate service delivery prior to any new facilities opening. These include, extending current
catheter laboratory throughput, developing a service at Rotorua Hospital and contracting to private
facilities.
4.9. The Midland DHBs should recognise that the rapidly changing technology, and consequent best
practice for cardiac services, may require additional catheter laboratories within the region within
ten years.
4.10. A workforce plan should be developed and should incorporate a professional development and
peer support component for all staff involved in delivering cardiac services within the region
Consideration should be given to identifying competencies required and allowing for
new ways of working to meet the needs of the service.
■
The plan should include a echocardiography workforce plan should be put in place
across the region to ensure a supported regional service with appropriate training and
continuing education to enable a sustainable service into the future.
■
There are few available specific recommendations for levels of staff providing cardiac
services. Recommendations have been identified in this plan for staffing levels for:
catheter laboratories, cardiac rehabilitation, cardiologists (medical, interventional and
electrophysiologists), and cardiac surgeons for the Midland region.
4.11. There is an urgent need to address cardiologist staffing in order to recognise the current waiting
times and growing need for secondary and tertiary cardiac services. It is critical that the total
cardiologist numbers for the region are available, irrespective of location, to ensure the delivery of
services to the regions population. The Cardiologist recommendations made are conservative
based on international trends, and it is recommended the Cardiologist and Cardiac Surgeon
recommendations be reviewed when the Australian Medical Workforce Advisory Committee
reports on Cardiology and Cardiothoracic Surgery become available in the next 12-months
■
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Midland Region Cardiac Services Plan - 2006
2.
Background
Cardiovascular diseases are diseases that affect the heart and circulatory system and include: coronary
heart disease, rheumatic heart disease, cerebrovascular disease and other forms of vascular and heart
disease. In 2000 coronary heart disease (CHD) [also known as ischaemic heart disease (IHD)] was the
cause of 22% of all deaths in New Zealand, with stroke the second ranked cause at 10%. Other cardiac
related deaths hold a further three places in the top 20 causes of death1, making cardiovascular disease the
leading cause of mortality in New Zealand accounting for 40% of all deaths in 2000.
Despite having the highest rate of mortality, cardiovascular disease death rate is decreasing in New
Zealand2. While the actual incidence of cardiovascular disease in New Zealand is not known, it is known
that the incidence of some risk factors for cardiovascular disease continue to increase e.g. ageing
population, obesity, and diabetes, while other risk factors have declined e.g. hypertension,
hypercholesterolaemia, tobacco smoking. Of concern is the high incidence of the risk factors and the
subsequent higher mortality rates from cardiovascular diseases for Māori and Pacific peoples.
The New Zealand Health Strategy3 includes reduction of the incidence and cardiovascular disease as one of
the 13 population health objectives. To support DHBs in addressing this priority a Cardiovascular Expert
Advisory Group and the Clinical Services Directorate of the Ministry of Health have developed a
Cardiovascular Toolkit4.
The complications or outcomes of CHD can be managed in a variety of ways. Angina can be managed
medically or by revascularisation. Acute myocardial infarction may be treated with thrombolysis or
revascularisation. Services to prevent and treat cardiovascular diseases are provided across community,
primary, secondary and tertiary services. Health services that focus on prevention and cessation of
smoking, nutrition, reducing obesity and increasing physical activity will impact on the number of patients that
develop cardiovascular diseases and require treatment services into the future.
Indirect costs of cardiac disease include the loss of quality of life for those with cardiac disease in the
community no longer able to lead an active or productive life, plus the affect on their carers. Australia has
estimated the Disability Adjusted Life Years (DALYs) for CVD as costing over 600,000 years of healthy
Australian life in 2004. This leads to significant financial costs for the individuals and the family from the loss
of income, and to the community through loss of tax revenue, benefit payments together with the cost of
health services and supportive aids and care. The estimated direct cost of CVD in Australia in 2004 was
1.7% of the national income.
The New Zealand Cardiovascular Advisory Group has identified four activities as critical to improving
cardiovascular health and reducing inequalities. These are:
■
■
■
■
Risk assessment and management
Service development and integration
Improving consumer knowledge and education
Addressing workforce issues.
This service plan concentrates on cardiac rather than cardiovascular services, so no specific information and
planning for cerebrovascular disease is included. Many of the strategies identified will have an effect on the
prevalence of cerebrovascular disease; however specific issues, relating to treatment are not addressed.
A number of reviews and articles published in the New Zealand Medical Journal in 2003 and 2004 indicate
that the current acute coronary syndrome services provided in New Zealand are less than ideal. In
particular, the issues relate to equity and appropriate care in certain clinical presentations5,6,7,8,9,10. While
clinical care is not dealt with, issues raised relating to service delivery will be discussed in this document.
This plan reviews the national & Midland DHB positions in relation to cardiac services, the impact of
demographic changes and options for service delivery across the region, together with the links across the
continuum of care from primary to secondary and / or tertiary services and back.
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Midland Region Cardiac Services Plan - 2006
This plan does not address paediatric cardiac services, which are provided by Starship Hospital in Auckland
for the Midland Region, or quaternary services, such as heart transplants, which are provided by Auckland
Hospital. The Midland DHBs would anticipate participation in any review of these services with Auckland
DHB, including review of any outreach services, options for delivery and future directions.
Services vary across the DHBs within the region. A number of initiatives have commenced within the
primary sector with the development of Primary Health Organisations. These are managed at a local level
and often are not part of a planned approach to prevention or treatment of cardiac disease.
Bay of Plenty and Taranaki DHB’s employ cardiologists while Waikato provides a visiting service to Lakes
and Tairawhiti DHBs and to Whakatane Hospital. Interventional cardiac services are provided by Waikato
DHB for the Waikato, Bay of Plenty, Lakes, Taranaki, and Tairawhiti District Health Board populations.
The cardiology service has good clinical links across the secondary and tertiary sectors of the region with an
annual clinical meeting that has lead to the development of standardised regional policies and procedures.
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Midland Region Cardiac Services Plan - 2006
3.
Ministry of Health / DHB Health Objectives and Guidelines
The Ministry of Health strategy, and DHB objectives and guidelines that relate to cardiac services have been
considered in the development of this service plan.
3.1.
New Zealand Health Strategies
3.1.1. The New Zealand Health Strategy
The New Zealand Health Strategy was published in 2000. The Strategy includes 13 health objectives, one
of which relates specifically to cardiovascular disease:
■ Reduce the incidence and impact of cardiovascular disease.
Five other health objectives support the cardiovascular disease objective:
■ Reduce smoking;
■ Improve nutrition;
■ Reduce obesity;
■ Increase the level of physical activity;
■ Reduce the incidence and impact of diabetes.
In addition, relevant to this plan, the Strategy identifies the need to reduce inequalities in health status
though ensuring:
■ Access and appropriate services for people from lower socio-economic groups;
■ Accessibility and appropriate services for Māori;
■ Accessibility and appropriate services for Pacific peoples.
3.1.2. He Korowai Oranga - Māori Health Strategy
He Korowai Oranga emphasises whānau health and wellbeing as its overall aim. The key themes
throughout the strategy are rangatiratanga, building on the gains already made, and the need to reduce
inequalities.
This is particularly relevant to this plan as Māori have double the mortality rate from all categories of
cardiovascular disease compared to the NZ European population.
3.1.3. Primary Care Strategy
The establishment of Primary Health Organisations throughout New Zealand is as a response to the New
Zealand Primary Health Care Strategy. The vision of this strategy is:
■ People will be a part of local primary health care services that improve their health, keep them well,
are easy to get to and co-ordinate their ongoing care.
■ Primary health services will focus on better health for a population, and actively work to reduce
health inequalities between different people.
The six key directions for primary care to achieve this vision are:
1. Work with local communities and enrolled populations;
2. Identify and remove local inequalities;
3. Offer access to comprehensive services to improve, maintain and restore people’s health;
4. Co-ordinate care across service areas;
Develop the primary health care workforce;
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Midland Region Cardiac Services Plan - 2006
Continuously improve quality using good information.
These strategies set the principles for the DHB and PHOs to focus on inequalities in the health system, look
at the long-term outcomes of interventions and to develop a collaborative Intersectoral approach to
healthcare. The MoH has also established a number of toolkits to support the DHBs in achieving the goals
of the strategies.
Each of the District Health Boards addresses the cardiovascular disease health objective in their District
Annual Plans as indicated in the extracts below.
3.2.
District Health Board - Cardiac Disease Objectives & Related Activities
3.2.1. Bay of Plenty District Health Board
BAY OF PLENTY DISTRICT ANNUAL PLAN 2004-05
Chronic Conditions and Co-morbidity Programmes of Care (PoC)
Chronic conditions, such as cancer, cardiovascular disease, diabetes, chronic respiratory disease and
depression, account for most of the burden of disease in the BOPDHB area.
To address these issues the BOPDHB will develop a Chronic Conditions PoC, which will focus on
prevention and management of chronic conditions and associated co-morbidities. This will place particular
emphasis on developing effective prevention interventions and chronic condition and co-morbidity
management interventions, for Prevention Interventions. See Appendix 2 for an example of the PoC
template.
■
■
■
■
■
■
Reduce tobacco smoking;
Improve eating practices;
Increase physical activity;
Increase the proportion of the population who have healthy body weight;
Reduce problematic alcohol use;
Enhance community resilience.
Specific Projects that will impact Cardiovascular Disease development include:
■ Kids Force Project Keep kids healthy over time (pilot initially with Sport BoP)
■ Cardiac Rehabilitation - Reduce mortality and morbidity
■ Risk Prevention
TAURANGA HOSPITAL CLINICAL SERVICES PLAN – NOVEMBER 2003
Cardiology
Scope: Provision of services to adults, children and neonates as inpatients, day patients and outpatients
with full diagnostic services at Tauranga Hospital (stress ECG, pacemaker service, echocardiography and
transoesophageal echocardiography) with partial diagnostic services at Whakatane Hospital. Angioplasty,
permanent pacemaker/defibrillator insertion and cardiac surgery is provided by referral at Waikato Hospital.
Key issues affecting this service:
■
■
■
■
■
■
Large growth in acute presentations and First Specialist Assessment (FSA) demands;
Increasing complexity of cases;
Shortage of CCU beds in absence of adjacent cardiac step-down facilities;
Delays in transferring to tertiary provider;
Recruitment of technical staff in difficult recruitment environment;
Increasing numbers of pre-operative cardiologist reviews for elective surgical patients.
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Midland Region Cardiac Services Plan - 2006
Proposed Service developments
■ Development of permanent pacemaker implantation service (2004-05)
■ Development of a dedicated CCU/step-down ward closely located to the clinical physiology service;
■ Development of acute chest pain assessment programme (2004). (Acute chest unit to be
established in 2005).
Coronary Care Unit
Scope: The Coronary Care Unit provides five beds for assessment and management of acute and chronic
coronary syndromes. All myocardial infarctions are initially treated at Tauranga Hospital.
Key issues affecting this service:
■ Inability to discharge patients due to hospital bed blockage:
■ A suitably staffed and adjacent step-down unit would result in more flexible management of
patients with Cardiac Care needs and provide an improved care continuum for patients during their
hospitalisation;
■ There is no procedure room in CCU for undertaking suitable cardiac procedures e.g. pacemaker
insertion, elective cardioversion;
■ Delays in transfer of patients to Tertiary Providers results in bed blockage in CCU.
Proposed Service Development
■ Development of dedicated Coronary Care Unit adjacent to a cardiac step-down ward to ensure
effective and efficient integration of a patient’s episode of care (refer Cardiology Proposed Service
Developments).
Demand Management Strategies:
Heart Failure Clinics
Heart failure clinics, managed by a nurse case manager with medical oversight, were introduced for patients
in the Western Bay of Plenty region in early 2002 and have proven successful at reducing the numbers of
hospital admissions.
Chest Pain Clinic
A chest pain clinic is planned for establishment in 2004 commencing for patients at the time of patient
presentation to the Emergency Department. This will involve early workup of necessary investigations.
Proposed Clinical Service Developments
Implantation of Permanent Pacemakers
The insertion of permanent pacemakers will be developed at Tauranga Hospital in the next two years using
local cardiologist skills and the necessary equipment, which is already available locally. This will reduce the
reliance on temporary pacemakers (and associated cost), reduce current long waiting lists for this service,
and reduce the clinical risk currently facing these patients.
3.2.2. Lakes District Health Board
LAKES DIStRICT ANNUAL PLAN 2004
Cardiovascular: The Atherosclerotic Envelope
This refers to a cluster of disease states linked through an underlying pattern of metabolic changes in the
body that lead to disorders of blood vessels; a major one of which is called atherosclerosis or ‘hardening of
the arteries’.
The abnormal blood vessels give rise to illnesses such as angina and heart attacks, heart failure, strokes
and a type of dementia, some forms of both kidney failure and poor eyesight, and impaired circulation, which
may result in amputation.
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Midland Region Cardiac Services Plan - 2006
Life-style factors such as smoking, fatty diet, obesity, lack of physical activity, increasing age, being male, as
well as possible heredity components, all increase the risk of atherosclerosis. Atherosclerosis is also
increased by high blood pressure, raised cholesterol, and especially diabetes; which frequently share these
same risk factors. In fact, cardiac/vascular disease is the major cause of ill health in people with diabetes.
This cluster of disease states is particularly prevalent in the Lakes region.
Cardiovascular
Lower hospitalisation rate for Maori and non-Maori with cardiovascular disease
Collaborate with the Ministry of Health, Midland DHBs and national organisations to implement the
Healthy Eating – Healthy Action strategy;
Review programmes/initiatives for patients with coronary artery disease/strokes;
Develop linkages with PHOs, health workers and community groups and others engaged in the
prevention and treatment of obesity and smoking;
Review appropriateness of cardiovascular education material for Maori & Pacific Island peoples;
Work with PHOs to determine the feasibility of introducing a primary care based screening register for
cardiovascular risk;
Ensure Statistics NZ ethnicity classification is adopted and used by all for data collection;
Examine feasibility of community cardiovascular risk educator nurse specialists.
Approach
Lakes DHB participation in healthy lifestyles network initiated by Toi Te Ora, Public Health;
Support Te Wai o Rona Diabetes Prevention Strategy, which will promote increased exercise and healthy
eating;
Lakes DHB support of Rotorua District Council’s initiatives to encourage more people to be active more
often;
Support for the implementation of health promotion work by PHOs within the Lakes district;
Work with other interested parties to scope the extent of the “statin gap” in the Lakes region and develop a
project to increase primary health use of statins for patients with appropriate clinical events and risk
factors. *Statins are lipid-lowering drugs and the “statin gap” refers to under-prescribing of these drugs that
are beneficial through a range of actions in reducing cardio-vascular complications.
Milestones
Te Whakaruruhau review of cardiovascular material in provider arm. May 2004.
Resourcing of Lakes DHB capacity to review & implement programmes for people with cardiovascular
Risks and
risks or disease;
Mitigation
Strategies
Partnership development with the community to foster improved access and intervention concordance.
Specific Projects include:
■ Lake Taupo PHO Services to improve access: Cardiovascular screening
■ Te Kupenga A Kahu Services to improve access: Chronic care management
LAKES ASSET MANAGEMENT PLAN
Clinical Trends for Lakes
Higher Rates of Cardiovascular Disease
(Hospitalisation rate for cardiovascular
disease is significantly higher than the
national rate.)
The increase in cardiovascular disease is
expected to continue. With the increase in
Maori aged over 55 (48.8% in the next ten
years) there will be an increase in Maori
cardiac presentations.
Impact
Cardiovascular disease is the leading cause of mortality in NZ. It
accounted for 41 percent of all deaths in 1999;
Maori have the highest rates of mortality for all categories of
cardiovascular disease;
The region-wide trend to earlier and definitive angiography to establish
certainty will increase over the next five – ten years. In recent years
over 40% of acute medical admissions in Lakes have been of a cardiac
nature with cardiac presentation.
Significantly impacted by the complications of diabetes and
compounded by the aging population, it is anticipated there will be
significant pressure on postoperative recovery beds. Vascular surgery
– major vessel repair in already compromised patients presents
significant risk and consequent need for HDU beds for post-operative
recovery and some ICU beds. Whilst some surgical procedures such
as amputation are very basic, there is still a need for HDU support given
the co-morbidities of this patient group.
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Midland Region Cardiac Services Plan - 2006
3.2.3. Tairawhiti District Health Board
TAIRAWHITI DHB DISTRICT ANNUAL PLAN 2004-05
Cardiovascular Disease
Cardiovascular disease is one of the leading causes of death in New Zealand. It accounted for 41 percent of
all deaths in 1999. Maori have the highest rates of death for all categories of cardiovascular disease. The
key risk factors for cardiovascular disease are smoking, hypertension, high serum cholesterol, diabetes,
obesity, lack of exercise and poor diet. Local PHOs are potentially the most effective means of
cardiovascular risk management.
TDH will continue to work across the sectors, promoting healthier lifestyles as part of a local strategy.
Objectives
Reduce the
incidence and
impact of
cardiovascular
disease
Improve the primary
treatment of
cardiovascular risk
Actions
Targets
Timeframes
June 2004
Work in partnership with MOH/PHU to
develop and implement population
programmes to reduce the level of
cardiovascular risk.
Population awareness of risk
Work with the local PHO based
cardiovascular screening assessment
Analyse outputs from the
programme to date
Dec 2004
Increase the uptake of statins
Measure baseline, 2003/04
and agree increase with
primary care
Sep 2004
Increased uptake in local
prevention programme
Smoking
Consumption of tobacco or inhalation of cigarette smoke is the number one preventable cause of morbidity
and mortality. It also accounts for an estimated 70 deaths per year in Tairawhiti. Smoking gives rise to
around 40 different medical conditions in particular cancer of the lung, respiratory, and cardiovascular
diseases.
The year 2004/05 will see the implementation of the local tobacco strategy, developed by the collaborative
group, Taki Tahi Toa Mano (TTTM). Modifying behaviour around cigarette smoking is a strategy that has
significant immediate benefits for the smoker, their family/whanau and the community. Hence, smoking
cessation is a key target for TDH and community action.
TDH has led the way in this by declaring the TDH campus smokefree and supporting staff who smoke to
undertake smoking cessation options. TDH is actively working with other agencies and sector groups to
encourage the spread of the smokefree message so that the healthy option – giving up smoking – becomes
the easier option for the Tairawhiti community.
Objectives
Actions
Targets
Timeframe
Reduce Smoking
Maintain focus on smoking cessation initiatives in
the community coordinated through local group
TTTM
Assess current services
against demand for these
services
Dec 2004
Continue to develop local promotion resources,
identify local promotion resources, identify local
role models, and use local media to assist in
monitoring strategies implemented, idea
development, identification of success
One Resource and one
Role model per year
Ongoing
Tairawhiti Social Development Taskforce join with
TDH on smokefree
50% Tairawhiti agencies
completely smoke free
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June 2005
Midland Region Cardiac Services Plan - 2006
Objectives
Actions
Targets
Timeframe
Recognise and maintain by Maori for Maori service
delivery
By Maori for Maori
services acceptance and
greater market share
All agreements include
cessation tobacco targets
June 05
TDH to include smoke free standards in
agreements with service providers as they come
up for renegotiation
Develop Public Health intelligence relating to
tobacco use
Collection of good local
data that effectively
monitors tobacco
consumption
June 05
March 05
3.2.4. Taranaki District Health Board
TARANAKI DHB DISTRICT ANNUAL PLAN 2003-04
Population Health Focus
While information, education and prevention strategies are seen as the key to managing improvement in
disease incidence rates, the impact of these messages and social change in behaviours on our health
system will not be seen in the short term. We must continue to plan for the expected growth in patient
numbers, particularly in the areas of cardiovascular and renal disease, diabetes and cancer.
We recognise the interrelationship between cardiovascular disease (which has a high chronic component)
with other diseases such as diabetes, chronic obstructive airways disease and renal disease and plan to
develop a Disease Prevention and Management Strategy over the coming year to address their combined
risk factors and growth patterns. The approaches considered in the strategy development will include
achieving seamless communication between all sectors, availability of appropriate access to services and
diagnostics, adequate infrastructure and ready access to clinical support as well as meeting the needs of the
people who face inequalities.
Disease Prevention and Management Strategy
Diabetes, Cardiovascular disease, and Cancers are all recognised nationally as being important disease
groups to target to improve the health of the population. They share the same risk factors, for example,
nutrition, obesity, smoking, blood pressure, except for Cancer which has sun as an additional risk factor.
They also have the same ability to drive costs at the secondary-tertiary end of care if population and primary
focused disease prevention and management activities are not focused upon. Therefore, this is a priority
area for us to focus on the Continuum of Care approach we have outlined in other parts of this Plan. We
want to ensure that all sectors [from Population health to tertiary services] are linked in a strategic response
to these disease states. There will be an over-arching Disease Prevention and Management Strategy, with
supporting strategic work for each of the particular disease states. This work will be aligned with national
and regional work.
Other strategy developments planned during 2004/05 are:
■ Sustainable Clinical Services Plan, including service delivery models for:
– nursing services; referred services; discharge planning and case management;
– coordination of emergency after-hours care and management plans for renal,
– diabetes, oncology, cardiology, ICU
■ Disease Prevention & Management (includes diabetes, cardiovascular, cancer)
■ Primary Health Care
■ Rural Health
■ Taranaki Inequalities Plan
■ Workforce Action Plan
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Midland Region Cardiac Services Plan - 2006
Development of these strategies will form the basis for informing future planning and implementation of
sustainable health service delivery.
Secondary Health services
Cardiology
Reducing the incidence and impact of cardiovascular disease continues to be a high priority for Taranaki
DHB and this diagnostic group represents the highest volume of all hospitalisations. Furthermore, like other
chronic diseases, the incidence is increasing as the percentage of people in the aged bracket of society
grows. Strategies to manage the volume of patients within the allocated resources include extending our
relationships with the primary sector and efficiency projects such as:
■ Implementation of a chest pain pathway in the emergency department – this has reduced the
number of hospital admissions thus ensuring that we focus our resources on those patients who
are in the highest need of secondary care.
■ A Heart Failure project pilot in South Taranaki was launched to reduce hospitalisations, free up
specialist resource in outpatients and thereby reducing waiting times and improving clinician
management of heart failure patients.
Our angiography service commenced approximately two years ago and while we have had several lengthy
interruptions over this time the service is now re-established. A recent audit indicated high levels of
performance in regard to elective service quality measures, including waiting time to treatment. We continue
to benefit from our close relationship with Waikato Health District Health Board cardiology department.
3.2.5. Waikato District Health Board
Waikato District Annual Plan 2004-2007
Cardiovascular disease is the leading cause of mortality and morbidity in NZ. The Board has identified
cardiovascular disease as an emerging theme. Examples of local initiatives to reduce the incidence and
impact of cardiovascular disease are:
■ Providing best practice and evidence based care for the management of acute cardiology
conditions within available resources;
■ Implementing a Maori community cardiovascular rehabilitation programme recognising that the
burden of cardiovascular disease falls disproportionately on Maori and cardiovascular mortality
ranks highest as a contributor to New Zealand ’s total ethnic health gap;
■ The provider division will consider how it may improve stroke management across continuum of
care;
■ The health promotion / prevention programmes e.g. Te Wai o Rona diabetes project, the Waikato
Healthy Eating Healthy Living programme for children.
HEALTH WAIKATO CLINICAL SERVICES PLAN
The Health Waikato Clinical Services Plan released for discussion in November 2001 identified the following
proposed changes for Cardiology and Cardiac Surgery Services.
The cardiology service is experiencing substantial demand pressures from the ageing population and for the
widening range of interventional services that can be offered.
Cardiothoracic surgery is a strong service facing demand beyond its resource capacity. A wide range of
cardiac valvular and arterial surgery, as well as aortic and thoracic surgical procedures are provided. With
ageing and high levels of cardiac disease in the Maori population, further demand growth is predicted.
Private sector cardiac surgery services in Hamilton are expected to be enhanced soon and cooperative
development may bring benefits to both sectors.
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Midland Region Cardiac Services Plan - 2006
Summary of proposals
Cardiology
■ Hub and spoke service model, with extended outreach role;
■ Potential Cardiovascular Services functional clinical grouping (Cardiology, Cardiac Surgery, and
Vascular Surgery);
■ Increased rates of catheterisation interventions, more day only procedures;
■ More ambulatory management of heart failure in conjunction with ED, sub-acute hospitals and
GP’s;
■ Admission ward includes CCU and telemetry beds;
■ Expansion of community-based cardiac rehabilitation programmes;
■ Increase drug and consumable costs.
Cardiac Surgery
■ Centralised service model;
■ Potential Cardiovascular functional clinical grouping (Cardiology, Cardiac Surgery & Vascular
Surgery)
■ Operating sessions progressively expanded to meet increasing demand;
■ Possible expansion of community-based cardiac rehabilitation programmes.
3.3.
Cardiovascular Guidelines
A number of New Zealand guidelines are available, or in development to support different aspects of cardiac
disease prevention and management. A brief outline, and link to the original document, where available, is
provided.
3.3.1. Health Eating - Action Plan - Oranga Kai - Oranga Pumau
The Ministry of Health released the Health Eating – Health Action strategy (HEHA) in 200311 followed by the
implementation plan12 in 2004. These documents provide a framework for bringing about the changes in the
environment in which New Zealanders live, work and play as this relates to nutrition, physical activity and
obesity. The key priorities identifies are:
■
■
■
■
■
Lower socioeconomic groups;
Children, young people, families/whanau;
Environments;
Communication;
Workforce.
3.3.2. Smoking cessation
The National Health Committee developed Guidelines for Smoking Cessation in 1999, which were endorsed
by the New Zealand Guidelines Group in May 200213 with a review commenced in 2004. These guidelines
indicate:
■ There is good evidence that even brief advice from health professionals has a significant effect on
smoking cessation rates. A supportive, ongoing relationship with a health professional is often an
essential precursor to successful quitting. Success in quitting smoking depends less on any
specific type of intervention than on delivering personalised empathic smoking cessation advice to
smokers, and repeating it in different forms from several sources over a long period.
■ Smoking cessation is a dynamic process that occurs over time rather than a single event. Smokers
cycle through the stages of contemplation, quitting and relapse an average of three to four times
before achieving permanent success.
■ Tobacco dependence is a chronic condition that often requires repeated intervention. However,
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Midland Region Cardiac Services Plan - 2006
effective treatments exist that can produce long-term abstinence.
■ These guidelines are designed for smoking cessation providers to assist all clients with smoking
cessation. The guidelines will also be useful in other settings. The guidelines are based on
comprehensive literature reviews and background information available at the time of publication.
■ The guidelines are not meant to replace clinical judgment and the recommendations may not be
appropriate for use in all circumstances. How the recommendations are implemented remains the
provider’s decision in the context of the individual smoker’s circumstances. Each cessation
provider is encouraged to individualise the way they develop or modify their systems to implement
these guidelines.
3.3.3. Cardiovascular Risk Assessment and Management
The New Zealand Guidelines Group released the best practice evidence based guideline, The Assessment
and Management of Cardiovascular Risk14 in December 2003. These comprehensive guidelines form the
basis for identification of patients at risk of a cardiovascular event and the appropriate intervention according
to the risk assessment.
3.3.4. Proposed Māori Specific Cardiovascular Plan
In 2001, the Ministry of Health in association with the New Zealand Guidelines Group convened a National
Cardiovascular Advisory Committee. The aim of this group was to ‘advise on the development of an
integrated managed approach to cardiovascular disease, from primary prevention through to tertiary
treatment in Aoteoroa, New Zealand. The work of the committee was to draw upon the best available
evidence and was to be conducted in accordance with the principles of the Treaty of Waitangi’.
A key task of this group was to facilitate the production of a Maori Cardiovascular Action Plan. To produce
this plan, a separate Maori cardiovascular group was formed. The overall aim of the Maori Cardiovascular
Action Plan is to improve Māori cardiovascular health and to remove inequalities in cardiovascular disease
outcomes between Maori and non-Maori. The action plan has six categories. These categories reflect the
need for a multi-level, multi-sector approach to improving cardiovascular outcomes. The categories for
action include the following areas: policy development, improved information systems, needs assessment,
quality standards, Maori workforce development and a proposed research agenda. No date for the release
of this plan has been identified.
The New Zealand Medical Journal published an article entitled ‘A call to action on Maori cardiovascular
health’ by Dale Bramley et al in 200415. The aims of this paper are to: provide a brief overview of the current
status of Maori cardiovascular health; outline the key themes of the Maori cardiovascular action plan, and
stimulate coordinated action by the health sector to reduce Maori cardiovascular disparities.
Although many of the determinants of health lie outside of the realm of the health sector, the sector has a
key role in ensuring that access to procedures is equitable and that healthcare responsiveness is based on
demonstrable need.
3.3.5. Pre-Hospital Admission of Fibrinolytic Therapy
Guidelines for pre-hospital administration of fibrinolytic therapy by New Zealand general practitioners16 were
published in 2004. These guidelines have been developed to provide a framework for safe and appropriate
administration of fibrinolytic agents in the New Zealand rural community, where access to a hospital with
fibrinolytic facilities is at least one hour away.
3.3.6. Acute Coronary Syndrome
The terms of reference for an Acute Coronary Syndrome Evidence Review Project are under development
through the New Zealand Guidelines Group. No date for anticipated completion of this guideline is yet
available.
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Midland Region Cardiac Services Plan - 2006
3.3.7. Cardiac Rehabilitation
A Cardiac Rehabilitation guideline was developed by the New Zealand Guidelines Group and published in
August 200217. The guideline applies primarily to patients with coronary heart disease, specifically those
following an acute coronary syndrome (acute myocardial infarction/unstable angina) and following coronary
artery bypass surgery and angioplasty. Most aspects will also apply to patients with chronic stable angina
and following surgery for valvular heart disease. Special consideration was given to:
■ Appropriateness and acceptability for Māori;
■ Appropriateness and acceptability for Pacific peoples;
■ Other socio-cultural/socio-economic factors in New Zealand.
3.3.8. Atrial Fibrillation
A guideline for The Management of People with Atrial Fibrillation and Flutter has been developed and
feedback from the consultation phase is now being considered and integrated by the Guideline
Development Team. When that is completed, it will be sent out for endorsement. The anticipated release
date is March 2005.
3.3.9. Heart Failure
A guideline for the Management of Heart Failure: health professionals guide was published in December
200118 by the Heart Foundation and endorsed by the New Zealand Guideline Group. The aim of this
guideline is to reduce morbidity and mortality from congestive heart failure. It is also hoped that patients’
understanding and satisfaction with their health care will be improves. Outcomes predicted are increased
survival and reduced morbidity as represented by either, functional scores or by hospital admission.
3.3.10. Prophylaxis against Bacterial Endocarditis
A committee of The National Heart Foundation published a technical report in July 1999 entitled ‘Prevention
of Infective Endocarditis Associated with Dental Treatment and Other Medical Interventions.19 This report
provides recommendations for prophylaxis against endocarditis in cardiac conditions and for specific
conditions, including: dental, oral, respiratory tract, oesophageal, genitourinary and gastrointestinal.
3.3.11. DHB Toolkit: Cardiovascular Disease
The Ministry of Health has produced a DHB Toolkit for Cardiovascular Disease20, this together with toolkits
for Tobacco, Improve Nutrition, Obesity, Physical Activity and Diabetes (available on
http://www.newhealth.govt.nz/toolkits) provide DHBs with evidence and information on priority areas where
the most gain can be made to reduce the incidence of cardiovascular disease.
The cardiovascular toolkit includes demographic information and information relating to:
1. Cardiovascular disease, risk assessment and management including:
– Cardiovascular risk factors;
– Cardiovascular assessment and risk management;
– Primary prevention of cardiovascular disease;
– Secondary prevention of cardiovascular disease;
– Cardiac rehabilitation
– Secondary prevention of ischaemic stroke.
Management of acute coronary syndromes:
– Acute pre-hospital care;
– Hospital care.
Heart Failure:
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Midland Region Cardiac Services Plan - 2006
– Management of heart failure;
Rheumatic heart disease;
Stroke services;
Cardiovascular disease and Māori;
Cardiovascular disease and Pacific peoples.
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Midland Region Cardiac Services Plan - 2006
4.
Current Situation and Issues
4.1.
Demographics
The demographics of the Midland DHB populations and the predicted changes over the next five years are
identified below. These are based on the medium predictions as per Statistics New Zealand Census 2001
data.
Table 1.
Midland DHB population and predicted changes
DHB
Bay of Plenty
Lakes
Waikato
Tairawhiti
Taranaki
Midland Total
2001
2006
2011
2016
2021
183,400
99,400
328,600
45,500
105,900
201,800
102,200
340,000
45,000
104,200
214,500
104,300
347,000
44,300
101,700
226,800
105,900
353,200
43,500
98,800
238,800
107,400
359,100
42,600
95,500
762,800
793,200
811,800
828,200
843,400
The age of the population, most at risk of developing cardiac disease, are those in the middle to older age
group. While the total populations for Tairawhiti and Taranaki decrease over the period, in all the Midland
DHBs, the proportion of the population over 40 is predicted to increase. The number over 65 years
continues to increase at a significantly greater rate than the overall population in each of the DHB areas.
See Figure 1.
Figure 1.
Predicted population 65_plus by Midland DHB 2001 - 2026
Predicted Population 65_Plus Years
80,000
60,000
40,000
20,000
0
Bay of Plenty
Lakes
2001
2006
Tairawhiti
2011
2016
Taranaki
2021
Waikato
2026
Māori and Pacific peoples have significantly higher incidence and mortality from cardiac disease than the
New Zealand European population. Figure 2 shows the ethnic breakdown of the Midland DHB populations.
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Midland Region Cardiac Services Plan - 2006
Figure 2.
Ethnicity of Midland DHB populations, 2001
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
Bay of Plenty
4.2.
Lakes
European
Māori
Tairawhiti
Pacific Peoples
Taranaki
Asian
Other
Waikato
Cardiac Disease Data
Cardiac disease mortality statistics are available in a number of publications and databases for both New
Zealand and international populations. There is little specific information on current incidence or prevalence
rates other than hospital data and self-reported information in documents such as A Snapshot of Health21,
which indicates that approximately one in five adults over 45 years reported they have been diagnosed with
heart disease.
4.2.1. Mortality Rates
In 2004 the Heart Foundation published a summary of recent statistical information on Cardiovascular
Disease in New Zealand22. The age-standardised rates shown in Table 2 show that in 2000 New Zealand
the CHD mortality rate for men was 24% higher than the 2002 Australian rate and 22% higher in women.
Between 1970 and 2000 in New Zealand, the CHD age-standardised death rates fell by 61% in men and
56% in women. In Australia between 1970 and 2002 the rates fell 75% for men and 72% for women.
Table 2.
Cardiovascular rates of death per 100,000 population in New Zealand, 2000 and Australia 20012.
Cause of death
Males
Females
Total
114
3
35
2
512
56
3
32
3
330
82
3
33
3
412
86
28
44
25
64
27
New Zealand
Coronary Heart Disease
Hypertensive Disease
Cerebrovascular Disease
Chronic rheumatic heart disease
All causes of death
Australia
Coronary Heart Disease
Cerebrovascular Disease
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Midland Region Cardiac Services Plan - 2006
Table 3.
Table 4.
Death rates per 100,000 from CHD in New Zealand according to ethnicity and age, 20002
25-44
years
45-64
years
65-74
years
75+
years
Others Non-Māori
Non-Pacific
Male
Female
Total
10
2
6
116
34
75
614
258
431
2310
1686
1924
Pacific
people
Male
Female
Total
23
9
16
364
78
219
1438
327
823
2014
1563
1722
Māori
Male
Female
Total
31
9
20
386
147
264
1124
713
905
2687
2202
2398
Total
population
Male
Female
Total
14
3
9
149
46
97
658
287
466
2319
1699
1935
Coronary heart disease and rheumatic fever data by Midland DHB23
District Health
Boards
Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
All New Zealand
Indicator
Adults 25-64 years
Adults 65+ years
Infectious Disease
Ischaemic heart
disease (mortality),
2000
Ischaemic heart
disease (mortality),
2000
Rheumatic fever (initial
attack- notifications),
2002
#
37
247
7
Rate / 100,000
36.8
862.3
4.4
SMR/SIR
83.3
86.9
213.8
1
#
32
89
Rate / 100,000
64.4
815.1
0
SMR/SIR
142.6
81.6
55.3
2
#
19
71
Rate / 100,000
85
1232.1
0
SMR/SIR
188.3
124.3
225.6
1
#
29
188
Rate / 100,000
50.9
10.93
0
SMR/SIR
113.7
112.1
53.1
#
87
399
5
Rate / 100,000
52.3
975
1.7
SMR/SIR
116.5
97.7
83.2
#
890
5,030
86
Rate / 100,000
44.8
980
2.6
Notes:
■ Standardised Mortality Ratios (SMR) and Standardised Incidence Ratios (SIR) are calculated by
comparing actual numbers of deaths or events to expected numbers, adjusting for age and sex.
The expected number of deaths or events is taken from the number of deaths or events in the New
Zealand population (the reference population).
■ The SMR/SIR of the reference population is always 100, a value of lower than 100 means that
fewer deaths than expected occurred in the local population after adjusting for differences in age
and sex; more than 100 means that there have been more deaths than expected.
■ Table 4 shows that all the Midland DHBs have worse rates than New Zealand as a whole for at
least one of the criteria shown and Tairawhiti for all three.
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Midland Region Cardiac Services Plan - 2006
In all categories male death rates are higher than female rates and Māori have higher rates than Pacific
peoples or others.
The death rates from CHD in 2000 are 88% higher for Māori males than non-Māori and 119% higher for
female Māori than non-Māori. The rates for Māori and non-Māori are falling with a 4% decrease in Māori
male death rates since 1997 and 18% in non-Māori males, and 12% decrease for both Māori and non-Māori
females.
Pacific CVD mortality rates are consistently and significantly higher than those of the total population (about
twice as high in middle age and 1.5 times higher in old ages). Male cardiovascular disease mortality rates
are higher than the corresponding female rates for all adult age groups.
The Ministry of Health published An Indication of New Zealanders’ Health in 200423 this document provides
information CHD mortality by DHB. The data for the Midland DHBs is summarised in Table 4.
It should be noted that data from the Heart Foundation and Ministry of Health documents are not directly
comparable as the age-standardisations are based on WHO and Segi world populations respectively.
4.2.2. Cardiac Disease Health Indicators
A summary of health indicators that impact on cardiac disease, the current position, affected groups and
trends, as identified in An Indication of New Zealanders’ Health23 are shown in Table 5.
Table 5. New Zealand health indicators for cardiac disease
Indicator
Current level
Trend
Variation within population
Socio-economic factors
School completion (6th Form Certificate or
higher), 2000, percent
Unemployment, 2003, percent
Population with low income, 2001, percent
Household crowding (need one or more
extra bedrooms), 2001, percent
Males – 59
Males – 4.4
Females – 5.0
Total – 4.7
Total – 22.6
Stable
Mäori – 40.6
Declining
Mäori – 10.2
Pacific – 7.7
European – 3.5
Mäori – 32
Pacific – 40
European – 19
Other – 36
Mäori – 23
Pacific – 43
European – 5
Asian – 20
Other – 25
Declining
Total 10.1
No information
Males – 40.6
Females – 27.4
Total – 33.9
Males – 19.0
Females – 20.0
Total – 20.0
Males – 4.6
Females – 3.8
Total – 4.2
Males – 17.9
Females – 19.4
Total – 18.7
Stable
Risk factors
Overweight, 2002/03, percent
Obesity, 2002/03, percent
Diabetes, 2002/03, percent
High blood pressure, 2002/03, percent
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Increasing
Possible increase
since 1996/97
Not available
Mäori – 36.0
Pacific – 40.6
European/Other – 34.3
Mäori – 27.1
Pacific – 48.5
European/Other – 19.9
Mäori – 8.2
Non-Mäori – 3.7
Mäori – 23.4
Pacific – 17.9
European/Other – 18.5
Asian – 13.7
Midland Region Cardiac Services Plan - 2006
Indicator
Current level
Trend
Variation within population
High total blood cholesterol, 2002/03,
percent
Males – 14.4
Females – 13.0
Total – 13.7
Not available
Tobacco smoking (14/15-year-olds) (daily
smoking), 2002, percent
Males – 9.9
Females – 14.9
Declining
Tobacco smoking (15+ years), 2002,
percent
Males – 26.2
Females – 25.5
Total – 25.8
Males – 35
Females – 35
Total – 35
Males – 27.2
Females – 11.7
Total – 19.1
Declining
Possible increase
since 1996/97
Mäori – 26.0
Pacific – 19.0
European/Other – 19.3
Asian – 4.0
5–17 years – 68
5–17 years –
possibly declining
18+ years –
increasing
Stable
Mäori and European people are
more active than Pacific peoples and
Other ethnic groups
Total fat intake, 1997, percent
Hazardous drinking, 2002/03, percent
Protective factors
Physically active, 1997–2000, percent
18+ years – 68
Declining
Mäori – 13.9
Pacific – 10.1
European/Other – 13.9
Asian – 12.8
Mäori males – 16.8
Mäori females – 34.3
Pacific males – 10.8
Pacific females – 17.6
Asian males – 7.5
Asian females – 3.9
European/Other males – 8.6
European/Other females – 10.8
Mäori – 46.4
Pacific – 31.9
European/Other – 22.1
Mäori – 37
Non-Mäori – 35
Consumption of at least 3 servings of
vegetables per day, 2002/03, percent
Males – 63.3
Females – 71.1
Total – 67.3
Consumption of at least 2 servings of fruit
per day, 2002/03, percent
Males – 42.8
Females – 63.8
Total – 53.7
Increasing
Males – 69.7
Females – 20.7
Total – 44.8
Declining
Mäori – 141.8
Pacific – 102.8
European/Other – 33.8
Asian – 31.3
Males – 1303.9
Females – 745.2
Total – 979.9
Declining
Mäori – 1819.1
Pacific – 1095.4
European/Other – 946.3
Asian – 837.2
Males – 2.2
Females – 1.8
Total – 2.6
No clear trend
Mäori – 5.2
Pacific – 13.8
European/Other – 0.7
Outcomes – adults (25–64 years)
Ischaemic heart disease mortality, 2000,
rate per 100,000
Outcomes – older people (65+ years)
Ischaemic heart disease mortality, 2000,
rate per 100,000
Infectious diseases
Rheumatic fever notifications, 2002, rate
per 100,000
Mäori – 64.5
Pacific – 41.1
European/Other – 72.5
Asian – 44.6
Mäori – 45.7
Pacific – 54.7
European/Other – 55.5
Asian – 55.3
The New Zealand Ministry of Health published the NZIER – Ageing New Zealand and Health and Disability
Services Report in December 200424 this document includes estimates of acute and sub-acute
hospitalisations (medical; surgical; assessment, treatment and rehabilitation (AT&R) and palliative care) and
aged residential care for ischaemic heart disease by gender and ethnicity based on three scenarios.
The three scenarios are based on the following assumptions:
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Midland Region Cardiac Services Plan - 2006
■ Scenario 1 & 2 - medium population growth;
■ Scenario 3 – high population growth;
■ Scenario 1 & 3 - a continuation of the 2001 rates of hospitalisation in the main diseases and
conditions affecting the population
■ Scenario 2 - changes in rates of incidence in the main diseases and conditions affecting the over
65s (in line with the collective views of the first-round consultees);
■ Scenario 1 & 2 - a ‘receding horizon’ of disease and disability onset and progression;
■ Scenario 3 - a ‘crisis scenario’ view of disease and disability onset and progression (years of
disability and disease are prolonged by increases in life expectancy).
Even with scenario 2 (the lowest rate), there are significant increases expected in hospital discharges over
the next 5 years.
Table 6.
Potential change in hospital discharges for coronary heart disease for all discharges – acute & sub-acute24
Percent Increase
2001–2011
Asian
Female
Scenario 1
Scenario 2
Scenario 3
<65
65–79
80+
<65
65–79
80+
<65
65–79
80+
123%
134%
144%
123%
111%
120%
132%
143%
166%
European
25%
9%
31%
25%
-2%
19%
28%
10%
33%
Māori
50%
67%
86%
50%
84%
105%
54%
69%
93%
Pacific
56%
57%
86%
56%
73%
106%
60%
57%
86%
Total female
37%
17%
34%
37%
9%
22%
40%
19%
36%
Asian
116%
140%
166%
116%
117%
141%
127%
149%
166%
Male
European
22%
14%
58%
22%
3%
43%
24%
15%
61%
Māori
45%
68%
90%
45%
85%
110%
49%
72%
101%
Pacific
55%
67%
86%
55%
84%
106%
57%
74%
115%
Total male
31%
21%
60%
31%
12%
46%
34%
23%
63%
All groups
33%
19%
45%
33%
11%
32%
36%
21%
48%
4.2.3. Prevention of Cardiac Disease
A number of studies have been undertaken in different countries looking what factors lead to the decrease in
mortality. The outcomes of a New Zealand study, and a more recent UK study, show that lifestyle factors
account for at least 50% of the mortality decrease, with smoking the most significant of these. The average
life-years gained by decreasing risk factors has been shown to be 20 years, compared with 7.5 years for
medical treatments and relatively modest gains from revascularisation. It should be noted this measure is
for mortality only and not quality of life.
The outcomes from a selection of studies is provided below:
1. A study in New Zealand looked at the trends in population cardiovascular risk factors (principally
smoking, cholesterol, and hypertension) from 1982 to 1993 in Auckland, New Zealand (population
996,000). Between 1982 and 1993, CHD mortality rates fell by 23.6%, with 671 fewer CHD deaths than
expected from baseline mortality rates in 1982. Forty-six percent of this fall was attributed to treatments
(acute myocardial infarction 12%, secondary prevention 12%, hypertension 7%, heart failure 6%, and
angina 9%), and 54% was attributed to risk factor reductions (smoking 30%, cholesterol 12%,
population blood pressure 8%, and other, unidentified factors 4%)25.
2. A similar study in the United Kingdom used the IMPACT mortality model to look at coronary heart
disease mortality rate decreases of 62% in men and 45% in women 25 to 84 years old in England and
Wales between 1981 and 2000. This study concluded that 42% of this decrease was attributed to
treatments in individuals (including 11% to secondary prevention, 13% to heart failure treatments, 8% to
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Midland Region Cardiac Services Plan - 2006
initial treatment of acute myocardial infarction, and 3% to hypertension treatments) and 58% to
population risk factor reductions (principally smoking, 48%; blood pressure, 9.5%; and cholesterol,
9.5%). Adverse trends were seen for physical activity, obesity, and diabetes26.
3. A recent paper estimates life-years gained from cardiological treatments and cardiovascular risk factors
in England and Wales between 1981 and 2000 (same population used in study 2. above). This paper
concludes that modest reductions in major risk factors (principally smoking, cholesterol and blood
pressure levels) lead to gains in life-years four time higher than cardiological treatment and that effective
policies to promote healthy diets and physical activity might achieve even greater gain27.
4. The INTERHEART study28 established a standardised case-control study of acute myocardial infarction
in 52 countries, representing every inhabited continent. 15152 cases and 14820 controls were enrolled.
The relation of risk factors to myocardial infarction was reported. Odds ratios and their 99% Confidence
Intervals for the association of risk factors to myocardial infarction and their population attributable risks
(PAR) were calculated. The results showed that the following factors were all significantly related to
acute myocardial infarction (p<0.0001 for all risk factors and p=0.03 for alcohol).
■ Smoking (odds ratio 2.87 for current vs never, (PAR 35.7% for current and former vs never);
■ Raised blood apolipoproteins (ApoB/ApoA1) ratio (3.25 for top vs lowest quintile, PAR 49.2% for
top four quintiles vs lowest quintile);
■ History of hypertension (1.91, PAR 17.9%);
■ Diabetes (2.37, PAR 9.9%);
■ Abdominal obesity (1.12 for top vs lowest tertile and 1.62 for middle vs lowest tertile, PAR 20.1%
for top two tertiles vs lowest tertile);
■ Psychosocial factors (2.67, PAR 32.5%);
■ Daily consumption of fruits and vegetables (0.70, PAR 13.7% for lack of daily consumption);
■ Regular alcohol consumption (0.91, PAR 6.7%); and
■ Regular physical activity (0.86, PAR 12.2%).
These associations were noted in men and women, old and young, and in all regions of the world.
Collectively, these risk factors accounted for 90% of the PAR in men and 94% in women. This study
concluded that abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors,
account for most of the risk of myocardial infarction, and consumption of fruits, vegetables, and alcohol,
and regular physical activity decrease the risk, worldwide in both sexes and at all ages, in all regions. This
finding suggests that approaches to prevention can be based on similar principles worldwide and have the
potential to prevent most premature cases of myocardial infarction.
4.2.4. Impact of Diabetes on Cardiac Disease
While there is no specific information on the incidence or prevalence of cardiac disease in the New Zealand
population, there is good data on diabetes for which the risk factors are similar (with the exception of
smoking).
Table 7.
Predicted increase in prevalence of adult diabetes patients 1996 - 201129
Predicted annual % increase in the prevalence
of diabetics - 1996 - 2011
European
Māori
Pacific
Total population
Male
3.3%
5.7%
6.3%
5.7%
- 34COPYRIGHT © MIDLAND DHBS, 2005
Female
2.9%
5.8%
6.1%
5.9%
Midland Region Cardiac Services Plan - 2006
In 2002, the New Zealand Public Health Intelligence unit of the MoH published Modelling Diabetes: A
Summary29, which estimates the burden of diabetes in New Zealand from 1996 to 2011. The expected
growth in prevalence of diagnosed diabetics (onset 25-89 years), by the different risk factors, are shown in
tables 7 & 8. While this is not cardiovascular disease modelling, there is no indication that the factors
affecting the prevalence of cardiac disease in the community are substantially different and it is likely that the
rate of increase will be similar to that of diabetes.
Table 8.
Relative contribution of variables to increase in diabetes prevalence 1996 - 201129
Male
31%
30%
21%
9%
9%
Obesity
Population size
Age
Ethnicity
Mortality
Female
29%
30%
19%
13%
9%
The MoH also published An Occasional Paper in February 2005 entitled ‘Influences in Childhood on the
Development of Cardiovascular Disease and Type 2 Diabetes in Adulthood’30. This document contains
information of specific activities and programmes that have shown benefit both within New Zealand and
other parts of the world. This paper identifies the following:
■ Atherosclerosis begins early in life. Cardiovascular disease and obesity cluster in childhood and
track through to adulthood. Risk factors can be identified early in life and are cumulative through
life.
■ Risk factors for New Zealand children present prior to conception include socio-economic
disadvantage, ethnicity, parental obesity, and maternal smoking.
■ Unhealthy diets and physical inactivity are the leading cause of cardiovascular disease and type-2
diabetes. They lead to disease through multiple mechanisms besides those resulting from
overweight and obesity. While the effects of diet and physical activity on health often interact, there
are additional health benefits from physical activity that are independent of nutrition and diet.
There are also significant nutritional risks that are unrelated to obesity. Physical activity is a
fundamental means of improving the physical and mental health of individuals.
■ Health habits are established early in life. Healthy children are more likely to grow into healthy
adults. Lifestyle choices for children and habits formed, within the context of their family or
whānau, and within the broader context of the structural features of society, economy, and
environment.
4.2.5. Māori Specific
Cardiac disease affects everyone but the burden of cardiovascular disease is greatest among Maori and
Pacific people. The Ministry of Health indicates:
■ Death from all cardiovascular diseases is higher among Maori than the general population.
Coronary heart disease is the leading single cause of death for Maori.
■ Maori have the highest rate of hospital admissions for heart failure (nearly three times that of
Europeans/others).
■ Maori and Pacific peoples have the highest discharge rates for both rheumatic fever and rheumatic
heart disease.
This situation is not unique to New Zealand with indigenous Australians also having higher rates of cardiac
disease, double the mortality rate of other Australians, and lower rates of intervention. Other relevant
publications that look at this issue and identify specific recommendations are included here. There are key
themes through these reports and these should be used by those involved planning, and providing services
to Māori, Pacific and lower socio-economic groups, where there is identified high risk of cardiac disease.
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Midland Region Cardiac Services Plan - 2006
1. The New Zealand Heart Foundation published a report on the socio-economic and ethnic inequalities in
cardiovascular disease31 in 2003. The recommendations in this report include:
■ A national strategy with long-term government investment and national and local targets;
■ A lifecourse perspective that addresses cumulative disadvantages throughout life;
■ Multiple interventions at multiple levels including intersectoral and from national down to the
individual;
■ Lifestyle interventions that focus on the wider determinants of lifestyle risk behaviours and the
environments;
■ Health sector interventions that set a precedent for the strategy across population, personal health
and disability support services;
■ Research based on intervention studies should be an essential component of the strategy.
2. The Māori Cardiovascular Action Plan currently under development has six categories that reflect the
need for a multi-level, multi-sector approach to improving cardiovascular outcomes. The categories
include:
■
■
■
■
■
■
Policy development;
Improved information systems;
Needs assessment;
Quality standards;
Māori workforce development
Research agenda.
3. The New Zealand Guidelines group published a literature review and summary of the barriers to care for
Māori with diabetes32. This paper includes a reference to work by S. Crengle that looks at barriers and
solutions for Māori at a primary care level. See Table 9
Table 9.
Barriers to care and solutions used in Māori primary care services (from 32)
Barrier
Financial barriers
Unable to afford user co-payment for GP
Unable to afford prescription co-payment
Geographic and transport barriers to reaching services
(whether GP or health promotion / education)
Lack of knowledge of health issues, screening
programmes, how to access health information.
Barriers within the healthcare system
Inability to receive healthcare at the time that it is needed;
Failure to effectively identify and reach those at risk;
Limited follow-up;
Lack of confidence / inability to negotiate aspects of health
system e.g. outpatient clinic appointments.
Cultural Barriers
Failure to provide information in ways that are appropriate
for use in Māori communities;
Failures to provide services that are appropriate and
acceptable to clients.
Solution
Markedly cheaper co-payments. E.g. all children under 16 years free:
reduced co-payments for adults.
Agreements with local pharmacists
Use of mobile clinics and satellite clinics to improve access and reduce
cost of accessing services for client.
Transport of patients to site of clinic / service.
Providing these services in a wide variety of locations, venues and
community activities e.g. on marae, at hui, sports grounds, childcare
institutions etc.
Provide information that is easily understood and appreciated by Māori.
Flexibility with appointment systems;
Ability to walk in and be seen;
Provision of services in satellite clinics or in mobile clinics;
Proactive outreach and follow-up;
Integration of community health and general practice services with a focus
on health promotion and education;
Assistance with appointment, including staff attending clinics.
Delivery of services using Māori cultural practices and beliefs;
Employment of Māori staff;
Presentation of information in ways that are appropriate and acceptable
for use with the Māori community;
Use of resources which are appropriate and acceptable for use with the
Māori community.
- 36COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
4. The first draft report of a research project looking at Māori with heart disease and the perspective of the
Māori patient, whānau, and healthcare practitioner in Te Tai Tokerau / Northland has been published33.
The project aims to improve healthcare practice and Māori access and experience of health care.
Interviews to date have indicated the following potential solutions:
Māori participants:
■ Information sharing through taking information to the Marae and involving Kaumatua and Kuia,
Māori health services and health professionals;
■ Health eating and physical activity health promotion activities, in particular to support healthy
lifestyles for tamariki;
■ Individuals with heart disease sharing experiences with whanau and community to raise awareness
of issues and treatment options;
■ Longer consultations with health professionals;
■ Specific information and support for Māori in seeking specialist referral;
■ Individual responsibility for own health;
■ Support network e.g. sharing goals to change lifestyle.
Practitioners
■ Whanau involvement – attendance at consultations, support for lifestyle modifications;
■ Marae based health promotion involving the community in the problem and acting for change;
■ Facilitating the community to work together;
■ Professional development for practitioners with secondary care playing a significant role;
■ Full cardiac rehabilitation service for patients, which also acts as a resource for primary care;
■ Access to interventions through outreach cardiology clinics, patient request for intervention and/or
treatment, education on referral criteria – especially impact of co-morbidities;
■ Team approach to service delivery and support for lifestyle changes and management of chronic
conditions;
■ Emergency response training and equipment in the community.
This plan intends to address access issues across the region and as there are significant issues for Māori,
participation will be invited at all stages of development and implementation.
4.3.
Current Clinical Cardiac Services
Cardiology encompasses all aspects of the care of patients with heart disease. This service aims to meet
the need for comprehensive risk assessment and risk modification, involving medical treatment of symptoms
and disease by drugs, non-surgical intervention or surgery as appropriate.
Patients access cardiac services through community, primary, secondary and tertiary care services.
Community and primary care services vary across the region from preventative programmes, targeted
services to ‘at risk’ individuals, management of individuals with identified cardiac disease and cardiac
rehabilitation programmes.
In secondary care patients receive more definitive diagnoses through investigations undertaken. This ranges
from reassurance for minor but important complaints, to emergency life saving treatment for patients with
myocardial infarction. It is important that treatment is delivered quickly when necessary. In particular, reestablishing coronary flow in patients sustaining heart attacks is of high priority in most secondary and
tertiary care. Investigations such as coronary angiography are also carried out. If patients require
interventions such as angioplasty or coronary artery bypass surgery they are generally referred for tertiary
care, although some intervention services (but not surgery) are becoming possible in secondary care.
Tertiary care delivers specialised investigation and treatment.
This includes most aspects of
electrophysiology and intervention for coronary artery disease. In addition, cardiac surgery is carried out
exclusively in tertiary centres. There are some forms of treatment that should be classified as being more
- 37COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
specialised than that provided by the average tertiary centre. These include cardiac transplantation and the
management of pulmonary hypertension.
Cardiology care must be highly integrated between three levels of care – primary, secondary and tertiary.
The aim is to provide a continuum of care for the patient across these service levels as necessary.
Cardiology services are also involved in palliation of conditions that are not amenable to cure34.
Many countries in the world have identified cardiovascular disease a major cause of morbidity and mortality
and have developed strategies to help manage all aspects of health care that relate to incidence and
treatment of cardiac disease. These strategies focus on:
■
■
■
■
Primary prevention through health promotion and risk assessment and management;
Acute coronary syndrome management ensuring timely treatment of acutely ill individuals;
Secondary prevention services following an acute episode, including rehabilitation services; and
Support across the sectors for those with chronic disease.
4.4.
Private Cardiac Services
In December 2003, 34% of New Zealanders were covered by health insurance35. The long waiting lists for
patients to see a cardiologist and to access elective treatment in the public system mean that it is likely that
many cardiac patients would have, and continue to, access services in the private sector.
NZHIS collects data from private hospitals in a paper-based system and the information is not readily
available to allow identification of the proportion of cardiac services provided in the private sector. Private
hospital data was available until 1995 and data relating to cardiothoracic services in public and private are
included in a report by Antony Raymont published in 200236. Relevant results from this report are included in
Table 10.
Table 10.
Cardiothoracic surgical discharge ratio (weighted) 1995 – Public & Private, 2000 – Public only
Cardiothoracic
Surgery
Region
Eastern Bay of Plenty
Western Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
1995
Public + Private
1.03
1.29
0.71
0.97
1.07
1.09
1999/2000
Public Only
1.09
1.25
0.73
1.02
1.10
1.16
Public Only
0.81
0.81
0.84
0.83
0.67
1.01
The Surgical Discharge Ratio (SDR) has been corrected for the age and gender ratio of the relevant
population and therefore equals 1.00 for New Zealand as a whole. Table 10 shows that public cardiac
surgery in the Midland region over the five-year period 1995 – 1999-2000 has decreased in comparison to
the rest of New Zealand.
CURRENT SITUATION
■ Bay of Plenty has one cardiologist working fulltime in private and three cardiologists provide private
services on a part-time basis in Tauranga and Whakatane.
■ Taranaki has one cardiologist providing services in private.
■ Tairawhiti has a physician working in private who provides cardiology services, including
echocardiography.
■ A number of the cardiologists employed at Waikato Hospital provide some services in private
practice. One cardiac surgeon provides private cardiac surgery at Braemar Hospital.
- 38COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
In addition there are a number of private cardiologists in other New Zealand cities and cardiac surgery units
at Private Hospitals in Auckland and Wellington. Complete data for patients in the Midland region accessing
these services is unknown, but Mercy Hospital, Auckland provided the data shown in Table 11. Wakefield
Hospital has indicated they provide very little service, if any, to the Midland population. Braemar Hospital did
not provide data.
Table 11.
Cardiac procedures undertaken at Mercy Hospital for Midland population.
PCI
2002
2003
666
772
Cardiac
Surgery
99
unknown
Private surgical services have been contracted to provide cardiac surgery for the Midland DHB’s at times
when the waiting times have become unacceptable. These services fulfil a critical component of the health
service in New Zealand. To date there has been no sub-contract to the private sector for interventional
cardiology services.
- 39COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
5.
Contracting and Funding
5.1.
Table 12.
DHB Agreements
Contract and actual volumes for cardiac service purchase units
Bay of
Plenty
Lakes*
Tairawhiti
Taranaki
Waikato
Midland
Contract
Actual
Contract
Actual
Contract
Actual
Contract
Actual
Contract
Actual
1668
1442
550
732
1101
987
1495
1495
0
0
0
0
244
98
207
64
839
1617
0
0
0
0
72
62
165
144
0
0
625
466
2000
1710
5814
6211
1400
1335
3000
2855
102.3%
0
0
0
0
3783
4075
3635
7482
7653
2891
2693
6473
5760
2334
6895
4075
3635
Contract
Actual
Contract
Actual
Contract
Actual
Contract
Actual
Contract
1668
1617
550
682
1100
1306
1495
1495
0
0
0
0
244
54
207
59
839
1511
0
0
0
0
72
50
165
124
0
0
625
527
2000
1600
5859
5987
1610
2136
3450
2865
101%
0
0
0
0
3854
4075
3502
7527
7604
3101
3449
6922
5954
2334
6860
4075
Contract
Actual
Contract
Actual
Contract
Actual
Contract
Actual
Contract
Actual
1633
1494
550
825
1100
1219
1495
0
0
244
67
207
91
839
1416
0
0
0
0
65
74
180
88
0
0
635
532
1730
1258
5859
6894
2040
1642
2755
3202
0
0
3928
4075
3505
% Contract
Achieved
2003
Cardiology Caseweight (CWD)
M10001
Cardiology 1st assessment
M10002
Cardiology subsequent assessment
M10003
Cardiology - Education and Management
M10004
Cardiac Surgery
S15001
2004
Cardiology Caseweight (CWD)
M10001
Cardiology 1st assessment
M10002
Cardiology subsequent assessment
M10003
Cardiology - Education and Management
M10004
Cardiac Surgery
3502
2005 ytd 31 Dec extrapolated to full year
Cardiology Caseweight (CWD)
M10001
Cardiology 1st assessment
M10002
Cardiology subsequent assessment
M10003
Cardiology - Education and Management
M10004
Cardiac Surgery
S15001
0
0
0
0
Notes:
■ Purchase unit definitions and measures – see Appendix 3
■ Lakes DHB outpatient volumes were based on a cardiologist being appointed;
■ Blank fields indicate volumes not supplied by DHBs.
- 40COPYRIGHT © MIDLAND DHBS, 2005
7492
8388
3534
3141
5972
5858
2334
5344
4075
3505
93.2%
89.0%
295.4%
89.2%
111.2%
86.0%
293.9%
85.9%
112.0%
88.9%
98.1%
229.0%
86.0%
Midland Region Cardiac Services Plan - 2006
5.2.
Outpatient Clinics
Table 13.
Cardiology first specialist assessment: subsequent attendance ratios
Bay of Plenty
Contract
2.0
Actual
1.4
2004
Contract
2.0
Actual
1.9
2005*
Contract
2.0
Actual
1.5
* Extrapolated full year
2003
Lakes
0.9
0.7
0.89
1.1
0.9
1.4
Tairawhiti
2.3
2.3
2.3
2.5
2.8
1.2
Taranaki
3.2
3.7
3.2
3.0
2.7
2.4
Waikato
2.1
2.1
2.1
1.4
1.45
2.0
Midland
2.2
2.1
2.2
1.7
1.7
1.9
The First Specialist Assessment to subsequent attendance ratio appears to be decreasing, on both a
contract and actual basis, despite increasing waiting lists. An example of DHB waiting lists in Figure 3
shows Bay of Plenty patients waiting for an FSA for greater than six months grew from 21 to 82 in a 12month period, while the number of patients treated also doubled over that time. An additional cardiologist
was appointed in July 2004, however the patients waiting for an FSA for longer than 6 months as at June
2005, had again reached 63.
Waikato had 46 patients waiting for greater than 6 months for an FSA as at June 2005. Tairawhiti DHB’s
average waiting time for an FSA has increased from 63 days in 2002-03 to 130 days in 2004-05. At Taranaki
DHB total patients waiting increased from 154 in December 2003 to 191 in November 2004, with the
numbers waiting over 6 months increasing from 31 to 64 over the same period.
Figure 3.
Bay of Plenty DHB Outpatient First Specialist Assessment Waiting List 2003-04
450
400
Patient Numbers
350
300
250
200
150
100
50
FSAs > 6mths
Patients Added to Waiting List
Patients Treated
Total on Waiting List as at end of
Linear (Total on Waiting List as at end of )
Linear ( FSAs > 6mths)
- 41COPYRIGHT © MIDLAND DHBS, 2005
Jun-04
May-04
Apr-04
Mar-04
Feb-04
Jan-04
Dec-03
Nov-03
Oct-03
Sep-03
Aug-03
Jul-03
0
Midland Region Cardiac Services Plan - 2006
Figure 4.
Waikato Hospital cardiology procedure waiting times as at June 2005
80
70
Number of Patients
60
50
40
30
20
10
0
0-1 mths
1-3 mths
Angiography
3-6 mths
6-12 mths
Angioplasty
12-24 mths
Pacemaker
24-36 mths
36-72 mths
Ablation
Figure 4 shows the length of time patients on the Waikato Hospital waiting list, as at June 2005 have been
waiting for various procedures.
Currently there is no ability for DHB providers to deliver any significant increase in volumes without additional
resource, both facility and workforce. Current demand is greater than contract volumes or resource is able
to deliver.
5.3.
DHB Expenditure on Cardiac Services
An estimate of the funding of cardiac disease related services for each DHB is provided in Table 13. Note
this is a high level estimate only to provide an indication of the funding provided to each service. No
conclusion is made in relation to expenditure but is provided to allow DHBs to consider opportunities in
relation to prioritising where for future spending could be considered. A graph of this expenditure as a
percent is shown in Figure 6.
Table 14.
Expenditure on cardiac services by Midland DHB’s, 2004.
Regional Public Health
Community laboratory
Community pharmaceuticals
Community Referred Cardiology Testing
Primary Care Providers - Capitation, GMS
Disease State Management Nursing
Other - please specify
Cardiac Education and Management
Cardiology IP
Cardiology OP
Cardiothoracic IP
Cardiothoracic OP
Total
* Missing data not provided by Tairawhiti DHB
Bay of Plenty
$ 626,899
$ 946,851
$ 10,607,095
$ 115,742
$ 1,966,232
$
51,667
$
$ 145,898
$ 6,445,300
$ 293,500
$ 2,875,960
$
16,163
$
$
$
$
$
$
$
$
$
$
$
$
Lakes
423,600
470,700
4,493,145
44,000
1,260,676
20,000
77,000
2,212,282
45,400
1,766,652
7,185
$ 24,091,307
$
10,820,640
- 42COPYRIGHT © MIDLAND DHBS, 2005
Tairawhiti*
$
257,056
$
204,709
$ 2,068,215
$
$
606,341
$
$
$
$
535,210
$
32,387
$
504,944
$
1,335
Taranaki
$
344,773
$
561,981
$ 6,139,985
$
263,000
$
665,436
$
60,000
$
$
81,287
$ 2,662,616
$
342,784
$ 1,576,613
$
6,875
Waikato
$ 1,144,721
$ 2,257,969
$ 15,398,691
$
150,346
$ 2,978,445
$
86,667
$
256,000
$
178,956
$ 11,825,660
$
578,396
$ 5,874,281
$
23,989
$
$ 12,705,349
$ 40,754,121
4,210,197
Midland Region Cardiac Services Plan - 2006
Notes:
■ Health Promotion $’s - as provided by MoH;
■ Community Laboratory – 1% total spend (potential underestimate);
■ Community Pharmaceuticals – provided by PHARMAC (cardiovascular, lipid modifying and
antithrombolytic agents);
■ Primary Providers – 9.2% of total funding (capitation + SIA, HP, CarePlus), based on MoH analysis
of consultation type;
■ DHB provider services - contract and IDF costs.
■ Other - as provided by individual DHBs.
The costs between DHBs are not directly comparable as this is high-level data only and the cost of
cardiology services provided through General Medicine have not been identified.
For comparison, the Australian breakdown in cardiac related expenditure data is shown in Figure 5. Note,
this includes aged care and research, not included in the Midland data.
Figure 5.
CVD expenditure by service, Australia, 200485
Specialists
4%
Research
3%
Diagnostics
4%
Other health
professionals
1%
Other
5%
Inpatients
41%
GP
6%
Aged care
10%
Pharmaceuticals
26%
- 43COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Figure 6.
Estimated percent of cardiac services expenditure by Midland DHB
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Bay of Plenty
Lakes
Taranaki
Waikato
NZ tertiary DHB
Regional Public Health
Community laboratory
Community pharmaceuticals
Community Referred Cardiology Testing
Primary Care Providers - Capitation, GMS
Disease State Management Nursing
Other - please specify
Cardiac Education and Management
Cardiology IP
Cardiology OP
Cardiothoracic IP
Cardiothoracic OP
Notes:
■ Tairawhiti data not included due to missing information;
■ Data included as supplied by a tertiary DHB outside of the Midland region
- 44COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
6.
Primary Prevention of Cardiac Disease
Primary prevention may be defined as ‘the long term management of people at increased risk but with no
evidence of cardiovascular disease’.
The Midland region includes DHBs with high proportion of Māori in the population, Lakes, Tairawhiti, while
the highest actual number of Māori live in the Bay of Plenty and Waikato regions. Māori have higher rates of
smoking, diabetes and obesity than the NZ European population and as a consequence have a significantly
higher rate of cardiac disease. All Midland DHBs have an ageing population and it is critical for DHBs to
participate and be supportive of intersectoral national and local programmes that focus on addressing risk
factors.
Primary prevention of cardiac disease may be undertaken at a population level through health promotion
activities or at an individual level where targeted programmes or preventative treatments may be provided.
Prevention can be undertaken through government action, by families, individuals, schools, communities,
and through the activities of healthcare providers. Action will be needed by food purveyors, manufacturers,
and restaurants, to change eating habits and by city planners, so that people can get the exercise they need.
There is general agreement internationally on the lifestyle factors that increase cardiac disease risk. The
DHB Cardiovascular Toolkit4 identifies these as:
1. Cigarette smoking.
Smoking is associated with a two- to three fold increase in CHD, stroke, and peripheral vascular
disease (PVD) and is identified as the single most preventable cause of heart disease. In 2002, the
MoH identified the prevalence of smoking in NZ as around 25 percent, with 44 percent for Māori males
and 51 percent for Māori females.
Hypertension
High blood pressure is a major risk factor for CHD. The MoH estimated in 1999 that in the population
over 15 years nearly 22 percent of males and 18.2 percent of females have high blood pressure.
Cholesterol
The risk of cardiovascular mortality increases with rising cholesterol levels.
Diabetes
Diabetes is a major risk factor for CHD, CVD, and stroke. Cardiac disease is the leading cause of
death in type 1 and type 2 diabetics.
Obesity
The risk of cardiovascular disease increases with a BMI greater than 25. Those with a BMI greater
than 30 (obese) are two to three times more likely to develop CHD. In 2000 an estimated 20 percent
of New Zealanders were obese, an increase from 11 percent in 1989.
Physical Activity
Sedentary people are nearly twice as likely to die from CHD than active people are. In 1997, the
estimate was that 40 percent of New Zealanders were physically inactive.
The Framingham study37 identified that there is a cumulative effect in the presence of two or more risk
factors results in a higher absolute risk of CVD.
6.1.
Health Promotion
Health promotion is defined as "The process of enabling people to increase control over and to improve their
health" (WHO). Many health promotion programmes focus on areas that allow individuals to understand
and determine lifestyles that will impact on their health and wellbeing.
- 45COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Health promotion draws upon principles of te Tiriti o Waitangi, social justice, equity, community and
development. Within health promotion, health/ hauora is understood as an holistic concept. Wairua (the
spiritual), hinengaro (mental), tinana (physical), te reo rangatira (language) and whanau {family) are all
elements which interact to produce wellbeing. The wellbeing of te ao turoa (environment) contributes also.
This approach requires that Maori health be understood in the context of the social, economic, and cultural
position of Maori.
The MoH Health Eating – Healthy Action framework identifies the approaches and key priority areas for
implementation to meet the goals of improving nutrition, increasing physical activity, and reducing obesity in
New Zealand.
There are a number of players in health promotion, including the Ministry of Health, PHARMAC, District
Health Board’s, Public Health Units, Primary Health Organisations, Non Government Organisations (NGOs),
Māori and Iwi providers, and the tertiary and research sector. Other non-health related organisations
including local government also play a role in health promotion e.g. provision of recreation facilities. It is
critical that the various players work together to ensure that there is an aligned approach to health
promotion. It is noted that due to changes in the New Zealand health sector the Public Health Advisory
Committee has recently released a consultation paper to look at options for enhancing the public health
structure to meet the needs of the New Zealand population into the future38.
The New Zealand Heart Foundation plays a large role in health promotion in relation to cardiac services in
New Zealand. The Heart Foundation is a charity that provides programmes and funds research in order to
achieve the following five objectives:
1. To ensure the Heart Foundation maintains its scientific credibility by being a recognised funder and
promoter of a broad range of public health, clinical and biomedical research about the causes,
prevention and treatment of cardiovascular disease. (3 years)
2. To reduce smoking prevalence from 25% to less than 20% (5 years)
3. To stabilise rates of obesity in children and adults by improving nutrition and increasing physical activity
(7 years).
4. To ensure New Zealanders at high cardiovascular risk (greater than 20% of cardiovascular risk over 5
years) are identified and offered evidence-based preventative, treatment and rehabilitation strategies (3
years).
5. To generate revenue and resources to support and sustain the achievement of the Heart Foundation
objectives.
The Heart Foundation has published a number of technical reports that provide useful clinical and statistical
data for clinicians and DHB staff. These reports are available on the Heart Foundation Website –
www.heartfoundation.org.nz.
CURRENT SITUATION
Health promotion activities occur in all DHB regions through the Public Health Units and NGO providers.
The Ministry of Health, Public Health Directorate purchases services in 12 public health service categories.
Public Health providers are contracted to address one or more service categories, including two areas that
are relevant to cardiac disease – tobacco control and nutrition and physical activity.
The Heart Foundation is a significant provider of health promotion activities and receives MoH funding to
support the School Food, Early Childhood, and the Pacific Islands Heartbeat programmes. PHARMAC
have run education programmes e.g. One Heart Many Lives campaign to raise awareness and decrease
the risk of cardiovascular disease over men aged over 35 years.
Some DHBs have joint venture programmes to support health promotion activities e.g.
■ Project Energize, a child health programme designed to improve the overall health of primary
schoolchildren. Funded by Waikato DHB and delivered by Sport Waikato, in association with
- 46COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Waikato Pasifika Health Trust, Te Kohao Health, and Nga Miro Health Centre, the project is split
into two arms, the Energize programme itself and a research component to analyse its
effectiveness after two years.
■ A joint activity programme for promote walking has been launched by Bay of Plenty, DHB Sport
Bay of Plenty and Tauranga City Council.
■ Health Rotorua Primary Health Organisation and Sport Bay of Plenty have launched a new
initiative involving working with children and their families. The ‘Family Lifestyle Coach’ will work
with children aged from 4 to 12years to assist them and their families, in helping them achieve a
more active lifestyle to improve their health and in particular address obesity.
Primary Health Organisations (PHOs) are charged with maintaining and improving the health of the
communities they serve. They are eligible to receive funding to provide health promotion programmes to
their communities. The programmes must be approved by the DHB who will generally include the Public
Health Unit in the appraisal of the programme. The MoH has provided a number of resources to support
PHOs in the understanding and development of these programmes.
PHOs are utilising this funding in a number of different ways e.g.
■ Employment of experienced health promotion workforce;
■ Subcontract to an organisation with experience in health promotion – often a partner organisation
in the PHO;
■ Quit smoking and physical activity and nutrition activities in specific communities.
Health promotion activities that target the healthy lifestyle factors are critical for DHBs to manage the longterm prevalence of cardiac (and other) disease. The evidence that lifestyle changes, not only decrease the
incidence of cardiovascular disease, but also significantly increases length of life is strong and covers all
nationalities. Addressing smoking rates, exercise, nutrition and obesity in the general population but in
particular, to children and those groups known to be at highest risk should be a priority.
Health promotion requires a collaborative approach while enabling individual providers to deliver specific
activities to their own populations. Establishment of local or district health promotion committee or steering
groups would enable an intersectoral approach to the development of a health promotion plan that supports
local communities. Membership of such a steering group could include DHB, PHOs, Public Health; regional
sports trust; councils, health promotion providers, schools.
Recommendation
District Health Boards and PHOs should support national activities that reduce smoking rates, improve
nutrition, reduce obesity, and increase physical activity in line with the New Zealand Healthy Eating Healthy
Action Strategy.
Establishment of local or district wide health promotion steering groups to enable the development of a
health promotion plan that supports intersectoral collaborative projects, that target at risk groups and
provides a supportive environment to change behaviour;
PHOs should be encouraged to participate in intersectoral projects, or provide supportive programmes, that
focus on the priority health promotion activities.
DHBs, PHOs, and other community providers should be encouraged to utilise the Heart Foundation as a
resource for information and potential support for programme development.
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6.2.
Identification and Management of ‘At Risk’ Individuals
Primary care has traditionally managed patients as they have attended the general practitioner. With the
development of PHOs, there is a requirement for PHOs to provide services to the enrolled population. The
PHO agreement requires that “Essential Primary Health Care Services will be evidence and best practice
based (where possible) and will aim to improve, maintain and restore health and ensure access to care.
They should be provided for individuals across their life span, for families, whanau, and communities taking
a broad view of health, including physical, mental, cultural, social and spiritual dimensions. Services should
be co-ordinated with other health care services and will aim to reduce health inequalities.”
Community health providers may have the ability to identify ‘at risk’ individuals through screening activities
run in specific environments e.g. marae, workplaces, and specific events. Linkages with primary care
providers are important to ensure follow-up of identified ‘at risk’ individuals.
Many primary care general practices have the ability to identify patients on their practice register at risk of
cardiac disease through practice management software (PMS). These can be set up to allow the
identification of specific risks e.g. smoking, hypertension, etc. A key component for identification of these
patients is coding of all patients to enable easy identification of those at risk.
Decision support tools are available that incorporate functions that help deliver the right information to
provide clinically based management approaches. Two such New Zealand based products are: MyPractice–
a .Net–based practice management system (www.orionhealth.com/news/MyPractice/); and Predict™ an
evidence-based disease management system supported by web-based software, designed to integrate into
primary
(or
secondary/tertiary)
care-based
electronic
PMS.
(www.enigma.co.nz/framed_index.cfm?fuseaction=newsletter&newsletteraction=
issuedisplay&Currentid=256&issueid=11).
A joint presentation at the 2005 Cardiac Society of New Zealand Annual Scientific Meeting by the University
of Auckland, ProCARE Network and Waitemata DHB was made on the use of PREDICT software in
ProCARE Network general practices. The integrated electronic clinical decision support system was
associated with a 4-5-fold increase in the documentation of cardiovascular risk and risk factors over a 12month period compared with the previous 12-months period. There was no disparity between Māori and
non-Māori in CVD risk being documented.
The recent Diabetes Free Check software upgrade (DITU) allows PMS systems to send data to a regionally
hosted server and include data for non-diabetic patients e.g. CVD patient data, that may then be used to
support and monitor the needs for patients in the region.
The development of a CHD register is one component of a CHD programme to enable identification,
evidence-based treatment options, monitoring and audit. Primary care has the ability to provide care to
these individuals through GP or practice nurse consultations; PHO employed specialist nurse led clinics or
community education programmes. Funding streams to support these initiatives may be available to PHOs.
Data collection should be consistent, irrespective of the system used, to enable DHBs to start to monitor and
plan services with better information on the incidence and prevalence of cardiac disease and the outcomes
of programmes for different populations.
CURRENT SITUATION
PHOs must get approval from the DHB funding arm for any Services to Increase Access (SIA) or Health
Promotion (HP) programmes. A number of these projects in the Midland PHOs relate to cardiovascular
disease prevention or identification and management of patients. However, in the majority of cases there is
little or no discussion with secondary care as to the type of intervention that will most benefit the population
as a whole, while ensuring required treatments are available. The risk of PHOs undertaking programmes to
identify ‘at risk’ patients is that they will inevitably find a number of patients who will require additional
resource for management – either from community or secondary / tertiary providers. It is critical that the
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Midland Region Cardiac Services Plan - 2006
resource is available to provide services to these patients as they are identified rather than compound a
situation of scare resource.
Currently there is no consistent approach to identification of “at risk” patients across the region. PHOs, in
general, are aware of their population and the demographics of the patients most at risk of developing
cardiac disease but do not have a cardiac register or have the ability to easily provide outcome data for
patients treated.
There are PHO’s that have, or are in the process of developing, SIA programmes that will screen specific
groups e.g. Māori men over 35 years of age. One of the risks in the development of these programmes is to
identify that the appropriate treatment programmes or services for those who are diagnosed with cardiac
disease. E.g. ensuring lifestyle change programmes are available, nutrition and dietary advice, as well as
the diagnostic and secondary care services.
Recommendation
That DHBs and PHOs determine the appropriate option for cost-effective use of available or new technology
to establish cardiovascular disease registers and data management.
DHB funders should ensure PHOs include secondary or tertiary general medicine or cardiology input into the
development of SIA and HP proposals to enable an integrated approach to service development.
Where this does not occur in the development phase, comment should be sought from the relevant
specialists to ensure the proposal does not adversely affect the hospital provider e.g. through a significant
increase in referrals without the resource to manage these.
PHOs represented on any established Cardiac Clinical Network.
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7.
Secondary Prevention
Secondary prevention may be defined as ‘the long-term management of people who have existing
cardiovascular disease, have had a cardiovascular event, have had a cardiovascular surgical procedure and
are at risk of a cardiovascular event’.
New Zealand does not have a national systemic risk assessment and management-screening programme
for cardiovascular disease. This is in part due to ongoing international debate as to the level of risk at which
cardiovascular risk screening and treatment should occur given limited resources. However the NHS
Coronary Heart Disease NSF have set standards for identifying and treating patients with established
disease and those with significant risk of CHD greater than 30% over 10 years. The US has set specific
targets in relation to the individual risk factors. (See Section 14.3 for further details.)
A multidisciplinary approach to cardiac disease shifts the emphasis from managing acute events and clinical
symptoms to providing a holistic and continuous assessment of risk to prevent imbalance, optimise therapy
and improve quality of life and prognostic outcomes. Comparison of a heart failure management
programme and usual care, identified gains from a multidisciplinary approach as having three key factors39:
■ Reducing inefficient / ineffective interventions e.g. inappropriate medication;
■ Avoiding repetition of procedures caused by infrequent evaluations, and providing continuity of
care;
■ Simulation analysis of consequences of behaviour. E.g. providing educational intervention as the
impetus for change behaviour,
Currently there are a number of good initiatives by providers but they are often undertaken in isolation of the
‘bigger picture’ for the DHB. Development and provision of services should fit within an overall planned
approach that meets the priorities of each DHB.
PHOs have access to funding for their population for SIA, HP, and CarePlus programmes, while secondary
care providers develop services based on the issues and needs they see within their environment. Ideally,
providers and other stakeholders from all levels of care should be involved in the discussion about services
with ‘what is best for the patient’ at the forefront of any decision.
7.1.
Primary Care
BACKGROUND
Most of the day-to-day management of cardiac disease goes on in the community - from initial diagnosis and
investigation through to chronic disease management and palliative care for end-stage disease. The
Ministry of Health estimates that 9.2% of all primary care consultations relate to CVD40.
The main emphasis in primary care is in the prevention of disease, the assessment of risk, including the
potential to maintain a CHD or CVD register. In addition, in primary care the symptoms of the disease must
be recognised, correctly diagnosed and correct treatment started. Many of these patients will need to be
referred on to secondary care for further assessment and treatment.
■ Primary Care has an important role to play in disease prevention, heart failure management,
cardiac rehabilitation, and aspects of the management of myocardial infarction. Cardiac services
should now be integrated and delivered through PHOs with involvement of secondary care
services. Services should be based on patient need and delivered in a setting most appropriate to
local circumstances.
■ In primary care, the development and maintenance of a CHD database would support the
identification and management of at risk patients. Software that integrates with PMS’s for disease
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management enables a greater focus on evidence-based practice and data management.
■ Secondary prevention of CHD is a key issue for New Zealand and is a national health objective.
The use of secondary prevention drugs is controlled by PHARMAC and the cost-effective use of
pharmaceuticals such as statins has been recognised with increased access. The NZ Guidelines
for the Assessment and Management of CVD Risk provide recommendations on appropriated drug
therapy for patients. However, it is recognised that not all patients who would benefit from drug
treatment are prescribed the appropriate medication or are compliant with the prescribed regimen.
■ Primary care also plays a role in monitoring patients against recommendations made to individuals
to decrease cardiac risk. This will include an understanding of relevant providers or organisations
in the community who may be accessed by the individual to support lifestyle or other changes.
■ Primary care also has an important role in supporting patients as they reach the end stage of their
disease and require palliative care support services.
There are many guidelines that are available to general practice to support the care of patients with cardiac
disease. This in itself causes issues for providers in ensuring easy access to the right part of the right
guideline to treat a patient who may have several co-morbidities. Ideally guidelines should be available
electronically to enable easy access and potentially link between the various disease management and
clinical components.
Examples of primary care measures relating to cardiac disease that could be considered:
■ Cardiac / cardiovascular disease register and annual practice audit;
■ Lifestyle surveys;
■ Physical activity campaigns with schools;
■ Healthy eating surveys;
■ Obesity baseline indices;
■ Smoking cessation services, including targeting Māori, young women, and pregnant women;
■ ‘At risk’ cardiovascular disease patients recall;
■ Primary / secondary collaborative programmes to develop care pathways and reduce DNA rates;
■ Patient held cardiac record;
■ Nurse led secondary prevention clinics;
■ GP’s with a special interest in cardiology;
■ 24-hour BP monitoring;
■ Hypertension and blood cholesterol management audits;
■ Information leaflets, available in different languages;
■ Psychologist services for chronic care and post acute event patients.
There are opportunities at a primary care level to develop nurse-led services. These include risk
assessment activities, patient education, monitoring, and support services. Development of these and other
services should be made in discussion with other stakeholders, including community and secondary based
service. The aim should always be to provide a patient-centred, coordinated and integrated service across
the health sectors.
Recommendations
Continuing education programmes should include updates on CVD guidelines as a regular component of
continuing education for providers.
PHOs should consider quality targets that identify specific measures against the CVD Guidelines, noting that
a CHD or CVD coding and / or a register will be a critical component of this.
DHBs should consider the option for including specific measures from the CVD guidelines as PHO
performance indicators.
PHOs should consider options for improving education and compliance for patients with cardiac disease.
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Midland Region Cardiac Services Plan - 2006
7.2.
Secondary / Tertiary Services
Patients are referred or admitted to secondary or tertiary services following an acute event, or for
determination of diagnosis and treatments options for disease management.
CURRENT SITUATION
Currently Waikato DHB provides revascularisation services, in the form of interventional cardiology and
cardiac surgery, to the Bay of Plenty, Lakes, Tairawhiti, Taranaki, and Waikato DHB populations. Cardiac
transplant surgery is provided by Auckland DHB. A cardiac multidisciplinary team meeting is held each
week, at which cardiologists from Bay of Plenty, Taranaki, and Waikato present individual cases to the team
for discussion on the appropriate management plan. Table 15 provides a brief outline of diagnostic and
revascularisation services provided by DHB.
During 2005, there was a backlog of cardiac surgery cases due to a number of factors including shortage of
registrars and cancellations due to a lack of available ICU beds. A review of Cardiac Surgical Services at
Waikato Hospital was undertaken in October 2004 and a number of resulting recommendations made in this
review were being implemented at the time this plan was written.
Table 15. Cardiac services at Midland DHB facilities
DHB
Bay of Plenty
Lakes
Taranaki
Tairawhiti
Waikato
Tauranga
Whakatane
Rotorua
Taupo
Gisborne
New
Plymouth
Hawera
Waikato
Thames
T’s
Cardiologists
3 FTE
-
-
-
-
2
-
-
-
Cardiac
Educators
Cardiac
Surgeons
CCU beds
1.8 FTE
1 FTE
1.2 FTE
0.4 FTE
1.2 FTE
0.8 FTE
0.4 FTE
10 = 7.5
FTE
2.3 FTE
-
3 FTE
-
-
-
-
-
-
-
3
-
-
5
4
4
-
3
4
-
6
-
--
-
-
-
-
-
-
42
-
-
Facility
Cardiology
dedicated
Beds
Outreach
Clinics
Pacing
Clinics
Own
service
From
Tauranga
and
Waikato
From
Tauranga
Pacing
only
Read
by
Waikato
Angiograms
Angioplasty
ICD & Pacing
EP Ablations
Cardiac
Surgery
Echo cardiography
♦ Read
by
Tauranga
Read
by
Waikato
♦ Referred
to Waikato
♦
Monthly
Waikato
ETT
Holter
Monitoring
Read
by
Tauranga
T’s – Taumaranui, Te Kuiti, Tokoroa,
Read
Read by
Read
Read
by
Waikato
by
by
Waikato
Waikato
Waikato
Complex cases referred to Waikato, ♦ General Ultrasounds being used for cardiology
Read
by
Waikato
It should be noted that following some clinics there is additional technician and/or cardiologist time required
for interpretation and reporting of diagnostic tests, e.g. a one day pacemaker clinic requires two days of
technician time for reporting, echocardiograms require both a technician and cardiologist report.
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Midland Region Cardiac Services Plan - 2006
In 2003_04, the average number of days waited across the region for transfer to Waikato Hospital for
cardiology services was 2.6 days. Forty percent of patients were transferred within 24 hours of the request
being made, while 6.4% patients waited > 7 days and less than 1% > 14 days. This represents significant
cost to the region. This cost of the delayed transfer was between $500,000 & $1million in 2003_04 (the cost
depends on whether patients waited in a medical bed or an estimate of 50% in coronary care bed). This
does not include the patients in beds at Waikato Hospital waiting for treatment.
Figure 7.
Number of days waited for transfer to Waikato DHB from Midland Facilities 2003_04.
35
30
Patient Numbers
25
20
15
10
5
0
0.5
1
2
Tauranga
3
4
5
6
Whakatane
7
8
9
Days
Lakes
10
11
12
Gisborne
13
14
15
Taranaki
16
19
25
Thames
Secondary Care Services and Issues & Opportunities
A brief outline of services, and issues and opportunities, identified by DHB providers during consultation for
this plan, is included below.
Bay of Plenty
Tauranga
■ Bay of Plenty DHB employs 3 FTE cardiologists based at Tauranga Hospital where inpatient and
outpatient services are provided. Visiting clinics are provided at Whakatane Hospital;
■ Diagnostic procedures are undertaken in the cardiac catheter laboratory but no interventional
services;
■ Chest pain unit – ‘one-stop shop’ commenced 2004.
■ A full pacing service will be available at Tauranga Hospital 2005;
■ A nurse-led heart failure clinic is available at Tauranga Hospital;
■ Phase I & II cardiac rehabilitation provided by Tauranga Hospital staff;
■ Two part-time Cardiac Nurse Educators, totaling 0.8FTE, provide education to inpatients and staff
at Tauranga Hospital.
Whakatane
■ General physicians manage acute and inpatients services;
■ Outreach cardiology outpatient clinics by cardiologists from Tauranga and Waikato.
■ Acute patients transferred to Waikato on discussion with Waikato cardiologists;
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■ An older echo machine available and used by general physician for urgent inpatient needs – no
technician. Private echocardiography available in Whakatane on a regular basis;
■ Phase I & II cardiac rehabilitation services are provided;
■ A cardiac nurse educator provides community based services.
ISSUES AND OPPORTUNITIES
■ Retain good relationship with Waikato cardiologists;
■ Waikato remain the interventional service provider for the region;
■ Improve transport systems.
Tauranga
■ The average number of outpatients added to the Tauranga waiting list increased from 59 in
2002_03 to 115 over the Feb 2004 – Jan 2005 period – an increase of 93%.
■ Increasing inpatient volumes;
■ Increased volume in pre-operative assessments for elective surgical patients;
■ Increasing workload causing difficulty in provision of regular outreach service to Whakatane;
■ Outpatient clinic organisation and coordination through: increased clinic space, cardiology clinic
service coordinator; and nurse chaperone for cardiology clinics (held in clinical physiology rather
than outpatients clinic area of Tauranga Hospital);
■ Long wait for angioplasty and surgery at Waikato leading to long inpatient stays;
■ Fourth cardiologist needed;
■ Dedicated CCU/step-down ward close to clinical physiology service;
■ Long wait time for rehabilitation programme;
■ Need resourced rehabilitation for privately treated patients;
■ Referral and attendance of Māori patients to rehabilitation programmes;
■ Rehabilitation programmes not provided for heart failure patients;
■ Cardiac CNS provides inpatient education and case management in the community for Māori
■ Shortage of cardiac step-down beds causes blockage of CCU beds. Note revamp of CCU planned
as part of campus redevelopment;
■ Regular cardiology team meetings required;
■ Regional cardiac nurse network not functioning;
■ Database of cardiac patients needed.
Whakatane
■ Bottle necks due to inadequate resourcing of tertiary service at Waikato;
■ Develop dedicated CCU adjacent to ICU/HDU to ensure effective and efficient integration of patient
episode of care;
■ CCU procedure room required for services such as pacemaker insertion, cardioversion;
■ Cardiology step-down unit for flexibility in management of patients;
■ Inadequate number of telemetry units for medical wards – leads to blocking of CCU beds;
■ Technician led echocardiography with updated echo machine;
■ Thrombolysis administration currently in CCU – transfer to ED to improve door to needle time;
■ Chest pain unit – including appropriate staff resources needed;
■ Multidisciplinary model of care for heart failure;
■ Robust Quit smoking programme required.
Lakes
■
■
■
■
Outpatient clinics and diagnostic services are provided by staff from Waikato DHB.
General physicians manage acute and inpatients services, Taupo stabilise and transfer patients;
Four CCU beds within ICU at Rotorua Hospital;
Thrombolysis provided in ED at Taupo and Rotorua Hospitals;
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Midland Region Cardiac Services Plan - 2006
■ Phase I cardiac rehabilitation services are provided at Rotorua Hospital and Phase II in Rotorua
and Taupo.
ISSUES AND OPPORTUNITIES
■ Unable to recruit cardiologist or general physician with an interest in cardiology, despite many
years of trying;
■ Need a service agreement with Waikato for cardiology services to the Lakes region based on cost
recovery, rather than profit;
■ Delay in transfer of patients to Waikato Hospital for angiography / angioplasty/ cardiac surgery improvement of resources at Waikato to enable appropriate service provision;
■ Six month waiting for cardiology FSA; six-months for dobutamine stress tests, long wait for
myocardial perfusion scan;
■ Currently all GP referred patients see a general physician, there are a number of patients that
could be referred directly to a cardiologist e.g. valvular conditions, complex conditions, possible
transplant patients, need to identify conditions that can be referred directly to cardiologist and
streamline process for those that General Physicians are unable to add value by seeing;
■ Patients treated at Waikato are seen by same cardiologist at Waikato Hospital for follow-up patients treated at Waikato Hospital should be followed-up through outreach outpatient service;
■ Echocardiography currently two echo technicians (total 1.2FTE) – one-year waiting for
echocardiogram, need oversight and credentialing for echo technicians;
■ Recruitment and retention problems particularly cardiac sonographers and ETT technicians;
■ Rheumatic fever complications should not be occurring as all preventable - rheumatic fever nurse
across Midland to manage register and track compliance of patients as often move within region
■ Heart failure management needed to prevent patients having frequent admissions;
■ Teaching support for medical staff and CCU nurses
■ Maintenance of regional policies and procedures – on-line option.
Tairawhiti
■
■
■
■
Waikato DHB provides outreach clinics and pacing clinics at Tairawhiti DHB;
General physicians manage acute and inpatients services;
A 0.7FTE cardiac care coordinator provides nurse-led heart failure clinics;
Phase I cardiac rehabilitation is provided by ward staff and a 0.5FTE cardiac rehabilitation nurse
who also coordinates Phase II cardiac rehabilitation services in Gisborne;
■ Thrombolysis provided at Te Puia and Gisborne.
Te Puia
■ Most clinics have PRIME trained staff and AEDs, St John provide monthly updates along coast;
■ Six lay people trained in emergency response;
■ Need to ensure professional upskilling with frequently changing doctors;
■ Acute patients managed at Te Puia – ECGs transmitted to Waikato CCU, thrombolysis
administered if recommended, troponin reader available;
■ Transport and access will always be an issue on the coast – locals recognise the constraints and
realities in choosing to live there;
■ Data collection and ability to understand benefits and economics is essential in future
developments;
■ Focus should be on communication and community education and upskilling.
ISSUES AND OPPORTUNITIES
■ Resourcing at Waikato major issue leading to significant delays through patients staying in hospital
for long periods prior to transfer for treatment;
■ Transport to Waikato;
■ An anaesthetist is capable of undertaking TOEs but not credentialed;
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■ Continuing education for medical, nursing, and technical staff;
■ Coordinated transport service to Waikato that enables timely treatment for cardiac patients.
Taranaki
■ Taranaki DHB employs two general physicians with an interest in cardiology, who provide inpatient
and outpatient services, included in general medical cover;
■ Non-interventional diagnostic services including nuclear cardiology and coronary angiography are
provided;
■ Echocardiography provided by a visiting echo technician on a six-weekly basis. An appointment
has been made for a technician commencing July 05;
■ Waikato provides an outreach-pacing clinic at Taranaki Base Hospital.
■ Nurse-led heart failure clinics are provided;
■ Phase I & II cardiac rehabilitation services are available in Hawera and New Plymouth;
■ Good relationship with community, including DSM, nurses around district.
ISSUES AND OPPORTUNITIES
■ Transport from Taranaki often causes delay for patients;
■ Radiology costs increasing through current JV arrangement;
■ Workforce recruitment and retention across nursing, technicians, sonographers and allied health
staff;
■ Cardiac rehabilitation - large classes (30 plus), held on-site, during working hours - increase
cardiac nurse educator role at Taranaki Base Hospital to 1.8 FTE;
■ Develop heart failure programme for North Taranaki;
■ Development of full pacemaker service;
■ Development of angioplasty - stent insertion capability;
■ Regional cardiology nurse meetings reinstituted as part of CNE.
Waikato
Hamilton
■ Waikato DHB employs 7.5 FTE cardiologists, 3 cardiac surgeons and provides a complete
diagnostic and interventional cardiology and cardiac surgery service;
■ Ward staff provide Phase I cardiac rehabilitation while 1.3 FTE cardiac rehabilitation nurses provide
phase II rehabilitation programmes in Hamilton;
■ One FTE heart failure nurse provides education and support to patients.
Thames
■ Outreach cardiologist service from Waikato;
■ Echo equipment requires new software to enable reading in Waikato;
■ Technician-led echo service required;
■ Cardiac rehabilitation is the most urgent issue for Thames patients –no level 2 programme;
■ Three event recorders required – currently only available through Waikato Hospital;
■ Chest pain unit and relevant staffing part of service and campus redevelopment;
Te Kuiti
■ Acute MI patients admitted for A&E, ECG transferred to Waikato for reading and thrombolysis
administered as appropriate prior to transport to Waikato Hospital;
■ Very elderly NSTEMI patients may be managed on site;
■ Some delay in transfer experienced if patient admitted to the ward but not for acute patients;
■ No issues re transport to Waikato
■ Myocardial infarction management routinely audited;
■ Heart failure admissions generally social cause – not a significant issue;
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Midland Region Cardiac Services Plan - 2006
■ Cardiac rehabilitation level 2 programme run every 8 weeks on site with referrals from Waikato
cardiology staff, GPs or ward referrals;
■ Level 3 rehabilitation being re-established with monthly meetings;
■ All cardiology outpatient clinics held at Waikato, occasional patient followed up by General
Physician at Te Kuiti.
Taumaranui
■ Two-bed high dependency unit including cardiac monitoring.
■ ECGs transferred to Waikato for reading;
■ Myocardial Infarction management routinely audited;
■ Cardiac rehabilitation levels 1, 2 and 3 – involve cardiac resource nurse, social worker, dietician
and sometimes medical staff;
■ David Simmonds project, Te Wai o Rona: Diabetes Prevention Strategy, very positive for area;
■ High Māori population, high DNA rates;
■ National Park servicing from St John – not all shifts include paramedics;
■ Scheduling of outpatient clinics at Waikato must be after 11am – impossible arrive by 8.30am;
■ St John ambulance transfer of patients requiring nurse escort means nurse may be away for whole
day, at times the ambulance may be diverted to transport a patient to Te Kuiti on return trip
meaning staff away for even longer.
Tokoroa
■ MOSS run facility;
■ Acute care provided prior to transfer to Waikato DHB;
■ Heart failure increasing numbers and frequent readmissions;
■ Clinical Director provides good support and has encouraged the development of regular audits
including treatment of STEMI & NSTEMI;
■ Intranet give access to protocols but not alerted to updated versions, new versions not always
updated electronically in a timely way;
■ No Level 1 or 2 cardiac rehabilitation programme available locally (Zipper club available);
■ Physiotherapy available 3 days per week only at present – recruitment for 1 FTE underway;
■ High Māori & PI population with high rates of diabetic disease;
■ Approximately 40% acute & inpatient load related to cardiovascular disease;
■ Non-compliance a problem leading to readmissions;
■ ALL staff have option to undergo CPR training;
■ Community & staff education needed;
■ Very good links with Waikato at medical and nursing staff levels, especially appreciative of
cardiologist service.
ISSUES AND OPPORTUNITIES
Inability to provide a timely service in relation to:
■ ACS management due to lack of bed availability, catheter lab availability (>85% angiography
performed on in-patients), access to cardiac surgery;
■ Revascularisation – lowest rate in NZ due to lack of access to catheter lab and cardiac surgery
problems including theatre and ICU access;
■ Electrophysiology – inadequate lab, cardiologist, and technician time to meet patients waiting (50
patients, some > 24 months mid-2004).
■ Pacing – increasing evidence for implantable defibrillators and resynchronisation therapy which are
expensive, time consuming procedures requiring resources to meet need;
– Echocardiography:
♦ Current equipment able to provide 20 – 40 echoes daily, which is inadequate to meet acute
inpatient and FSA needs. Elective patients unable to access service leading to >500
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■
■
■
■
■
■
■
■
■
■
patients on a waiting list at any time.
♦ Digital echo laboratory has ongoing information technology problems;
♦ Lack of access to echo means any echos undertaken as part of a research protocol is
undertaken after hours;
♦ Storage of images – labour intensive (4-5 hours per month of archive) relatively expensive
system ($24,000 for 2-years disk storage at current service level).
Inadequate workforce and resources for regional outreach services.
Need for continued regional approach to ensure equity of access for all patients in region;
Cardiac surgery - appointment of 4th cardiac surgeon, expansion of cardiac theatre services,
recruitment and retention of appropriate levels of cardiac theatre, ITU nursing staff and perfusion
staff;
Development of cardiac surgery facility at Braemar Private Hospital;
Increase cardiac investigation units to four (currently two), one of which should be a dedicated
electrophysiology / pacing suite.
A fifth suite for Cardiac MRI or CT should be included in Waikato Hospital campus development.
Increase in echo machines to four (currently two) with appropriate staffing;
Appointment of three cardiologists – one specialising in electrophysiology; or;
Decrease secondary cardiology workload through improved access to acute general medical and
older people services; or
A combination of the above two options.
Acknowledgment
It should be noted that, irrespective of the issues identified in relation to delay in access to tertiary services,
all physicians and cardiologists across the region acknowledged the positive relationship with Waikato
cardiologists.
The development of regional protocols and the current annual meeting are seen as a very positive
opportunities and all nursing and medical staff would like to see the meeting continue and potentially be
better resourced to enable more staff to attend and a mechanism for ensuring knowledge transfer of
information to all relevant staff.
7.2.1. Secondary Care Cardiology
It is estimated that between 30-40% of acute general medical admissions have a significant cardiovascular
component, this is likely to increase as the population ages and the number of patients with diabetes
continues to grow. In addition, advances in surgical and anaesthetic techniques have an increasing number
of complex surgical procedures being performed in greater numbers of patients with higher likelihood of
significant cardiovascular disease. This has lead to an increase in the number of referrals for cardiology
review following preoperative assessment. General physicians provide a significant amount of care to
patients with cardiac disease, especially in facilities not employing a cardiologist.
An acceptable specialist service in cardiology has been defined by the Cardiac Society of Australia and New
Zealand (CSANZ) as the provision of:
■ Acute coronary care facilities for assessment and treatment of acute cardiological problems
including acute myocardial infarction, unstable angina, and arrhythmias;
■ ECG;
■ Chest x-ray;
■ Echocardiography with Doppler imaging and stress testing.
An optimum specialist service also provides:
■ Ambulatory ECG monitoring;
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■
■
■
■
Electrophysiology and pacing;
Nuclear imaging:
Cardiac catheterisation including interventional procedures,:
Cardiothoracic surgery.
The AMWAC and CSANZ infrastructure requirements for a sustainable resident specialist service in
cardiology are shown as Appendix 5.
Drivers of workload for secondary cardiology include:
■ Ageing population;
■ Increasing diabetic population with subsequent cardiovascular disease;
■ Rapidly increasing prevalence of heart failure;
■ Increase in patients surviving an acute event and developing chronic cardiac conditions over time;
■ Increase in patients requiring cardiology review prior to surgery.
NON-CARDIAC SURGERY
The issues in relation to non-cardiac surgery are predicted to increase with the aging population and the
expectations of the population for treatment. Cardiovascular complications following non-cardiac surgery
form a cost in terms of perioperative morbidity and mortality. It is estimated that up to one-third of patients
undergoing non-cardiac surgery in the United States have coronary artery disease (CAD) or risk factors for
its development. More than one million operations are complicated by adverse cardiovascular events, such
as perioperative myocardial infarction (MI) or death from cardiac causes. In high-risk populations, such as
patients undergoing vascular surgery, the incidence of perioperative MI can reach 34%. Perioperative MI
causes substantial morbidity and prolonged hospitalisations, and has mortality rates as high as 25-40%.
Therefore, it is not surprising that surgeons and anaesthetists frequently consult cardiologists to "clear" a
patient for non-cardiac surgery.
Recommendations for a systematic approach to assess cardiac risk for non-cardiac surgery and strategies
to manage that risk may assist both anaesthetists and cardiologists to manage the workload generated from
this group of patients. The American College have developed guidelines that provide a step-wise approach,
using the urgency of the surgery, the clinical risk predictors of non-cardiac surgery, the surgery-specific risk,
and functional capacity to determine the options based on need and risk41. These may be useful if there are
no current protocols in place within the regions hospital facilities.
CARDIOLOGIST VERSUS GENERAL PHYSICIAN
General physicians provide most of the care for cardiac patients in facilities where there are no cardiologists
and a variable level of care in other facilities. It is important that this is recognised and this role is seen as a
component of the over cardiac service in the Midland region.
The outcome for patients with acute myocardial infarction seen by cardiologists and general physicians has
been reviewed in New Zealand and in the United Kingdom. The New Zealand review looked at patients
managed by general physicians at Taranaki Hospital and in Waikato where they were managed by
cardiologists8. Outcomes in terms of medical treatments, mortality at 6 months and readmission rates were
similar; however there was a significant difference in the angiography (not undertaken at Taranaki at the time
of the study) and revascularisation procedures, which were referred less frequently at Taranaki. Quality of
life was not assessed on discharge, although a significantly higher rate of anti-anginal nitrate prescribing was
noted for patients in Taranaki. The low rate of referral for angiography indicated that high-risk patients might
be disadvantaged by the conservative approach. The United Kingdom study42 showed that patients cared
for by a cardiologist had a significantly better survival rate at 18 months. The most important factor affecting
survival was access to effective medication.
Both of these studies indicate that the adherence to guidelines and protocols is important for patient
management. In a regional service, it is critical to maintain a strong relationship between cardiologists and
general physicians to promote best practice for all patients.
- 59COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Figure 8.
Ischaemic heart disease admissions by Midland DHB of domicile and gender
2000
Female
1800
Male
1600
1400
1200
1000
800
600
400
200
BoP
Lakes
Tairawhiti
Taranaki
2004_05
2003_04
2002_03
2001_02
2004_05
2003_04
2002_03
2001_02
2004_05
2003_04
2002_03
2001_02
2004_05
2003_04
2002_03
2001_02
2004_05
2003_04
2002_03
2001_02
0
Waikato
Figure 8 indicates that Waikato and Taranaki have a decrease in the number of patients admitted to hospital
with ischaemic heart disease, while this trend is less obvious for Bay of Plenty and Lakes patients and
continues to increase in Tairawhiti. Overall, there was a 13% decrease in hospital admissions for IHD in the
Midland region between 2001_02 and 2004_05 (extrapolated from 31 March ytd to 30 June).
Table 16.
Percent ischaemic heart admissions by Midland DHB of domicile, ethnicity, and gender
Other/Not
Female
Stated
Male
European
Maori
PI
Asian
2001_02
74.5%
9.5%
0.1%
0.3%
15.6%
35.6%
64.4%
Bay of Plenty 2002_03
76.2%
10.9%
0.5%
1.0%
11.5%
35.6%
64.4%
2003_04
76.7%
11.7%
0.4%
0.8%
10.4%
33.4%
66.6%
2001_02
76.1%
18.4%
1.7%
1.2%
2.6%
44.7%
55.3%
61.1%
DHB
Lakes
Tairawhiti
Taranaki
Waikato
Year
2002_03
75.7%
20.3%
1.4%
0.7%
1.9%
38.8%
2003_04
74.5%
19.4%
2.5%
1.9%
1.6%
43.3%
56.7%
2001_02
62.9%
29.9%
1.1%
0.0%
6.1%
42.0%
58.0%
2002_03
69.3%
25.4%
0.7%
0.7%
3.9%
52.3%
47.7%
2003_04
62.0%
34.1%
0.7%
0.3%
3.0%
43.9%
56.1%
2001_02
80.8%
8.1%
0.1%
0.3%
10.7%
39.9%
60.1%
2002_03
84.1%
8.4%
0.2%
0.9%
6.3%
38.6%
61.4%
58.9%
2003_04
86.3%
7.3%
0.5%
0.6%
5.2%
41.1%
2001_02
86.5%
8.7%
1.1%
1.2%
2.5%
37.3%
62.7%
2002_03
87.4%
9.2%
1.3%
1.2%
1.0%
39.0%
61.0%
2003_04
87.6%
9.0%
0.7%
1.6%
1.1%
39.1%
60.9%
Table 16 shows admissions by ethnicity and gender and as the ‘other/not stated‘ groups has decreased for
all DHBs and indicates that the changes in ethnicity percent over the 3 years are most likely due better
coding practices. There is no obvious change in the trend in admissions by ethnicity. There appears to be
an increase in females admissions in relation to males, however, the only actual increase in female
- 60COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
admissions occurred in Tairawhiti where female admissions increased from 111 in 2001_02 to 134 in 200203 (20.7%) while male admissions increased from 153 to 171 (10.8%).
The proportion of European admissions to hospital is higher than the proportion in the community. Māori, PI
and Asian admissions to hospital are lower than the proportion in the community and this may be significant
given the high proportion of heart disease particularly in the Māori population.
The Ministry of Health has identified that admissions to hospital for ischaemic heart disease are lower for
those living in the lowest two deprivation quintiles. Between 1988 and 2001, 86% of Waikato DHB and 70%
of New Zealand IHD discharges were for those living in quintiles 1 to 3.
No conclusions are drawn from this information and more detailed analysis of hospital data across all
cardiac admissions would be required to provide the complete picture.
CURRENT SITUATION
Cardiologists at Tauranga and Waikato Hospitals provide secondary cardiology services. Taranaki Base
Hospital employs two general physicians with an interest in cardiology. Whakatane, Rotorua, Taupo, and
Thames Hospitals utilise general physicians to treat acute cardiac patients and refer acute, inpatient and
outpatients to Cardiologists as per agreed protocols.
Waikato cardiologists provide outreach services to Lakes, Tairawhiti and pacing services to Taranaki DHB
patients. Waikato and Tauranga cardiologists provide services at Whakatane Hospital. Outreach services
provided include:
■
■
■
■
■
■
■
■
■
■
Outreach clinics;
Inpatient consultation by arrangement with physician;
Cardiac Care unit training and support onsite;
Senior & junior medical officer training and support;
Pacing Clinics;
Echocardiography reporting;
Profession support, guidance, training and review of echosonographers;
Provide leadership support and education of CCU nursing staff, RMO’s and physicians;
Ensure guidelines and protocols are up to date and relevant to current practice;
Ongoing 24 hour 7 days per week cardiologist access /advice for consultants for acute and
emergency.
There must be sufficient resource at the DHB providing the outreach service to enable these services to be
delivered. An estimate of cardiologist resource is identified in the workforce section of this plan. While acute
patients will continue to be transferred from Whakatane to Waikato, it is recommended that outreach
services to Whakatane Hospital should be provided from one centre, ideally Tauranga.
The British Cardiac Society (BCS) released a paper in July 2005 entitled “Cardiac workforce requirements in
the UK”43. This paper looks at service levels and workforce across specialist and non-specialist cardiac
care. This paper predicts significant increases in secondary and tertiary level care and makes some
assumptions about activities as indicated here (paediatric services have been excluded):
Cardiac activities which are generally consultant-based:
■ Diagnostic cardiac catheterisation and angiography;
■ Percutaneous Coronary Interventions (PCI), carotid intervention, atrial septal defect (ASD), or
patent foramen ovale (PFO) closure;
■ Device implantation and replacement;
■ Invasive cardiac electrophysiology studies and ablations;
■ Trans-oesophageal and stress echocardiography;
■ Reporting cardiac resynchronization, magnetic resonance and nuclear studies;
- 61COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
■ Management of rare conditions;
■ Formal clinical management e.g. clinical director, service director, lead clinician,
Cardiac activities which are generally non consultant based but with consultant supervision:
■ Device follow-up;
■ Reporting non-invasive cardiology investigations, echocardiography.
Cardiac activities which are generally non consultant based, but with consultant lead and direction:
■ Secondary prevention;
■ Rapid access chest pain clinics;
■ Acute chest pain and thrombolysis;
■ Pre-assessment for angiography and PCI;
■ Post myocardial infarction follow-up;
■ Post PCI follow-up;
■ Rapid access heart failure clinics;
■ Monitoring and follow-up of heart failure;
■ Cardiac rehabilitation.
7.2.2. Diagnostics
Diagnostic are a critical component of cardiac services. Some diagnostic tests are undertaken at a primary
care level e.g. various blood tests including cardiac enzymes and troponins, 24-hour ambulatory blood
pressure monitoring and electrocardiograms (ECG). Not all GP surgeries have ECG machines on site,
although the RNZCGP Standard for General Practice recommends that an ECG machine should be readily
accessible – or within 10 minutes and that all rural practices should have a portable ECG machine with
defibrillator. (Aiming for Excellence - http://www.rnzcgp.org.nz/aiming.php)
Non-invasive tests include: electrocardiogram (ECG), echocardiogram, event recorder monitoring, exercise
tolerance test (ETT), holter monitoring, myocardial perfusion scans, and tilt table tests.
Invasive tests include: transoesophageal echocardiogram (TOE), cardiac catheterisation (angiogram),
electrophysiology studies (EP studies). See Appendix One – Glossary, for information on individual tests.
While specific issues for each test have not identified, diagnostic tests identified with access issues include,
myocardial perfusion scans, tilt table testing, together with those identified specifically below. These tests
are currently undertaken at Waikato, Tauranga and Taranaki Hospitals and by a private service in Gisborne.
It should be noted that the predictions made are on a total population basis (per million population) which do
not allow for demographic changes within specific groups, e.g. ethnic groups and age bands. For example
predictions for Taranaki & Tairawhiti would suggest they will need less cardiac services into the future, as the
total population is decreasing, however the older population who will require these services are increasing in
number and while the volume changes predicted are small they are not a true reflection of the real need in
these areas.
Echocardiography
Echocardiograms are recommended as a diagnostic tool for heart failure, arrhythmias and other conditions
that require an understanding of the function of the heart. Cardiac technicians or cardiologists generally
undertake these, although there are physicians within the region who are competent in echocardiography.
Currently the New Zealand Cardiology Guidelines for Primary Referral have noted that direct access echo is
endorsed by the working party with proviso it has sufficient funding, resources and staffing. The Guideline
for the Management of Chronic Heart Failure indicates: “echocardiogram for the assessment of left
ventricular function is an important part of the investigation. However, if this is delayed due to local resource
constraints, then treatment should continue on an empirical basis.”
- 62COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
The Canadian Cardiovascular Society has developed Guidelines for the Provision of Echocardiography in
Canada44. This document is intended to provide an objective reference for current standards of practice in
echocardiography in Canada and may be a useful reference for the Midland region service.
The BCS has predicted echocardiography studies per million population at:
■ Transthoracic echocardiography
42,800 – 47,700
■ Stress echocardiography:
6,000
■ Transoesophageal echo:
2000
For comparison the 2004-05 levels of some of the echocardiography procedures undertaken at Waikato
Hospital and Bay of Plenty Hospitals were:
■ Transthoracic echos
■ Stress echo
■ Transoesophageal echo
Waikato – 3226 (9530 pmp), Bay of Plenty - 1036 (5206 pmp)
Bay of Plenty – 105 (525 pmp)
Waikato – 93 (275 pmp)
CURRENT SITUATION
Echocardiography is the diagnostic test with the most significant access issues across the Midland region.
Where a service is available the waiting lists are long e.g. Waikato may have over 500 patients on the
waiting list at any one time, and this impacts on other services. See Figure 9. Examples include: patients
requiring an echo prior to their clinic appointment and the lack of access leading to increased FSA and
follow-up waiting times; pre-op patients may require an echo prior to surgery and the waiting time or inpatient
stay may be prolonged; and despite best practice guidelines recommending echos to clarify diagnosis of a
specific condition in primary care, GPs are generally unable to access echos for these patients. Any
research protocols requiring echos are undertaken outside of normal working hours and this limits the ability
of the cardiologists to recruit patients into trials.
Some facilities have older outdated echocardiography equipment and no technician e.g. Whakatane and
Thames. Echo technicians are trained on the job and there are significant shortages in New Zealand.
Ideally trainees have a degree in Applied Science but may be school leavers or others who undertake a
Diploma of Applied Science during training. There are few qualified staff available in New Zealand and
recruitment from overseas (often UK) often an 8-month process. The region is at risk with a number of
facilities employing one or two cardiology technicians e.g. Taranaki has recently contracted a technician from
Auckland to provide a visiting echo service while undertaking the employment process.
Funding for echocardiograms is included in the inpatient and outpatient clinic prices and cardiology
Community referred tests. The current Purchase Unit is CS04.01 Med Tech Cardiology Community
Referred and contract price is $115.74. Actual prices (ex BoP DHB) are:
■ Standard echo by cardiologist
$257.36
■ Standard echo by echocardiographer
$181.76
■ More complicated echoes up to
$398.68
Funding for the Community Referred Tests is inadequate in all Midland DHBs to meet the demand based on
current guidelines. It is unknown at this time what the demand would be if access was opened to meet the
primary care guideline requirement for echocardiography. Some of these patients will be referred for
outpatient clinics in order to access this diagnostic test.
- 63COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Figure 9.
Patients waiting for echocardiography at Bay of Plenty and Waikato DHBs as at June 2005.
1250
1000
750
500
250
0
Bay of Plenty
Waikato
Patient waiting > 6 months
Patients Waiting < 6 months
Recommendation
A review of access of diagnostic tests, including myocardial perfusion scans and tilt table testing, across the
region should be undertaken; with the view to agreeing a means to achieve equitable access into the future.
A full review of echocardiography across the region should be undertaken and a planned approach to
identify, update and replace equipment where necessary, to enable an agreed and equitable level of access
to echocardiography into the future. This should include access to cardiologist reporting of all echos and
medical supervision of the service.
The agreed level of access should be based on clinical criteria, together with access to BNP testing,
recognising the cost implications of the decision for the DHBs.
An echocardiography workforce plan should be put in place across the region to ensure a supported
regional service with appropriate training and continuing education to enable a sustainable service into the
future.
B-type Natriuretic Peptide
An alternative diagnostic test for heart failure that continues to be assessed for its accuracy and place in
treatment is B-type natriuretic peptide (BNP). BNP is a cardiac neurohormone released by ventricles in
response to increased wall stress. BNP and N-terminal proBNP (NT-proBNP) assays have potential value
in a number of clinical situations including: diagnosis of heart failure in patients with acute dyspnoea, as a
prognostic indicator in heart failure; acute coronary syndrome, valve disease; and for monitoring
effectiveness of heart failure treatment. The New Zealand and Australian heart failure guidelines were
published in 2001 and 2002 and neither recommends the use of BNP as a routine test, although both
acknowledge the potential with further evidence.
A recent systematic review looked at 19 studies that used BNP to estimate the relative risk of death or
cardiovascular events in heart failure patients and 5 studies in asymptomatic patients45. The review
concluded “although systematic reviews of prognostic studies have inherent difficulties, including the
possibility of publication bias, the results of the studies in this review show that BNP is a strong prognostic
indicator for both asymptomatic patients and for patients with heart failure at all stages of disease”. The
relative risk of death was shown to increase by about 35% for each 100-pg/ml increase in BNP in patients
with heart failure. Raised BNP values also predicted survival in patients not known to have heart failure, with
double the risk in patients with a BNP value >20 pg/ml.
CURRENT SITUATION
BNP tests are available to Midland GPs through the ‘send away’ lab test contract at a cost of $54 - $75
each. Most DHB providers restrict access to registrars and specialists. Waikato Hospital experienced a
rapid growth in tests ordered from 50 in January 2003 to 323 in November 2003, peaking at 545 in
September 2004, with an average of approximately 400 per month in 2005. Waikato and Canterbury
- 64COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Hospital Laboratories undertake BNP testing for general practice in the Midland region under the ‘send
away’ laboratory test contract. Whakatane Hospital laboratory began providing BNP tests in July 2004.
Further detail by DHB is seen in Table 17, although breakdown of the DHB of origin of the Waikato tests has
not been included.
Extrapolation of the April year to date data, indicates BNP tests undertaken for the Midland DHBs are
expected to cost close to $400,000 in 2004-05. Waikato cardiologists promote appropriate use of this
expensive assay and locally developed guidelines have been circulated in the region. These are
attached as Appendix Five. Appropriate use of BNP should reduce the need for echocardiograms and
local cardiologists indicate this is the emphasis that is appropriate for primary care in order to include
or exclude a diagnosis of heart failure.
Table 17.
BNP tests and costs by Midland DHB 2003 - 2005
2003
#
Eastern BoP
Western BoP
Lakes
Tairawhiti
Taranaki
Waikato
Midland
Figure 10.
2004
$
116
$ 6,196
13
87
2142
2358
$710
$4,344
$149,940
$161,189
#
181
132
47
83
256
4488
5186
2005
$
#
$12,670 360
$7,026 138
$3,290 114
$4,688 207
$13,666 258
$310,870 4803
$352,124 5880
Comment
$
2005 – extrapolated full year
$25,200Hospital requests only, GP included in Waikato
$7,484Hospital requests only, GP included in Waikato
$7,980Hospital requests only, GP included in Waikato
$11,886GP & hospital requests
$13,991GP & hospital requests
$336,210Waikato hospitals plus Waikato, Lakes, & BoP GP requests
$394,771
BNP test volume and cost by laboratory 2003-05 (extrapolated full calendar year)
7000
$450,000
$394,771
6000
$350,000
5000
Number
BNP Tests
$400,000
$300,000
4000
$250,000
3000
$200,000
$150,000
2000
$100,000
1000
$50,000
0
$0
2003
Canterbury Hospital Laboratory
2004
Whakatane Hospital
2005
Waikato Hospital Laboratory
Midland Annual Cost
What is unknown at this time is whether BNP testing is being used appropriately and in accordance
with the guidelines. Over 75% of the BNP tests ordered are by general practitioners. Figure 10 shows
that number of tests and total cost by laboratory providing the service.
Recommendation
PHOs ensure the regional BNP guidelines are implemented and the use of BNP monitored against these
guidelines.
DHBs review the options available to review or audit the use of BNP testing against the regional guidelines.
- 65COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Pacing and Electrophysiology
Pacing
Cardiac pacing is a well-established discipline involving treatment of patients with bradycardia related
symptoms such as syncope, dizziness, dyspnoea, and tiredness. It is also increasingly used in patients with
advanced heart failure, often combined with a defibrillator as the evidence accumulates showing significant
benefit in these patients. Management involves selection of suitable pacing modes, implantation of devices,
and regular follow-up in specialised clinics. The ideal facility for pacemaker implantation is an operating
theatre or dedicated pacing laboratory in which the highest standard of sterility can be maintained. While is
both feasible and commonplace to implant pacemakers in general cardiac catheterisation laboratories (as
occurs at Waikato Hospital) or even in a general radiology department, as at Tauranga and Taranaki Base
Hospitals, it is unlikely that operating theatre standards can be maintained in such areas, which should be
regarded as sub optimal for pacing46. Ideally this service should have at least two trained implanting
cardiologists, a fully trained physiological measurement technician and access to a bioengineering service
for equipment maintenance.
The British Pacing and Electrophysiology Group advised a level of 450 new and 100 replacement
pacemaker systems per million population each year. Cardiac Care Network (CCN) of Ontario recommends
870 pm adult patients (>20 years). It should be noted that both of these recommendations are for
bradycardia related symptoms and take no account of the expanding heart-failure indications. The BCS43
has indicated that the need will double to 900 pmp new devices into the future.
The UK recommends a caseload of 60 implantations a year to maintain competence. At this level it is
appropriate for Bay of Plenty and Waikato to provide this service in the Midland Region, see Table 18. In
time it is likely that Taranaki and Lakes DHBs should also provide a pacing service for their populations,
providing professional competency standards, including appropriate volumes can be maintained.
CURRENT SITUATION
Table 18. Predicted pacemaker implantations by Midland DHB domicile population
DHB
2006
2011
2016
@ 550pmp
2011
2016
@825pmp
@1100pmp
Bay of Plenty
111
118
125
177
249
Lakes
56
57
58
86
116
Waikato
187
191
194
37
48
Tairawhiti
25
24
24
84
109
Taranaki
57
56
54
286
389
Midland Total
436
446
456
670
911
CCN Ontario @ 870 pmp >20 years.
480
508
532
Assumptions:
■ No demographic factors included in predictions;
■ UK recommendations appropriate for the New Zealand situation
■ Shaded 2011 & 2016 columns represent volumes at the 2005 British Cardiac Society predicted
rates.
Waikato Hospital provides a full pacing service including outreach-pacing clinics at Rotorua, Taupo, New
Plymouth and Thames. Cardiologists from Tauranga Hospital provide pacing clinics at Tauranga and
Whakatane will provide a full pacemaker service from late 2005. It is anticipated that Tauranga will provide
80% of the Bay of Plenty DHB pacemaker services by 2011. The pacemaker services at Waikato are
undertaken within the Cardio Respiratory Investigation Unit (CRIU) and the proposed Tauranga service will
be undertaken in an operating theatre. In 2004-05 Waikato implanted 228 pacemakers, which is a rate of
290 pmp, significantly below the current recommended rate of 550 pmp.
- 66COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Electrophysiology
Cardiac electrophysiology (EP) refers to diagnosis, assessment and interventional treatment of cardiac
rhythm disturbance using radio frequency, surgical and other methods of ablation and specialised pacing
techniques and also includes treatment or prophylaxis of patients with (or prone to) arrhythmias using
implantable defibrillators. The service is tertiary and is principally concerned with treatment in a specialist
centre where appropriate supporting facilities are available. Diagnostic procedures may be undertaken
where there is expertise outside the tertiary unit but this should be done in association with a specialist
centre.
The definition includes all activity within cardiac electrophysiology - specifically:
■ Diagnostic electrophysiology study;
■ Radio frequency and other forms of ablation;
■ Implantation and revision of cardiac defibrillator.
EP has been noted in the UK Fifth report on the provision of services for patients with heart disease47 as
being an important component of everyday cardiology. The UK has not predicted the total number of EP
procedures but has made recommendations for specific procedures and the CCN of Ontario has made initial
recommendations based on achievable levels rather than needs.
■ Insertion of implantable cardioverter-defibrillators (ICDs) are proven life saving devices for some
patients and the UK recommended 50 ICDs pmp in 2002, noting that new indications would require
a rapid increase to 200-300 ICDs pmp. In the 2005 paper the BCS recommends that a level of 700
ICD’s pmp will be required into the future. CCN Ontario recommendations 104 pmp > 20 years in
2003 (this equals 57 for Midland population in 2006, marginally higher than current rate of 50 pmp);
■ EPS CCN Ontario recommendations 410 pmp > 20 years (this equals 224 for Midland population in
2006). The BCS has indicated a level of between 350 – 700 pmp diagnostic and therapeutic
invasive cardiac electrophysiology studies.
■ Ablations – 24 pmp >20 years ((this equals 131 for Midland population in 2006, no UK
recommendation);
■ Cardiac resynchronization therapy devices are identified by the BCS as a future device, with a
recommendation of 107 pmp.
A dedicated electrophysiology laboratory is an efficient use of resources in hospitals, providing a
comprehensive electrophysiology service. The use of catheter electrode ablation has proved to be
extremely effective and cost efficient for the treatment of cardiac arrhythmias. However, these procedures
are time consuming and in the absence of a dedicated laboratory, tie up valuable cardiac catheterisation
time.
CURRENT SITUATION
EP is undertaken at Waikato Hospital for the Midland region. In 2004_05 Waikato Hospital undertook 63 EP
and ablation procedures (80 pmp), however, the waiting list for EP services included 50 patients, some
having been on the list for 24 months or longer. The reasons for the delays in treatment include insufficient
catheter laboratory time, availability of trained cardiologists and technical staff. Some treatments are not
currently available at Waikato (atrial fibrillation ablation) due to resource limitations and patients are
transferred to Christchurch Hospital for this therapy.
Waikato Hospital implanted 32 ICDs (41 pmp) in 2004-05.
- 67COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Figure 11.
Waikato hospital ablation waiting list @ June 2005
25
Patients Waiting
20
15
10
5
0
<1w eek
Table 19.
1-3 months
3-6 months
6-12 months >12 months
>2 y ears
Predicted number of electrophysiology screenings by Midland DHB domicile population
100
250
250
250
350
700
2006
2006
2011
2016
2011
2016
Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
20
10
5
10
34
50
26
11
26
85
54
26
11
25
87
57
26
11
25
88
75
37
16
36
121
159
74
30
69
247
Midland Total
79
198
203
207
284
580
pmp
DHB
Table 20.
1-4 w eeks
Predicted number of ICD implants by Midland DHB domicile population
pmp
DHB
Bay of Plenty
Waikato
Tairawhiti
Taranaki
Lakes
Midland Total
40
2006
8
14
2
4
4
32
200
2006
40
68
9
21
20
159
300
2011
64
104
13
31
31
244
300
2016
68
106
13
30
32
248
400
2011
86
42
18
41
139
700
2016
159
74
30
69
247
325
580
Assumptions:
■ The shaded 2006 figures are based on an estimate of the rate in 2003_04; however the rate of EP
decreased from 132 pmp in 2002-03 to 80 pmp in 2004-05, while ICD implants have remained
static at 41 pmp.
■ The non shaded column recommendations are based on the 2002 predicted best practice rate;
■ Shaded 2011 & 2016 columns represent volumes at the 2005 British Cardiac Society predicted
rates.
- 68COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Cardiac Catheterisation and Cardiac Angiography
Cardiac angiography is used to investigate:
■ Angina not adequately controlled by medical treatment, or medical treatment not tolerated.
■ Angina or ischaemia early post-myocardial infarction.
■ Angina/non Q wave myocardial infarction associated with myocardial necrosis (elevated troponin T
or I) or intermittent ST/T changes.
■ Myocardial ischaemia on the treadmill within 9 minutes (stage I to III) of the Bruce protocol (or
equivalent by stress echocardiography, nuclear perfusion).
■ Patients >40 years or at risk of coronary disease undergoing valve or other non-coronary cardia
surgery.
■ Unexplained "cardiomyopathy", ventricular arrhythmias, or cardiac arrest.
■ Congestive heart failure with regional left ventricular wall motion abnormalities.
■ Episodic congestive heart failure and normal or near normal left ventricular systolic function.
■ Myocardial ischaemia precluding occupational licensing.
■ Chest pain - uncertain diagnosis after non-invasive assessment.
■ AMI - cardiogenic shock, alternative to thrombolysis, clinically failed reperfusion with thrombolysis.
CURRENT SITUATION
The current waiting times for angiography at Waikato Hospital are shown in Figure 12. Waiting times at
Taranaki Base and Tauranga Hospitals are shorter than at Waikato with the majority of patients seen within
6 months.
Cardiac catheterisation and angiography are provided at Taranaki Base Hospital, with some nuclear
medicine diagnostic procedures also undertaken. It should be recognised that this service is dependent on
the employment of cardiologist(s) or general physicians with an interest in cardiology. Should either of the
current staff leave, the service at Taranaki could be at risk due to the difficulty of attracting specialist staff to
the smaller centres.
Figure 12.
Waikato Hospital - angiography waiting list as @ June 2005
90
80
Patients Waiting
70
60
50
40
30
20
10
0
<1w eek
1-4 w eeks
1-3 months
3-6 months
>6 months
Levels of need for coronary angiography and catheterisation have been estimated by the British Cardiac
Society48 as being 2.2 to 2.5 times the number of revascularisation procedures.
- 69COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Table 21.
Predicted cardiac catheterisation and angiography by Midland DHB domicile population
1750
2150
2150
2150
2550
2950
Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
Total
-70% PCI
2006
883
447
197
456
1488
3470
555
2006
1085
549
242
560
1828
4263
777
2011
1153
561
238
547
1865
4363
796
2016
1219
569
234
531
1898
4452
812
2011
1367
665
282
648
2212
5175
1023
2016
1673
781
321
729
2605
6108
1275
Midland Total
2915
3486
3568
4799
4152
4833
Tauranga Hospital
Taranaki Base Hospital
Waikato Hospital Total
371
182
2362
456
224
2807
484
219
2865
512
212
2916
574
259
3319
703
291
3839
Revascularisation Rate pmp
Assumptions:
■ The predictions are based on:
– 2006
1000 PCI + 750 CABG pmp (shaded column – based on current rate)
– 2006
1400 PCI + 750 CABG pmp
– 2011
1400 PCI + 750 CABG pmp
– 2016
1400 PCI + 750 CABG pmp
– Shaded 2011
1850 PCI + 700 CABG pmp (BCS 2005)
– Shaded 2016
2250 PCI + 700 CABG pmp (BCS 2005)
■ For comparison CCN Ontario recommends 2300 PCI + 1200 CABG pmp and 540 angiograms pmp
> 20 years. For the 2006 populations the CCN Ontario recommendations would lead to an
additional 150 PCI, 65 CABG and 800 fewer angiograms.
■ 70% PCIs follow angiograms, and should be counted as a single procedure and these numbers
have therefore been removed from the total.
Note the level of CABG may be too low based on current services, and the time required to increase PCI
rates to the recommended levels. However, total revascularisation numbers should be appropriate and
agreement should be reached on how these can be achieved.
Revascularisation, in particular, PCI procedures, are predicted to increase significantly to meet best practice
recommendations of 1000-1400 pmp, and possibly higher as better information becomes available on the
safety, effectiveness and long-term outcomes of these procedures. The Cardiac Care Network of Ontario
recommend 540 angiography procedures per 100,000 > 20 years.
Recommendations for resource needs to improve access to pacing, electrophysiology, and coronary
angiography are included in Section 11.
Recommendation
The Midland region should agree the recommended rates for diagnostic procedures as identified:
- Pacemakers – 550 pmp
- Electrophysiology – 250 pmp
- Implantable cardioverter-defibrillators (ICD) – 200 pmp by 2006, 300 pmp by 2011;
- Angiography – 2.5 times the revascularisation volume.
The 2005 British Cardiac Society predictions should be noted and predicted rates reviewed annually.
- 70COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
7.2.3. Chest Pain Units
Chest pain units and rapid access chest pain clinics are designed to provide prompt assessment of patients
with acute chest pain with no high-risk features at presentation. Chest pain unit length of stay is generally
less than 24 hours. Investigations will include troponin testing, an ECG and, where appropriate, an exercise
tolerance test with results provided back to the GP within a significantly shorter timeframe than waiting for a
Cardiology First Specialist Assessment.
The rational for rapid assessment of chest pain symptoms includes:
■ Chest pain is common, frightening for the patient and worrying for the general practitioner and
emergency staff, as it can be difficult to distinguish cardiac from non-cardiac pain;
■ Exertional angina can progress to unstable angina, acute myocardial infarction or death; and
predicting a stable clinical course from symptoms alone is difficult;
■ Non-invasive techniques can risk stratify patients by showing the degree of reversible ischaemia,
and therefore identifying those requiring immediate angiography;
■ Treatments to relieve symptoms and improve prognosis can be given and revascularisation
targeted for those high risk patients.
■ For patients with chest pain considered to be non-cardiac, chest pain units provide rapid
reassurance.
The physical location of the chest pain unit or site where patients with chest pain are observed is variable,
ranging from a specifically designated area of the ED to a separate unit with the appropriate equipment.
Similarly, the chest pain unit may be administratively a part of ED and staffed by emergency physicians or
may be administered and staffed separately.
Chest pain units have been recommended by the Cardiac Society of Australia and New Zealand (CSANZ) in
the Management of Unstable Angina Guidelines - 200049 and the American College of Cardiology and
American Heart Association (ACC/AHA) ACC/AHA 2002 Guideline Update for the Management of Patients
with Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction)50.
Hospitals with a high admission rate of low-risk patients to “rule-out MI” (70% to 80%) will experience the
largest cost savings by implementing a chest pain unit approach but will have the smallest impact on the
number of missed MI patients. In contrast, hospitals with relatively low admission rates of such patients (30%
to 40%) will experience greater improvements in the quality of care because fewer MI patients will be missed
but will have a smaller impact on costs because of the low baseline admission rate.
There are limited reviews looking a key outcome measures for chest pain units. A prospective audit,
undertaken in an Australian tertiary facility, of the feasibility, safety and efficacy of a structured clinical
pathway for patients presenting with chest pain demonstrated that the use of an accelerated chest pain
assessment protocol eliminated missed myocardial infarction; allowed early, safe discharge of low-risk
patients; and led to early identification and management of high-risk patients51. Rapid access chest pain
clinics have been shown to be effective but the frequency in scheduling of clinics may be an important factor
in determining how the service is utilised in practice52.
Rapid access clinics may also be useful for the assessment of suspected cases of heart failure and cardiac
arrhythmias allowing for a definitive diagnosis to be made and appropriate management commenced.
CURRENT SITUATION
Chest pain clinics are held at Tauranga Hospital. A chest pain unit has recently been established at Waikato
Hospital and is planned for Tauranga hospital later in 2005. The option exists for further units to be
established in other secondary care facilities across the region. Taranaki Base Hospital has a chest pain
protocol for a few years, this has been recognising as leading to the efficient management of patients since it
has been in place.
- 71COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Recommendation
Complete an evaluation of the chest pains units at Waikato and Tauranga Hospitals and determine the
option for establishment of chest pain units at other secondary care facilities across the region. Evaluation
criteria should include effectiveness, acceptability and cost-effectiveness data from before establishment
(where available) and after such as:
-
proportion of patients with acute chest pain who are admitted to hospital;
length of stay of patients admitted with non-ischaemic pain (both ED and hospital)
the rate of adverse events within 30 days among those discharged;
patient related factors for health related quality of life and satisfaction with care.
7.2.4. Coronary Care and Cardiac Care Beds
A Coronary Care Unit (CCU) is defined as a designated ward of a hospital which is specifically staffed and
equipped to provide observation, care and treatment to patients with acute cardiac problems, such as acute
myocardial infarction and unstable angina and who may have undergone interventional procedures from
which recovery is possible. The CCU provides special facilities and utilises the expertise and skills of
medical, nursing and other staff trained and experienced in the management of these conditions.
Cardiac care beds often have access to telemetry monitoring, plus experienced cardiac nursing services to
monitor and care for patients requiring less intensive monitoring than those in CCU.
A paper published in March 2005 identified recommendations for the structure, organisation, and operation
of intensive cardiac care units (ICCU) in Europe53. This paper recommends four intensive cardiac care
beds per 100,000 population with a ratio of 1: 3 intermediate CCU beds. This is significantly higher than the
British Cardiac Society recommendation in 1994 of: 4 CCU beds per 100,000 population46. The European
recommendations for ICCU beds would lead to 32 ICCU beds and 96 CCU beds for the Midland region.
Note that Europe currently has a greater number of cardiologists and is providing higher levels of
interventions than New Zealand or the United Kingdom.
A recent report of the Intensive Care Clinical Advisory committee to the Ministry of Health54 indicated “In
New Zealand, combined coronary care/intensive care units are common in provincial areas, and coronary
care accounts for a significant proportion of patient throughput in these units. Given the need to most
efficiently use existing ICU capacity and to meet future demand, it is appropriate that there be further
development of combined or mixed ICU/HDU/CCU units in New Zealand.”
The British Cardiac Society also recommends:
■ A contiguous progressive care area with at least 1.5–2 times the number of CCU beds, depending
upon whether an additional cardiology team ward is available for continued care. This would result
in 39 – 52 cardiac care beds based on current CCU bed numbers in the region, increasing to 48-64
in 2006.
■ Telemetry is used for monitoring of high-risk pre- and postoperative patients, the number of
telemetry channels necessary being similar to, but additional to, the CCU bed number for the
population.
CURRENT SITUATION
One of the reasons sighted for delays in transfer of patients from outlying DHBs to Waikato Hospital for
treatment has been a shortage of Cardiac Care beds. While all of the larger facilities have CCU beds (often
combined with ICU) Waikato Hospital is the only Midland facility with dedicated cardiac care beds. All other
facilities manage patients in general medical wards. Tauranga Hospital campus redevelopment will include
a 6-bed CCU and a 14-bed cardiac ward.
Table 22 indicates that DHB’s, with the exception of Waikato, meet the British Cardiac Society
recommendations for CCU beds. This may be misleading in that the outlying hospital facilities in the
- 72COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Waikato district have HDU beds with telemetry available, although these (and beds at Rotorua) may be used
for non-cardiac related patients. It is unclear whether the British 1994 recommendations are appropriate in
the current cardiac service environment or in the New Zealand situation, although they are identified as the
current standard in the NSF reports. The average patient length of stay has tended to decrease but the
number of patients with increasing co-morbidities and the ageing population may affect this into the future.
Table 22.
CCU and Cardiac Care beds by Midland DHB, current and predicted need
Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
Midland
2005
Cardiac
CCU
(Current)
Care
9
14-18
4
6-8
3
5-6
4
6-8
6
9-12
40-52
26
2006
Cardiac
CCU
Care
12-16
8
6-8
4
3-4
2
6-8
4
21-28
14
48-62
32
2011
CCU
9
4
2
4
14
32
Cardiac
Care
14-18
6-8
3-4
6-8
21-28
50-66
Assumptions:
■ CCU beds based on four per 100,000 population
■ Cardiac care beds at 1.5-2 times CCU bed numbers
Options for managing current Cardiac Care bed numbers include early discharge of suitable cardiac surgery
and same day discharge of PCI patient to the DHB of domicile or home. Noting that Waikato currently
discharge patients PCI patients to Hilda Ross House. Support services for this to occur relate to transport;
nursing education, wound care, physiotherapy and patient support through telephone follow-up, access to
nursing and/or medical advice. A pilot programme for same day angioplasties was undertaken at the
Monash Medical Centre and over a 50-month period (September 2000 to December 2002) there were no
readmissions, the decrease in bed use contributed to the angioplasty waiting list drop from 6 weeks to 2
weeks and cost savings were also made55.
A joint Midland initiative to review early discharge and other potential solutions should be undertaken to
determine options for managing patients within the current cardiac care bed numbers, or whether other
solutions are required.
Recommendation:
Midland DHBs should undertake a review to determine options for managing cardiac patient throughput
including:
-
Earlier discharge of post-cardiac surgery patients back to a facility in the DHB of domicile, this would
require development of criteria for patient selection and the need to ensure services required were
available e.g. wound care, physiotherapy;
-
Same day discharge of selected patients undergoing PCI to a facility in the DHB of domicile, or home
with support and education provided through experienced cardiac nursing staff.
- 73COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
7.3.
Revascularisation
Revascularisation procedures include coronary angioplasty and coronary artery bypass graft (CABG).
Coronary angioplasty includes percutaneous transluminal coronary angioplasty (PTCA) where a balloon
pump is used to widen the narrowed blood vessel and percutaneous coronary intervention (PCI), which
encompasses all forms of percutaneous revascularisation including PTCA and stenting.
Table 23.
Standardised discharge ratios for Midland DHB residents, relative to a national mean of one
Standardised Discharge Ratios
2002/03
2003/04
Jul to
Dec 04
Change
since
2002/03
Angioplasties
0.64
0.68
0.55
-14.1%
Coronary Artery Bypass grafts (CABG)
0.7
0.99
0.62
-11.4%
Heart Valve Replacements and Repair
0.83
0.82
0.74
-10.8%
Angioplasties
0.85
0.95
0.73
-14.1%
Coronary Artery Bypass grafts (CABG)
0.87
0.96
0.84
-3.4%
Heart Valve Replacements and Repair
0.77
0.76
1.13
46.8%
Angioplasties
0.58
0.71
0.62
6.9%
Coronary Artery Bypass grafts (CABG)
0.57
0.77
1.01
77.2%
Heart Valve Replacements and Repair
0.71
1.35
0
-
Angioplasties
0.58
0.6
0.8
37.9%
Coronary Artery Bypass grafts (CABG)
0.84
0.58
0.97
15.5%
Heart Valve Replacements and Repair
0.7
0.51
0.48
-31.4%
Angioplasties
0.86
0.96
1
16.3%
Coronary Artery Bypass grafts (CABG)
0.85
0.93
0.88
3.5%
Heart Valve Replacements and Repair
0.82
0.86
1.02
24.4%
Procedure
DHB of
Domicile
Bay of
Plenty
Lakes
Tairawhiti
Taranaki
Waikato
Notes:
■ Based on interim DHB data provided by NZHIS.
■ This data gives an indication of the procedures undertaken within the public hospital system for
DHB domicile patients, indicating that patients closer to the intervention service are more likely to
receive an angioplasty (Waikato, Bay of Plenty and Lakes patients) compared with those at a
distance (Taranaki and Tairawhiti patients).
■ There is no indication of the appropriate level of service (other than a comparison with New
Zealand as a whole), nor how many patients were treated in the private sector.
■ No age, ethnicity, or gender information provided.
Table 23 shows that the rate of procedures undertaken, by patient domicile DHB relative to the national SDR
of 1, is lower in the Midland Region than New Zealand as a whole.
Midland cardiologists present patient information to a weekly multidisciplinary team meeting held at Waikato
Hospital to determine the best treatment option – medical, PCI or cardiac surgery.
- 74COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
7.3.1. Percutaneous Coronary Interventions (PCI)
PCI procedures may be undertaken acutely as a primary angioplasty where the patient presents within a
short time period of the onset of pain with an ST-elevation MI. However, the majority of PCI are currently
undertaken following a NSTEMI or for patients with unstable angina. The minority (approximately 20%) are
performed as elective outpatient procedures to treat stable but limiting angina. This is in contrast to most
centres in Australia where the majority are performed as elective procedures.
Table 24.
Predicted percutaneous coronary interventions for the Midland Region
pmp
Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
Midland Total
1000
2006
202
102
45
104
340
793
1400
2006
283
143
63
146
476
1110
1400
2011
300
146
62
142
486
1137
1400
2016
318
148
61
138
494
1159
1800
2011
386
188
80
183
625
1461
2200
2016
499
233
96
217
777
1822
Notes:
■ 2006 shaded column based on approximate current rate of 1000 pmp;
■ PCI rate of 1400 pmp is based on Cardiac Society recommendations to meet need. This should be
revised on publication of the New Zealand Acute Coronary Syndrome guidelines.
■ The shaded 2011 & 2016 columns are based on the 2005 BCS predicted rates..
At this time, patient safety issues would question PCI being undertaken at a facility without cardiac surgery
being available within 30 minutes. A study led by Dartmouth Medical School (DMS) concluded that patients
who undergo the procedure in hospitals without cardiac surgeons have a higher rate of mortality than those
in hospitals with a cardiac surgery program. The study investigates the outcomes of over 600,000 Medicare
enrolees who underwent a PCI at a US acute care facility between 1999 and 2001. This study concluded
that patients who underwent PCI at a hospital without a cardiac surgeon onsite had a 29% overall increased
risk of mortality compared to those who had the procedure in a hospital with surgical backup56.
Currently the Cardiac Society of Australia and New Zealand recommend that coronary interventional
procedures are preferably performed in hospitals with on-site surgical support. The Council of the Society
believes that the requirements for on-site cardiac surgical facilities for laboratories performing coronary
interventional procedures may be omitted in certain circumstances. These are detailed in the Society’s
Policy on Support Facilities for Coronary Angiography and Percutaneous Coronary Intervention57.
The safety issues together with the predicted volume of PCI, the resource and capital costs required to
establish an interventional service indicates that Waikato Hospital should continue to provide all
percutaneous revascularisation for the Midland region. This recommendation should be reviewed at a time
when evidence supports that patient safety can be guaranteed and a substantial increase in PCI or changes
in best practice require an increase in facilities providing PCI within the region.
Stents
Most coronary angioplasty procedures are now performed with the use of coronary stents. These bare
metal stents (BMS) are endoprostheses made of a fine cylindrical mesh of stainless steel placed inside
coronary arteries to keep the affected section of these vessels (dilated by balloon angioplasty) open. This
technology has lead to improvements in safety and outcomes with a decreased incidence of restenosis –
from 20-30% patients within six months to about 15%. Rates vary depending on the size, location, and
complexity of the lesion.
- 75COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Drug Eluting Stents
Advances have led to the development of coronary stents coated with pharmaceutical agents, which reduce
restenosis. Drug-eluting stents (DES) release anti-proliferative agents from their surface with the objective of
limiting cell growth around the stent using cytotoxic, cytostatic and other agents. There has been
considerable enthusiasm for the use of DES, however they are significantly more expensive than BMS. A
number of Randomised Controlled Trials (RCTs) have shown benefit and the UK National Institute for
Clinical Excellence finalised a protocol in May 2005 for review of guidelines for coronary artery stents for the
treatment of ischaemic heart disease in relation to the developments in DESs58. The Cochrane
Collaboration is currently undertaking a review to assess the safety and clinical effects of routine stenting
with drug-eluting compared with non-eluting coronary artery stents in adults with stable angina or ACS.59.
While this service plan does not intend to make recommendations in relation to the clinical use of DES, it is
important for DHBs to understand the implications of new technologies on the budget. An economic
analysis of DES was undertaken in Quebec, Canada in 200460. This paper reviews available randomised
clinical trials of DES containing sirolimus or paclitaxel, to BMS, for: efficacy, potential impact of the health
care budget, selection of high-risk patients, and potential rates of DES. The key points relevant to the New
Zealand environment in this review include:
Efficacy:
■ No difference in mortality or myocardial infarction;
■ Drug-eluting stents have been associated with a substantial decrease in the need for repeat target
vessel revascularisation (OR 0.26, 95% CI: 0.11-0.52);
Potential Impact on Health Care Budget
■ The cost analysis undertaken in Quebec is based on the purchase cost of the DES, the restenosis
rate, the number of PCIs undertaken annually, and the average number of non-DES per procedure.
■ Selecting patients at highest risk for restenosis allows DES to be used effectively and to generate
cost-savings for the health service. Patients and features associated with increase risk of
revascularisation include: diabetes, lesion length and vessel diameter.
■ Understanding the number of patients within the high-risk group (RR of 2-3) allows a cost-effective
budget to be provided for DES insertion. Quebec has recommended a 20% rate of DES of total
stents using a RR of 2.67.
Limitations
■ The potential for additional benefits of DES due to treatment of patients currently not eligible for
PCI was not been considered in this analysis.
■ If patients that otherwise might undergo CABG can be directed to DES use, then substantial
savings could be made.
Conclusion
■ The conclusion reached in the Quebec analysis indicates that ‘irrespective of the level of financing
adopted for DES, ethical considerations underpinning the universality of our health care system
dictate that equally deserving patients should have equal access to this technology’. ‘An evaluation
of the local results with DES is necessary to aid future decision-making regarding this technology.’
CURRENT SITUATION
The Waikato Cardiologists recognise the need to restrict DES use to high-risk patients and have developed
recommendations that include: the use of either a Cypher (sirolimus-eluting), Taxus (paclitaxel-eluting), or
Endeavor (ABT-578 eluting) stent in Percutaneous Coronary Intervention for patients with symptomatic
coronary artery disease in the following groups:
■
■
■
■
Target artery is less than 3 mm in calibre (internal diameter)
Lesion longer than 15 mm.
Diabetic patients
Restenotic lesions
- 76COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
A recent review of the use of DES at Waikato Hospital between July 2002 and June 2004 indicated a strong
trend towards a reduction in symptomatic stent restenosis at a medium follow-up of 12.5 months. A
reduction in chest pain was also noted although this was not statistically significant. See table 25.
Table 25.
Waikato hospital outcomes for DES July 2002 – June 2004
DES
N=
Age
Male
F/Up median
Deaths
Figure 13.
Controls Outcome
31
63
79%
12.5mths
1
49
61
60%
16.3mths
1
Readmission with Chest Pain
26%(8)
27%(18)
30%↓
p=ns
Symptomatic In Stent Restenosis
13%(5)
26%(14)
57%↓
p=0.12
Waikato Hospital stent use March – May 2005
160
90.0%
140
80.0%
120
70.0%
60.0%
100
50.0%
40.0%
80
60
30.0%
40
20.0%
20
10.0%
0
0.0%
Angioplasty
DES
Multiple DES
Patient #
DES = Drug Eluting Stent,
BMS
Multiple BMS
DES + BMS
% Total
BMS = Bare Metal Stent
Drug eluting stents are currently not available as an ICD-10 code and therefore not included as a component
of the pricing of any purchase unit. Waikato use DES under agreed criteria. The number and type of stents
used at Waikato Hospital between March and May 2005 are shown in Figure 12.
Prolonged administration of clopidogrel (at least 6 months) in addition to aspirin, is considered mandatory to
minimise the risk of late stent thrombosis with DES. PHARMAC currently funds clopidogrel for up to 4
weeks supply post stenting. Waikato is currently funding patients for the remaining 5 months at $300 per
month.
The cost of DES and clopidogrel are currently met by the tertiary centre and not passed on to the
contributing DHBs. There is no national process available at this time, although a new technologies group
has recently been established to look at new procedures. There is no simple process, as issues that arise
may include: tertiary adjustor received, need for regional agreement for any new technology to be funded by
all DHBs, ability for DHBs to pay for high cost items, etc.
Recommendation
The Midland region should agree to work towards the recommended rates for PCI at 1400 pmp and CABG
at 750 pmp, while recognising the need to vary these to attain, an overall revascularisation rate of 2150 pmp
to allow time for required resources to reach the recommended PCI rate.
- 77COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
At this time the volume of PCI and the resource and capital costs required to establish an interventional
service, leads to the recommendation that Waikato Hospital should continue to provide all percutaneous
revascularisation for the Midland region. This recommendation should be reviewed at a time when evidence
requires a substantial increase in PCI or best practice requires an increase in facilities providing the service
within the region, providing patient safety concerns can be addressed.
Waikato DHB should raise the issue of funding for drug eluting stents and associated costs at a national
level; the new technologies group is likely to be the appropriate forum.
Midland DHBs should agree a methodology for determining whether sharing costs for new technologies,
when these fall outside any national process, is appropriate.
7.3.2. Cardiac Surgery
Cardiothoracic surgery includes procedures on the heart, lungs, chest wall, and related blood vessels. The
main cardiac surgical procedures are coronary artery bypass grafting (CABG) and heart valve surgery.
Table 26 compares patient numbers and average caseweights for patients undergoing cardiothoracic
surgery across the Midland region. Without looking at these cases in more detail, it would appear that the
complexity is increasing gradually and while there is some variability from year to year, patients from
Tairawhiti, Lakes, and Taranaki appear to utilise higher CWDs than Bay of Plenty and Waikato. In general,
the CWDs appear to be higher in the North Island DHBs than Christchurch and Dunedin cardiac units. No
breakdown of the surgery included in these caseweights has been undertaken and further investigation
would be required before making any assumptions.
Table 27 shows the Standardised Discharge Ratio for both CABG and valve replacements for Midland
DHBs are less than for New Zealand as a whole. Table 27 relates to revascularisation procedures and
shows that in 2002-03, Midland patients were disadvantaged for access to angioplasty and CABG services
compared with those treated in other cardiac units in New Zealand. Without understanding the number of
Midland patients who access CABG procedures through private facilities, it is not possible to understand the
current rate of all CABG procedures per million population in the Midland region.
Table 26.
Cardiothoracic Surgery - DHB domicile residents discharged from all hospitals, with case-weighted totals
Cardiothoracic Surgery
DHB
Bay of Plenty
2002/03
Patient
Number
s
CWDs
Patient
Number
s
CWDs
138
980
162
1199
73
490
32
252
17
150
32
214
146
989
300
2095
7.1
78
611
24
178
68
549
333
2034
641
4352
Average CWD per patient
6.8
- 78COPYRIGHT © MIDLAND DHBS, 2005
36
248
44
365
288
1845
601
4166
6.7
7.2
7.9
6.9
8.8
8.3
6.1
Average CWD per patient
Totals
509
8.1
Average CWD per patient
Waikato
71
7.4
Average CWD per patient
Taranaki
7.4
7.8
Average CWD per patient
Tairawhiti
Jul to Dec 04
CWDs
Average CWD per patient
Lakes
2003/04
Patient
Number
s
6.7
6.4
6.9
6.8
7.0
Midland Region Cardiac Services Plan - 2006
Table 27.
Actual treatment thresholds, discharges and standardised discharge ratios by cardiac unit for CABG and
angioplasty patients treated July 2002 – June 2003
Standardised Discharge
Number of Discharges
Ratio (for ‘catchment’ DHBs)
Actual
Treatment Treated at Unit Treated at Unit
Threshold for
(from all
(from catchment
Cardiac Unit
CABG
CABG
Angioplasties
locations)
DHB's)
Auckland
38
1773
1698
1.134
0.866
Waikato
35
844
863
0.797
0.754
Wellington
40-45
1112
1177
0.891
0.927
Christchurch
47-52
1016
1017
0.965
1.559
1.421
1.424
Dunedin
48
588
578
Bold figures represent those significantly under the national SDR
Shaded figures represent those significantly over the national SDR
Increasing complexity is believed to be because ‘simpler’ cases are undergoing PCI and greater numbers of
older patients with more co-morbidities are being accepted for cardiac surgery. A recent review of Waikato
cardiac surgery indicates that the increasing complexity of cases seen at Waikato Hospital is comparable to
that seen in other cardiac surgical units.
The number of discharges in Table 27 translates into CABG pmp ranging from 1108 for Waikato to 2023 for
Dunedin based patients. The New Zealand rate in 2003 was 1333 CABG pmp undertaken in public
facilities.
Table 28.
Numbers of patients discharged from DHB hospitals, with for acute and elective cardiothoracic surgery
2002/03
DHB
Waikato
Patient Numbers
Patient Numbers
Patient Numbers
Elective
Acute
Elective
Acute
Elective
374
240
377
189
187
85
39.1%
66.6%
33.4%
68.8%
60.9%
6.7
804
57.1%
Av. CWD per Patient
Capital &Coast
Av. CWD per Patient
604
963
42.9%
74.4%
31.3%
7
332
458
25.6%
78.3%
7
127
21.7%
7.1
301
544
347
431
150
223
35.6%
64.4%
44.6%
55.4%
40.2%
59.8%
5.9
6.2
7
299
263
333
196
144
111
53.2%
46.8%
62.9%
37.1%
56.5%
43.5%
Av. CWD per Patient
Otago
6.9
7.1
Av. CWD per Patient
Canterbury
Jul to Dec 04
Acute
Av. CWD per Patient
Auckland
2003/04
6
6.3
5.4
254
147
263
166
149
73
63.3%
36.7%
61.3%
38.7%
67.1%
32.9%
6.5
6.5
6.5
Note:
■ Based on interim data provided by NZHIS.
■ Total Midland numbers may not match the Waikato numbers in different tables as patients may
receive surgery in other centres.
- 79COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
The information indicates that Waikato is currently providing lower access to cardiac surgery than other
public hospitals in New Zealand. The Waikato cardiac surgery rate pmp in 2002_03 = 788, 2003_04 = 722
and 2004-05 = 690 (July – Dec).
Table 29.
Numbers of Midland DHB domicile residents discharged from all hospitals, for cardiothoracic surgery
2002/03
DHB
Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
Midland Total
% Total
2003/04
Jul to Dec 04
Acute
Elective
Acute
Elective
Acute
81
57
102
60
50
Elective
23
58.7%
41.3%
63%
37.0%
68.5%
31.5%
46
32
49
22
23
9
59%
41.0%
69%
31.0%
71.9%
28.1%
12
12
24
12
13
4
50%
50.0%
66.7%
33.3%
76.5%
23.5%
41
27
31
13
21
11
60.3%
39.7%
70.5%
29.5%
65.6%
34.4%
212
121
188
100
98
48
63.7%
36.3%
65.3%
34.7%
67.1%
32.9%
392
249
394
208
205
96
61.2%
38.8%
65.4%
34.6%
68.1%
31.9%
Note:
■ Proportion of elective cardiothoracic surgery undertaken at Waikato Hospital lower than Capital and
Coast and Canterbury DHBs, similar to Otago but higher than at Auckland.
■ Elective access has decreased since 2002-03.
■ Access to acute versus elective service across the region is relatively equitable.
As technology improves PCI options and outcomes, it is likely that fewer patients will be treated with cardiac
surgery. However, patients with multiple co-morbidities will continue to drive a need for CABG, at least for
the near future.
Table 30.
Predicted coronary artery bypass grafts for the Midland Region 2006 - 2011
pmp
Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
Midland Total
750
2006
151
77
34
78
255
595
750
2011
161
78
33
76
260
609
750
2016
170
79
33
74
265
621
Notes:
■ 750 pmp is the UK recommended CABG rate pmp, however this may underestimate demand until
the PCI rate increases to the recommended rate of 1400 pmp. For example if 1000 pmp is
required then 793 CABG should be undertaken for the Midland population.
■ 750 pmp includes all CABG surgery – public and private. However it must be recognised that
patients may receive cardiac surgery in private at a lower acuity than the public system.
■ 750 pmp is marginally higher than the current Waikato Hospital rate of 722 pmp in 2003-04.
■ CCN Ontario recommend 110 pmp > 20 years, this results in a recommendation of 607 CABG for
the Midland region in 2006 – similar to the volume based on 750 pmp.
- 80COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
CURRENT SITUATION
The projected decrease in CABG procedures means there are not likely to be any new cardiac surgery units
established in New Zealand public hospitals in the foreseeable future.
A review of the Waikato cardiac surgery unit in 2004 resulted in a number of recommendations. Those
under consideration include:
■ Staffing levels:
– 4th cardiac surgeon;
– ICU nursing increase;
– Locum cardiac surgical cover.
■ Restructure of cardiac surgery and cardiology as Cardiac Services.
Ongoing issues facing the Waikato Cardiothoracic Surgery unit include access to ICU beds and theatre staff
recruitment and retention in order to meet the competency needs when dealing with patients with high comorbidity undergoing surgery.
Recommendations
Coronary bypass graft surgery predicted numbers at 750 pmp should be reviewed if the recommended level
of PCIs cannot be reached in the short term to work towards attaining a total revascularisation procedure
rate of 2150 pmp.
7.4.
Cardiac Rehabilitation
The World Health Organisation defines cardiac rehabilitation as: the rehabilitation of cardiac patients is the
sum of activities requires to influence favourably the underlying cause of the disease, as well as the best
possible physical, mental and social conditions, so that they may, by their own efforts preserve or resume
when lost, as normal a place as possible in the community. Rehabilitation cannot be regarded as an
isolated form of therapy but must be integrated with the whole treatment, of which it forms only one facet,
(WHO 1993).
Comprehensive cardiac rehabilitation programmes have been shown to reduce mortality from CHD, reinfarction rates and hospital admissions and improve quality of life for the patient and their family. A
Cochrane review of cardiac rehabilitation showed a 31% reduction in cardiovascular disease mortality for
exercise-based programmes and 26% for comprehensive cardiac rehabilitation61.
The New Zealand Cardiac Rehabilitation guidelines were published in August 200217. These are
comprehensive guidelines that include recommendations for identification of patients, programme format,
content and settings, audit and evaluation. The cardiac rehabilitation guideline summary is attached as
Appendix Eight.
Three levels of cardiac rehabilitation are recommended:
Phase I – Inpatient rehabilitation
■ Phase I rehabilitation in hospital includes early mobilization and education helping the patient,
spouse, partner, whanau and family begin to develop an understanding of heart disease. The
patients should be given a discharge plan (with a copy sent to the GP) usually offering medical
follow-up, information and referral to Phase II programmes.
Phase II – Outpatient rehabilitation (from one or two up to twelve weeks after discharge)
■ Phase II rehabilitation is a supervised programme beginning as soon as possible after discharge
and referral. Programmes should include:
– An exercise component (home activity and/or supervised exercise sessions);
– Educations sessions aimed at increasing understanding of the disease process, risk factors,
treatment and nutrition advice;
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Midland Region Cardiac Services Plan - 2006
– Guidance for the resumption of physical, sexual and daily living activities, including work;
– Psychosocial support.
Phase III – Long-term maintenance
■ Phase III promotes long-term maintenance of the skills and behaviour changes learned within
Phase I and II.
CURRENT SITUATION
In 2002 a review of cardiac rehabilitation services in New Zealand was undertaken and published in the New
Zealand Medical Journal in 200462. This study showed at that time there were 41 centres in New Zealand
offering phase I and II cardiac rehabilitation. There was variation in facilities, equipment, format of the
service, duration of the programmes and the number of sessions offered. The quality of current service
provision was difficult to assess. Programme performance indicators (e.g., participation rate, drop-out rate)
are kept by some rehabilitation centres, but patient outcome measures, (e.g., quality of life, re-hospitalisation
rate, mortality) were kept by very few.
The 2002 New Zealand audit identified:
■ Of 2001 eligible patients, 1085 (54%) were not referred for phase I or phase II cardiac
rehabilitation;
■ 763 patients (38%) were referred to phase II cardiac rehabilitation;
■ 198 completed four or more sessions, only 9.9% of the total eligible patients;
■ Those with no access to transport, being female, older and/or a diagnosis of heart failure were less
likely to be referred to either a phase I or phase II programme. Ethnicity did not affect referral
although age and socioeconomic status did affect completion.
No specific information has been provided to indicate changes to the DHB programmes since the audit was
reported or the guidelines implemented.
Table 31.
Midland cardiac rehabilitation programmes
DHB
Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
Tauranga
Whakatane
Rotorua
Taupo
Gisborne
New Plymouth
Hawera
Hamilton
Matamata
Taumaranui
Te Awamutu
Te Kuiti
Thames
Tokoroa
Phase II
Outpatient
Phase III
Support
Heart Foundation
Affiliation
3
3
3
Three
Two
Two
Two
One
Two
One
Three
One
One
One
One
One
One
Yes
One
One
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Yes
No
intermittent
3
3
3
3
3
No
3
No
No
Each of the Midland DHB facilities run phase I rehabilitation through Ward staff or cardiac educators. Each
DHB funds a Phase II cardiac rehabilitation programme, although concerns have been expressed that these
do not meet the recommendations of the Cardiac Rehabilitation guidelines in a variety of ways, particularly
with regard to access for patients outside the main centres. A number of the educators within the region
provide a telephone follow-up and advise service for patients, including those unable to attend classes. It
- 82COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
should be noted that patients receiving cardiac treatments in private may also be referred to hospital-based
phase II cardiac rehabilitation programmes.
Phase III programmes are primarily independent ‘cardiac clubs’, which act as support groups. A Directory of
Cardiac Rehabilitation Programmes is available on the Heart Foundation website.
http://www.heartfoundation.org.nz/. This directory indicates there are there are 22 support groups in the
Midland region, of which 17 are affiliated to the Heart Foundation. See Table 31.
Phase II issues, identified during consultation for this plan, include:
■ Long waiting list for rehabilitation (> 4 months) – Tauranga;
■ Large classes (30+) – New Plymouth;
■ Programmes generally held during normal business hours (all);
■ Few classes outside main urban areas;
■ Transport for disabled and older patients (note the Heart Foundation recently established a pilot
transport service in the Western Bay of Plenty to transport patients from outlying areas (Katikati
and Te Puke) to the cardiac rehabilitation programme in Tauranga);
■ Attendance of Māori;
■ Different team mix across the region, most include nursing and physiotherapists, few include
community psychologists or counselors;
■ Some but informal and inconsistent linkages to Disease State Management (DSM) and community
nurses;
■ Lack of linkages between primary and secondary/tertiary services
■ Database to enable audit and monitoring of referred patients against attendance and outcomes e.g.
further hospital admissions, death;
■ Linkages across region and support for individuals practicing alone have stopped due to lack of
leadership and support.
Table 32.
Cardiac rehabilitation attendance data for selected programmes
Site
Tauranga
2003
#
2004
%
#
%
Total invitations issued
241
304
Total attendees
151
62.7%
206
67.8%
Attended 4 or more sessions
127
84.1%
133
64.6%
Total clinic visits
770
85.0%
936
85.5%
DNA any sessions
90
37.3%
98
32.2%
Rotorua
Total invitations issued
Total attendees
Unknown
Unknown
66
70
Attended 4 or more sessions
48
72.7%
52
74.3%
Total clinic visits
294
48.4%
343
81.6%
DNA any sessions
Unknown
Unknown
New Plymouth
Total invitations issued
584
Total attendees
161
Attended 4 or more sessions
27.6%
Unknown
Total clinic visits
755
93.8%
DNA any sessions
423
72.4%
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Midland Region Cardiac Services Plan - 2006
Site
2003
2004
Gisborne
Total invitations issued
70
Total attendees
40
57.1%
Attended 4 or more sessions
31
77.4%
Total clinic visits
202
84%
DNA any sessions
15
21.4%
New Zealand
February 2002
Attended four or more sessions
26.0%
DNA any sessions
58.0%
63
Victoria Australia
1998
Attendance of eligible pts
44.5%
5 year survival improvement of attendees
35%
Queensland, Australia
1999_2000
Eligible patients referred to Cardiac Rehab
49%
Completed programme
<33%
Note:
■ This information represents class attendance data supplied only, no data on telephone follow-up
services has been included;
■ The Cardiac Rehabilitation Guidelines recommend data collection for performance indicator and
audit purposes, however there is no national, regional, or even local database available to support
this;
■ Data availability is variable within DHBs and across the region.
■ Waikato DHB ran 48 classes in 2004 & 2005 but the data did not provide a breakdown of class
attendances;
■ Outcomes from current programmes would be difficult to assess due to lack of information.
Figure 14.
Cardiac rehabilitation attendee by ethnicity percent for selected Midland DHBs
100.0%
80.0%
60.0%
40.0%
20.0%
2003
Western Bay of Plenty
Eastern Bay of Plenty
2005
Lakes
Tairawhiti
Total
Unknown
Pacific Is
Other
Maori
European
Unknown
Pacific Is
2004
- 84COPYRIGHT © MIDLAND DHBS, 2005
Other
Maori
European
Unknown
Pacific Is
Other
Maori
European
0.0%
Midland Region Cardiac Services Plan - 2006
Figure 14 shows the ethnicity of any cardiac rehabilitation class where this has been provided. This gives no
indication of the expected percent of attendance by ethnicity, as in most cases the ethnicity of non-attendees
is not, or has not been made, available.
A challenge facing the DHBs is to provide phase II cardiac rehabilitation programmes to: Māori, those living
outside the main centre, and heart failure patients. Currently all programmes in the Midland region are run
by hospital providers. The guidelines recommend three options – hospital based, primary care and homebased.
■ Hospital-based programmes, in general, have good access to a multidisciplinary team and provide
services to those patients who live within the urban areas.
■ Community – based programmes are an option for rural areas, however, may have less access to
the full range of disciplines recommended and there is a need to up skill the workforce. The
evolution of PHO’s may support the development of PHO based specialist staff with the support of
hospital cardiac nurse educators.
■ Home-based cardiac rehabilitation programmes are useful for those who are unable to attend a
group session. This is a labour intensive programme that generally relies on one individual rather
than a team approach.
The Ontario Cardiac Care Network has predicted patient numbers for cardiac rehabilitation services. They
based these on 40% of cardiac hospitalisations being potentially eligible for cardiac rehabilitation, with 80%
attending, plus an additional 20% for non-hospitalised referrals. This volume equaled 0.4% of the adult
population > 19 years in 2001 with an additional 5000 (15%) annual increase as the service is able to deliver
to a great proportion of the hospitalised population.
Using predicted angiography and PCI volumes rather than hospitalisations, plus heart failure hospitalisations
the volumes shown in Table 33 rehabilitation patient numbers are predicted for the Midland region. To
provide the volume of services predicted, increased resources would be required in each DHB. What is not
included in this prediction is the patient domicile within the DHB, which will impact on the service
development required. This is a very high level estimate only and would require reworking in consultation
with staff before acceptance of these volumes.
Table 33.
Predicted Midland DHB patient numbers for cardiac rehabilitation
2004
Current
2006
IHD
Heart
Failure
2011
Total
IHD
Heart
Failure
2006
Total
2011
Expected numbers
based on 0.4%
population >19 years +
annual increase
Bay of Plenty
620
693
222
915
736
256
992
569
Lakes
130*
351
111
462
358
128
486
282
453
Tairawhiti
70
155
58
212
152
63
215
119
191
Taranaki
161
358
136
494
349
150
499
296
486
1512
3556
Waikato
1168
349
1516
1192
394
1585
941
Totals
2724
876
3600
2787
990
3777
2207
914
Note:
■ Current volumes are for IHD and generally do not include HF;
■ Current volumes for Bay of Plenty are referred volumes;
■ Taranaki volumes are for the New Plymouth cardiac rehabilitation programme only (excludes
Hawera);
■ Current Lakes are actual patient attendee volumes rather than referred patient number.
■ Using 0.4% of the population greater than 19 years underestimated the volumes for 2006 when
- 85COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
compared with the estimate based on treatment volumes, however adding a 12% annual increase,
leads to similar volumes by 2011. This equals 0.44% of the predicted Midland population in 2011.
Recommendation
A review of all Midland DHB phase I and phase II cardiac rehabilitation programmes be undertaken against
the New Zealand Cardiac Rehabilitation Guidelines.
Options for providing community or home-based rehabilitation be undertaken to ensure that all eligible
patients (including rural, Māori, Pacific peoples, elderly and heart failure patients) have access to cardiac
rehabilitation.
A regional coordination model for the delivery of cardiac rehabilitation services that would provide
programmes close to home and promote access to cardiac rehabilitation in groups traditionally
underrepresented; high quality central data collection; the creation of a district or regional cardiac
rehabilitation registry to allow future planning, coordination, monitoring and evaluation of services in Midland.
Establish a regional network of rehabilitation staff to encourage peer support and education activities.
- 86COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
8.
Acute Coronary Syndrome
Acute coronary syndromes (ACS) are divided into unstable angina (UA), non-ST segment elevation
myocardial infarction (non-STEMI associated with myocardial necrosis), and ST segment elevation
myocardial infarction (STEMI).
Papers published in the New Zealand Medical Journal in 20048,9,10 looked at the differences in the
presentation and management of ACS patients presenting to hospital facilities across New Zealand. These
papers showed that general physicians tended to provide more conservative management of NSTEMI
patients, that generally there were low levels of investigations, evidence-based treatments and
revascularisation for ACS patients and this varied significantly between facilities with and without intervention
facilities.
Treatment of ACS is a constantly and rapidly evolving field. The Midland region currently uses New Zealand
guidelines for the management of ACS which are based on European Cardiac Society and ACC/AHA
Guidelines. The Cardiac Society, Ministry of Health, and the New Zealand Guidelines Group are developing
new ACS guidelines for New Zealand following a review of international research. This work is expected to
be published this year. In the interim the angioplasty recommendations included below, are based on
principles derived from the European Society of Cardiology Guidelines for Percutaneous Coronary
Interventions published March 200564:
Principles for the treatment of Acute Coronary Syndrome:
1. Appropriate treatment in the community as early as possible (following symptom development) where
there may be delay in access to trained professionals;
2. Primary angioplasty is the treatment of choice for STEMI and should be undertaken within 12 hours of
the onset of symptoms when presenting to Waikato Hospital where interventional facilities are available;
3. Where access to primary angioplasty is >3 hours from presentation, thrombolysis is the treatment of
choice for STEMI;
4. Patients with contraindications to thrombolysis or failure of thrombolysis 45-60 minutes after
administration, should be immediately transferred to Waikato Hospital for primary or rescue angioplasty
providing transport can be achieved expeditiously;
5. After thrombolysis, routine angiography (within 24 hours if possible) is a strategy increasingly
recommended in international guidelines, even if the patient is asymptomatic and without demonstrable
ischaemia. Note this has significant resourcing implications;
6. If an interventional facility is not available within 24 hours, patients who have received successful
thrombolysis, with evidence of spontaneous or inducible ischaemia prior to discharge, should be
referred for coronary angiography and revascularisation as appropriate;
7. Patients with non-ST elevation acute coronary syndrome (Unstable angina and non-STEMI) require
further risk stratification.. A clear benefit from early angiography (<48 hours) and, when required,
angioplasty or CABG surgery has been reported only in the high-risk groups;
8. To enable appropriate treatment, an efficient and coordinated transport service across the region is
critical.
Figure 15 shows a flow diagram of the diagnostic and treatment options for STEMI and non-STEACS
patients.
- 87COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
Figure 15.
Acute Coronary Syndrome flow diagram
ACUTE CORONARY SYNDROME
NSTEACS
STEMI
REPERFUSION
NSTEMI
UAP
Risk Stratify
PRIMARY PCI
THROMBOLYSIS
HIGH RISK
LOW RISK
Risk Stratify
EXERCISE TEST
ANGIOGRAPHY
HIGH RISK
LOW RISK
REVASCULARISATION
MEDICAL TREATMENT
STEMI – ST Elevation Myocardial Infarction
NSTEACS – Non-ST Elevation Acute Coronary Syndrome
UAP - Unstable Angina Pectoris
8.1.1. ST Elevation Myocardial Infarction (STEMI)
When patients with acute chest pain are first seen, the working diagnosis is that they are suffering from an
acute coronary syndrome. The 12-lead electrocardiogram (ECG) is at the center of the decision pathway for
management since it permits distinction of those patients presenting with ST-segment elevation from those
presenting without ST-segment elevation. Serum cardiac biomarkers are obtained to distinguish unstable
angina from non-ST-segment MI (NSTEMI)) and to assess the magnitude of an ST-segment elevation MI
(STEMI).
The prognosis in STEMI is largely related to the occurrence of two general classes of complications: (1)
electrical complications (arrhythmias) and (2) mechanical complications ("pump failure"). Most out-ofhospital deaths from STEMI are due to the sudden development of ventricular fibrillation. The vast majority
- 88COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
of deaths due to ventricular fibrillation occur within the first 24 h of the onset of symptoms, and, of these, over
half occur in the first hour. Therefore, the major elements of pre-hospital care of patients with suspected
STEMI include (1) recognition of symptoms by the patient and prompt seeking of medical attention; (2) rapid
access to individuals or a team capable of performing basic life support, including defibrillation; (3)
expeditious transportation of the patient to a hospital facility that is continuously staffed by physicians and
nurses skilled in managing arrhythmias and providing advanced cardiac life support; and (4) expeditious
implementation of reperfusion therapy. Reperfusion options of thrombolysis and primary PCI are discussed
in more detail later in this section.
The biggest delay usually occurs not during transportation to the hospital but between the onset of pain and
the patient's decision to call for help. This delay can best be reduced by education of the public by health
care professionals concerning the significance of chest pain and the importance of seeking early medical
attention. Increasingly, monitoring and treatment are carried out by trained personnel, local general
practitioners or ambulance paramedics, further shortening the time between the onset of the infarction and
appropriate treatment. General guidelines for initiation of fibrinolysis in the pre-hospital setting are included in
Section 8.3.1.
Patients who fail thrombolysis may require rescue PCI (see Principle 4) and this may be undertaken as
‘facilitated angioplasty’. In ‘facilitated angioplasty’, patients are given thrombolysis, followed by a platelet
glycoprotein IIb/IIIa receptor antagonist prior to angioplasty. There have been trials of facilitated angioplasty
compared with stenting, but to date none have convincingly demonstrated that the extra time and effort
involved are rewarded with improved outcomes compared with the much simpler strategy of placing a stent
at the outset65. It is possible that the results from facilitated angioplasty will depend largely on the timing of
presentation, with the most benefit likely to be with those patients presenting 2 to 3 hours after onset of
symptoms. Two large ongoing trials may provide definitive answers to these issues66.
8.1.2. Non-ST-Elevation Myocardial Infarction
The diagnosis of NSTEMI is established if a patient with the clinical features of unstable angina develops
evidence of myocardial necrosis, as reflected in elevated cardiac biomarkers. Approximately three times
more patients are admitted to hospital each year with NSTEACS (non-ST elevated acute coronary
syndrome – unstable angina and non-STEMI) than with STEMI.
Among patients with NSTEACS studied at angiography, approximately 5% have left main stenosis, 15%
have three-vessel coronary artery disease, 30% have two-vessel disease, 40% have single-vessel disease,
and 10% have no critical coronary stenosis; some of the latter have Prinzmetal's variant angina. Therefore
this group of patients requires further risk stratification to determine appropriate diagnostic and treatment
options. The Midland region has developed clinical guidelines to assist in this stratification. The timeliness
of the diagnostic and treatment procedures for this group of patients is currently restricted due to access to
catheter laboratories and staff.
8.2.
Emergency Care
Treatment and care for emergency cases, such as acute myocardial infarction (AMI) and cardiac arrest are
critical. In Australia around 25 percent of all people who have an AMI die within an hour of the first
symptoms, with over half of all deaths occurring prior to a patient reaching hospital67. The survival rate
doubles when a patient is treated in hospital within one hour of symptoms developing and the longer the
patient is without treatment the greater the risk of myocardial damage. The treatment of choice for AMI is
primary percutaneous intervention (PCI). Where this is not available within the recommended time-period
patients should receive thrombolysis.
In a cardiac arrest the sooner cardiopulmonary resuscitation (CPR) and defibrillation are given then greater
the chances of survival.
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Midland Region Cardiac Services Plan - 2006
One of the issues that leads to treatment delays is recognition of signs and symptoms of cardiac events.
This applies both to the individual in recognising the earliest signs and to the community at large in
recognising and acting appropriately.
8.2.1. Community First Response
The Midland region covers a large geographic area with many rural communities that do not have rapid
access to health professionals. A number of these areas are also popular holiday destinations at which time
the populations increase significantly.
Basic life support [cardiopulmonary resuscitation (CPR)] initiated by a trained layperson until medical or
ambulance arrives, can double the chance of successful resuscitation following cardiac arrest. A New
Zealand telephone survey of 400 subjects looked at prior training, knowledge, and attitudes towards
resuscitation. The study concluded that although attitudes of the community toward CPR are positive,
theoretical knowledge relating to basic CPR is poor. This suggests that present community CPR
educational strategies have limited efficacy68.
Defibrillation is the definitive treatment, but is rarely successful if the patient has been in ventricular fibrillation
(VF) for longer than 10 mins, with 7-10% of patients lost for every minute that elapses. The automatic
external defibrillator (AED) automates many of the stages in performing defibrillation without requiring
decisions by the first responder. The simplicity of the AED allows a wider range of first responders to
perform defibrillation, and may consequently improve survival from out of hospital cardiac arrest.
A recent review identified eight controlled clinical trials in the Cochrane Library that compared AED use to no
AED use, or to standard basic life support (BLS) interventions. Most of the studies had small sample sizes,
which made it difficult to detect a significant difference in survival rates. A meta-analyses or larger
prospective trial would need to be conducted to determine the impact of AED use by first responders on
survival from out of hospital cardiac arrest. However, in these trials the use of AEDs by first responders
increased the probability of survival from out of hospital cardiac arrest in seven of the eight studies69.
AED technology is well proven in a number of countries around the world70. The American Heart
Association, in conjunction with a variety of other national and international organizations, developed the
International Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiac care, which
recommend:
■ Healthcare workers with a duty to perform cardiopulmonary resuscitation should be trained,
equipped, and authorised to perform defibrillation.
■ Public access defibrillation should be established:
– When the frequency of cardiac arrest is such that there is a reasonable probability of the use of an
AED within five years;
– When a paramedic response time of less than five minutes cannot be achieved;
– When the AED can be delivered to the patient within five minutes.
England’s Coronary Heart Disease NSF71 standard five aims that: ‘people with symptoms of a possible heart
attack should receive help from an individual equipped with and appropriately trained in the use of a
defibrillator within 8 minutes of calling for help, to maximise the benefits of resuscitation should it be
necessary.’ The Department of Health had trained 6000 people in CPR and the use of an AED, by Dec
2003 and aimed to provide 3000 AEDs in public places around the country by the end of 200472.
The New Zealand Resuscitation Council (NZRC) policy states73: “The availability of automatic external
defibrillators (AED's) provides the technological capacity for early defibrillation both by ambulance crews and
by lay responders. To achieve the earliest possible defibrillation, the New Zealand Resuscitation Council
(NZRC) therefore endorses and promotes the concept that non-medical individuals be trained, allowed and
encouraged to use defibrillators for the management of cardiac arrest.”
The NZRC recommends that all resuscitation personnel with a professional responsibility to respond to
persons in cardiac arrest be authorised, trained, equipped, and directed to operate a defibrillator. This
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recommendation includes all first responding emergency personnel (NZRC Levels 3,4,5,6 and 7), in both the
hospital and out-of-hospital setting.”
CURRENT SITUATION
There are few formal approaches to CPR training and maintenance or AED’s in the community. A number
AED’s have been donated for community use around the region but there is no central register of these
devices. A full analysis of where AED’s are situated throughout the region has not been undertaken.
Examples of programmes in the Midland region include:
■ Waikato DHB has established Community First Response Groups (First responders and First Aid
Kits in Rural Communities). The aim is to enable rural communities to have appropriates trained
people (First Responders) to assist in emergencies in rural areas where an ambulance will taken
longer than 20 minutes to respond to an event. Initial and ongoing training and First Aid Kits are
available to the First Responders through St John Ambulance under contract to the DHB.
Communities close to Te Kuiti and Taumaranui are the initial pilot sites.
■ Rotorua has a public access defibrillator project which has two components:
– Teach the Rotorua community CPR, including use of AEDs
– Place AEDs in areas that are 15 minutes from the Ambulance station or where organisations have
purchased there own. There are now 14 units around the Rotorua area (2 Māori Health providers,
Fire Rescue unit, volunteer fire units, 2 x GP practices, RSA, City Focus, Aquatic Centre, golf
course, St John events volunteer staff, local physician).
This project is lead by Lakes DHB physician, Kingsley Logan and St John Area Manager, Rob Gardiner
with funding through a local Rotary Club. St John Ambulance is involved in monitoring and training.
The AED’s have been used on a number of occasions with at least two lives saved.
■ Bay of Plenty DHB have proposed a Marae and Community Assistance Programme with a pilot site
to be initiated in the Te Whānau A Apanui area in the Eastern Bay of Plenty. The proposed
programme is to train laypersons within the area to provide first response emergency care until
medical or ambulance services can be accessed. The costs identified include $5000 one-off
development costs, $3000 for initial staff training and updates, $7000 per AED.
Western Bay of Plenty has St John supplied (community funded) AED’s at the Mount Action Centre,
Tauranga Airport, 3 medical centres, BoP Polytechnic, Tauranga Citizen’s Club & Mount Mainstreet
Office.
St John Ambulance provides CPR and AED initial and ongoing training and maintenance (mainly battery
checks and replacement every 2-3 years at approximately $400 each) for all AED’s sold through the
organisation. However, a number of other companies supply AEDs and the training and maintenance of
equipment by these organisations has not been investigated. See Appendix 6 for a list of the Fire First
Response and Co Response Units and PRIME locations that have AEDs.
A Home Automated External Defibrillator Trial (HAT) is underway funded by the United States National
Institutes of Health (NIH). The trial is being conducted in the United States, Canada, Australia, UK, and New
Zealand and is intended to enrol 7000 patients over 2.5 years and follow the patients for an additional two
years. Patients will be randomised equally between home AED are and the control arm. Waikato and
Tauranga Hospitals are participating in this trial.
Recommendation
The Midland DHBs should review CPR training and access to AEDs and trained personnel in the
community, in particular in the rural areas when there may be delay for emergency first response.
DHB policy on access to first response services in the region should be developed. The ECCT should be
involved, if not responsible, for the development of this policy.
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8.3.
Thrombolysis
8.3.1. Pre-hospital thrombolysis
Early treatment with thrombolysis (within four hours) for eligible patients has been shown to uce morbidity
and mortality from myocardial infarction. Meta-analysis confirms a reduction of mortality (all in-hospital
cause) by 2% per hour of earlier treatment74. Guidelines for the delivery of thrombolysis by general
practitioners16 have been developed and endorsed by the NZ Regional Committee of the Cardiac Society of
Australia and New Zealand and published in the New Zealand Medical Journal. Advantages demonstrated
in the Coromandel trial of pre-hospital thrombolysis include75:
■ Decreased bed-stay (5.2 vs. 7.1 bed days);
■ Quicker access to thrombolysis c.f. hospital administration (135 vs. 270 minutes);
■ Transport savings – only unstable treated patients require helicopter transport c.f. all non MI
patients not treated with thrombolysis;
The regional Emergency Care Coordination Team (ECCT) service specification indicates that ECCT’s
should endeavour to address such issues as: new developments such as pre-hospital procedures (e.g.
thrombolysis) and use of mobile telemetry (e.g. ECG’s).
The Coronary Heart Disease NSF76 standard five aims that: people thought to be suffering from a heart
attack should be assessed professionally and, if indicated, receive aspirin. Thrombolysis should be given
within 60 minutes of calling for professional help. As at December 2003 there were, 17 ambulance trusts
trained and equipped to provide pre-hospital thrombolysis, with a further 11 expected by the end of 200477.
CURRENT SITUATION
Thrombolysis is used in ST-segment-elevation MI’s (STEMI) rather than non-STEMI. There is some
anecdotal information that the number of STEMI’s is decreasing. While PCI is now determined as the
treatment of choice, where patients cannot reach an intervention facility within the required timeframe (2- 3
hours from presentation with chest pain – see section on angioplasty for more information) thrombolysis
should be given promptly. Where access to hospital is greater than one hour the option of community
thrombolysis should be available
Waikato DHB is the only Midland DHB currently funding pre-hospital thrombolysis. Six rural settings –
Coromandel, Whitianga, Whangamata, Kawhia, Te Kuiti, and Matamata are currently involved. A review will
be undertaken in 2005 to identify other potential sites in Waikato. The contract for these sites is managed
through the New Zealand Rural Institute of Health. This contract includes service coverage as agreed by the
Midland ECCT and Waikato DHB, GP initial upskilling and annual education, equipment maintenance and
drug kit recall protocols
Reteplase, the thrombolytic agent currently in use, is funded through the PHARMAC Hospital Schedule as a
Discretionary Community Supply Pharmaceutical.
The MoH undertook a cost utility analysis in 2001, which indicated the equipment costs, totalled $21,000 for
set-up. It is understood that there are now new companies in the market, which has decreased the cost of
mobile electrocardiography, and the use of a cell phone is no longer recommended, so that current costs are
approximately $16,000. Annual costs include equipment maintenance (approximately $400 for the
defibrillator and mobile ECG) and replacement of used or expired drug kits ($3000 per patient). A dedicated
computer and software is required at the site the ECGs are read.
Recommendations
The Midland DHBs should undertake a review of the region to determine localities where access to a facility
providing thrombolysis is greater than one hour.
That community thrombolysis programmes should be rolled out across the region.
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The option for Waikato coronary care unit receiving all ECGs should be considered.
The option for the NZ Rural Institute to hold the contract for community thrombolysis for all DHBs in the
Midland Region should be considered.
8.3.2. Hospital thrombolysis
The acute nature of myocardial infarction has required that appropriate patients should receive thrombolysis
within 60 minutes of the onset of symptoms – call-to-needle time is used as the audit criteria as the health
providers have less control over the time from symptom development to call for help. Once a patient arrives
in a facility there is little time to transfer patients from the emergency department to Coronary Care (CCU) or
Intensive Care units (ICU). The door to needle time of no more than 30 minutes is recommended and is
critical to ensure the best outcome for the patient20, 42. To meet this timeframe it is recommended that
thrombolysis should be administered at the department of admission – in most cases this will be the
emergency department unless there is a direct admission to the CCU.
The practice at each facility has not been reviewed for this plan, however it is known that at least one facility
undertook an audit in 2004, which showed average door-to-needle time of greater than 30 minutes.
Thrombolysis is administered in the CCU at this facility.
Recommendation
In the absence of a New Zealand agreed standard the Midland DHBs cardiologists, physicians, and
emergency medicine specialists should agree a standard time in which thrombolysis should be administered
to appropriate AMI patients – call-to-needle time and door-to-needle time.
Each facility should undertake regular audit of door-to-needle time against the agreed criteria.
Each facility should undertake regular audit of call-to-needle time against the agreed criteria.
8.4.
Primary Percutaneous Coronary Interventions
When coronary angioplasty is performed on patients with an acute myocardial infarction it is called primary
PCI The outcomes of various international studies continue to promote the effectiveness of primary PCI. A
review, incorporating analysis, interpretation and comparison of scientific literature prepared by the Medical
Advisory Secretariat of the Ontario Ministry of Health and Long-Term Care, was completed in August
2004.78 The recommendations from this review include:
■ Based on a meta-analysis of 22 prospective randomised controlled trials, there is level 1 evidence
that primary angioplasty significantly improves survival by 2 percentage points (7% to 5%) and
combines outcomes of re-infarction, stroke and mortality by 6 percentage points (14% vs 8%),
compared to in-hospital thrombolysis;
■ The advantage for primary angioplasty becomes less significant with time from onset of symptoms
and should ideally be performed within 120 minutes following the onset of chest pain;
■ Primary angioplasty and early thrombolysis are complementary technologies, which can improve
outcomes for patients with acute myocardial infarction (AMI) and ST elevation myocardial infarction
(STEMI) when either are administered within a 120 minutes from the onset of chest pain;
■ Every effort should be made to decrease the access time for patients with AMI from the onset of
symptoms to administration of thrombolysis or primary angioplasty.
Many other studies have been published since this meta-analysis was undertaken. The results of a recent
prospective, multinational (including New Zealand), observational registry study79, published in the British
Medical Journal, February 2005, looked at the relation between access to a cardiac catheterisation
laboratory and clinical outcomes in patients admitted to hospital with suspected acute coronary syndrome.
The conclusion was to support the current strategy of directing patients with suspected ACS to the nearest
hospital with acute care facilities, irrespective of the availability of a catheterisation laboratory, and argue
against early routine transfer of these patients to tertiary care hospitals with interventional facilities. This
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study also questions whether the results of some of the randomised trials are at variance with this result due
to exclusion of high-risk patients. Published and local cardiologists responses to the article, indicate
major limitations to the study interpretation80. All responses indicated, given the evidence, they support
the call to improve and expand the resources for routine direction of these patients to regional facilities with
the specialised abilities to implement this PCI.
It is acknowledged that the ability to provide primary angioplasty at all facilities, is currently not feasible or
viable in the ‘real’ world’. In the interim the PCI recommendations below (approved by the Cardiology
Services Clinical Director), are based on principles derived from the European Society of Cardiology
Guidelines for Percutaneous Coronary Interventions published March 200581:
■ Primary angioplasty is the treatment of choice for STEMI and should be undertaken within 12 hours
of the onset of symptoms when presenting to Waikato Hospital where interventional facilities are
available;
■ Where access to primary angioplasty is >3 hours from the onset of symptoms, thrombolysis is the
treatment of choice for STEMI;
■ Patients with contraindications to thrombolysis or failure of thrombolysis 45-60 minutes after
administration, should be immediately transferred to Waikato Hospital for primary or rescue
angioplasty providing transport can be achieved expeditiously;
■ After thrombolysis, routine angiography (within 24 hours if possible) is a strategy increasingly
recommended in international guidelines, even if the patient is asymptomatic and without
demonstrable ischaemia. Note this has significant resourcing implications;
■ If an interventional facility is not available within 24 hours, patients who have received successful
thrombolysis, with evidence of spontaneous or inducible ischaemia prior to discharge, should be
referred for coronary angiography and revascularisation as appropriate;
■ Patients with non-ST elevation acute coronary syndrome (Unstable angina and non-STEMI) require
further risk stratification.. A clear benefit from early angiography (<48 hours) and, when required,
angioplasty or CABG surgery has been reported only in the high-risk groups;
■ To enable appropriate treatment, an efficient and coordinated transport service across the region is
critical.
8.5.
Transport
A critical component of cardiac services is patient transfer for acute treatment or inter-hospital transfer for, or
following treatment. Road transfer is provided by ambulance and air ambulance by a number of fixed wing
and helicopter services from within and outside the region.
First Response services are also provided by Fire Units and PRIME trained staff. See Appendix 6 for
locations in the St John Ambulance Midland region (excludes Taranaki).
One of the issues facing the cardiac service is ensuring those involved with patient transfer acknowledge the
urgent nature of specific transfers even after the patient has been stabilised. With the increasing use of
primary angioplasty, the number of patients requiring urgent transfer to Waikato Hospital is going to
increase. There are many anecdotal stories of patient transfer being delayed for various reasons including:
ambulance required for trauma, no ambulances available as all booked for patient transfer (no urgency
criteria), no one to sign off flight leading to 12 hour delay of transfer.
The Ambulance Delivery, Retrieval and Transfer Protocols were published in 2003 by the Ministry of Health,
Ambulance New Zealand, and ACC Healthwise, joint working party82. These protocols have been
developed for District Health Boards, Emergency Care Co-ordinating Teams (ECCTs), and Ambulance
providers in developing and implementing local protocols to implement Roadside to Bedside.
Recommendations are made in relation to the following:
■ Access to specialist skill set advice;
■ Arranging inter-hospital transfers;
■ Co-ordination of inter-hospital transfers – ease for clinicians;
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■ Organisation of inter-hospital transfers;
■ Outcome measures;
■ Alignment of existing protocols.
While the Midland ECCT have considered these protocols and do not intend to implemented them in their
entirety, it is critical for the Midland region to have a coordinated approach to patient transfer to ensure best
practice and best outcomes for the cardiac patient.
Ambulance
Services related to cardiac disease provided by Ambulance include:
■ Emergency response;
■ Transfer of patients – acute and inter hospital;
■ First aid training courses that include basic life support (CPR) education;
■ Automated External Defibrillator (AED) distribution, maintenance, and training.
Midland St John Ambulance staff are supportive of community first response including the use of AEDs.
Most cardiac patients from the Bay of Plenty and Lakes regions are transferred by road ambulance,
although there are areas in each of these DHBs (e.g. Te Kaha and Turangi) where delay in an ambulance
getting to the patient may lead to further delay in the patient receiving optimal treatment.
Air Ambulance
To be effective, the air ambulance network needs to be integrated with, and complement, both road based
ambulance services and the emergency care functions, inter-hospital transfers and other services of District
Health Boards.
CURRENT SITUATION
Currently air ambulance is used for most cardiac transfers (irrespective of the medical urgency) from
Tairawhiti and Taranaki to Waikato, while only urgent transfers are made by air ambulance from Bay of
Plenty and Lakes regions.
Organisation of transfers varies depending on the DHB. Estimates of the flights from Gisborne are: local
services 50%, Hawkes Bay service 25%, Waikato 25%. Taranaki utilise their own flight team for some
transfers and on other occasions use Auckland, Waikato and rarely Wellington services. The organisation is
undertaken by the local DHB and the lack of coordination continues to cause delays and consequently
impacts on patient outcomes. While there is no hard data on the issues, this in itself is a problem, as there is
no ability to measure the quality of the service from an overall perspective.
Most cardiac transfers are undertaken with a nurse with appropriately skills and training (Level 6 ACLS),
although there are occasions where the patient is unstable and a doctor may be required. Currently this
would be either the Waikato flight crew or the Auckland service. Waikato ICU staff were involved with 72
cardiac related transports in 2004.
A major concern for the Hamilton based air ambulance service is the availability of nursing staff for
predominantly cardiac transfers. There are many occasions when the Hamilton service cannot be accessed
due to nursing staff being unavailable. In 2004, of 23 requests for nurse-assisted cardiac transfers, nine
(39%) were declined due to the lack of nurse availability and were presumably carried out by other services.
Waikato nursing staff, from Waikato Hospital ICU and ED, participate in the Air Ambulance roster outside of
their normal Waikato rostered shifts. Currently there are sufficient staff to cover for often only two days per
week. Workload, and not the rate of pay, is cited as the reason for the difficulty in recruiting staff to this
roster. An additional concern is the medical supervision of these flights. Currently there is minimal medico
legal oversight of the transports. This is not a sustainable situation and requires a joint DHB and air
ambulance resolution.
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An option to overcome this situation has been proposed by Grant Bremner, Pilot/Manager, from the
Westpac Waikato Air Ambulance service in conjunction with the following Waikato Hosptial staff: Gerry
Devlin (Clinical Director Cardiology), Max Lynds (Operations Manager Cardiology Services), Sue Martin
(Clinical Nurse Leader Cardiology), John Torrance (Clinical Director ICU), Liz Singer (Operations Manager
ICU).
An outline of the proposal is provided here:
■ Regionally coordinated transport service from Waikato Hospital based on:
– Clinically driven time guidelines
– Appropriate level of care (Flight nursing skills, qualification) consistent with nationally expected
professional standards.
– A system that guarantees access to an appropriately skilled flight nurse labour resource to provide
a consistent quality transport system.
– Standard of aircraft (affordable, appropriate, accessible)
– A regional communication coordination of cardiac transport.
■ Establish the MU2 (recently purchased aircraft) as the lead aircraft based in Hamilton
– This aircraft is pressurised, has a cruise speed of 280kts, and a range of 1000 miles. A flight to
new Plymouth will take 20 minutes. A flight to Wellington will takes .45 minutes. The aircraft has
the ability to carry two stretcher patients.
■ Two flight nurses – total 1FTE employed by Waikato Hospital and seconded to the air ambulance
service.
– Remaining shifts undertaken at Waikato Hospital to ensure appropriate skills and training.
– The air ambulance service should not be an employer of medical or nursing staff within the current
service provision.
A full proposal to identify implications for the DHBs in relation to flight numbers and costs has yet to be
undertaken. It is anticipated that the need to timely flights to Waikato Hospital will increase as the evidence
for primary angioplasty grows, together with an ongoing need for rescue angioplasty following failed
thrombolysis. A review of when the option for nurse only flight crew is appropriate versus a medical flight
crew is also required.
The Midland Region EECT needs analysis of air ambulance services includes the regions cardiac service
requirements. The needs analysis includes recommendations relating to: communication systems, universal
despatch criterion, regional transport coordinator, transport teams at other hospitals, aviation medicine
trained flight teams, regional plans for transfer and retrieval of patients, etc.
Recommendations:
That ambulance triage criteria for cardiac patients be reviewed to ensure timely transfer to treatment facility.
A coordinated approach to all cardiac transport is required and a regional review should be undertaken to
determine options for the future.
That the Midland DHBs recognise the Midland ECCT air ambulance needs analysis incorporates the air
ambulance service needs for cardiac patient transfer within the region.
That a Midland DHB and air ambulance proposal be established that clearly identify implications for the
DHBs in relation to flight numbers and costs, together with efficiencies and benefits for patient care.
That Waikato DHB employ two flight nurses – total 1FTE to be seconded to the air ambulance service for
cardiac transfers. That the remaining shifts be undertaken at Waikato Hospital to ensure appropriate skills
and training.
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9.
Chronic Conditions
The National Health Committee has recently released a discussion paper83 entitled “People with Chronic
Conditions” which aims to link with other research and consultation undertaken in 2005 to:
■ Find out what helps and what hinders in living with chronic conditions;
■ Identify the key issues in supporting people with chronic conditions
■ Advise the Minister of Health on changes to improve how people are supported.
No date has been advised for the final report. However, themes identified through focus groups and
identified in the discussion paper are considered in the recommendations below.
Acute cardiac disease may lead to a chronic condition that will have a significant impact on the quality of life
of the individual. The most common chronic condition is heart failure. Rheumatic fever is included
specifically, as if managed inappropriately to prevent acute relapses, patients are likely to develop chronic
cardiac disease, generally valvular.
9.1.
Heart Failure
BACKGROUND
There is little current information on the epidemiology of congestive heart failure (CHF) in New Zealand or
Australia. Two of the reasons for this are the lack of a universally agreed definition, and difficulties in
diagnosis, particularly when the condition is mild. International literature consistently indicates a sharp
increase in prevalence with age, and a significantly higher rate in the male population84. In Australia, it is
estimated that about 4% of the population aged 45 or more have chronic heart failure85. The prevalence of
CHF has been shown to increase from approximately 1% in those aged 50 to 59 years, to over 50% in those
85 years and older18. The number of patients with CHF is expected to rise due to a number of factors:
■
■
■
■
Ageing of the population;
The projected increase in the number of elderly people with CHD and hypertension;
The decrease in mortality associated with myocardial infarction;
Improved diagnosis of CHF with the greater utilisation of sensitive techniques, such as
echocardiography and brain natriuretic peptides.
CHF is a common condition with a poor prognosis and leads to a number of debilitating symptoms for the
individual. The most common causes of heart failure are coronary heart disease (especially previous
myocardial infarction), and hypertension. Other common causes are cardiomyopathies (including alcohol
induced and idiopathic), genetic disorders, and valvular heart disease, e.g. rheumatic fever. The most
common cause for patients under 75-years is myocardial dysfunction resulting from AMI. People with
diabetes have a two – eight times greater risk of heart failure compared with people without diabetes.
The Australian Heart Foundation publication The Shifting Burden of Cardiovascular Disease in Australia86
indicates: heart failure has a high hospitalisation rate, approximately 25% of patients are readmitted within
one year of their first hospitalisation particularly in the elderly, hospitalisations are frequent, reoccur at a fast
rate and are often of a long duration.
Heart failure admissions to hospital increased by 5.6% for Midland domicile patients between 2001-02 and
2003-04. Figure 16 shows the breakdown by ethnicity of patients admitted between 2001_02 and 2004_05.
Note the 2004_05 figures are an extrapolation of year to date data as at 31 March 2005, for the full year.
Over the 2001-2005 period, the percent of admissions by ethnicity has remained stable with the majority of
heart failure admissions being European - 68-69% and 26-28% Māori. This relates to the ethnic proportions
of the Midland region of 70% European and 26% Māori. Admissions for heart failure are slightly higher for
males at 54% than females at 46%, this trend has remained consistent over the 2001-02 to 2004_05 period.
The New Zealand hospitalisation rate for Māori with heart failure is three times higher than for other New
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Midland Region Cardiac Services Plan - 2006
Zealanders. This trend is not reflected in the Midland data from NZHIS presented in Figure 16. Further
analysis of the data would be required to confirm or refute this.
Figure 16.
Heart failure admissions by ethnicity and Midland DHB of domicile
700
600
500
400
300
200
100
BoP
Lakes
European
Tairawhiti
Maori
PI
Asian
Taranaki
2004_05
2003_04
2002_03
2001_02
2004_05
2003_04
2002_03
2001_02
2004_05
2003_04
2002_03
2001_02
2004_05
2003_04
2002_03
2001_02
2004_05
2003_04
2002_03
2001_02
0
Waikato
Other/Not Stated
Life expectancy depends on how severe the heart failure is, whether its cause can be corrected, and which
treatment is used. About half of people who have mild heart failure live at least 10 years, and about half of
those who have severe heart failure live at least 2 years. Mortality is higher than most cancers.
International studies of OECD countries including New Zealand, suggest that CHF costs the health care
system between 1-2% of health care expenditure and this continues to rise. Hospital admissions account for
around two-thirds of the expenditure, so that most treatment programmes that reduce hospitalisations are
generally cost-effective. When nursing home care was included in the UK data the cost of heart failure rose
to 4% of all National Health expenditure.
A guideline for the Management of Health Failure: health professionals guide was published in December
200118 by the Heart Foundation, and endorsed by the New Zealand Guideline Group. The majority of heart
failure is diagnosed and managed in primary care, however certain patients may require specialist referral
where the diagnosis is uncertain, or the cause may be addressed through investigations or intervention. As
the condition deteriorates, some patients may require admission to hospital for acute management.
PRIMARY CARE
General practice manages the care of the majority of heart failure patients in the community. Many clinical
guidelines on assessing and managing heart failure have been published in recent years, including those for
Australia and New Zealand. An audit of prescribing for heart failure in Central Auckland general practice
concluded there was scope for improving prescribing as the percent of recommended drugs prescribed to
“at risk” patients were:
■ Warfarin – 51%;
■ Aspirin – 32%
■ β-Blockers – 9%
■ ACE-inhibitor – 96%
■ 38% patients prescribed ACE-I’s had no echocardiographic evidence of left ventricular dysfunction.
Barriers to diagnosing and managing heart failure in primary care have been explored in a review of 25
general practitioners from Victoria and South Australia87. This review looked at issues in relation to
diagnosis difficulties, low use of echocardiograms, low dose and low use of ACE inhibitors and low use of ß
blockers. The needs identified by general practitioners for improved heart failure diagnosis and
management include:
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■ Echocardiography:
– Improved access;
– Understanding of the role;
– Having knowledge of significance of specific findings.
■ Ace inhibitors and β-Blockers:
– When to use, when and how to titrate;
– Side effects and influence of comorbidities.
■ Patient – related issues:
– How to explain to patients the value of echocardiography and other treatments;
– Avoiding risk of medication side effects, especially if the patient is feeling well.
■ Communication:
– Better communication, especially when patients are hospitalized;
– Improved linkage with specialists.
Following the Auckland audit and the review in Australia, programmes were put in place to improve the care
of patients with heart failure. The Auckland Heart Care project required additional resources such as access
to echocardiograms, longer consultations, patient resources, rapid access to cardiologist advice, cardiac
nurse specialist, and patient visit for dose titration funding. The cost savings over 10 years (NPV) have been
estimated at $1.49 return for every $1 spent.
The Australian National Institute of Clinical Studies (NICS) has established a multi-faceted programme
aimed at improving assessment and diagnosis, pharmacological management, patient self-management.
Details of interventions and the Heart Failure Forum 2004 can be seen on the NICS website –
http://www.nicsl.com.au/projects.aspx
There is anecdotal evidence that targeting heart failure patients at, or before, their first hospital admission, for
education, support needs, and to improve clinical care, will lead to the greatest benefits. Approximately 25%
of heart failure patients are readmitted within one-year of their first hospitalisation and forty percent of
patients die within one year of their first hospitalisation88. Elderly patients may have frequent hospitalisations
that recur at a fast rate and are often of long duration.
REHABILITATION
Pharmacological management is the mainstay of heart failure management, however, care provided by
specialised nurses has been shown to improve outcomes for patients with chronic heart failure, significantly
reducing the number of unplanned readmissions, length of hospital stay, hospital costs, and mortality89. A
number of models of nursing services have been trialled, most based at a secondary care level where
patients are identified at admission. Programmes include, specialised nursing care; multi-disciplinary heart
failure clinics, exercise rehabilitation, the treatment of sleep disorders, depression, obesity and cachexia.
A multidisciplinary approach to heart failure care might include all or some of the following: cardiologist, GP,
case manager, pharmacist, dietician, physiotherapist, occupational therapist, social worker, psychologist /
counsellor. A 10-week multidisciplinary programme in Frankston Victoria, Australia demonstrated90:
■ Decreased admission rate of 16%,
■ Decreased readmission rate of 45%.
■ Length of stay decreased by 35%
■ Non-admitted ED presentations decreased by 61%
■ DRG placement from 16th to 24th.
A meta-analysis of nine randomised trials looked at the effect of exercise training on survival in patients with
heart failure due to left ventricular systolic dysfunction. The conclusion was that properly supervised medical
training programmes showed clear evidence of an overall reduction of mortality and admission to hospital91.
A Cochrane review of exercise based rehabilitation for heart failure concluded that exercise training
improves exercise capacity and quality of life in patients with mild to moderate heart failure in the short
term92. However, there is no information of the effect of training on clinical outcomes. The findings are
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Midland Region Cardiac Services Plan - 2006
based on small-scale trials in patients who are unrepresentative of the total population with heart failure.
Other groups (more severe patients, the elderly, women) may also benefit but larger-scale trials of longer
duration enrolling a wider spectrum of patients are required to address these questions.
The review of cardiac rehabilitation services in New Zealand undertaken in 200261 indicated that a diagnosis
of heart failure had a negative association with referral to a cardiac rehabilitation with only 10.5% of eligible
patients referred. Discussion with the cardiac rehabilitation nurses in the region indicates some frustration in
the inability to provide a rehabilitation service for heart failure patients as recommended in the New Zealand
guidelines. The New Zealand evidence-based best practice guideline for cardiac rehabilitation includes
recommendations for heart failure patients.
PALLIATIVE CARE
Eventually, for a person with chronic heart failure, quality of life may deteriorate and the possibilities for
further treatment may become limited. End of life for advanced heart failure many indicate a life span of
days or many months. Keeping the person comfortable may eventually become more important than trying
to prolong life. The person and the family members should be involved in these decisions. Much can be
done to provide compassionate care, relieve symptoms, and maintain the person's dignity through a
palliative approach to care.
Recognition of the need for palliative care for advanced heart failure is relatively new. Publications that may
be useful in the approach to support advanced palliative care patients are referenced here.93,94,95.
Palliative care services for patients with chronic conditions, as against cancer, tend to be managed through
district nursing, rather than hospice services in the Midland region.
CURRENT SITUATION
The use of BNP testing enables GPs to better diagnose heart failure in the current environment of limited
access to echocardiograms. This test allows GPs to confirm or exclude this diagnosis without an
unnecessary long wait for a specialist appointment, however, as identified earlier there is a need to ensure
appropriate use of this test.
Pinnacle PHO is working with the Waikato cardiology department to develop a heart failure project. No other
specific PHO heart failure programmes have been identified in the consultation for this service plan, however
with the ongoing development of PHO services and the implementation of Care Plus in the region, it is
possible that new initiatives will be developed.
Waikato Hospital employs a 1FTE programme coordinator for heart failure working predominantly in a case
management role. Hawera employs a 0.4FTE as a cardiac educator whose role includes a heart failure
nurse-led clinic. Tauranga Hospital also runs a nurse-led heart failure clinic where the aim is to optimise
drug therapy and support patients to stay out of hospital. Tauranga Māori Health unit, Te Puna Hauora,
employs a Clinical Nurse Educator who provides education to cardiac inpatients (0.5FTE) and provides a
case management role (0.5FTE) in the community. Tauranga Hospital has recently received additional MoH
funding for an Heart Failure initiative.
To date there has been little collaboration or cooperation between primary and secondary care when
establishing services for heart failure patients. For example, when secondary care has established heart
failure nursing positions in order to prevent patients rebounding into hospital, little, if any discussion, has
taken place as to the issues faced by primary care in managing heart failure in the community. The
development of primary care programmes has not always been with the knowledge or support of secondary
services.
To ensure heart failure management is coordinated, it is important that there is an integrated approach from
primary and secondary within each DHB area. DHB funders should ensure that any funding proposal for
services for heart failure patients have had input from both primary and secondary and ideally be jointly
developed. Primary care proposals that include heart failure should have strong linkages with nursing and
medical services that include upskilling and agreed management protocols.
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It is critical that trust develops across the sectors so that services are not duplicated and that patients are at
the centre of any service. There are opportunities for hospital-based cardiac Clinical Nurse Specialists and
PHO clinical staff and Practice Nurses to have closer working relationships in support of heart failure
management. Nurse and/or general physician heart failure clinics have been shown to decrease
admissions and will heap manage the cardiologist workload.
The aims for the region for heart failure should include:
■ Heart failure diagnosed and patients assessed and managed according to the best available
evidence;
■ Patients and carers with a better understanding of their condition and better access to high quality
self-management resources and support;
■ Chronic care management systems in place to support clinicians and enable heart failure patients
to receive best practice care;
■ Accurate clinical performance data available on a routine basis at the local and regional level;
Recommendation
PHOs should include DHB cardiologists, cardiac nurse specialists, and/or general physicians in the
development of any programmes to be provided in primary care for heart failure patients – including Care
Plus or SIA funded care.
DHBs should ensure heart failure patients have access to multidisciplinary cardiac rehabilitation as part of
the review of cardiac rehabilitation programmes in the districts. Heart failure should be a specific component
of the recommended review of cardiac rehabilitation programme.
DHBs should review palliative care options available for patients with end stage cardiac conditions.
9.2.
Rheumatic Fever
BACKGROUND
New Zealand has high rates of acute rheumatic fever (ARF) for an industrialised country. In 1997, the rate
was 2.6 cases per 100,000 compared to less than 0.1 cases per 100,000 in United States, Canada,
England, Wales, and Scotland. Australia has a low overall rate but a high incidence in the aboriginal
population. The Midland rate in the 1995 – 2000 period was 3.8 per 100,000 - higher than that of New
Zealand as a whole. Rheumatic fever is not usually a severe acute illness but its long-term sequelae
significantly affect longevity if appropriate follow-up of the individual does not occur. The critical component
is prevention of second (and subsequent) attacks. The standard recommendation is for long-term antibiotic
prophylaxis for 10 years or until the individual turns 21, whichever is the longer.
A New Zealand Public Health Report published in June 200196 showed that a total of 608 cases were
notified in New Zealand between 1995 and 2000, of which 142 (23.4%) were from the Midland region, which
has approximately 19.6% of the New Zealand population. The Midland region data is shown in Table 34.
The report indicates that 73.5% of cases were aged 5-14 years and of these the annual incidence rate (per
100,000) for Pacific peoples was 64.5, for Māori 31.9 compared with a European rate of 1.7. Note 48 of the
608 cases (8.9%) were recurrent episodes. Recurrent attacks are preventable by long-term antibiotics.
The Public Health Report surveyed the register-based recurrent ARF prevention programmes across New
Zealand. It was noted that the absence of a register-based programme to coordinate prophylaxis did not
imply unsatisfactory provision, as individuals are still referred to a provider responsible for maintaining
contact and administering prophylaxis. Register-based programmes have been shown to be better than
individual GP practice or hospital based services at maintaining contact with clients and preventing recurrent
ARF episodes, although more research has been recommended.
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Table 34.
Acute Rheumatic Fever notifications 1995-2000
District
Acute Rheumatic Fever 1995 - 2000
Cases Notified
Eastern Bay of Plenty
Tauranga
Rotorua
Taupo
Gisborne
Taranaki
Waikato
Ruapehu
Midland Total
New Zealand
Annual Incidence
(per 100,000)
3.3
1.6
3.6
0.5
13.1
0.6
3.4
5.0
3.8
2.8
10
11
14
1
36
4
61
5
142
608
CURRENT SITUATION
Figure 17 shows that hospital admissions continue to increase for acute rheumatic fever. Although the
numbers are small, total admissions for the Midland region increased from 24 – 45 between 2001_02 and
2003_04. The 2004_04 data included is an extrapolation of the year to date data at 31 March 2005 to the
full year. During this period, 75% of admissions were for 0-14 year olds.
Figure 17.
Acute Rheumatic Fever hospital admissions by Midland DHB of domicile
17.5
15
12.5
10
7.5
5
2.5
0
BoP
Lakes
2001_02
Tairawhiti
2002-03
Taranaki
2003_04
Waikato
2004_05
Figure 18 shows the admission rate for 0-14 year olds per 100,000 population in each of the Midland DHBs.
This identifies Bay of Plenty, Lakes, and Tairawhiti populations have the highest admission rates. While
figure 19 shows the high proportion of Māori and PI and ‘other’ ethnicity admissions to hospital for ARF.
Rheumatic Fever is essentially a paediatrician diagnosis - with suspected cases being referred to a
paediatric outpatient clinic or being admitted acutely to hospital. Patients with rheumatic fever receive
extensive follow-up for prophylaxis provision. The only ARF prevention programmes available in the
Midland region are in Whakatane, Rotorua General Practice Group and through the Tairawhiti Public Health.
Toi Te Ora-Public Health (the Bay of Plenty District Public Health Unit) intends setting up a comprehensive
rheumatic fever register, to record incident cases and track their follow-up.
Programmes use a register to coordinate community-based prophylaxis, collate information on timeliness of
prophylaxis delivery, and maintain parenteral prophylaxis. Other functions may also include routinely
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Midland Region Cardiac Services Plan - 2006
informing other health care providers (e.g. dentists) of clients Rheumatic Fever diagnosis), generating or
prompting prescriptions where applicable and accumulating data for auditing prophylaxis updates.
Figure 18.
Acute Rheumatic Fever admissions 0-14 year olds per 100,000 population by Midland DHB of domicile
35
30
25
20
15
10
5
0
BoP
Lakes
2001_02
Figure 19.
Tairawhiti
2002-03
2003_04
Taranaki
Waikato
2004_05
Acute Rheumatic Fever hospital admissions in Midland DHBs per 100,000 population by ethnicity
45
40
35
30
25
20
15
10
5
0
European
Maori
2001_02 2002-03
PI
2003_04 2004_05
Other
Prophylaxis with parenteral penicillin prevents recurrent ARF, minimises cardiac sequelae and has been
found to be cost-effective when compared with expenses associated with hospitalisation of recurrent ARF
cases and the subsequent loss of quality of life and life expectancy.
ARF patients tend to be young and therefore often mobile, without an appropriate management programme
it is often difficult to maintain contact with individuals and ensure they receive long term monthly antibiotic
prophylaxis. Each public health unit should ensure their districts are covered by comprehensive rheumatic
fever registers, to record incident cases and track their follow-up. It would be anticipated that coordinated
programme(s) would decrease the incidence of recurrent ARF episodes, and subsequent cardiac disease
including bacterial endocarditis and the need for valve replacement. This will require a system for GPs to
notify/inform Public Health Units about prophylaxis.
Recommendation
The Midland Region public health units should ensure development of comprehensive rheumatic fever
registers, to record incident cases and track their follow-up.
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Midland Region Cardiac Services Plan - 2006
10. Resources
10.1. Equipment
10.1.1. Cardiac Catheterisation Laboratory
Cardiac catheterisation laboratories may provide all or some of the following:
■ diagnostic coronary angiography,
■ pacemaker and cardiac defibrillator implantation,
■ pacemaker lead monitoring and extraction,
■ diagnostic and interventional cardiac electrophysiological procedures,
■ percutaneous coronary interventions.
The laboratories consist primarily of x-ray imaging and physiological measuring equipment.
The Cardiac Society of Australia and New Zealand have developed policies and guidelines for cardiac
catheterisation services.
The Auckland region published a Regional Cardiac Catheterisation Laboratories Strategic Direction to 2008
Business Plan and Business Case in March 200397. This paper has identified the following criteria for
monitoring whether further cardiac catheterisation laboratories should be required for the Auckland region:
■
■
■
■
Waiting times: inpatients not greater than 2 days; outpatients as per national criteria;
Capacity: at 85% occupancy; (Note this is identified as the key criteria);
Equity of access for Māori & Pacific in the Northern Region;
Equity of access for resident adults outside of Auckland DHB
CURRENT SITUATION
There are cardiac catheter laboratories situated in three of the Midland DHBs. Waikato provides the full list
of services identified above; while those at Tauranga and Taranaki Base hospitals undertake coronary
angiograms and temporary pacemaker insertion (Tauranga plans to commence a full pacemaker service
during 2005).
Patients from outlying facilities e.g. Whakatane and Rotorua are generally referred directly to Waikato rather
than to Tauranga to prevent two transfers where angioplasty may be required.
In 2004 Waikato identified that 85-90% of coronary angiography was performed on acute patients. In June
2005, 51 patients had been waiting longer than six months for an angiogram.
Currently there is no capacity to increase procedures undertaken at Waikato Hospital due to facility and
staffing resources. Limitations at Tauranga and Taranaki Base Hospitals relate to access to radiology (no
dedicated laboratories) and staffing resources.
CATHETERISATION LABORATORIES REQUIREMENTS FOR THE MIDLAND REGION
The catheter laboratory requirements for the Midland region for cardiac services alone are based on:
■ Best practice procedure recommendations identified in the respective sections of this document;
■ All percutaneous interventions undertaken at Waikato Hospital;
■ Full laboratory service for 10 sessions per week and 46 weeks per annum.
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Midland Region Cardiac Services Plan - 2006
Table 35.
Electrophysiology, defibrillation and pacing laboratory session and catheter laboratory requirements
Waikato
Electrophysiology
Defibrillation
2006
Pacing
Total sessions
Session/lab/pa
Waikato Labs
Tauranga
Pacing Sessions
Session/lab/pa
Tauranga Lab
Table 36.
2011
2016
2011
2016
198
106
203
163
207
165
284
217
580
387
350
191
495
460
1.1
173
539
460
1.2
175
547
460
1.2
260
761
460
1.7
1316
460
2.9
27.5
460
0.1
50
460
0.1
53
460
0.1
75
460
0.2
106
460
0.2
Coronary angiography and angioplasty laboratory requirements
Cath Labs Required
2006
2011
2016
2011
2016
PCI
Diagnostic procedures
1.0
1.6
1.0
1.6
1.0
1.6
Waikato
Tauranga
Taranaki
2.7
0.3
0.1
2.7
0.4
0.1
2.7
0.4
0.1
1.3
1.8
3.1
1.6
2.1
3.7
0.5
0.1
0.6
0.2
2006
2011
2016
2011
2016
3.8
0.4
0.1
3.3
3.9
0.5
0.1
3.5
3.9
0.5
0.1
3.5
4.8
0.7
0.1
5.6
6.6
0.8
0.2
7.6
Table 37. Total Laboratory Requirements for Midland Region
Catheter Laboratories
Waikato
Tauranga
Taranaki
Midland Total
Note:
■ Tauranga and Taranaki services currently provided in radiology;
■ Tauranga pacemaker service to be undertaken in main theatre initially, which has potential access
risks;
■ Tauranga numbers based on current service level to Bay of Plenty patients only.
Waikato and Tauranga Hospitals are currently undergoing campus redevelopments and should include the
option to meet the increasing catheter laboratory requirements for the near future within the campus plans.
However, any laboratories developed as part of the campus redevelopment will not ease the current
problem for another five years, it is critical that other options are considered including:
■ Increase volumes at Tauranga and Taranaki Hospitals:
– This will require increased access to the laboratories currently based in the radiology departments;
– A review of staffing implications;
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Midland Region Cardiac Services Plan - 2006
–
A review to determine how many patients and procedures currently undertaken at Waikato could
be undertaken in these facilities. Tauranga has potential to provide the ‘cold’ i.e. elective catheter
laboratory and pacing service to Tairawhiti and Lakes patients. An estimate of this volume is
provided in Table 38.
■ Increasing throughput at Waikato Hospital, although this will be difficult with current staffing issues:
– Through extending current hours;
– Process review
■ Development of a catheter laboratory in the radiology department at Rotorua Hospital:
– A room is believed to be available but requires review of suitability;
– Establishment and staffing of the service would be from Waikato hospital, at least in the initial
period;
– This option may increase the chance of cardiology appointment to Lakes DHB.
■ Contract services to a private facility:
– This option is currently under consideration by Waikato DHB;
– Options include Braemar Hospital, Hamilton (most of the staff also work at Waikato Hospital),
and/or Auckland facilities.
Table 38. Tauranga Hospital Catheter Laboratory Requirements with Extended Service.
Tauranga Catheter
Laboratory
BoP Pacing + Diagnostic angiography
As above plus - Lakes & Tairawhiti OP
angiography
As above plus Lakes & Tairawhiti
pacing x 80%
2006
2011
2016
2011
2016
0.31
0.41
0..5
0.48
0.61
0.37
0..44
0..46
0.55
0.70
0.44
0. 51
0.53
0.66
0.84
Assumptions:
■ Outpatient angiography currently undertaken at Tauranga Hospital equals 100% of the Bay of
Plenty volume;
■ Outpatient angiography approximately 18% of total angiography – based on current Bay of Plenty
volume;
■ Lakes & Tairawhiti pacing volumes based 80% total recommended volume – remainder undertaken
at Waikato.
The Northern DHB Support Agency (NDSA) estimated the capital cost for a cardiac catheterisation
laboratory at $3.1million in 2002-03, rising in 2005/06 to $3.3 million. A high level breakdown of these costs
is provided in Table 39, for further detail, refer to the NDSA paper.
Table 39.
Cardiac catheterisation laboratory capital cost 2002-0386
Item
Clinical Items
Information Systems
Fit out
Total
- 106COPYRIGHT © MIDLAND DHBS, 2005
$
(millions)
$1.7
$0.4
$1.0
$3.1
Midland Region Cardiac Services Plan - 2006
It should be noted that the current catheterisation laboratories at Waikato are obsolete and replacement cost
is approximately $1.2 million with an additional $250,000 required to fund haemodynamic and physiology
software required for the Mac Lab.
Recommendation
Waikato Hospital should plan for four cardiac catheter laboratories on site.
Tauranga Hospital should plan for one dedicated catheter laboratory to undertake cardiac diagnostic
angiography and pacemaker services for the Bay of Plenty, and the option considered at a regional level, for
providing elective services for the Lakes and Tairawhiti DHBs as indicated, together with respiratory and
other appropriate services,
That options identified to increase cardiac catheter laboratory services be considered to ensure appropriate
service delivery prior to any new facilities opening. These include, extending current catheter laboratory
throughput, developing a service at Rotorua Hospital and contracting to private facilities.
That all appropriate software and equipment costs be included for current and new laboratories;
The Midland DHBs should recognise that the rapidly changing technology and consequent best practice for
cardiac services may require additional catheter laboratories within the region within ten years.
10.1.2. Other equipment
Specific needs identified during the consultation for this plan include other equipment such as:
■ Echocardiography machines – across the region. See Diagnostics – Echocardiography for
recommendations;
■ Event recorders – Waikato Hospital. Eight available, each patients use is for a one month period;
■ Telemetry – Whakatane Hospital;
■ Emergency department capability of receiving electronic ECGs – faxed copies often difficult to
read.
This is not a detailed or exhaustive list of equipment required to meet the needs of the cardiac service in the
Midland region. Specific equipment requests should be identified at an individual DHB level.
10.2. Workforce
Workforce planning is critical to prevent cardiac disease in the community through supportive programmes
to change behaviour, to provide best practice primary and secondary prevention services and to improve the
quality of care of patients with acute and chronic diseases.
A number of countries including Australia and the United Kingdom are undertaking projects to review the
requirements of the cardiology workforce going forward. The British Cardiac Society 2005 cardiac workforce
paper43 identifies cardiologist requirements but non-consultant workforces are grouped together rather than
recommendations being made for specific professions. The recommendations made in this section are
based on current literature and it is recommended that these be reviewed when more up-to-date
recommendations are available. In particular the updated AMWAC reports expected late 2005 - The
Specialist Cardiology Workforce in Australia and The Cardiothoracic Surgery Workforce in Australia.
The UK Department of Health recognised that a critical component of the CHD National Service Framework
was identifying the key priorities for workforce development. The particular shortages of skills identified in
the UK are similar to those in New Zealand:
■ Cardiology physiology skills in a range of areas, including skills needed to staff catheter
laboratories;
■ Theatre skills including perfusion and cardiac anaesthesia;
■ Cardiothoracic surgeons;
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Midland Region Cardiac Services Plan - 2006
■ Critical care nursing
■ Cardiologists
■ CHD skills in primary care;
■ Cardiac rehabilitation skills.
The UK Care Group Workforce team recommendations for CHD were published in 200398.
A detailed stocktake of the cardiac workforce in each DHB facility and in primary care has not been
undertaken. Where specific needs have been identified nationally or locally, or where specific
recommendations for staffing levels are available, these have been identified in this section. Specific cardiac
services are identified here but there are a number of other competencies required to provide an integrated
multidisciplinary approach to care e.g., pharmacist, physiotherapist, psychologist, dietician etc.
Implementation of this plan should identify the skills required for cardiac service delivery into the future,
including those roles where no specific recommendations have been made, and a regional workforce
development plan agreed. Consideration should be given to identifying competencies required rather than
staff groupings and allowing for new ways of working to meet the needs of the service. In addition, it is
important to identify networks across the region that will provide peer support and continuing education, in
particular for those working in facilities with small numbers of staff in any component of the service.
In addition, staff at outreach facilities should have formal links to the ‘hub’ or the cardiac service responsible
for the policy and procedures under which they work. These links should be through employment
agreements, policies and procedures, continuing education and communication processes. This should
apply to medical, nursing, allied health and technical staff.
Recommendation
The Midland DHBs should identify the skills required and agree a regional workforce development plan for
cardiac services.
Consideration should be given to identifying competencies required and allowing for new ways of working to
meet the needs of the service.
This plan should incorporate a professional development and peer support component for all staff involved in
delivering cardiac services within the region.
10.2.1. Cardiology
Cardiologists
Midland DHBs current employ 11.7 FTE cardiologists - 7.5 FTE Waikato, 3 FTE Bay of Plenty and 1.2 FTE
Taranaki (based on 60% current role relating to cardiology specific services). This gives a ratio of 1.48 per
100,000 population. Including private and public cardiologists time at approximately 16.5 FTEs the ratio
becomes 2.1 per 100,000 population.
Figure 20 shows that the specialist to population ratio for specialist cardiologists across Europe and other
countries is very variable. Excluding the high ratios of Greece and Italy and those less than two per
100,000, the mean value is 4.3 cardiologists per 100,00099.
Actual and recommended levels of cardiologists vary within and between countries. For example in 2001
rates in the Canadian regions varied from 1.39 – 4.74 (2.88) per 100,000100 and in 1999 in Australia there
was between 1.2 and 8.4 (5.1) cardiologists per 100,000 population, the average ratio is the bracketed
figure. New Zealand cardiologist numbers are similar to the United Kingdom at 1 to 1.5 (1.2) per 100,000 in
2001. The United Kingdom has recognised that long waiting times for diagnosis and treatment in cardiac
services was contributing to one of the highest levels of heart disease death rates in the developed world.
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Midland Region Cardiac Services Plan - 2006
Figure 20.
Cardiologists per 100,000 population in 2000
25
21
20
16.6
7.6
6.6 6.5 6.5
5
5.3 4.9 4.9
4.1 3.9 3.8
3.2
3
Spain
10
Austria
15
2.9 2.6
2.1 1.7 1.5
1.2 0.7
Ireland
United Kingdom
Midland
Finland
Germany
New Zealand
Canada
Norway
Denmark
Sweden
The Nederlands
Australia
Iceland
Switzerland
France
Portugal
Belgium
Italy
Greece
0
There are few agreed recommendations for cardiologists; however, the British Cardiac Society in June 2005
recommended the following levels to the Department of Health in England101 52.7 – 84.2 cardiologists per
million population. Based on these recommendations between 41.8 and 66.8 FTE cardiologists would be
required for the Midland region in 2006.
The AMWAC Report 1999.5 – The Specialist Cardiology Workforce in Australia: Supply and Requirements
1998 – 2009, noted there were few issues with regard to service, waiting times (average 7.7 days for urgent
and 36 days for routine first specialist appointments), and excessive hours of work, with the national average
of 1 cardiologist to 20,000 > 25 years population. For the Midland region to reach this ratio would require 25
cardiologists in 2006 increasing to 26.3FTE in 2011.
One of the features of cardiology is that non-specialist providers provide at least some of the services in
most facilities. The range of cardiac services provided by non-specialist providers increases in facilities
where no specialist cardiologist is employed.
New Zealand as a whole and Midland specifically, have low numbers of cardiologists for the population and
this contributes to the waiting times for First Specialist Appointments (FSA) shown in Table 40.
Table 40.
Midland DHB waiting times for cardiology First Specialist Appointments as at April 2005
Bay of
Plenty
Urgent
Semi-urgent
Routine
Next available
2-3 months
6-12 months
Taranaki
1-4 weeks
9-10 months
Not appointing
Waikato
1-2 months
2-9 months
9-12 months
The increasing level of specialty services within cardiology of medical, interventional, and electrophysiology
should also be considered when recommended staffing levels. Identification of cardiologist levels by these
specialities has been undertaken in Canada.
The cardiologist recommendations in Table 41 are conservative but realistic in the short-term based on the
ability to recruit and the need to determine a planned approach to cardiac service development. These
recommended levels should be reviewed on release of the AMWAC updated Cardiology Workforce Report,
expected to be completed at the end of 2005.
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Midland Region Cardiac Services Plan - 2006
Table 41.
Cardiologist Requirements for the Midland Region
Medical
Cardiologist
DHB
Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
Midland Total
2006
4.6
2.4
1.0
2.4
7.8
18.2
2011
4.9
2.4
1.0
2.3
8.0
18.7
Interventional
Cardiologist
2006
1.0
0.5
0.2
0.5
1.7
4.0
2011
1.1
0.5
0.2
0.5
1.7
4.1
Electrophysiologist
Total
Cardiologists
2006
0.4
0.2
0.1
0.2
0.7
1.6
2006
6.1
3.1
1.4
3.1
10.2
23.9
2011
0.4
0.2
0.1
0.2
0.7
1.6
2011
6.4
3.1
1.3
3.1
10.4
24.3
Assumptions:
■
■
■
■
■
Total cardiologist requirement @ 3 per 100,000 population;
Interventional cardiologist @ 0.5 per 100,000 population;
Electrophysiologist @ 0.2 per 100,000 population;
Based on DHB population, not necessarily where the service is delivered.
Note – totals may not add due to rounding
Recommendation
There is an urgent need to address cardiologist staffing in order to recognise the current waiting times and
growing need for secondary and tertiary cardiac services. It is critical that the total cardiologist numbers for
the region are available, irrespective of location, to ensure the delivery of services to the regions population.
The Cardiologist recommendations made are conservative based on international trends, and it is
recommended the Cardiologist and Cardiac Surgeon recommendations be reviewed when the Australian
Medical Workforce Advisory Committee reports on Cardiology and Cardiothoracic Surgery become available
in the next 12-months, and as diagnostic and treatment levels are revised.
General Physicians
General physicians play a key role in secondary care cardiology services across the Midland region. While
there is no information that identifies the proportion of a physician’s time spent providing cardiac care, it is
clear that this is a large proportion of this role and is likely to grow as the prevalence of cardiac disease in the
community increases.
Options exist for the role of general physicians in cardiology to be reviewed, particularly with the close
relationships that exist in the region. A relatively high proportion of patients with cardiac disease also have
other chronic co-morbidities and the general physician may be the appropriate first contact for general
practitioners in managing the complexities of these patients, as well as providing long term management
options.
RACP & IMSANZ published a paper in September 2005 entitled Restoring the Balance102. This document
looks at general physicians in New Zealand and Australia and options for this specialty into the future, in
particular, from a workforce, continuing education and needs basis.
Cardiac Technicians
Cardiac technologists provide technical services within the cardiology team, which may include:
■ Cardiac catheterisation investigations;
■ Holter monitoring;
■ ECG and event recorder analysis and reporting;
- 110COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
■ Tilt table testing;
■ Electrocardiography
■ Exercise stress testing
■ Assisting in the implantation of pacemakers and implantable cardioverter defibrillators;
■ Cardiac ultrasound;
■ Cardiopulmonary technologists are also trained in cardiac and respiratory function procedures.
There is some inconsistency in terminology with the group who may be known as physiology / cardiac /
cardiopulmonary technologists and technicians. In general, technologists hold positions that are more
senior, have a degree qualification, and tend to work independently, while technicians have a certificate level
qualification and work under supervision.
Currently there is a voluntary registration process for technologists/technicians although there is a national
process underway with the Clinical Training Agency and the Society of Cardiopulmonary Technologists
(SCT) to establish a national training programme run through Otago University, via the Wellington School of
Medicine, for a Post Graduate Certificate in Clinical Physiology. It is anticipated this may support the
recruitment of cardiac technologists who to date tend to be recruited from overseas. The last two qualified
staff, recruited to Tauranga Hospital, were from the UK and took an 8-month recruitment process.
Waikato DHB cardio-respiratory investigation unit (CRIU) has been short of technologists for some time and
is currently recruiting for 1.4 FTE cardio/respiratory technologists out of a complement of 7.5 FTE.
Tauranga Hospital physiology department has a complement of eight staff, some part-time and this includes
four trainees three physiology and one in echocardiography. Whakatane Hospital employs three ECG
technologists, one of whom is a trainee.
It has been suggested that nursing and GP staff can be trained up undertake some roles e.g.
echocardiography. However, the ability to read and report on echocardiograms requires additional expertise
that would require upskilling and credentialing. Current recommendations are that all echocardiograms are
reported by cardiologists.
There are no recommendations available for specific staffing levels for cardiac technologists.
Recommendations for cardiac catheter laboratory specific procedures are identified in Tables 41 & 42,
however this excludes staffing requirements for some of the diagnostic procedures identified above..
Recognition of the growing demands on the service and the implications for cardiac technologists and the
long lead-time to employ and / or staff must be considered in the development of a workforce plan.
Sonographers
The Specification for Diagnostic Non-Medical Sonography Training, from the CTA, December 2000
indicates, “Training in vascular and cardiac ultrasound may be available in future.” The response from
CTA request for an update in June 2005 indicated “Since 2000, nothing has been added to the basic
DMU qualification for ultrasonographers as a national need would have had to be demonstrated by the
DHBs collectively requesting it. There was never that much interest in it, however, currently, UNITEC is
piloting a new diploma, which the MRTB will review at the end of the year. It might become the national
standard qualification if the Board approves it. This could result in a number of specialties being developed
as a part of the diploma including the cardiac option.”
Staff training and support in echocardiography is critical. There are small numbers of staff in the region,
which leaves the service vulnerable when one sonographer leaves. For example, Taranaki has recently
required a visiting service every six-weeks, while undertaking an 8-month employment process from the UK
to replace the last sonographer who left.
The BCS is predicting levels of echocardiography 3-4 times current Waikato current volumes and a rate of
28-40 sonographers pmp, which would require 22 – 32FTEs for the Midland region.
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Catheter Laboratory Workforce
Staffing requirements for cardiac catheter laboratories to function efficiently and effectively require both
clinical and support staff.
Table 42.
Predicted cardiac catheter laboratory workforce requirements 2006 - 2016
2006
PCI/Dx
EP/ Pacing
/Defib
2011
Total
PCI/Dx
2.49
9.4
2.5
1.2
4.6
3.6
1.8
1.8
1.8
1.8
2.55
7.6
2.5
1.3
2.5
2.5
1.3
1.3
1.3
1.3
0.31
0.9
0.2
0.1
0.4
0.3
0.2
0.2
0.2
0.26
0.8
0.3
0.1
0.3
0.3
0.1
0.1
0.1
0.12
0.4
0.1
0.1
0.1
0.2
0.1
0.1
0.12
0.4
0.1
0.1
0.1
0.2
0.1
0.1
0.1
0.1
EP/ Pacing
/Defib
2016
EP/ Pacing
/Defib
Total
PCI/Dx
Total
2.55
9.8
2.5
1.3
4.9
3.7
1.9
1.9
1.9
1.9
2.59
7.8
2.6
1.3
2.6
2.6
1.3
1.3
1.3
1.3
0.37
1.0
0.3
0.1
0.5
0.4
0.2
0.2
0.2
0.28
0.8
0.3
0.1
0.3
0.3
0.1
0.1
0.1
0.12
0.4
0.1
0.1
0.1
0.1
0.1
0.1
0.12
0.4
0.1
0.1
0.1
0.1
0.1
0.1
0.12
0.4
0.1
0.1
0.1
0.1
0.1
0.1
0.12
0.4
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.1
Waikato
Catheter Laboratories
Nurse
Medical Radiation Technologist
Radiographer
Technician
Cardiologist
Interventionalist
Clerical / Booking
Support – orderly
Support -Healthcare Assistant
Tauranga
Catheter Laboratories
Nurse
Medical Radiation Technologist
Radiographer
Technician
Cardiologist
Clerical / Booking
Support – orderly
Support -Healthcare Assistant
Taranaki
Catheter Laboratories
Nurse
Medical Radiation Technologist
Radiographer
Technician
Cardiologist
Clerical / Booking
Support – orderly
Support -Healthcare Assistant
2.49
7.5
2.5
1.2
2.5
2.5
1.2
1.2
1.2
1.2
0.25
0.7
0.2
0.1
0.3
0.2
0.1
0.1
0.1
(.43/.23/.41)
1.07*
1.9
2.1
1.1
0.5
0.5
0.5
0.5
0.06
0.1
0.1
0.1
0.0
0.0
0.0
(.44/.35/.38)
1.17
2.1
2.3
1.2
0.6
0.6
0.6
0.6
0.11
0.2
0.2
0.1
0.1
0.1
0.1
(.45/.36/.38)
1.19
2.2
2.4
1.2
0.6
0.6
0.6
0.6
0.1
0.2
0.2
0.1
0.1
0.1
0.1
2.59
9.9
2.6
1.3
5.0
3.8
1.9
1.9
1.9
1.9
0.39
1.1
0.3
0.1
0.5
0.4
0.2
0.2
0.2
Figures in brackets indicate the proportion of electrophysiology, pacing and defibrillation undertaken with in the recommended catheter
laboratories required. Each of these services has different staffing requirements which are taken into consideration in the recommended
numbers.
Table 42 staffing levels are based on Bay of Plenty and Taranaki undertaking catheter laboratory
procedures for their own populations, and Waikato undertaking the majority of acute work and elective
angiography for Waikato, Lakes and Tairawhiti DHB populations as per the current situation.
Table 43 indicates the staffing required for catheter laboratories in Tauranga and Waikato where Tauranga
Hospital undertakes elective catheter laboratory procedures for Bay of Plenty, Lakes, and Tairawhiti DHBs.
See Section 10.1.1 for further discussion of these options.
The BCS 2005 paper suggests a total of invasive cardiac clinicians of 50.4 – 61FTE pmp. The Waikato
recommendations above in Tables 42 & 43 are close to this at approximately 50FTE pmp.
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Midland Region Cardiac Services Plan - 2006
Table 43.
Predicted cardiac catheter laboratory workforce requirements – option two
2011
PCI/Dx
Waikato
Catheter Laboratories
Nurse
Medical Radiation Technologist
Radiographer
Technician
Cardiologist
Interventionalist
Clerical / Booking
Support – orderly
Support -Healthcare Assistant
Tauranga
Catheter Laboratories
Nurse
Medical Radiation Technologist
Radiographer
Technician
Cardiologist
Clerical / Booking
Support – orderly
Support -Healthcare Assistant
EP/Pacing
/Defib
2016
PCI/Dx
3.58
9.4
2.5
1.2
4.7
3.6
1.8
1.8
1.8
1.8
2.53
7.6
2.5
1.3
2.5
2.5
1.3
1.3
1.3
1.3
1.15
2.1
0.34
1.0
0.3
0.2
0.3
0.3
0.2
0.2
0.2
0.3
0.3
0.2
0.1
0.1
0.49
1.3
0.3
0.2
0.6
0.5
0.2
0.2
0.2
0.1
0.2
2.48
7.4
2.5
1.2
2.5
2.5
1.2
1.2
1.2
1.2
1.10
2.0
0.31
0.9
0.3
0.2
0.3
0.3
0.2
0.2
0.13
0.3
0.3
0.1
0.1
0.1
0.44
1.2
0.3
0.2
0.6
0.4
0.2
0.2
0.2
0.1
0.2
2.2
1.1
0.5
0.5
0.5
0.5
EP/Pacing
/Defib
Total
2.3
1.2
0.6
0.6
0.6
0.6
Total
3.68
9.7
2.5
1.3
4.8
3.7
1.8
1.8
1.8
1.8
Cardiac Nursing
Nursing staff work within most aspects of cardiac care, including: surgery, ITU, CCU, catheter laboratories,
cardiology and cardiothoracic wards, outpatient, and primary care services. Experienced cardiac nursing
services should be recognised within a workforce development plan.
Ward nurse to patient ratios vary depending on the acuity of the patient. Specific levels for different levels of
hospitals vary from 1: 1 for a patient in ITU, 1: 2 in CCU, 1: 4 for medical services in a tertiary hospital,
through to 1: 6 in a rural hospital. The BCS 2005 paper suggested the UK will require 344 – 571FTE pmp
inpatient nursing care for coronary care units and cardiac care wards. The total number of inpatient cardiac
care nursing staff in the Midland region has not been reviewed against these recommendations.
Specialist nurse programmes of care for heart failure patients have been shown to have the potential for cost
benefits (both in terms of absolute cost savings and in terms of facilitating a more efficient healthcare
system) 103. A UK-wide heart failure service found that for each specialist heart failure nurse appointed in the
UK (with a caseload of 200–250 patients per annum), nominal savings of £49 000 per annum could be
generated.
Table 44.
Cardiac rehabilitation nurses required at one per 225 cardiac rehabilitation patients.
2006
4.1
2.1
0.9
2.2
6.7
16.0
Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
Midland Total
- 113COPYRIGHT © MIDLAND DHBS, 2005
2011
4.4
2.2
1.0
2.2
7.0
16.8
Midland Region Cardiac Services Plan - 2006
Allowing for one nurse to: 225 cardiac rehabilitation patients, as identified in Table 32, would require the staff
numbers identified in Table 44 for the Midland DHBs. This is a very high level prediction and further detailed
calculations should be undertaken before considering staff required for this service.
The BCS 2005 paper43 recommends a total cardiac rehabilitation clinical staff of 20FTE pmp. This
recommendation is based on two staff supervising each exercise class with a ratio of staff to patients at 1 to
<10, ideally 1:5, with an involvement of > 6FTE of multidisciplinary cardiac rehabilitation practitioners (clinical
physiology, dieticians, exercise physiologists, nursing, occupational therapy, pharmacy, physiotherapy, audit
and administration)
There are many opportunities for nurse-led services within cardiac patient care, including nurse practitioner
development, e.g. heart failure, risk assessment, patient follow-up, education and rehabilitation programmes
at a hospital and primary care level.
An example of an integrated approach to care might include development of a support network for practice
nurses through education and contact with hospital-based Clinical Nurse Specialists in cardiac care may be
an appropriate support for a new primary care led service.
10.2.2. Cardiac Surgery
Cardiac Surgeons
Waikato DHB current employs 3 FTE cardiac surgeons; giving a ratio of 0.4 FTE per 100,000 population.
CABGs are not the only procedure undertaken by cardiac surgeons, however, they form a significant
component of the workload and are used as an indicator of the overall workload.
Available numbers of cardiac surgeons and the associated CABG rate include:
■ AMWAC 2001
0.4 per 100,000
CABG - 880 pmp
■ Canada 2001
0.9 per 100,000
CABG – 870 pmp
■ New Zealand 2003 0.4 per 100,000
CABG – 900 pmp
■ Midland 2003
0.4 per 100,000
CABG – 788 pmp
Note the New Zealand CABG rates are for public funded services only.
Waikato DHB currently employs three fulltime cardiothoracic surgeons and four registrars and is advertising
for a fourth surgeon that will increase opportunities for private practice and academic association with the
Waikato Division of the Auckland Medical School.
Table 45.
Cardiac Surgeon recommendations for the Midland region
Bay of Plenty
Lakes
Tairawhiti
Taranaki
Waikato
Midland Total
2006
0.8
0.4
0.2
0.4
1.4
3.2
Assumptions:
■ Based on 0.4 FTE per 100,000 population;
■ Public funded service only;
■ Based on DHB population, not where the service is delivered.
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2011
0.9
0.4
0.2
0.4
1.4
3.2
Midland Region Cardiac Services Plan - 2006
Cardiac Anaesthetists
Cardiac anaesthetists (CA) are anaesthetists with specialist cardiac skills. As an increasing number of the
cardiac surgery patients have more co-morbidities, the cardiac anaesthetist role becomes more critical.
Many CAs also provide intra-operative transoesophageal echocardiography (TOE). In 2001, there were 24
CAs in New Zealand of whom six were employed at Waikato Hospital.
The Canadian review of cardiovascular workforce indicates an average of 1.84 CA per 100,000 population.
The Midland region would have 14.6 FTE based on this rate. As the Canadian cardiac surgeon
recommendations are over double that of New Zealand and Australia, it is possible that the anaesthetist
estimates are not appropriate for the New Zealand situation. The United Kingdom estimated there were
approximately 300 CA in 2003, which equals approximately 0.6 FTE per 100,000 population, or 4 FTE for
the Midland population. An increase in the overall number of anaesthetists was recommended in the UK
workforce report, as it was felt that an increasing need for CA would draw anaesthetists away from other,
less popular areas of service.
Opportunities to fill gaps in this area are limited as nurse-led anaesthesia concentrates on less complicated
anaesthetic procedures.
Cardiac Perfusionists
The role of a cardiovascular perfusionist, is to operate and control extracorporeal circulation equipment
during cardiopulmonary by-pass, operate and control such equipment during any medical situation where it
is necessary to support, or temporarily replace, the patients circulatory function, and ensure the safe
management of physiological functions by monitoring all necessary physiological and pharmacological
variables. All these duties are performed upon prescription by a cardiac surgeon or medical practitioner
The Clinical Training Agency (CTA) report ‘Health Technologist and Technician Training in New Zealand’104
indicated that in 2002 there were eighteen certified perfusionists based in New Zealand (eight in Auckland,
two in Dunedin, three in Wellington, two in Christchurch and two in Waikato, with at least two vacancies in
New Zealand). Certification is now a requirement for employment as a perfusionist, and annual
recertification commenced in 2002. Staff are trained within the hospital they are employed at under the
framework and objectives developed by the Australasian Board of Cardiovascular Perfusionists (ABCP).
This is relatively specialist field with a small number of staff employed across New Zealand,, which means
the service can be vulnerable when staff leave or are unavailable. Collaboration across New Zealand is
important for this specialty. Training staff requires a significant commitment from the hospital and the CTA
report noted that vacancies are difficult to fill.
Cardiothoracic Theatre Nurses
Theatre nursing appears to have suffered from the format of the current nursing programmes, where there is
little if any theatre component. Some hospitals, including Waikato, have established an in-house
programme for third-year students and new graduates to provide an opportunity to expose nurses to
employment opportunities within theatre and improve recruitment and retention issues. Waikato Hospital is
continually advertising for theatre nursing staff, as are many other DHBs.
Cardiothoracic theatre nursing requires qualified and experienced staff. Waikato Hospital currently has a
‘protected team’ of staff allocated to cardiothoracic theatre sessions. This team consists of four registered
and two enrolled nurses who provide services to three cardiothoracic theatre sessions on a Monday and
Friday and two on Tuesdays, Wednesdays and Thursdays. In addition the team members are on call 24
hours a day, seven days a week for one week in three, this is dependent on staff turnover and can be 1
week in two.
The team development has been in place for 5-6 years and has improved working practices, however staff
morale is not great and this contributes to the turnover of staff within the team. The increasing complexity of
patients undergoing cardiothoracic surgery has meant that the skill-mix of staff is critical and there is an
ongoing need for training and development of staff.
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Midland Region Cardiac Services Plan - 2006
Recruitment and retention of qualified theatre nursing staff and, in particular, experienced cardiothoracic
theatre nurses is a challenge for all New Zealand DHBs.
10.2.3. Primary Care
Specific cardiac expertise in the primary sector is rare. The 45 mobile Maori Disease Management Nursing
roles established in 2000 were put in place without the support and ongoing education needs to sustain the
service. There are now only eleven (approximately) of these nurses still in the role.
There is a need to understand the skill development and support services needed to support the primary
care in management of CHD patients. Some of these will be identified in the development of specific
projects, however a collaborative approach to workforce development and upskilling across the sectors will
support the integration cardiac services that support the patient centred approach. Some of the services
traditionally based in the hospitals have the potential to be based in the PHOs with good support and
coordination with the secondary service.
The NHS has identified heart failure management, upskilling of practice nurses, primary care CHD nurse
specialists, GP training in thrombolysis, GP specialists in heart failure, as specific options for workforce
development in primary care.
10.3. Systems
Cardiac disease is a chronic lifelong disease that can be treated to relieve symptoms, improve quality of life,
and reduce early death. A myriad of interventions, such as drugs, surgical procedures and education about
lifestyle adjustments, is used in ambulatory and hospital settings. Clinical practice guidelines and care maps
have been developed to improve consistency of treatment based on research evidence. A range of health
services is needed to help individuals both in the immediate or acute phase and in the community with
rehabilitation and support as needed. Community interventions are particularly important for individuals with
a chronic illness such as heart failure, because much of their time is spent living in the community rather
than in a hospital.
Monitoring the use of interventions and health services can provide information for planning and evaluating
health services to meet the changing needs of the population. To date, no national, regional or local
database on individuals with cardiac disease has been established to provide person specific data on the
use of interventions and health services. Waikato DHB cardiology service contributes data to an
international registry of coronary interventions. NZHIS collates information on hospital admissions and rates
of procedures and compares interventions at a national level. There is no readily accessible data related to
primary and rehabilitation services. Linkages between an individual's entry into the system and his/her
health outcome would be ideal.
Better collaboration, cooperation, and data would provide the opportunity for Midland DHBs to agree specific
objectives and targets in relation to decreasing the burden of cardiac disease. There is insufficient publicly
available data to measure all potential objectives; however, there is an opportunity for PHOs to work with a
clinical network and the DHBs to establish specific objectives and targets that can be measured for their own
population, or jointly through agreeing to share data to allow for a “Midland approach”.
Examples that could be considered providing data was available might include:
■ Reduce hospitalisations of older adults with congestive heart failure as the principal diagnosis.
Target: 50% decrease in adults over 65 years between 2006 and 2011.
■ Reduce coronary heart disease deaths. Target: x per 100,000 population
■ Reduce Māori and Pacific peoples’ coronary heart disease deaths. Target: x per 100,000
population
■ Increase the proportion of eligible patients with heart attacks who receive artery-opening therapy
within an hour of symptom onset.
■ Increase the proportion of adults who call and receive early pre-hospital care and treatment
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Midland Region Cardiac Services Plan - 2006
■ Reduce the proportion of adults with high blood pressure and increasing the proportion of adults
with high blood pressure whose blood pressure is under control.
■ Increase the proportion of adults with high blood pressure who are taking action (e.g. losing weight,
increasing physical activity, or reducing sodium intake) to help control their blood pressure.
■ Reduce the mean total blood cholesterol levels among adults and reduce the proportion of adults
with high total and LDL blood cholesterol levels.
The Midland DHBs have agreed a common clinical information management platform and the long term IT
strategy is to eventually be able to share information electronically throughout the region, given all Midland
DHBs use the same browser. There are a number of sub-projects within the long-term IT strategy and it is
important the cardiac service needs across the region are agreed and considered as a component of the
overall strategy. This should include all aspects of care including cardiac rehabilitation and primary care.
Regional implementation of the Picture Archiving and Communication Systems (PACS) has identified
cardiology as a service with a specific need but the current system available does not include the specific
cardiology requirements. The implications for the service, in particular Waikato cardiology, should be
recognised until a PACS solution can be identified, as the current system is labour-intensive (4-5 hours per
month of archive) and relatively expensive ($24,000 for 2-years disk storage at current service level).
Recommendation
Monitoring the use of interventions and health services can provide information for planning and evaluating
health services to meet the changing needs of the population. To date, no database on individuals with
cardiac disease has been established to provide person specific data on the use of interventions and health
services. The Midland DHBs should agree the cardiac service needs for region and ensure these are
considered as a component of the overall region IT strategy.
Regional implementation of the Picture Archiving and Communication Systems (PACS) has identified
cardiology as a service with a specific need but the current identified system does not include cardiology
requirements. This should be recognised and the implications for the service, in particular Waikato
cardiology, understood until a PACS solution can be identified.
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Midland Region Cardiac Services Plan - 2006
11. Service Co-ordination
Cardiac service networking and coordination of services improves the integration, coordination, and
continuum of care for patients across service settings and geographical areas. There are three main
components to service coordination:
1. From the patient perspective to enable support across the continuum of care;
From the treatment perspective to enable an integrated multidisciplinary approach to care with
appropriate quality of service delivery across cardiac services; and
To ensure seamless coordination of the services delivered by different DHBs through the ‘hub and
spoke’ model of service delivery..
11.1. Patient Care Co-ordination
In cardiac services, patients move between primary, secondary, and tertiary services and generally require
ongoing care or rehabilitation. Few specific issues were identified during consultation, other than the lack of
service co-ordination of outpatient clinics at Tauranga Hospital and the service gap due to lack of
rehabilitation programmes in some areas. Linkages between Level I and Level II cardiac rehabilitation rely
on contact between cardiac nurses in these areas, who may be in different DHBs, this can breakdown
where there is change in personnel or no hospital-based service. However, no discussion has taken place
with service users, not has a patient pathway through the services been mapped to clearly identify
coordination concerns.
Mapping the patient pathway would be useful to identify specific areas where improvement or changes can
be made to ensure patient and carer are at the centre of care, by understanding patient and carer
experiences better and by gaining insight into their needs. This should be undertaken with patients using
the different services and pathways across the continuum of care.
Reviews undertaken with patients in England have indicated a number of priorities for patients relating to
cardiac services105. The issues relating to services leading to the NHS National Framework (growth in CHD,
inequity of CHD across the population and lack of planning across services) are similar to those seen in New
Zealand and there is a subsequent expectation that the patient priorities identified below will also be similar.
Education - Patients require education to enable then to take responsibility for prevention of disease by
adopting a healthy lifestyle and about the significance of symptoms of ill health.
Timely treatment - Patients with heart disease are worried and require explanation and reassurance. The
patient groups in felt strongly that where possible, the initial contact should be with a Consultant Cardiologist
with follow up consultations managed by Specialist Registrars under consultant supervision. Care should
then pass on as soon as possible to the community where there could be intermediate services of teams of
General Practitioners and Nurse Practitioners.
Patients are frustrated by waiting for different steps in the process of their care, particularly chest x-rays,
ECGS and blood tests. ‘One-stop shops’ that also include exercise testing and echocardiography are seen
as highly desirable.
Better communication between primary and secondary care and between departments in hospitals is
considered essential. Delays due to investigation results not being available, loss of records, no
communication of changes in drug treatment all lead to frustrations and delays.
Information - As well as education, patients want good communication and the provision of clear and
accurate information about their condition and proposed investigations and treatments. Patients wish to
make fully informed decisions about all aspects of their care. Special attention should given to patients and
families whose first language is not English.
Safety - Patient safety is an absolute pre-requisite. This includes the need for information about the
outcomes of various procedures so that they can give truly informed consent.
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Midland Region Cardiac Services Plan - 2006
Privacy - Patient privacy, especially during outpatient appointments is of great importance. Cultural
considerations must be respected.
Rehabilitation and after-care - An essential component in assisting heart patient’s recovery is the provision
of comprehensive community rehabilitation services in order to promote well-being, monitor progress and
provide information, advice and support for key carers who often play an important role in the patient’s
rehabilitation.
Self-empowerment - Patients can be empowered to carry out as much care as possible for themselves.
For example, training and equipment allows monitoring of blood pressure or anticoagulation.
Recommendation
Mapping the patient pathway would be useful to identify specific areas where improvement or changes can
be made to ensure patient and carer are at the centre of care, by understanding patient and carer
experiences better and by gaining insight into their needs. This should be undertaken with patients using
the different services and pathways across the continuum of care.
11.2. Integrated Care
There are a large number of organisations, and individuals within those organisations, that have the
opportunity to make a difference to the quality of life of the population and individuals with identified cardiac
disease. DHB’s need to ensure that services are available across all aspects of prevention, diagnosis and
treatment, that the approach is multidisciplinary and that service development includes all stakeholders. Bay
of Plenty DHB has developed a Programme of Care framework to ensure that all services fit within the
continuum of care for specific patient conditions (see Appendix Two).
Figure 21.
The New Zealand Heart Foundation Heart Health Continuum
Engagement with the Health Sector
The Heart Health Continuum
District Health Boards
Public Health Providers - - - - - - Primary Health Organisations - - - - Secondary/Tertiary Services
POPULATION FOCUS
INDIVIDUAL FOCUS
- - - - - - - - - - - - - Health Promotion Activities - - - - - - - - - - - - - Clinical Activities - - - - - - - - - - - - § Environmental
§ Regulatory
§ Economic
§ Community action
§ Organisational
development
§ Social marketing
§ Health education
§ Screening
§ Health information § Risk assessment
§ Clinical care
§ Rehabilitation
Smoking
Nutrition
Physical Activity
Cardiac Clinical Care
and Rehabilitation
Cardiovascular Guidelines
Coalitions/Alliances
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NS 2004
Midland Region Cardiac Services Plan - 2006
There are many examples of services established without involvement of stakeholders, from new services
by hospital providers, SIA services in primary care, and hospital services previously provided from another
DHB. While these are may be appropriate, they are developed in isolation without identifying implications for
other parts of the sector, and the perceived gap being filled may be misconceived and stakeholders may
become resentful rather than supportive of “what is best for the patient”.
DHBs should ensure that all stakeholders are involved in any new development or are consulted prior to any
agreement and the question always at the forefront of any decision is always “what is best for the patient”.
The New Zealand Heart Foundation is keen to engage with the health sector and support developments that
meet the national, DHB and Heart Foundation objectives in relation to cardiovascular disease. The Medical
Director, Professor Norman Sharpe has proposed a Heart Health Continuum (Figure 21), to identify the
relationships involved in the continuum of activities and services related to cardiac care.
Recommendation
DHBs should ensure that all stakeholders are involved in any new development, or are consulted prior to
any agreement, and the question always at the forefront of any decision is always “what is best for the
patient”.
That the Midland DHBs agree a relationship with the Heart Foundation that promotes an alliance to facilitate
the development of appropriate strategies and programmes to prevent and manage identified cardiovascular
disease for the people of the Midland region.
That this relationship be formalised through a Memorandum of Understanding between the Heart
Foundation and the individual DHB’s or jointly as the Midland DHBs.
11.3. Clinical Care Networks
The current framework for health services does not lend itself to coordination and integration of service
delivery across sectors and in particular across District Health Boards. The number of individuals and
organisations involved in delivering cardiac services requiring education, coordination, and integration lends
this service to the development of local cardiac networks that would function within a regional clinical
network.
A number of countries have developed clinical networks. The NHS National Service Framework for CHD
recommends the development of Cardiac Networks across the United Kingdom. The Scottish Department
of Health defined a managed clinical network as “linked groups of health professionals and organisations
from primary, secondary and tertiary care, working in a co-ordinated manner, unconstrained by existing
professional and health board boundaries, to ensure equitable provision of high quality clinically effective
services.”106
In Canada, the Cardiac Care Network of Ontario, established in 1990, has a mandate to coordinate the
provision of advanced cardiac care services and to advise the Ministry in relation to these services. Key
factors for network success that have been identified as a result of the CCN experience include107:
■
■
■
■
■
■
A clear purpose that establishes the boundaries of the mandate of the network;
Clear priorities together with realistic timeframes;
Clinical leadership and partnership;
The capacity for information/data collection and sharing;
Dedicated funding; and
A mechanism to keep the Ministry appraised of network activities.
Clinical networks have been established through the Greater Metropolitan Clinical Taskforce in New South
Wales, Australia across a number of clinical areas, including cardiac services. The characteristic is
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described by “a Clinical Network is a collaborating group of professionals or health service departments
working in a co-ordinated way to improve equity of access and equity of outcome for people with the
disorder which is the subject of the network, across area health service and/or institutional boundaries.” The
main goal of a Clinical Network is clinical supported and led improvement in quality of patient care the
dimensions of which are consumer involvement, access, appropriateness, effectiveness, safety, and
efficiency. A network does not replace a staff member’s allegiance and loyalty to his/her current site of
employment. Rather it provides the potential for that person’s or that hospital’s reputation and job
satisfaction to be enhances by the linking of services.
The benefits of the networks include the ability for local providers and management to work together to
coordinate their approaches around quality assurance, audit, benchmarking, as well as workforce
development, service improvement, research, and development. A guide for the establishment and
development of Cardiac Networks is available on the Modernisation Agency website108.
The Midland region currently holds an annual Cardiac Care meeting. This meeting is clinically focused and
well attended by Cardiologists, physicians and coronary care nurses in the region. The meeting is organised
by the Waikato DHB Cardiology department and supported through pharmaceutical company sponsorship.
This meeting has allowed the region to develop joint clinical protocols and procedures and staff in the region
view the meeting very positively.
The collaboration across the Midland region could be developed further through the formal adoption of a
clinical network. This would expand the focus to encompass all aspects of cardiac care from prevention,
through to tertiary level care with a collaborative approach to the development and delivery of services.
Networks could include representation from:
■
■
■
■
■
■
■
■
NZ Heart Foundation
Primary care providers
Secondary care
Ambulance services
Patient representatives
Rehabilitation services
Tertiary care
DHBs.
Recommendation
The current framework for health services does not lend itself to coordination and integration of service
delivery across sectors and in particular across District Health Boards. The number of individuals and
organisations involved in delivering cardiac services requiring education, coordination, and integration, lends
this service to the development of a regional clinical network.
An outline of a proposed network is included in this plan, with further detailed development options occurring
as a DHBNZ Management Action Programme (MAP) project.
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12. District Health Board Cardiovascular Disease Strategies
A number of District Health Boards have published strategies relating to cardiovascular disease on their
websites. Note DHB’s have not been approached and not all websites are easy to search for documents
such as these.
12.1. C&C DHB: Resource Allocation & Cardiovascular Resource Allocation 2004109
Capital & Coast DHB have developed a report that reviews models of resource allocation, which not only
address the current needs, but reduces the prevalence of CVD in 10 years time. This report indicates:
Resource allocation is a complex and multi-factorial activity that is at the heart of a DHB’s functions. It is
inherently a developmental and iterative process. The CPHAC resource allocation working group (RAWG)
has considered a number of the aspects of resource allocation that should be considered in developing a
robust and transparent process.
Key principles that have emerged during the discussions include:
■
■
■
■
DHB funding is limited which means that trade-offs and comparison of relative benefit are essential;
There is no single, simple approach to resource allocation;
Cost effectiveness information is not a sufficient sole basis for allocative decision making;
Consultation is difficult to do well, and must balance representation, complexity (or depth), and
timing;
■ Incorporating innovation needs to be considered at a system level and not at a marginal level;
■ Specific weighting needs to be given to addressing inequalities and specific mechanisms deployed.
From this work the following work streams have been developed110.
District Annual Plan Activities
4.6.1 Reduce smoking
■ C&C DHB is committed to becoming a smokefree organisation by 1 January 2005.
■ The Public Health Service for C&C DHB, Regional Public Health, is proactive in tobacco control
and smokefree health promotion.
■ Support PHOs to work with public health and other NGOs to reduce smoking and environmental
tobacco smoke in their respective populations.
■ Improve Pacific primary care workforce capacity to support smoking cessation.
■ Work with midwives and primary care providers to reduce smoking during pregnancy, support
smoking cessation.
4.6.2 Improve nutrition
■ Supporting work in school settings to improve available food choices.
■ C&C DHB participates in Porirua Healthcare Cluster. This inter-sectoral group works to improve
environmental factors affecting food choices, including work with retail outlets, supermarket tours
etc.
■ Work with PHOs, with public health input, to ensure improving nutrition is part of all health
promotion plans and to support evidence-based approaches.
■ C&C DHB is promoting healthy food options in the hospital cafeteria.
■ Improve food security for low-income families by working with WINZ and other groups to improve
access to income support where indicated
■ Strengthen Healthy Lifestyles Pasifika, Pacific elderly programme and other Pacific-led projects to
improve nutrition.
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■ Support community-based programmes to improve nutrition in whanau and Maori communities
The DHB has commissioned a literature review on nutrition and prisons, nutrition and rest home care.
A clinical dietician role has been funded to focus primarily on diabetes but also to work across public health
nutrition and physical activity team, hospital and community provider interface to share tailored, relevant
nutrition information and evidence-based findings.
The DHB has signaled schools as a key setting for action on nutrition. Through joint planning with Regional
Public Health and joint decision-making with Ministry of Health, the DHB is expanding ‘health promoting
schools’ activity. Health promoting schools is a vehicle for schools, families and communities to act
collectively to change environmental factors affecting food security, ffood choices and nutritional health.
4.6.3 Reduce obesity and increase physical activity levels
During 2004/05 C&C DHB will participate in inter-sectoral project to reduce child obesity along with other
agencies like DHBNZ, Ministry of Health and Ministry of Social Development. This project will involve
improving the availability of health food options in school cafeterias.
5.6.3 Achieving integrated care - Cardiovascular
■ Continue and develop an integrated care project for people with heart failure - initiated in 2003/04.
■ Improve services for young people requiring prophylaxis and support to manage rheumatic fever
and its sequelae.
■ A joint planning exercise between HHS and Planning and Funding will examine demand and
supply trends for cardiac and cardiothoracic services in the district. The pattern of future service
delivery will be determined.
■ Implement resource allocation service priorities for cardiovascular diseases
■ Implementing the NZGG guidelines for cardiovascular risk modification
■ Reducing the use and funding of hospital services by developing models of care that includes
frequent attender case coordination, hospital in the home services, and promoting the role of expert
patient
■ Assessing the introduction of new health technologies in terms of contribution to the balance
between community and hospital based services.
CVD Resource Allocation Strategy Implementation
Key strategies include:
■ Determine, negotiate and agree equitable service delivery levels for cardiology and cardiothoracic
services for Maori and Pacific peoples
■ Determine, negotiate and agree service delivery mechanisms for providing patient advocacy
services for Maori and Pacific peoples to support them in gaining equitable access to mainstream
cardiology and cardiothoracic services
■ Develop funding proposals for community based service models that implement the NZ Guidelines
Group recommendations for cardiovascular risk modification, particularly targeting Maori and
Pacific peoples
■ Assessing the introduction of new health technologies in terms of contribution to the balance
between community and hospital based services.
Determine Equitable Service Delivery Levels
As part of a report into access to all specialised services in the C&C District, an analysis has been
completed of access by ethnicity to cardiology and cardiothoracic outpatient and inpatient services. This has
demonstrated unequal access to services by ethnic group.
This analysis has not related service access to underlying morbidity patterns within each ethnic group. That
is, it has examined access with respect to equality not equity.
A thorough epidemiological analysis is required, and will be performed, to determine what levels of access to
cardiology and cardiothoracic services would be consistent with need.
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This analysis will provide a basis for negotiating access targets for ethnic groups with the C&C provider arm.
Develop Advocacy Services
The international literature on access by minority ethnic groups to mainstream health services consistently
demonstrates lower levels of service access. A variety of reasons are postulated for this from pragmatic
factors such as finances, transport and access to telephone to more systemic factors such as institutional
discrimination.
The development of advocacy services will support and assist Maori and Pacific peoples to make informed
choices and access mainstream health services, in a timely manner, that are appropriate to their needs.
Services provided by an advocacy service could include for example: facilitating attendance at clinic
appointments, ensuring interpreters are available, or participating in discussions with providers on treatment
choices.
Implement CVD Risk Modification
In December 2003, the New Zealand Guidelines Group published its report on recommendations for
accessing and managing CVD risk in individuals. See Appendix Three.
Addressing the unequal CVD risk burden that Maori and Pacific peoples could potentially be addressed
through targeting interventions at different levels:
■ At an individual level by, for example: providing CVD assessment vouchers to at risk groups that
they could use to access risk assessment and treatment services
■ At a Primary Care Provider level by targeting for funding interventions providers who have high
populations of at risk patients
■ At a community level by engaging with communities with high risk populations to develop
interventions tailored to the needs and specific characteristics of those communities
CVD risk modification requires lifestyle changes; it is not merely a medical intervention. A purely medical
approach is highly likely to miss the very individuals and communities it is desired to target. Therefore it is
considered highly desirable to adopt an approach that involves people within the context of the community in
which they live. It is proposed during 2004/05 to develop a funding proposal for 2005/06 DAP funding using
a community engagement approach. The mechanisms for implementing this approach will be developed
during the next few months.
Assessment of New Health Technology
New Health Technology Fund
A $600k fund has been established in the price volume schedule to fund new health technologies that the
provider arm wishes to adopt during the financial year. A template for applications is available.
The forum for decision-making is the funding management committee.
Work with National Organisations on approaches to new treatments
The management of established CVD is changing continually in response to new technology and evidence
of benefits. The affordability in the New Zealand context of some of the developing treatments should be
considered in a broad context, not in a DHB specific manner. The financial implications of implementing
some of the developing technologies are substantial.
C&C would like to work with national organisations such as the National Heart Foundation and Ministry of
Health to contribute to developing sustainable funding policies and nationally equitable access to treatments.
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12.2. The Waitemata DHB Cardiovascular Action Plan 2003111
The Waitemata DHB Board approved the Cardiovascular Action Plan in October 2003. The summary from
this plan is included below.
Cardiovascular disease is the leading cause of mortality and morbidity in Maori, Europeans and Pacific
people in the Waitemata district. Large inequalities exist between ethnic groups, with higher mortality rates in
Maori and Pacific. Cardiovascular population health gain is a major strategic priority for the Waitemata
District Health Board.
A Cardiovascular Advisory Group has been formed that includes experts and representatives from the areas
of public health, cardiovascular epidemiology, Maori health, Pacific people, primary and secondary care
practitioners and consumers. This group collated epidemiological information, cost-effectiveness data, and
presentations from experts and relevant organisations on activities to improve cardiovascular health gain in
our district. Resulting from this key themes for action in order to maximise cardiovascular health gain were
population health interventions and identification and treatment of those deemed to be at greatest risk of
further events.
This report includes a plan of action for the first year of a 3-5 year plan and includes the following
interventions:
Tobacco control activities
■ Appointment of tobacco control advocacy and coordination services for the Waitemata district with
ASH (Action on Smoking and Health). This includes assisting in skill transfer to Maori and Pacific
providers in our district.
■ Extension of smoking cessation services in our hospitals, including services that will target Maori
patients and their whanau.
■ Support and implementation of the Waitemata DHB Smoke-Free Policy
■ Smoking Reduction Community Development Project – initiated in Helensville as an area of high
need
■ Participation in Ministry of Health public health contract negotiations
Improvement in nutritional intake and physical activity
■ Strategies in these areas to be considered for Year 2 and 3 plans
Improved clinical decision support services to identify and treat those at highest risk of
cardiovascular events
■ An evaluation of PREDICT, an integrated electronic clinical decision support tool, to assist primary
care in assessing cardiovascular risk and treating appropriately according to New Zealand
guidelines. This project is in collaboration with primary care and the University of Auckland. There
will be priority enrolment for Maori and Pacific patients in order to determine the appropriateness
and effectiveness of the tool in our population.
Improved cardiac rehabilitation services
■ Advise and support the development of a New Zealand Heart Manual with the National Heart
Foundation and investigate the feasibility of piloting the manual’s implementation in our district.
■ Collaborate with Te Hotu Manawa Maori to develop a parallel Maori-specific manual and pilot
programme.
Improved organised stroke care
■ Investigate the options for organised stroke care in Waitemata along with the operational and
funding implications of implementing the new stroke guidelines.
Services that improve and target Maori cardiovascular health
■ Maori as a high-risk group will be targeted in most of the interventions outlined above
■ A Maori specific cardiac rehab programme development and pilot is planned in collaboration with
Te Hotu Manawa Maori
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■ Cooperate with an audit of access to tertiary cardiovascular procedures by ethnicity in our district,
to be performed by the Department of Maori and Pacific Health, University of Auckland
■ Consideration of the concept of Maori specific healthy lifestyle planners to offer services to Maori
patients and their whanau in their homes –Years 2 and 3.
12.3. Hutt Valley DHB Cardiovascular Service Plan 2002112
The Cardiovascular Services Plan for Hutt Valley DHB was consulted on as part of District Strategic
Planning 2001-2002.
The plan includes objectives and strategies aimed at the following outcomes:
Increase self care
■ patient education and management;
■ cardiac rehabilitation;
■ medication compliance.
Enhanced primary and community care
■ subsidised GP visits;
■ assertive recall systems;
■ disease management nursing services;
■ workforce development.
Better co-ordination and information
■ care management of high-risk people;
■ co-ordinated plans of care;
■ referral and care pathways
12.4. The Canterbury Heart Health Strategy, September 2004113
Canterbury DHB has committed to reducing the incidence of cardiovascular disease in order that the
demand created does not continue to increase.
Summary of Recommendations
1. Develop an information strategy with respect to heart health
Better evaluation of what we do, better audit of treatment and improved understanding of the prevalence of
risk in Canterbury
2. Decrease the incidence of cardiovascular disease
A combined population-based approach using public health services and high-risk approach-using primary
care services
3. Devolve supported impact reduction of cardiovascular disease to primary care / community
Treatment is not reaching those most in need of it. Hospital services must be moved into the community
4. Training and research with respect to heart health
Improved understanding of barriers to access and improving the ability of generalists to support the
specialists
5. Improved quality of care post acute events
Advantage must be taken of the best technology where possible.
Staffing levels should be appropriate.
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6. A cost neutral approach
The use of available expertise by effective collaboration across levels of care and between organisations.
The District Health priorities should be honoured by all departments. Sources of funding for primary care
initiatives to be investigated should include:
a. Reinvesting pharmacy subsidies for statins into primary care
b. Use of Primary Health Organisations’ “Services to improve access funding” for screening
c. Use of Primary Health Organisations’ “Care plus” funding for improving quality of treatment for
diagnosed cases of cardiovascular disease and their families
d. Reinvesting any savings made through reduced smoking rates into primary care and public health.
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13. International Precedents
Many countries in the world have identified coronary heart disease as a major cause of morbidity and
mortality and have developed strategies to help manage all aspects of health care that relate to incidence
and treatment of cardiac disease.
A brief outline of the strategies and directions of some countries is provided here.
13.1. United Kingdom
The National Service Framework for Coronary Heart Disease was published in March 200027. This NSF
sets out twelve service standards covering:
■ Reducing heart disease in the population;
■ Preventing CHD in high-risk patients;
■ Heart attack and other acute coronary syndromes;
■ Stable angina;
■ Revascularisation;
■ Heart Failure;
■ Cardiac Rehabilitation.
Service models are described for each area and clinical audit criteria are identified. National programmes
identified as needed to underpin the delivery of the NSF are:
■
■
■
■
■
Finance: revenue and capital
Human resources, workforce planning, education and training;
Research and development;
Practical tools, especially clinical decision support systems;
Information for health.
The NHS Modernisation Agency, includes the Coronary Heart Disease Collaborative (CHDC) which is a
national NHS funded programme designed to make improvements in the way CHD services are delivered to
patients. The Collaborative is a key element in the delivery of standards laid out in the National Service
Framework (NSF) for CHD.
The goal is to improve the experience and outcomes for people who have, or who are at risk of developing
heart disease, by redesigning the whole pathway of care. Key to the approach is getting managers,
clinicians, and the whole multi-disciplinary team to work together to review the system of care. Phase 1 of
the CHD Collaborative started in October 2000 with 10 local CHD programme teams aiming to create
improved methods of service delivery for patients with suspected or diagnosed CHD.
These teams consist of CHD service providers working together as a logical local CHD network. From April
2002, the Collaborative became 30 local CHD network programmes covering the whole of England, working
together with the support of the national team. Each CHD Collaborative has six projects which focus on
redesigning the system of care delivery, in line with the NSF:
■
■
■
■
■
■
Secondary Prevention
Acute Myocardial Infarction
Angina
Heart Failure
Cardiac Surgery
Cardiac Rehabilitation
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The CHDC website114 is an excellent resource on how the CHDC is working towards its goal and provides
practical examples and tools for change management processes, treatment guides and policies and
procedures. The service improvement resource guides include, secondary prevention, acute myocardial
infarction, heart failure, angina, cardiac rehabilitation, revascularisation. The Collaborative has produced a
strategic plan for the period 1 April 2003 – 31 March 2006 entitled ‘Mapping the Future Coronary Heart
Disease Collaborative Summary Strategic Plan 115.
Progress to date on implementing the NSF for Coronary Heart Disease has been published46. It should be
noted that while not all progress has required additional funding, significant resource has been made
available including £600 million for capital investments in cardiac centres, £125 million for new or
replacement catheterisation laboratories and funding for workforce, and research and development.
13.2. Australia
In March 2004 Australia published a National Strategy for Heart, Stroke and Vascular Health in Australia116.
The aim of this strategy is to improve the cardiovascular health status of the Australian population to be
among the best in the world, through:
■ Progressively reducing the inequalities in health outcomes associated with heart, stroke and
vascular disease, particularly through a focus on preventative and management practices in
relation to Aboriginal and Torres Strait Islander peoples;
■ Optimising the outcomes of care and management of heart, stroke and vascular disease across the
continuum of care, by identifying and promoting proven interventions;
■ Supporting the dissemination and uptake of preventative practices in relation to heart, stroke and
vascular disease and promote consistence in these practices; and
■ Promoting the role of consumers in maintaining and managing their own cardiovascular health.
The following are the key areas identified for action:
■ Heart, stroke and vascular disease in Aboriginal and Torres Strait Islander peoples:
■ Prevention of heart, stroke and vascular disease for:
■ The general population;
■ People and groups identified as being at high risk; and
■ People who have heart disease or stroke;
■ Cardiac emergency treatment and acute care;
■ Stroke emergency treatment and acute care;
■ Heart failure;
■ Rehabilitation for patients with heart, stroke and vascular disease; and
■ Consumer engagement and information.
It is acknowledged in this document that dedicated funding from a range of sources for a heart, stroke and
vascular health strategy will be required if Australia is to improve its cardiovascular status to be among the
best in the work.
13.3. United States of America
The USA has identified heart disease and stroke as one of the Health People 2010 objectives117. The goal
is ‘improve cardiovascular health and quality of life thought the prevention, detection, and treatment of risk
factors; early identification and treatment of heart attacks and strokes; and prevention of recurrent
cardiovascular events.
Progress reports against the objectives are available on the website at http://www.healthypeople.gov
The specific objectives and targets (where these are not developmental) are:
12.1
Reduce coronary heart disease deaths. Target: 166 per 100,000 population
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12.2
Increase the proportion of adults aged 20 years and older who are aware if the early warning
symptoms and signs of a heart attack and the importance of accessing rapid emergency care by
calling 911.
12.3
Increase the proportion of eligible patients with heart attacks who receive artery-opening therapy
within an hour of symptom onset.
12.4
Increase the proportion of adults aged 20 years and older who call 911 and administer
cardiopulmonary resuscitation (CPR) when they witness out-of-hospital cardiac arrest.
12.5
Increase the proportion of eligible persons with witnessed out-of-hospital cardiac arrest who receive
their first therapeutic electrical shock within 6 minutes after collapse recognition.
12.6
Reduce hospitalizations of older adults with congestive heart failure as the principal diagnosis.
Target: 50% decrease in adults over 65 years between 1997 and 2010.
12.7
Reduce stroke deaths. Target: 48 deaths per 100,000 population.
12.8
Increase the proportion of adults who are aware of the early warning symptoms and signs of stroke.
12.9
Reduce the proportion of adults with high blood pressure. Target: 16 percent.
12.10
Increase the proportion of adults with high blood pressure whose blood pressure is under control.
Target: 50 percent.
12.11
Increase the proportion of adults with high blood pressure who are taking action (e.g. losing weight,
increasing physical activity, or reducing sodium intake) to help control their blood pressure.
Target: 95 percent.
12.12
Increase the proportion of adults who have had their blood pressure measured within the preceding
2 years and can state whether their blood pressure was normal or high. Target: 95 percent.
12.13
Reduce the mean total blood cholesterol levels among adults. Target: 199 mg/dL (mean).
12.14
Reduce the proportion of adults with high total blood cholesterol levels. Target: 17 percent.
12.15
Increase the proportion of adults who have had their blood cholesterol checked within the preceding
5 years. Target: 80 percent.
12.16
Increase the proportion of persons with coronary heart disease who have their LDL-cholesterol level
treated to a goal of less than or equal to 100mg/dL.
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14. Future Directions
14.1. Non-invasive Imagining Technologies
CT Angiography Multi-detector CT (MDCT) scanners are a rapidly evolving technology from 4-slice CT
scanners in 1999 to 64-slice CT scanners being available in 2004. Tauranga Hospital’s 64-slice CT scanner
is to be installed in August 2005.
Cardiac multi-detector CT represents a step forward in the ability to evaluate the coronary arteries. The
coronary arteries provide a challenge because of their small size (3 to 4 mm), tortuous course, and
susceptibility to cardiac and respiratory motion. In addition, evaluation of cardiac function requires excellent
temporal resolution on the order of </=100 msec. Echocardiography, nuclear medicine techniques, and
magnetic resonance imaging (MRI) have been used non-invasively for a variety of cardiac indications, but
no single technique provides a comprehensive assessment.
There is an expectation that cardiac MDCT will be in use in New Zealand within five years, particularly as
radiology review future needs as a component of campus redevelopments. It is important for the Midland
region to consider the most appropriate facility(ies) for this service to be delivered.
It is currently understood that the patients who would be likely to benefit from this service rather than
conventional angiography would be those with atypical pain. These are patients who are expected to have
near normal coronary arteries or patients with a clinical diagnosis of infarction due to non-acute coronary
syndrome aetiology (eg myocarditis or rate related ischaemia with atrial fibrillation etc) where the need for
surgical or catheter based intervention is unlikely. MDCT is unsuitable in patients with calcified vessels or
stents, which limits a large number of potential patients. There is currently a risk of four times the radiation of
a standard catheter & no change in risk of contrast nephropathy.
It is expected that developments will continue in this technology to improve options for use and to alleviate
issues and risks for the patients and operators,
14.1.1. MRI Imaging
Advantages of MRI over cardiac CT include: superior temporal resolution, no iodinated contrast, (with the
added risks of allergies and contrast nephropathy), no ionizing radiation, and the capability to measure flow
velocities and to assess valvular regurgitation, which CT does not.
The Ontario Medical Advisory Secretariat (MAS) undertook a systematic review of the effectiveness, safety
and cost-effectiveness of using functional cardiac magnetic resonance imaging (MRI) for the assessment of
myocardial viability and perfusion in patients with coronary artery disease (CAD) and left ventricular
dysfunction118. Conclusions reached were:
■ There is some evidence that the accuracy of functional cardiac MRI compares favourably with
alternate imaging techniques for the assessment of myocardial viability and perfusion.
■ There is insufficient evidence whether functional cardiac MRI can better select which patients [who
have CAD and severe LV dysfunction (LVEF less than 35 per cent)] may benefit from
revascularization compared with an alternate non-invasive imaging technology.
■ There is insufficient evidence whether functional cardiac MRI can better select which patients
should proceed to invasive coronary angiography for the definitive diagnosis of CAD, compared
with an alternate non-invasive imaging technology.
■ There is a need for a large prospective (potentially multi-centre) study with adequate follow-up time
for patients with CAD and LV dysfunction (LVEF less than 35 per cent) comparing MRI and PET.
– Since longer follow-up time may be associated with restenosis or graft occlusion, it has been
suggested to have serial measurements after revascularization.
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This technology is currently used at Waikato Hospital for imaging structural heart disease. What is yet to be
determined is the use of MRI to image coronary arteries.
14.1.2. PET Scanning
Clinical studies have shown that Positron Emission Tomography (PET) imaging is more accurate than other
tests such as electrocardiogram (ECG) stress testing, single photon emission computed tomography
(SPECT), and the angiogram in detecting coronary heart disease. Whereas these tests often produce “false
positive” reports detailing the presence of coronary artery disease in a patient where none exists, PET has a
95% diagnostic accuracy rating in identifying coronary heart disease. PET can also be used during the
staging phase of cardiac disease treatment and to determine effectiveness of drug and invasive treatments.
14.1.3. Heart FABP:
The traditional markers Troponin T, Troponin I, and CK-MB offer diagnostic safety not before about 3 hours
post myocardial infarction. In contrast, h-FABP (heart-Fatty Acid-Binding Proteins) can be detected as early
as 20 minutes after an AMI.
The unique advantages of Heart FABP in myocardial infarction are:
■ h-FABP is the most sensitive marker for early assessment of AMI.
■ h-FABP is most suitable for monitoring of recurrent infarction.
■ h-FABP is uniquely sensitive for detection of early post-operative infarction.
■ h-FABP has higher cardiac specificity than myoglobin.
■ h-FABP enables early risk stratification of patients suffering from AMI.
Fatty Acid Binding Proteins are small intracellular molecules- small cytosolic proteins responsible for the
transport and deposition of fatty acids inside the cell. Due to its small size, FABP leaks rapidly out of
damaged dying cells, leading to a rise of serum levels.
h-FABP has the same kinetics of liberation into the patient's blood as myoglobin, but is more reliable and
sensitive marker of myocardial cell death. That is because h-FABP concentration in skeletal muscle is
significantly lower than myoglobin concentration. FABPs have a high degree of tissue specificity. Various
types of FABP have been detected including Heart FABP (primarily present in heart and striated muscle
cells).
14.2. Genetic Screening
Genetic screening may help families with inherited cardiac disease in the near future. The ability to identify
modifiers and genetic mutations that affect cardiac disease phenotypes provides insight into mechanisms of
disease and paves the way toward the eventual development of individualized therapies.
14.3. Cellular Therapy to Treat Heart Disease
Cellular therapy for treating CHD and CHF and other heart conditions is a growing field of clinical research.
Potential cell treatments for patients with congestive heart failure (CHF) and ischemic heart disease are of
great interest to medical researchers and treating physicians.119
14.4. Cardiac Surgery
14.4.1. Minimally Invasive Direct Coronary Artery Bypass (MIDCAB)
Also known as ‘keyhole’ surgery, in which a small chest incision is made without requiring the breastbone to
be split.
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Midland Region Cardiac Services Plan - 2006
14.4.2. Totally Endoscopic Robotically Assisted Coronary Artery Bypass Grafting (TECAB)
The UK National Institute for Clinical Excellence has developed draft recommendations for TECAB and
these have been circulated for comment closing 22 March 2005.. Catheter-based interventions for
myocardial revascularisation have been developed that produce less surgical trauma, avoid the need for
general anaesthesia, and shorten recovery time. 120
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Midland Region Cardiac Services Plan - 2006
15. Appendices
APPENDIX ONE.
Glossary
APPENDIX TWO.
Chronic Conditions Programmes of Care Framework - BOPDHB
APPENDIX THREE. Purchase Units
APPENDIX FOUR.
NZ Guidelines Group: Assessment and Management of CVD Risk
APPENDIX FIVE.
Infrastructure Requirements for a Sustainable Resident Specialist Service in
Cardiology
APPENDIX SIX.
Guidelines for the Use of BNP in Diagnosis of Heart Failure
APPENDIX SEVEN. Ambulance Support Services – Midland Region
APPENDIX EIGHT.
Cardiac Rehabilitation Guideline Summary
APPENDIX NINE.
Midland Region Cardiac Services Plan Recommendations
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Midland Region Cardiac Services Plan - 2006
APPENDIX ONE.
GLOSSARY
Ablation: The irreversible damaging or destroying of the tissue in order to cure or control cardiac rhythm
disturbances
Angioplasty: See PCI.
Coronary artery bypass surgery (CABG): coronary artery bypass grafting. This is the operation that is carried
out to “bypass” blocked coronary arteries in patients suffering from coronary heart disease. In certain
circumstances this treatment is life saving. Cardiac surgeons in tertiary centres carry out this procedure.
Cardiac surgeons: A cardiac surgeon is a surgeon who carries out operations on the heart. Cardiac surgeons
work in close conjunction with cardiologists. Many, but not all, cardiac surgeons also practice as thoracic
surgeons and operate on abnormalities of other structures in the chest, such as the lungs.
Cardiologists: A cardiologist is a physician who diagnoses and treats patients with heart disease. The treatment
may involve the use of drugs, the use of tubes and small balloons inserted into the body by the cardiologist
to clear blockages, and also the implantation of pacemakers and defibrillators. The role of the cardiologist
stops short of open heart surgery, which is carried out by the cardiac surgeon. Cardiologists and cardiac
surgeons have a very close relationship. In general patients are not referred directly to cardiac surgeons
but reach cardiac surgeons via cardiologists. Cardiologists all have a general knowledge of cardiology.
Many of them extend their knowledge within a subspecialty of cardiology such as percutaneous coronary
intervention (PCI), electrophysiology, echocardiography, grown-up congenital heart disease (GUCH), etc.
Cardioversion - Cardioversion can restore an abnormal heart rhythm and is a frequently recommended procedure for
patients with atrial fibrillation. It is carried out under a brief general anaesthetic. A small electric shock is applied to
the chest, which normalises the heart rhythm in most patients. Advantages are improved quality of life for the
patient, fewer acute admissions for patients when compromised by their condition or to prevent a complication like
a stroke
Congestive Heart Failure (CHF): A condition where the heart pumps inefficiently due to conditions that affect
the hear or lungs; may cause fluid back up in the lungs and/or legs adversely affecting the heart muscle.
Coronary Heart Disease (CHD): Also known as coronary artery disease. This is a disease that leads to angina
and heart attacks and is caused by narrowing of the coronary blood vessels.
Clinical governance: This is the careful scrutiny of medical practice. It involves development and audit of
services for treating patients, the assessment and management of risk, the investigation of adverse
incidents, and the establishment of standards for services. It is the cornerstone of modern medical
practice.
Coronary Angiography - This is when a special dye is injected into the arteries around the heart under a local
anaesthetic and X-Rays are taken. The dye shows up on the X-Rays revealing the arteries and the presence of
any narrowing or blockages. Your doctor will explain the risks and benefits of your treatment options and answer
any questions you or your family may have.
Coronary Angioplasty: See Percutaneous Coronary Intervention and Percutaneous Transluminal Coronary
Angioplasty.
Drug-eluting Stent (DES): Stents are endoprostheses made of a fine cylindrical mesh of stainless steel placed inside
coronary arteries to keep the affected section of these vessels (dilated by balloon angioplasty) open. Drug-eluting
stents (DES) release anti-proliferative agents from their surface with the objective of limiting cell growth around the
stent using cytotoxic, cytostatic and other agents.
Echocardiography: This is a study of the heart using ultrasound (sound beams). The sound beams (which are
not audible) are reflected from the heart and produce a picture, which is interpreted by the cardiologist.
Many of these procedures are carried out by echocardiography technicians under the supervision of a
cardiologist. Most investigations are carried out by placing an ultrasound probe on the chest wall and
obtaining a picture by shining the sound beams at the heart. Occasionally this does not provide adequate
images because the wall of the chest obstructs the sound beams. Under these circumstances a probe can
be swallowed by the patient, who is lightly sedated. This probe can be pointed at the heart from inside the
gullet (oesophagus). This produces very much better pictures. This is known as transoesophageal
echocardiography.
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Midland Region Cardiac Services Plan - 2006
Electrophysiology (EP): Electrophysiology is the assessment of the mechanism underlying abnormalities of
cardiac rhythm. This is done by introducing thin wires through the veins to the heart under X-ray control.
Electrical impulses within the heart can be measured through the wires.
Event Recorder Monitoring - To record any heart arrhythmias that may be felt by the patient while being worn over
several days.
Exercise Tolerance Test (ETT) - An Exercise Tolerance Test shows cardiovascular abnormalities not present at rest
and determines adequacy of cardiac function with exercise.
Holter Monitoring To obtain a 24-hour record of a patient's heartbeat and to determine if there are any cardiac
arrhythmias present
High Dependency Unit HDU: This stands for high dependency unit, and is where patients are looked after when
too ill for an ordinary ward and not ill enough for ITU.
Implantable Cardioverter-Defibrillator (ICD): An electrical device, which is the size of a large pacemaker. It can
be inserted under the skin and connected to the heart. It delivers an electric shock to the heart if the heart
goes into a dangerous rhythm. An ICD is used in patients who have had serious life threatening cardiac
arrhythmias, have previously experienced sudden cardiac death from which they have been resuscitated,
or are in danger of suffering a life threatening arrhythmia. They are implanted to correct the heart rhythm
should a cardiac arrest occur.
Intensive Therapy Unit (ITU) Also know as Intensive Care Unit (ICU): Is where patients are looked after when
very unwell and usually when critical ventilation or other support of breathing is needed.
Myocardial infarction (MI) This is when a coronary artery becomes blocked and part of the heart muscle dies as
a result. This is treated by urgent unblocking of the artery either by a balloon (PCI), insertion of a stent, or
by thrombolysis. Other names for this condition are heart attack and coronary thrombosis.
Myocardial Perfusion Scan This scan is to assess the supply of blood to the heart and to determine whether there is a
difference under rest and stress. These scans are based on physical stress either on a treadmill (Stress Perfusion
Scan) or, if the patient is unable to use the treadmill, chemicals are infused to stress the heart (Chemical
Perfusion Scan). The patient must be monitored while receiving the infusion. The scanning is carried out in the
Nuclear Medicine Department.
Nurse practitioner: A nurse who takes over a role which was formally undertaken by a doctor and takes clinical
decisions about a patient’s care. This is usually carried out within strict guidelines.
Pacemaker A small internal device that delivers low energy electrical pulses to the heart in order to make the heart beat
faster..
Paediatric cardiologists: Paediatric cardiologists are paediatricians who specialise in cardiology. Like the adult
cardiologists described under “cardiologists”, their duties encompass all aspects of care of children with
heart disease, stopping short of open-heart surgery.
Percutaneous Coronary Intervention (PCI): This is where a tube is passed in through the skin into an artery,
and then manipulated as far as the heart. The tube is then used to introduce balloons and other equipment
that can clear the coronary arteries from inside. This technique encompasses all forms of percutaneous
revascularisation including PTCA and stenting.
Percutaneous transluminal coronary angioplasty (PTCA): is where a balloon pump is used to widen the
narrowed blood vessel
Primary care: Primary care is another term for general practice. This is the care to which any patient can refer
themselves.
Radiofrequency ablation: This is when a radiofrequency impulse is passed into the heart and in doing so puts
right an abnormality of electrical conduction within the heart. This allows the heart to return to a normal
rhythm and to prevent dangerous or distressing rhythm disturbances occurring in the future.
Revascularisation: Revascularisation is the restoration of blood flow through the arteries to the heart (the
coronary arteries) using either CABG or PCI.
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Midland Region Cardiac Services Plan - 2006
Risk factors: Risk factors are the factors that can be identified in a particular patient that make them at risk, for
example, from having coronary heart disease. The most important coronary risk factors are smoking, high
cholesterol, hypertension (high blood pressure), obesity, diabetes, and a strong family history of premature
heart disease.
Secondary care: Secondary care refers to care carried out in a most hospitals. This is the first port of call for
patients who are referred by their general practitioner except in certain circumstances when the general
practitioner may go straight to the tertiary centre. Because tertiary centres usually have surrounding
populations, they take on the role of secondary care for the population—that is, they act as a DGH for their
local population.
Tertiary care (centre): Tertiary care is very specialised care given to patients with heart disease. Patients are
referred to tertiary care centres if they have a problem that is too complex for the local hospital. Most types
of care are provided both in secondary and tertiary centres, but the tertiary centres sometimes have more
sophisticated equipment and specialists with interest in very specialised areas of cardiology diseases. In
particular, tertiary care is where cardiac surgery is performed. Cardiac surgery is not carried out in
hospitals, which are not tertiary centres.
Tilt Table Testing: This is a diagnostic test for syncope (faint). The patient is gradually tilted from a lying down position to
an upright position, initially with no medication then with an isoprenaline infusion, which requires close monitoring.
This diagnostic procedure can take up to two hours plus some recovery time.
Thrombolysis: Thrombolysis is the administration of drugs which dissolve clots to patients who are having heart
attacks. Dissolving the clot improves the function of the heart and saves many lives. In some patients the
blood clot is cleared with a balloon (PCI) rather than by thrombolysis.
Transoesphageal Echocardiogram (TOE) - The patient is sedated and the transducer is inserted into the oesophagus,
this transmits the sound waves. The sound waves bounce off the walls of the heart and return to the machine,
forming pictures of the heart. An Echo gives useful information to the doctor about the heart's pumping function
and size. It can also locate holes in the heart, any leaks or blockages of the valves, and find blood clots or the
causes of strokes. The test is painless, requires no preparation and will take between 45 and 60 minutes.
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Midland Region Cardiac Services Plan - 2006
APPENDIX TWO.
CHRONIC CONDITIONS PROGRAMMES OF CARE MODEL & FRAMEWORK - BOPDHB
Activities along the Care
Continuum
BOPDHB Chronic Conditions Conceptual Model
Populations of Increasing Need at risk of, or diagnosed with,
Chronic Progressive Conditions
Population with
General
early chronic
population at risk
conditions and few
of a chronic
other conditions
condition
Promotive/
Preventive/
Detective
Care
Population with
advanced chronic
conditions and multiple
other conditions
Population coping with
severe frailty and
terminal conditions
Health education particularly around
prevention of complications
Supportive
(Palliative) Care
Active
Curative Care
condition-specific and
restorative
Diagnosis
suppo rtive ,
condition-spe cific
and mainte nance
care
Maintenance
Populations with Chronic Progressive Conditions
Family/whanau &/or Caregivers
Dying
bereavement
support
Death
Support & grief
services for
family/whanau
&/or caregivers
Condition Progression: Increasing Proportion of Supportive & Palliative Care
Activities to meet Population Care Needs
Modified from Source: World Health Organisation. Cancer Pain Relief and Palliative Care, Report of a WHO Expert Committee. Publication #1100804. Geneva: World Health Organisation, 1990.
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Midland Region Cardiac Services Plan - 2006
Chronic Conditions Programmes of Care Framework - BOPDHB
POPULATIONS WITH INCREASING NEED AT RISK OF OR DIAGNOSED WITH CHRONIC PROGRESSIVE CONDITIONS
Activities across the Continuum of care
Prevention/
General population Issues
to be informed by 04/05
BOPDHB HNA
Population at risk of developing
a chronic condition
Population with early chronic conditions
& few other conditions
Population with advanced chronic
conditions & multiple other conditions
Population coping with severe
frailty and terminal conditions
•
Community
development
programmes to support
community determined
health management &
sociological
understanding of
wellness, illness & death
Specific Public Health
issues programmes eg
tobacco control
Enrolled population
health promotion –
awareness raising
•
•
•
Self-management education, skills and
tools to limit & slow progression of
comorbidities
•
•
Planned access to ‘specialist care’
programmes to assist in stabilising
comorbidities, slowing the rate of
progression of the condition and ‘preempting’ treatment or management
options
Planned access to appropriate
diagnostic tools
Public health
programmes for early
detection
Public health diagnostic
tools
•
Promotion
•
•
Detection
•
•
•
•
•
•
•
-
•
•
1
Self-management
interventions
Age, gender and culturally
appropriate health education
Screening for five risk factors
Tools, skills & knowledge to aid
self-detection of range of
conditions
Range of primary health
practitioners skilled in detection
Diagnostic tools specific to
developing condition (blood
and urine tests Point of Care
tests)
Self-management education, skills and
tools to limit & slow progression of
comorbidities and introduce conditionspecific supportive and maintenance
palliative care options
Access to appropriate diagnostic tools
for identifying potential complications
Identified health education
management plan
Access to programmes to prevent
1
‘functional decline’ including homebased programmes
learning
competency
identification and removal of local
environmental hazards
•
Tools, skills & knowledge to aid in selfdetection of comorbidities
•
Regular ‘expert care’ to assist in
detection of comorbidities, symptoms
and signs of progression &/or
deterioration
Diagnostic tools specific to potential
complications
•
•
•
4
•
•
2
Tools, skills & knowledge to aid in selfdetection of comorbidities, symptoms
and signs of progression &/or
deterioration
Planned specialist care outpatient
interventions for early detection
Regular access to diagnostic tools to
manage limiting comorbidities, slowing
the rate of progression of the condition
and ‘pre-empting’ treatment or
management options
•
•
•
•
Refer: Prevention of Functional Decline in Elderly Persons. NEJM vol. 347, No.14. 3Oct02.page1068-1074 www.nejm.org
2
Specialist care refers to secondary health care practitioners (mainly consultants in medicine) with specific competencies around chronic conditions – often involves a multi/interdisciplinary team
3
Specialist care refers to secondary health care practitioners (mainly consultants in medicine) with specific competencies around chronic conditions – often involves a multi/interdisciplinary team
4
Expert care refers to primary health practitioners with specific and expert knowledge around a condition and it’s primary management. This does usually not involve a ‘team of practitioners’
- 139-
COPYRIGHT © MIDLAND DHBS, 2005
Self-management education,
skills and tools to limit & slow
progression of comorbidities
Planned access to ‘specialist
3
care’ programmes to assist in
stabilising comorbidities and/or
slowing the rate of progression of
the condition
Planned access to appropriate
diagnostic tools
Tools, skills & knowledge to
assist in self-detection of
symptoms / sign or other
problems
Appropriate access to regular
culturally appropriate palliative
care provision to ensure timely
intervention that addresses
condition deterioration
Midland Region Cardiac Services Plan - 2006
Curative
Care
General population Issues
to be informed by 04/05
BOPDHB HNA
Population at risk of developing
a chronic condition
Population with early chronic conditions
& few other conditions
Population with advanced chronic
conditions & multiple other conditions
•
•
Education programmes
(group)
Targeted management of at
risk populations e.g smoking
cessation for pregnant women
Provision of personal
behavioural health
interventions to stabilise or
reduce risk eg cholesterol
control, antihypertensive
strategies
Case-managed provision of a
suite of evidence-base
interventions for populations
having multiple risk factors (>3)
(e.g brief interventions
programme delivery, green
prescriptions, support groups,
etc)
•
•
For populations with under
three risk factors, facilitated
access to specific information
about risk impact and
management
For populations with more than
three risk factors, case
managed access to specific
information about risk impact
and management
•
Continuity processes incorporating
provider, information and over time
components including informal and
formal mechanisms e.g. Whanau and
Whakawhanuatanga
•
Case Management delivered by a
Specialist team (e.g. ESRD Team)
within an organised district/regional
network including formal mechanisms
e.g. Whanau and Whakawhanuatanga
•
Access to expert care programmes that
maximise independence functionality
and autonomy, predominantly delivered
in community settings
•
Case management by specialist care
teams within an organised
district/regional network
Planned programmes that maximise
independence, functionality autonomy
and quality of life, predominantly
delivered in clinical settings.
Ensure provision of
population protection
interventions around
environmental regulation
eg potable water
supplies
•
•
•
Continuity
•
Mgmt.
•
Recovery
&/or
Rehab
•
•
•
•
Education programmes (group) for
targeted disease populations e.g
people with diabetes, Hypertension,
renal disease, morbid obesity etc
Provision of targeted condition
management and maintenance
interventions eg Insulin, asthma meds
Availability of tools for monitoring the
condition specific to existing and
potential comorbidities
Case-managed provision of a suite of
evidence-base interventions for
targeted disease populations having
multiple comorbidities (>3) organised
within a primary/secondary network
Planned access to a full range of
effective therapeutic interventions eg
statins, ACEI’s
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•
•
•
•
•
Population coping with severe
frailty and terminal conditions
Personal commitment, skills, &
knowledge to aid with adherence to a
treatment plan.
Planned regular specialist health care
Appropriately planned, advanced,
access to specialist interventional
knowledge and technologies
Case-managed provision of a suite of
evidence-base interventions for
targeted disease populations having
advanced chronic multiple conditions
organised within a district/regional
network
Planned access to a full range of
effective therapeutic interventions eg
statins, ACEI’s
•
Case Management delivered by
a Specialist Palliative Care team
within an organised district
network including formal
mechanisms e.g. Whanau and
Whakawhanuatanga
Midland Region Cardiac Services Plan - 2006
•
Support for
daily living
•
•
•
Palliative
Care
•
•
Care for
Family
/ Whanau
- 141COPYRIGHT © MIDLAND DHBS, 2005
Case managed multidisciplinary
provision by a specialist health care
team
Intensive specialist support
programmes that maximise
independence
Planned appropriate access to
supportive technologies
Appropriate planned awareness raising
& skill development around potential
outcomes and the implications of
premature death
Appropriate coordinated access to a
range of supportive and palliative
services that support quality of life
provided within a district palliative care
network
Appropriate planned access to
supportive and palliative care
programmes including respite care
Case managed palliative caret team
to facilitate:
•
Social connection
•
Access to resources such as
technology & equipment
•
Whanau and
Whakawhanuatanga models of
continuity management
•
Care support that enhances
quality of life & functionality
Access to the ‘Single Point of
Coordination Service’ that will
determine the need for:
•
Care coordination
•
Domiciliary specialist care
•
Regular access to an expert
palliative care team
•
Interventions for symptom
management including access to
acute problem resolution
•
Short and long-term residential
care
Access to the ‘Single Point of
Coordination Service’ that will
determine the need for
Family/whanau:
•
Support for end stage transition
•
Bereavement counselling
•
Programmes for social reintegration of whanau /family
following family member death
Midland Region Cardiac Services Plan - 2006
APPENDIX THREE. PURCHASE UNITS DATA DICTIONARY V9
PF Purchase PF Purchase Unit
Unit Code
Code Description
Purchase Unit Definition
Unit of Measure Unit of Measure Definition
S15001
Cardiothoracic Inpatient Services
(DRGs)
See Appendix for a generic DRG
purchase unit definition and health
specialty mapping table.
Cost weighted
discharges
S15002
Cardiothoracic - 1st
attendance
See Appendix for a generic 1st specialist Attendances
assessment definition. First attendance to
general surgeon or medical officer at
registrar level or above or nurse
practitioner for specialist assessment.
Number of attendances to a
clinic/department/acute assessment unit.
S15003
Cardiothoracic Subsequent
attendance
See Appendix for a generic subsequent Attendances
specialist assessment definition. Followup attendances to cardiothoracic surgeon
or medical officer at registrar level or
above or nurse practitioner.
Number of attendances to a
clinic/department/acute assessment unit.
M10001
Cardiology - Inpatient See Section 32 for a generic DRG
Services (DRGs)
purchase unit definition and health
specialty mapping table.
M10002
Cardiology - 1st
attendance
See Section 32 for a generic 1st specialist Attendances
assessment definition. First attendance to
cardiologist or medical officer at registrar
level or above or nurse practitioner for
specialist assessment.
Number of attendances to a
clinic/department/acute assessment unit.
M10003
Cardiology Subsequent
attendance
See Section 32 for a generic subsequent Attendances
specialist assessment definition. Followup attendances to cardiologist or medical
officer at registrar level or above or nurse
practitioner.
Number of attendances to a
clinic/department/acute assessment unit.
M10004
Cardiac Education and Cardiac education and case management Clients
Management
by multi-disciplinary teams in hospital or
community-based setting.
Number of clients managed by the
service in a year ie caseload at the
commencement of the financial year plus
all new cases year to date.
M10005
Specialist Paediatric
Cardiac - Inpatient
Services (DRGs)
See Section 32 for a generic DRG
purchase unit definition and health
specialty mapping table.
As per the specifications for the
calculation of Inlier Equivalent
Separations version 8 (WIES8) and
Weighted Inlier Equivalent Separations
version 8 (WIES8A).
M10006
Specialist Paediatric
Cardiac - 1st
Attendance
See Section 32 for a generic 1st specialist Attendances
assessment definition. First attendance to
cardiologist, paediatrician, or medical
officer at registrar level or above or nurse
practitioner for specialist assessment.
Number of attendances to a
clinic/department/acute assessment unit.
M10007
Specialist Paediatric
See Section 32 for a generic subsequent Attendances
Cardiac - Subsequent specialist assessment definition. FollowAttendance
up attendances to paediatric cardiac
specialist or medical officer at registrar
level or above or nurse practitioner.
Number of attendances to a
clinic/department/acute assessment unit.
M10008
Cardiac Outreach
Service - WH
CHF project to provide support to prevent Service
readmission and lower length of stay.
There is a Service Spec & reporting
requirements, Integration project.
Agreed lump sum amount. Service
purchased in a block arrangement
M10009
Cardio-vascular
models of care
Integration Project - General Practice
Service
teams, providing in the community,
services for patients with Chronic CardioVascular Disease
Agreed lump sum amount. Service
purchased in a block arrangement
- 142COPYRIGHT © MIDLAND DHBS, 2005
Cost weighted
discharges
Cost weighted
discharges
As per the specifications for the
calculation of Inlier Equivalent
Separations version 8 (IES5) and
Weighted Inlier Equivalent Separations
version 8 (WIES8A).
As per the specifications for the
calculation of Inlier Equivalent
Separations version 8 (WIES8) and
Weighted Inlier Equivalent Separations
version 8 (WIES8A).
Midland Region Cardiac Services Plan - 2006
APPENDIX FOUR.
NZ GUIDELINES GROUP: ASSESSMENT AND MANAGEMENT OF CVD RISK
In December 2003, the New Zealand Guidelines Group (http://www.nzgg.org.nz) published its report
on recommendations for assessing and managing CVD risk in individuals. The key messages are
summarised below:
■ Assessment of absolute cardiovascular risk is the starting point for all discussions with
people whom have cardiovascular risk factors measured. Reduction in cardiovascular risk is
the goal of treatment.
■ Risk assessment for most asymptomatic men is recommended from the age of 45 (or from
the age of 35 if they have risk factors). Risk assessment for most asymptomatic women is
recommended from the age of 55 (or from the age of 45 if they have risk factors).
■ Maori should be assessed for cardiovascular risk 10 years earlier than non-Maori.
■ There is an urgent need to focus intervention programmes on Maori, who bear the greatest
burden of cardiovascular disease in New Zealand. The ‘outcome gap’ between Maori and
non-Maori is widening.
■ A fasting lipid profile, fasting plasma glucose and two blood pressure measurements are
recommended investigations for comprehensive risk assessment.
■ People with known cardiovascular disease and those at high risk because of diabetes with
renal disease, or some genetic lipid disorders, are clinically defined at very high risk.
■ Cardiovascular mortality is high in people with impaired glucose tolerance (IGT) or diabetes
and most will require intensive intervention. Particular attention is required for Maori who
have a high rate of cardiovascular and renal complications from diabetes.
■ Lifestyle change and drug intervention should be considered together. The intensity of
intervention recommended depends on the level of cardiovascular risk:
– A life free from cigarette smoke, eating a heart healthy diet and taking every opportunity to
be physically active is recommended for people at less than 10% 5-year CV risk
– Lifestyle interventions for people at more than 10% 5-year CV risk are strongly
recommended and this group should receive individualised advice using motivational
interviewing techniques relating to smoking cessation if relevant, a cardioprotective diet and
regular physical activity – cardiovascular risk should be reduced in people at greater than
15% 5-year CV risk by lifestyle interventions, aspirin, blood pressure lowering medication
and lipid modifying therapy (statins).
– There should be a greater intensity of treatment for higher risk people (more than 20 – 30%)
– after myocardial infarction, comprehensive programmes that promote lifestyle change for
people are best delivered by a cardiac rehabilitation team.
– Most people with angina or after myocardial infarction will be taking at least four standard
drugs, low-dose aspirin (75 – 150 mg), a beta-blocker, a satin and an ACE-inhibitor
– virtually all ischaemic stroke and transient ischaemic attack survivors should be taking low
dose aspirin, a combination of two blood pressure drugs and a statin.
- 143COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
APPENDIX FIVE.
INFRASTRUCTURE REQUIREMENTS FOR A SUSTAINABLE RESIDENT SPECIALIST
SERVICE IN CARDIOLOGY
Hospital facilities and services - urban practice
■ CCU providing hardwire and telemetry ECG monitoring, haemodynamic monitoring,
temporary pacing facilities (ie., access to imaging intensifier)
■ electrophysiology laboratory including permanent pacemaker service
■ stress testing - treadmill, ECG, echocardiographic or nuclear
■ echo/Doppler including transoesophageal echo
■ ambulatory ECG monitoring
■ cardiac catheterisation laboratory
Hospital facilities and services - rural practice
Essential requirements include:
■ CCU providing hardwire and telemetry ECG monitoring, haemodynamic monitoring,
temporary pacing facilities (ie., access to imaging intensifier)
■ stress testing (ECG)
■ echo/Doppler
■ cardiac catheterisation laboratory in major rural centres
Desirable hospital facilities and services include:
■ permanent pacemaker
■ echo or nuclear stress testing
■ transoesophageal echo
■ ambulatory ECG monitoring
Skilled nursing/allied health and ancillary staff requirements - urban and rural practice
■ trained CCU nursing staff and trained cardiac technicians in ECG and echocardiography
■ physiotherapist with cardiac rehabilitation training, occupational therapist, dietitian, social
worker
■ secretary/receptionist
Other services essential in close proximity
■ radiology, pathology and an emergency department
Other services desirable in close proximity
■ vascular ultrasound and arteriography, nuclear medicine and library facilities
Surgery/office facilities
■ depending on proximity and availability of facilities in the local hospital - electrocardiography
and stress testing (ECG, +/- echo)
■ echo/Doppler
■ secretarial/reception area, consulting suite, procedural suite and data storage facilities
Infrastructure requirements for a sustainable outreach service in cardiology
■ within the hospital - a consulting suite, ECG and chest x-ray, pathology (haematology and
biochemistry)
■ support staff requirements include receptionist
Source: AMWAC and CSANZ (AMWAC 1998.7)
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Midland Region Cardiac Services Plan - 2006
APPENDIX SIX.
GUIDELINES FOR THE USE OF BNP IN DIAGNOSIS OF HEART FAILURE
PATIENT PRESENTING WITH DYSPNOEA OR
POSSIBLE CARDIAC OEDEMA
HISTORY
EXAM
CXR
ECG
BNP
IF DIAGNOSIS
REMAINS UNCLEAR
BNP < 40
PMOL/L
HEART FAILURE
UNLIKELY
(2%)
BNP 40220PMOL/L
INDETERMINATE RESULT
Possibilities include
– Heart Failure
– ACUTE PE
– Cor Pulmonale
Echo for the sole
purposes of
excluding heart
failure is unhelpful
If heart failure
strongly suspected
specialist
opinion/echo may be
appropriate.
HEART FAILURE LIKELY
(95%)
Begin treatment for
failure. Specialist
opinion and echo may
be appropriate for
determining aetiology:
G Devlin: Cardiologist
Anglesea Heart & Health Waikato
NB: BNP may be increased by AF, Renal
Failure, LVH, ACS, acute PE, COR
Pulmonale, age.
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BNP >
220PMOL/L
Midland Region Cardiac Services Plan - 2006
APPENDIX SEVEN. AMBULANCE SUPPORT SERVICES – MIDLAND REGION
Note: St John Ambulance Midland Region does not include Taranaki
DHB
Bay of Plenty
Lakes
Fire First
Response Units
Fire Co Response Units
Fire Station
PRIME
Location
Maketu
Matakana Island
Matata
Greerton
Mt Maunganui
Ohope
Edgecumbe
Katikati
Kawerau
Pukehina
Papamoa
Tauranga Airport
Tauranga
Whakatane Board Mills
Whakatane
Murupara
Opotiki
Waihau Bay
Whakatane
Mamaku
Ngongataha
Mangakino
Rotorua
Taupo
Reporoa
Tongariro
Turangi
Gisborne
Te Puia
Tologa Bay
Te Araroa
Tairawhiti
Patutahi
Tokomaru
Tologa
Waikato
Putaruru
Cambridge
Bennydale
Tahuna
Chartwell
Hamilton
Matamata
Cambridge
Huntly
Kawhia
Morrinsville
Otorohanga
Pukete
Te Aroha
Matamata
Morrinsville
Mokau
Otorohanga
Te Awamutu
Tokoroa
Piopio
Putaruru
Raglan
Taumaranui
Te Anga
Te Aroho
Te Kaha
Te Kauwhata
Te Kuitu
Tirau
Tokoroa
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Midland Region Cardiac Services Plan - 2006
APPENDIX EIGHT.
NEW ZEALAND CARDIAC REHABILITATION GUIDELINE SUMMARY17
■ Comprehensive cardiac rehabilitation programmes have been shown to reduce mortality
from coronary heart disease, re-infarction rates and hospital admissions and improve quality
of life for the patient and their family.
■ The main goals of cardiac rehabilitation are:
– To prevent further cardiovascular events by empowering patients to initiate and maintain
lifestyle changes
– To improve quality of life through the identification and treatment of psychological distress
– To facilitate the patient's return to a full and active life by enabling the development of their
own resources.
■ Prior to hospital discharge, all eligible patients should be referred to attend a comprehensive
cardiac rehabilitation programme.
■ The main components of a comprehensive cardiac rehabilitation programme are:
– Empowering patients to make lifelong changes
– Exercise programmes
– Nutrition management
– Weight management
– Smoking cessation
– Managing psychosocial aspects of life
– Pharmacotherapy
– Ongoing personal follow-up and support.
■ Cardiac rehabilitation provides the opportunity to coach and encourage positive lifestyle
behaviours and increases compliance with medication use.
■ For personal behaviour change, several key elements need to be present:
– A belief that change is possible
– Motivation to make the change
– A support network and personal capacity to enact and sustain change.
■ Physical activity improves functional capacity, risk factors and significantly reduces
cardiovascular disease and total mortality. The benefits of regular, moderate physical activity
are likely to outweigh any small increased risk of sudden death associated with vigorous
exercise.
■ A cardioprotective dietary pattern reduces cardiovascular and total mortality and is
recommended. Modification of dietary fat should not be considered in isolation from a whole
diet approach.
■ All patients with coronary heart disease should be strongly encouraged to stop smoking and
to avoid second-hand smoke.
■ Up to 1 in 4 patients will experience a disabling level of anxiety or depression following a
myocardial infarction. Psychosocial interventions are recommended.
■ Pharmacotherapy with aspirin, a beta-blocker, an ACE inhibitor and a statin can provide
substantial benefits and these medications should be considered in all patients.
■ Cardiac rehabilitation should be viewed as a continuum from initial admission through to
long-term follow-up. This requires integration between primary and secondary care.
■ Audit, evaluation and patient feedback are integral aspects of quality improvement.
■ Specific groups may require special consideration. Patients requiring extra support or varied
options may include women, the elderly, the socio-economically disadvantaged and those
living in rural areas. People with diabetes are at particularly high risk and warrant priority.
■ Ensuring Mäori and Pacific peoples access to cardiac rehabilitation programmes is important
and will help reduce disparities in cardiovascular disease outcomes. Existing programmes
may need reorientation to increase responsiveness to Mäori and Pacific peoples needs.
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Midland Region Cardiac Services Plan - 2006
Psychosocial management:
■
■
■
■
Assess level of social support needed.
Monitor symptoms of depression and anxiety.
Advise on return to vocational activity, driving and return to sexual activity.
Refer to home or hospital based comprehensive cardiac rehabilitation programme.
Smoking goal:
■
■
■
■
Complete cessation
Assess tobacco use. Strongly encourage patient and family to stop smoking and
avoid smoke. Facilitate counselling, pharmaco therapy and cessation programmes as
appropriate.
Physical activity goal:
■ At least 30 minutes on most days of the week
■ Assess exercise risk, preferably with exercise test to guide prescription. A gradual increase
to periods of physical activity of at least 30 minutes most days of the week and an increase
in daily lifestyle activities is advised.
■ Vigorous exercise is not routinely recommended.
■ The benefits of regular moderate physical activity overall, considerably outweigh any risk of
sudden death.
Nutrition management goal:
■ Adoption of a cardioprotective dietary pattern
■ This dietary pattern includes:
– Large servings of fruit, vegetables and whole grains
– Low fat dairy products
– Small servings of unsalted nuts and seeds regularly
– Fish or legumes frequently in place of fatty meat and full fat dairy products
– Small lean meat servings.
■ Weight management goal:
■ For overweight or obese patients, an individually planned nutritionally balanced diet may be
considered. The initial goal of weight loss should be to reduce the patient's weight by 10%.
Encourage exercise and nutrition goals.
Lipid lowering medication goals:
■
■
■
■
Total cholesterol < 4 mmol/L
LDL cholesterol < 2.5 mmol/L
Ensure cardioprotective dietary change. Promote exercise and weight management.
Assess fasting lipid profi le. Start drug therapy (statin generally most appropriate; consider
adding fibrate if low HDL or high TGL).
BP control goal:
■
■
■
■
■
<120-140 / 80-90 or lower if diabetes
Ensure lifestyle measures. Add BP medication individualised to patient characteristics.
Antiplatelet agents Continue aspirin indefinitely. If aspirin contraindicated, consider warfarin.
Beta blockers Continue betablockers indefinitely unless contraindicated.
ACE inhibitors Continue ACE inhibitor indefinitely in high-risk, post MI patients (anterior MI,
previous MI, LV dysfunction or CHF). Consider chronic therapy in other patients.
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Midland Region Cardiac Services Plan - 2006
APPENDIX NINE.
MIDLAND REGION CARDIAC SERVICES PLAN RECOMMENDATIONS
The high mortality rate and predicted increase in cardiac disease have significant implications for the
Midland region. There are a large number of guidelines and recommendations for the prevention and
management of cardiac disease but little evidence on the incidence, prevalence and impact of the
disease in the community. Many of the recommendations included in this service plan relate to better
collaboration and cooperation; however there is a need for investment to ensure services can be
provided to meet current need, as well as allowing service development, and improved data and audit
systems. Once these tools are in place, the ability for the Midland service to meet the needs of the
changing population and to implement rapidly changing best practice treatment options will be
improved.
It is recommended that the Midland region agree specific targets and objectives. In choosing these it
is important to identify those that can be measured easily and in a timely fashion e.g. heart failure
hospitalisations. Mortality data is available but information is delayed and while important to
understand changes in mortality it will be several years before outcomes will be known. The United
States targets and objectives provide an indication of options for consideration.
PRIMARY PREVENTION
Primary prevention may be defined as ‘the long term management of people at increased risk but with
no evidence of cardiovascular disease’.
Health Promotion
Health promotion activities that target healthy lifestyle factors are critical for DHBs to manage the
long-term prevalence of cardiac disease. The evidence that lifestyle changes not only decrease the
incidence of cardiovascular disease but also significantly increase length of life is strong and covers
all nationalities. Addressing smoking rates, exercise, nutrition and obesity in the general population
but in particular, to children and those groups known to be at highest risk, should be a priority.
1. DHBs and PHOs should support national activities that reduce smoking rates, improve nutrition,
reduce obesity, and increase physical activity, in line with the New Zealand Healthy Eating
Healthy Action strategy.
2. Consideration should be given to the establishment of local or district wide health promotion
steering groups, to enable the development of health promotion plans than support intersectoral
collaborative projects that target at risk groups, and provide a supportive environment to change
behaviour.
3. PHOs should be encouraged to participate in intersectoral projects, and provide supportive
programmes, that focus on the priority health promotion activities.
4. DHBs, PHOs, and other community providers should be encouraged to utilise the Heart
Foundation as a resource for information and potential support for programme development.
Identification and Management of At Risk Individuals
Currently there is no consistent approach to identification of “at risk” patients across the region.
PHOs, in general, are aware of their population and the demographics of the patients most at risk of
developing cardiac disease but do not have cardiac registers, or the ability to provide outcome data
for patients treated.
5. DHBs and Primary Health Organisations (PHO’s) should jointly determine the appropriate option
for cost-effective use of available or new technology to establish cardiovascular disease registers
and data management.
6. DHB funders should encourage PHO inclusion of secondary or tertiary general medicine or
cardiology input into the development of SIA and HP proposals to enable an integrated approach
to service development.
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Midland Region Cardiac Services Plan - 2006
6.1. Where this does not occur in the development phase, comment should be sought from staff
in the relevant speciality to ensure the proposal does not adversely affect the hospital
provider e.g. through a significant increase in referrals without the resource to manage
these.
7. PHOs should be represented on any established Cardiac Clinical Network.
SECONDARY PREVENTION
Secondary prevention may be defined as ‘the long-term management of people who have existing
cardiovascular disease, have had a cardiovascular event, have had a cardiovascular surgical
procedure, and are at risk of a cardiovascular event’.
Specific issues identified at a secondary care level include waiting lists for diagnostic procedures and
beds blocked due to lack of access to tertiary services. These are principally due to resource issues:
equipment, facilities and staff.
Primary Care
The NZ Guidelines for Assessment and Management of CVD Risk provide recommendations on
appropriated drug therapy for patients. It is recognised that not all patients who would benefit from
drug treatment are prescribed the appropriate medication or are compliant with the prescribed
regimen.
8. Primary care continuing education programmes should include updates on CVD guidelines as a
regular component of education for providers.
9. PHOs should consider quality targets that identify specific measures against the CVD guidelines,
noting that CHD or CVD coding and/or register will be a critical component of this.
10. PHOs should consider options for improving education and compliance for patients with cardiac
disease.
11. DHBs should consider the option for including specific measures from the CVD guidelines as
PHO performance indicators.
Secondary Care
12. Patients cared for by a cardiologist compared with a general medical physician have been shown
to have a better longer-term survival rate. The most important factor affecting survival has been
identified as access to effective medication and therefore the adherence to guidelines and
protocols is vital for patient management. In a regional service, it is critical to maintain a strong
relationship between cardiologists and general physicians to promote best practice for all
patients.
Chest Pain Units
13. Chest pain units have been shown to improve patient care. It is recommended that an evaluation
of the chest pains units at Waikato and Tauranga Hospitals be undertaken within 12-months of
commencing operation, to determine the option for establishment of chest pain units at other
secondary care facilities across the region. Evaluation criteria should include effectiveness,
acceptability and cost-effectiveness data from before establishment (where available) and after,
such as:
–
–
–
–
proportion of patients with acute chest pain who are admitted to hospital;
length of stay of patients admitted with non-ischaemic pain (both ED and hospital);
the rate of adverse events within 30 days among those discharged;
patient related factors for health related quality of life and satisfaction with care. .
Diagnostics
There are long waiting lists for many diagnostic procedures in the region, including angiography,
electrophysiology and echocardiography. It is estimated that the cost of patients waiting for transfer to
Waikato Hospital for diagnostic or treatment procedures cost the Midland DHBs over $1 million in
2003-04. This does not include the cost of patients waiting at Waikato Hospital.
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Midland Region Cardiac Services Plan - 2006
14. A review of all diagnostic tests across the region should be undertaken with the view to agreeing
a means to ensure appropriate and equitable access into the future.
Echocardiography
Significant access issues to echocardiography are encountered in all districts across the region.
These relate to workforce, equipment and funding of the service. Many patients are not referred, as
GP’s understand patients will often wait for months, if not years, leading to uncertainty about the true
level of need in the region.
15. A full review of echocardiography across the region should be undertaken and a planned
approach to identify, update and replace equipment where necessary, to enable an agreed and
equitable level of access to echocardiography into the future. This should include access to
cardiologist reporting of all echos and medical supervision of the service.
15.1. The agreed level of access should be based on clinical criteria, together with access to Btype-Natriuretic Peptide (BNP) testing, recognising the cost implications of the decision for
the DHBs.
16. An echocardiography workforce plan should be put in place across the region to ensure a
supported regional service with appropriate training and continuing education to enable a
sustainable service into the future.
B-type-Natriuretic Peptide
The emergence of BNP testing as a useful diagnostic test in suspected heart failure is noted and this
may help reduce demand for echo in patients with suspected heart failure. This test is included as an
issue for DHBs due to the rapid increase in expenditure with little monitoring of this test against
guidelines for use.
17. DHB providers and PHOs should adopt the regional BNP guidelines and monitor the use of BNP
against these guidelines.
17.1. DHBs should consider options to review, or audit, the use of BNP testing against the
regional guidelines.
Catheter Laboratory Procedures
18. The Midland region cannot meet the current demand for diagnostic and treatment procedures
with the facilities and staffing available. Nor are the current treatment levels meeting best practice
recommendations. Midland DHBs should agree to work towards the recommended rates for
diagnostic and treatment procedures as identified, recognising the implications for catheter
laboratories and staffing which are identified in the resource section of this paper:
– Angiography – 2.5 times the revascularisation volume
– Electrophysiology – 250 pmp
– Implantable cardioverter-defibrillators (ICD) – 200 pmp by 2006, 300 pmp by 2011;
– Pacemakers – 550 pmp
The 2005 British Cardiac Society predictions should be noted and all predicted rates reviewed
on an annual basis.
Revascularisation
Revascularisation procedures include percutaneous coronary interventions (PCI) and coronary artery
bypass graft (CABG). Midland cardiologists currently present patient information to a weekly
multidisciplinary team meeting held at Waikato Hospital to determine the best treatment option –
medical, PCI or cardiac surgery. Current access to all revascularisation procedures is below
international recommendations at approximately 1700 pmp for the publicly funded services. The vast
majority of PCI and CABG are performed on patients with acute coronary syndromes. Access to
Cardiac Care beds, staffed ICU beds (post operatively) and the interventional suites at Waikato
Hospital is problematic and has meant patients remain in other hospitals in the region for several
days, delaying revascularisation and prolonging costs significantly. These bottlenecks adversely
affect staff morale throughout the region.
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Midland Region Cardiac Services Plan - 2006
19. The level of revascularisation procedures recommended is 1400 pmp PCI and 750 pmp CABG.
These should be adjusted, if required, to retain 2150 procedures per million population. Noting
the 2005 British Cardiac Society is predicting 2200 – 3000 PCI and 700 CABG pmp per annum
will be required in the future.
20. At this time, patient safety, and the volume of PCI, and the resource and capital costs required to
establish an interventional service, leads to the recommendation that Waikato Hospital should
continue to provide all percutaneous revascularisation for the Midland region.
This
recommendation should be reviewed at a time when safety of treatment away from a cardiac
surgery unit is acceptable, and there is a substantial increase in PCI or best practice requirement
for an increase in facilities providing the service within the region.
Percutaneous Coronary Interventions
21. Consideration should be given to extending the same day discharge programme (currently to
Hilda Ross facility at Waikato Hospital) for suitable patients to a facility in the DHB of domicile, or
home:
21.1. Resource for this might include education, telephone follow-up, access to nursing and/or
medical advice.
New Technologies
Drug eluting stents are not currently included in any ICD10 code and therefore there is no current
funding stream.
22. Waikato DHB should raise the issue of funding for drug eluting stents at a national level; the new
technologies group is likely to be the appropriate forum.
23. Midland DHBs should agree a methodology for determining whether sharing costs for new
technologies, when these fall outside any national process, is appropriate.
Cardiac Surgery
A recent review of Waikato cardiac surgery services has been undertaken and an implementation
plan developed.
24. In addition, consideration should be given to earlier discharge of suitable cardiac surgery patients
to a hospital facility closer to their home.
24.1. For this to occur patients would require access to care including, wound care and
physiotherapy as agreed with the Waikato Hospital cardiac surgery service.
Cardiac Rehabilitation
Cardiac rehabilitation has been shown to: reduce mortality from CHD, re-infarction rates, reduce
hospital admissions and improve quality of life. Three phases of cardiac rehabilitation are
recommended:
■ Phase I – inpatient rehabilitation in hospital includes early mobilization and education;
■ Phase II rehabilitation is a supervised programme beginning as soon as possible after
discharge and referral. Programmes should include:
– An exercise component (home activity and/or supervised exercise sessions);
– Educations sessions aimed at increasing understanding of the disease process, risk factors,
treatment and nutrition advice;
– Guidance for the resumption of physical, sexual and daily living activities, including work;
– Psychosocial support
■ Phase III promotes long-term maintenance of the skills and behaviour changes learned
within Phase I and II, and are generally community or Heart Foundation run programmes.
A challenge facing the DHBs is to provide appropriate phase II cardiac rehabilitation programmes to
under-represented groups, in particular, Māori, Pacific peoples, those living outside the main centre,
and heart failure patients. Currently all programmes in the Midland region are run by hospital
providers.
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Midland Region Cardiac Services Plan - 2006
25. It is recommended that there be a review of all Midland DHB phase I and phase II cardiac
rehabilitation programmes against the New Zealand Cardiac Rehabilitation Guidelines.
26. A regional coordination model should be developed for the delivery of cardiac rehabilitation
services that would provide programmes close to home and promote access to cardiac
rehabilitation in groups traditionally underrepresented; high quality central data collection; the
creation of a district or regional cardiac rehabilitation registry to allow future planning,
coordination, monitoring, and evaluation of services in Midland.
26.1. This model should include options for providing community or home-based rehabilitation to
ensure that all eligible patients (including rural, Māori, elderly and heart failure patients)
have access to cardiac rehabilitation.
27. A regional network of rehabilitation staff should be established to encourage peer support and
education activities.
ACUTE CORONARY SYNDROME
Acute Coronary Syndrome (ACS) includes unstable angina (UA), non-ST segment elevation
myocardial infarction (non-STEMI) and ST segment elevation myocardial infarction (STEMI).
Treatment and care of acute cardiac episodes are critical, as the longer the patient is without
treatment, the greater the risk of myocardial damage.
28. Treatment of ACS is a constantly and rapidly evolving field. The Cardiac Society, Ministry of
Health, and the New Zealand Guidelines Group are developing ACS guidelines for New Zealand
due to be released this year. In the interim the principles for the treatment of Acute Coronary
Syndrome should be adopted for the Midland Region:
–
–
–
–
–
–
–
–
Appropriate treatment in the community as early as possible (following symptom
development) where there may be delay in access to trained professionals;
Primary angioplasty is the treatment of choice for STEMI and should be undertaken within
12 hours of the onset of symptoms when presenting to Waikato Hospital where
interventional facilities are available;
Where access to primary angioplasty is >3 hours from the onset of symptoms, thrombolysis
is the treatment of choice for STEMI;
Patients with contraindications to thrombolysis or failure of thrombolysis 45-60 minutes after
administration, should be immediately transferred to Waikato Hospital for primary or rescue
angioplasty providing transport can be achieved expeditiously;
After thrombolysis, routine angiography (within 24 hours if possible) is a strategy
increasingly recommended in international guidelines, even if the patient is asymptomatic
and without demonstrable ischaemia. Note, this has significant resourcing implications;
If an interventional facility is not available within 24 hours, patients who have received
successful thrombolysis, with evidence of spontaneous or inducible ischaemia prior to
discharge, should be referred for coronary angiography and revascularisation as
appropriate;
Patients with non-ST elevation acute coronary syndrome (Unstable angina and non-STEMI)
require further risk stratification.. A clear benefit from early angiography (<48 hours) and,
when required, PCI, or CABG surgery has been reported only in the high-risk groups;
To enable appropriate treatment, an efficient and coordinated transport service across the
region is critical.
Emergency Response
29. The Midland DHBs should review CPR training and access to AEDs and trained personnel in the
community, in particular in the rural areas when there may be delay for emergency first response.
30. A Midland region policy on access to first response services in the region should be developed.
The ECCT should be involved, if not responsible, for the development of this policy.
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Midland Region Cardiac Services Plan - 2006
Thrombolysis
Pre-hospital Thrombolysis
31. The Midland DHBs should undertake a review of the region to determine localities where access
to a facility providing thrombolysis is greater than one hour.
31.1. Community thrombolysis programmes should be rolled out to identified localities across the
region.
31.2. The option for Waikato coronary care unit receiving all ECGs should be considered.
31.3. The option for the NZ Rural Institute to hold the contract for community thrombolysis for all
DHBs in the Midland Region should be considered.
Hospital Thrombolysis
32. In the absence of a New Zealand agreed standard, the Midland DHBs cardiologists, physicians,
and emergency medicine specialists should agree a standard time in which thrombolysis should
be administered to appropriate AMI patients – call-to-needle time and door-to-needle time.
32.1. Each facility should undertake regular audit of door-to-needle time against the agreed
criteria.
32.2. Each facility should undertake regular audit of call-to-needle time against the agreed
criteria.
Transport
A critical component of cardiac services is patient transfer for acute treatment or inter-hospital transfer
for, or following, treatment. There is a need for a coordinated approach to patient transfer to ensure
best practice and best outcomes for the cardiac patient.
33. Ambulance triage criteria for cardiac patients should be reviewed to ensure timely transfer to
treatment facility.
34. A coordinated approach to all cardiac transport is required and a regional review should be
undertaken to determine options for the future.
35. The Midland DHBs recognise the Midland ECCT air ambulance needs-analysis incorporates the
air ambulance service needs for cardiac patient transfer within the region.
36. The outlined air ambulance proposal included should be developed further as a joint proposal
that clearly identifies implications for the DHBs in relation to flight numbers and costs, together
with efficiencies and benefits for patient care.
37. An urgent recommendation for consideration is that Waikato DHB employs or identifies two flight
nurses – total 1FTE to be seconded to the air ambulance service for cardiac transfers. That the
remaining shifts be undertaken at Waikato Hospital to ensure appropriate skills and training.
CHRONIC CONDITIONS
Acute cardiac disease may lead to a chronic condition that will have a significant impact on the quality
of life of the individual. The most common chronic condition is congestive heart failure (CHF), which
has a worse prognosis than most cancers. Rheumatic fever is included specifically, as if acute
relapses are not prevented; patients are likely to develop chronic cardiac disease, generally valvular.
Heart Failure
The number of patients with CHF is expected to continue to rise. An integrated multidisciplinary
approach to care can support patients in decreasing hospital admissions and improving quality of life.
38. PHOs should include DHB cardiologists, cardiac nurse specialists, and/or general physicians in
the development of any programmes to be provided in primary care for heart failure patients –
including Care Plus or SIA funded care.
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Midland Region Cardiac Services Plan - 2006
39. DHBs should ensure heart failure patients have access to multidisciplinary cardiac rehabilitation
as part of the review of cardiac rehabilitation programmes in the districts. Heart failure should be
a specific component of the recommended review of cardiac rehabilitation programmes.
40. DHBs should review palliative care options available for patients with end stage cardiac
conditions.
Rheumatic Fever
New Zealand, and specifically the Midland region, has high rates of acute rheumatic fever (ARF) for
an industrialised country. Recurrent bouts of ARF are preventable, but occurrence causes a
compounding of valvular damage caused by the initial episode and increases the severity of the
resultant chronic rheumatic heart disease. Currently there is only one DHB-wide rheumatic fever
register in the Midland region managed by the Tairawhiti Public Health Unit.
41. The Midland Region Public Health Units should ensure development of comprehensive
rheumatic fever registers, to record incident cases and track their follow-up.
RESOURCES
Cardiac Care Beds
The current number of cardiac care beds available in the region is inadequate for the throughput of
patients and current delays for diagnosis and treatment.
42. Midland DHBs should undertaken a review to determine options for managing cardiac patient
throughput, this should include earlier recommendations 20 & 23 for earlier discharge of patients
home or to a facility closer to home.
Cardiac Catheterisation Laboratories
The number of catheter laboratories required for cardiac services have been identified in this service
plan. Recommendations include:
43. Waikato Hospital should plan for four cardiac catheter laboratories on site.
44. Tauranga Hospital should plan for one dedicated catheter laboratory to undertake cardiac
diagnostic angiography and pacemaker services for the Bay of Plenty. An option for
consideration, is for Tauranga to deliver elective services for the Lakes and Tairawhiti DHBs, this
would allow Waikato to focus on acute service delivery for all Midland DHBs.
45. That options identified to increase cardiac catheter laboratory services be considered to ensure
appropriate service delivery prior to any new facilities opening. These include, extending current
catheter laboratory throughput, developing a service at Rotorua Hospital and contracting to
private facilities.
46. The Midland DHBs should recognise that the rapidly changing technology, and consequent best
practice for cardiac services, may require additional catheter laboratories within the region within
ten years.
Workforce
47. The Midland DHBs should identify the skills required and agree a regional workforce
development plan for cardiac services for the region.
47.1. This plan should incorporate a professional development and peer support component for
all staff involved in delivering cardiac services within the region
47.2. Consideration should be given to identifying competencies required and allowing for new
ways of working to meet the needs of the service.
47.3. There are few available specific recommendations for levels of staff providing cardiac
services. Recommendations have been identified in this plan for staffing levels for: catheter
laboratories, cardiac rehabilitation, cardiologists (medical, interventional and
electrophysiologists), and cardiac surgeons for the Midland region.
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48. There is an urgent need to address cardiologist staffing in order to recognise the current waiting
times and growing need for secondary and tertiary cardiac services. It is critical that the total
cardiologist numbers for the region are available, irrespective of location, to ensure the delivery of
services to the regions population. The Cardiologist recommendations made are conservative
based on international trends, and it is recommended the Cardiologist and Cardiac Surgeon
recommendations be reviewed when the Australian Medical Workforce Advisory Committee
reports on Cardiology and Cardiothoracic Surgery become available in the next 12-months.
Systems
49. Monitoring the use of interventions and health services can provide information for planning and
evaluating health services to meet the changing needs of the population. To date, no database
on individuals with cardiac disease has been established to provide person specific data on the
use of interventions and health services. The Midland DHBs should agree the cardiac service
needs for region and ensure these are considered as a component of the overall region IT
strategy.
50. Regional implementation of the Picture Archiving and Communication Systems (PACS) has
identified cardiology as a service with a specific need to be included but the current system being
implemented does not include the specific cardiology requirements. This should be recognised
and the implications around time, cost and storage space for the service, in particular Waikato
cardiology, understood until a PACS solution can be identified.
51. Better collaboration, cooperation, and data would provide the opportunity for Midland DHBs to
agree specific objectives and targets in relation to decreasing the burden of cardiac disease.
There is insufficient publicly available data to measure all potential objectives; however, there is
an opportunity for PHOs to work with a clinical network and the DHBs to establish specific
objectives and targets that can be measured for their own population, or jointly through agreeing
to share data to allow for a “Midland approach”.
Objectives that could currently be agreed include:
■ Reduce hospitalisations of older adults with congestive heart failure as the principal
diagnosis. Target: 50% decrease in adults over 65 years between 2006 and 2011;
■ Improve the management of acute coronary syndrome. Target 80% of all ACS patients
undergo angiography within 72 hours of admission by 2011.
Other options that would require data not currently collected at a DHB level include:
■ Increase the proportion of adults who call and receive early pre-hospital care and treatment;
■ Reduce the proportion of adults with high blood pressure and increasing the proportion of
adults with high blood pressure whose blood pressure is under control;
■ Increase the proportion of adults with high blood pressure who are taking action (e.g. losing
weight, increasing physical activity, or reducing sodium intake) to help control their blood
pressure.
SERVICE COORDINATION
Patient Care Coordination
52. Mapping the patient pathway would be useful to identify specific areas where improvement or
changes can be made to ensure patient and carer are at the centre of care.
Integrated Service Delivery
53. DHBs should ensure that all stakeholders are involved in any new development, or are consulted
prior to any agreement, and the question always at the forefront of any decision is always “what is
best for the patient”.
54. The Midland DHBs should agree a relationship with the New Zealand Heart Foundation that
promotes an alliance to facilitate the development of appropriate strategies and programmes to
prevent and manage identified cardiovascular disease for the people of the Midland region.
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Midland Region Cardiac Services Plan - 2006
That this relationship be formalised through a Memorandum of Understanding between the
Heart Foundation and the individual DHB’s or jointly as the Midland DHBs.
Clinical Care Network
55. The current framework for health services does not lend itself to coordination and integration of
service delivery across sectors and in particular across District Health Boards. The number of
individuals and organisations involved in delivering cardiac services requiring education,
coordination, and integration, lends this service to the development of a regional clinical network.
An outline of a proposed network is included in this plan, with further detailed development
options occurring as a DHBNZ Management Action Programme (MAP) project.
- 157COPYRIGHT © MIDLAND DHBS, 2005
Midland Region Cardiac Services Plan - 2006
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