Cardiac Services Plan for the Midland Region

CARDIAC SERVICES PLAN

FOR THE

MIDLAND REGION

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.

- 2- COPYRIGHT © MIDLAND DHBS, 2005


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

3.1. New Zealand Health Strategies 17

3.2. District Health Board - Cardiac Disease Objectives & Related Activities 18

3.3. Cardiovascular Guidelines 24

4. 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

5. Contracting and Funding 40

5.1. DHB Agreements 40

5.2. Outpatient Clinics 41

5.3. DHB Expenditure on Cardiac Services 42

6. Primary Prevention of Cardiac Disease 45

6.1. Health Promotion 45

6.2. Identification and Management of ‘At Risk’ Individuals 48

7. Secondary Prevention 50

7.1. Primary Care 50

7.2. Secondary / Tertiary Services 52

7.3. Revascularisation 74

7.4. Cardiac Rehabilitation 81

8. Acute Coronary Syndrome 87

8.2. Emergency Care 89

8.3. Thrombolysis 92

8.4. Primary Percutaneous Coronary Interventions 93

8.5. Transport 94

9. Chronic Conditions 97



9.1. Heart Failure 97

9.2. Rheumatic Fever 101

10. Resources 104

10.1. Equipment 104

10.2. Workforce 107

10.3. Systems 116

11. Service Co-ordination 118

11.1. Patient Care Co-ordination 118

11.2. Integrated Care 119

11.3. Clinical Care Networks 120

12. 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

13. International Precedents 128

13.1. United Kingdom 128

13.2. Australia 129

13.3. United States of America 129

14. 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



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



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 113Table 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



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:



– 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;



■ 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.



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



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.



■ 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



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.

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



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



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.



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.



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;



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.



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.



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. Risks and Mitigation Strategies

Resourcing of Lakes DHB capacity to review & implement programmes for people with cardiovascular risks or disease; 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 Impact

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.

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.



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 Actions Targets Timeframes Reduce the incidence and impact of cardiovascular disease

Work in partnership with MOH/PHU to develop and implement population programmes to reduce the level of cardiovascular risk.

Population awareness of risk Increased uptake in local prevention programme

June 2004

Improve the primary treatment of cardiovascular risk

Work with the local PHO based cardiovascular screening assessment Increase the uptake of statins

Analyse outputs from the programme to date Measure baseline, 2003/04 and agree increase with primary care

Dec 2004 Sep 2004

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 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 Tairawhiti Social Development Taskforce join with TDH on smokefree

Assess current services against demand for these services One Resource and one Role model per year

50% Tairawhiti agencies completely smoke free

Dec 2004

Ongoing June 2005



Objectives Actions Targets Timeframe Recognise and maintain by Maori for Maori service

delivery 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

By Maori for Maori services acceptance and greater market share All agreements include cessation tobacco targets Collection of good local data that effectively monitors tobacco consumption

June 05 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



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.



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,



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.



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:


http://www.newhealth.govt.nz/toolkits


– Management of heart failure; Rheumatic heart disease;

Stroke services;

Cardiovascular disease and Māori;

Cardiovascular disease and Pacific peoples.



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 2001 2006 2011 2016 2021

Bay of Plenty 183,400 201,800 214,500 226,800 238,800 Lakes 99,400 102,200 104,300 105,900 107,400 Waikato 328,600 340,000 347,000 353,200 359,100 Tairawhiti 45,500 45,000 44,300 43,500 42,600 Taranaki 105,900 104,200 101,700 98,800 95,500 Midland Total 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

0

20,000

40,000

60,000

80,000

Bay of Plenty Lakes Tairawhiti Taranaki Waikato

2001 2006 2011 2016 2021 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.



Figure 2. Ethnicity of Midland DHB populations, 2001

50,000

300,000

350,000

250,000

100,000

150,000

200,000

0Bay of Plenty Lakes Tairawhiti Taranaki Waikato

European Māori Pacific Peoples Asian Other

4.2. Cardiac Disease Data

dise both New Zealand and international populations. There is little specific information on current incidence or prevalence rates other than hos lf-reported inf n in doc ch as A hot of Health21, which indicates that approximately one in five adults over 45 years reported they have been diagnosed with heart disease.

4.2.1. MortIn 2004 the H d a summa of recent sta cal information on Cardiovascular Disease in Ne e age-standardised r shown in Ta w that in 2000 New Zealand the CHD mortality rate s 24% higher than he 2002 Australian rate and 22% higher in women. Between 1970 ealand, the CHD e-standardise eath rates fell by 61% in men and 56% in wome n 1970 and 2002 rates fell 75% for men and 72% for women.

Cardiac ase mortality statistics are available in a number of publications and databases for

pital data and se ormatio uments su Snaps

ality Rates eart Foundation publishe ry tisti

w Zealand22. Th ates ble 2 shofor men wa t

and 2000 in New Z ag d dn. In Australia betwee the

Table 2. Cardiovascular rates of death per 100,000 population in New Zealand, 2000 and Australia 20012.

Cause of death Males Females Total

New Zealand

Coronary Heart Disease 114 5 6 82Hypertensive Disease 3 3 3 Cerebrovascular Dis 35 32ease 33 Ch tic he e 2 3 ronic rheuma art diseas 3 All th 512 33 causes of dea 0 412

Austra lia

Coronary se 86 44 Heart Di ase 64 Cerebrovascular Dis 28 25ease 27



Table 3. Death rates per 100,000 from CHD in New Zealand according to ethnicity and age, 20002

25-44 years

45-64 years

65ye

-74 ars

75+ years

Male 10 116 614 2310 Female 1686 2 34 258

Others - Non-Māori Non-Pacific Total 6 75 431 1924

Male 201423 364 1438 Female 9 78 327 1563

Pacific people

otal 16 219 82T 3 1722 Male 31 386 1124 2687 Female 9 147 713 2202

Māori

otal 20 264 905T 2398 14 149 6Male 58 2319

Female 3 46 287 1699 Total population

Total 9 97 466 1935

Table 4. Coronary heart disease and rheumatic fever data by Midland DHB23

Adults 25-64 years Adult ears Infectio se s 65+ y us DiseaDistrict Health

Boards Indicator Ischae heart Ischa eart Rheumatic fever (initial

attack- n ations), mic emic h

diseas ality), e (mort2000

diseas ), e (mortality2000

otific2002

# 37 247 7 Rate / 100,000 36.8 862.3 4.4

Bay of Plenty

SMR/SIR 83.3 86.9 213.8 # 32 89 1

Rate / 100,000 64.4 815.1 0 Lakes

SMR/SIR 142.6 81.6 55.3 # 19 71 2

Rate / 100,000 85 1232.1 0 Tairawhiti

SMR/SIR 188.3 124.3 225.6 # 29 188 1

Rate / 100,000 50.9 10.93 0 Taranaki

SMR/SIR 113.7 112.1 53.1 # 87 399 5

Rate / 100,000 52.3 975 1.7 Waikato

SMR/SIR 116.5 97.7 83.2 # 890 5,030 86 All New Zealand

Rate / 100,000 44.8 980 2.6

Notes: ■ Standardised Mortality Ratios (SMR) and Standardised Incidence Ratios (SIR) are calculated by

ue of lower than 100 means that

■ 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.

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 valfewer 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.



In all categories male death rates are higher than female rates and Māori have higher rates than Pacific peoples or others.

The de th rates from CHD in 2000 are 88% hfemale Māori than non-Māori. The rates for M

a igher for Māori males than non-Māori and 119% higher for āori and non-Māori are falling with a 4% decrease in Māori

ificantly higher than those of the total population (about old ages). Male cardiovascular disease mortality rates

are higher than the corresponding female rates for all adult age groups.

The ublished An Ind cation of New Zealanders’ Health in 004 this document provides inf y DHB. Th Mid s is summ ble 4.

It s at data from the Heart Foundation and Ministry of Health documents are not directly co dardisation on W Segi world respectively.

4.2 dA summary of health indicators that impact on cardiac disease, the curre ffected groups and trends, as identified in An Indication of New Zealanders’ Health23 are shown .

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 signtwice as high in middle age and 1.5 times higher in

Ministry of Health pormation CHD mortality b

ie d

2a

23

ata for the land DHB rised in Ta

hould be noted thmparable as the age-stan s are based HO and populations

.2. Cardiac Disease Health In icators nt position, a in Table 5

Ta icators for cardiac disease ble 5. New Zealand health ind

Indicator Current level Trend Variation within population

Socio-economic factors

School completion (6th Form Certificate or higher), 2000, percent

Males – 59 Stable Mäori – 40.6

Males – 4.4 Mäori – 10.2 Females – 5.0 Pacific – 7.7

Unemployment, 2003, percent

Total – 4.7

Declining

European – 3.5 Mäori – 32 Pacific – 40 European – 19

Population with low income, 2001, percent Total – 22.6 Declining

Other – 36 Mäori – 23 Pacific – 43 European – 5 Asian – 20

Household crowding (need one or more extra bedrooms), 2001, percent

Other – 25

Total 10.1 No information

Risk factors


Overweight, 2002/03, percent Stable

er – 34.3 Total – 33.9

European/OthMales – 19.0 Mäori – 27.1 Females – 20.0 Pacific – 48.5

Obesity, 2002/03, percent

tal – 20.0

Increasing

er – 19.9 To European/OthMales – 4.6 Mäori – 8.2 Females – 3.8 Non-Mäori – 3.7

Diabetes, 2002/03, percent

Total – 4.2

crease since 1996/97 Possible in

Males – 17.9 Mäori – 23.4 Females – 19.4 Pacific – 17.9 Total – 18.7 .5 European/Other – 18

High blood pressure, 2002/03, percent Not available

Asian – 13.7



Indicator Current level Trend Variation within population

Males – 14.4 Mäori – 13.9 High total blood cholesterol, 2002/03, 3.0

Not available 1

– 13.9 sian – 12.8

percent Females – 1Total – 13.7

Pacific – 10.European/Other A

Males – 9.9 Mäori males – 16.8 Females – 14.9 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

Tobacco smoking (14/15-year-olds) (daily smoking), 2002, percent

les – 10.8

Declining

European/Other femaMales – 26.2 Mäori – 46.4 Females – 25.5 Pacific – 31.9

Tobacco smoking (15+ years), 2002,

r – 22.1 percent

Total – 25.8

Declining

European/OtheMales – 35 Mäori – 37 Females – 35 5 Non-Mäori – 3

Total fat intake, 1997, percent Declining

Total – 35 Males – 27.2 Mäori – 26.0 Females – 11.7 Pacific – 19.0 Total – 19.1 er – 19.3 European/Oth

Hazardous drinking, 2002/03, percent Possible increase since 1996/97

ian – 4.0 AsProtective factors

5–17 years – 68 5–17 years – possibly declining

Physically active, 1997–2000, percent

+ years – 68 18+ years – creasing

ean people are peoples and

roups 18in

Mäori and Europmore active than Pacific Other ethnic g

Males – 63.3 Mäori – 64.5 Females – 71.1 Pacific – 41.1 Total – 67.3 European/Other – 72.5

Consumption of at least 3 servings of vegetables per day, 2002/03, percent

Stable

Asian – 44.6 Males – 42.8 äori – 45.7 MFemales – 63.8 Pacific – 54.7Total – 53.7 European/Other – 55.5

Consumption of at least 2 servings of fruit creasing per day, 2002/03, percent

In

Asian – 55.3 Outcomes – adults (25–64 years)


Ischaemic heart disease mortality, 2000, Declining rate per 100,000

Asian – 31.3 Outcomes – older people (65+ years)


Ischaemic heart disease mortality, 2000, Declining

Asian – 837.2

rate per 100,000

Infectious diseases


Rheumatic fever notifications, 2002, rate per 100,000

No clear trend

Total – 2.6 European/Other – 0.7

The New Zealand Ministry of Health published the NZIER – Ageing New Zealand and Health and Disability

hos AT&R) and palliative care) and

s are based on the following assumptions:

Services Report in December 200424 this document includes estimates of acute and sub-acute pitalisations (medical; surgical; assessment, treatment and rehabilitation (

aged residential care for ischaemic heart disease by gender and ethnicity based on three scenarios.

The three scenario



■ Scenario 1 & 2 - medium population growth; ario

■ Scenario 1 & 3 - a continuation of the 2001 rates of hospitalisation in the main diseases and ting the p

■ ng r i e in a s con ns er th the collective views of the first-roun s - a ing n’ ase and dis on d p o

io 3 - a ‘cri cen view ise nd ility t a ogr (y of ability and disease are pr ed b rea life ctaith cenario 2 (t es , the sig nt in es ed ita rg er

ars.

■ Scen 3 – high population growth;

conditions affecS

opulation a nccenario 2 - cha

n line wies in tes of i denc the m i sen disea and

; ditio affecting the ov

65s (i■ Sc

d consultee )set anena

■ Scenario 1 & 2 ‘reced horizo of dise ability rogressi n; r sis s a

olongrio’ of d ase a disab onse nd pr ession ears

dis y inc ses in expe ncy). Even w s he low t rate) re are nifica creas expect in hosp l discha es ovthe next 5 ye

Table 6. Potential ch hos scha r co hea se scha acu b-aange in pital di rges fo ronary rt disea for all di rges – te & su cute 24

Sc 1 Sc 2 Sc 3 enario enario enarioPercent Increase 2001–2011 <65 65–79 80+ <65 65–79 80+ <65 65–79 80+

Asian Female 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 Male 116% 140% 166% 116% 117% 141% 127% 149% 166% 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%

3. Prevention of Cardiac Disease umber of studies have been undertaken in different countries looking what factors lead to the decrease in tality. The outcomes of a New Zealand study, and a more recent UK study, show that lifestyle factors ount for at least 50% of the mortality decrease, with smoking the mos

4.2.A nmoracc t significant of these. The average

medfor m

The

1. w Zealand (population

life-years gained by decreasing risk factors has been shown to be 20 years, compared with 7.5 years for ical treatments and relatively modest gains from revascularisation. It should be noted this measure is ortality only and not quality of life.

outcomes from a selection of studies is provided below:

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, Ne996,000). 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



initial treatment of acute myocardial infarction, and 3% to hypertension treatments) and 58% to population risk factor reductions (principally smoking, 48%; blood pressure,

269.5%; and cholesterol,

nd 2000 (same population used in study 2. above). This paper risk factors (principally smoking, cholesterol and blood time higher than cardiological treatment and that effective

27

4. d a standardised case-control study of acute myocardial infarction d continent. 15152 cases and 14820 controls were enrolled.

idence risks

ollowing factors were all significantly related to factors and p=0.03 for alcohol).

middle vs lowest tertile, PAR 20.1% for top two tertiles vs lowest tertile);

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

ed t l 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 approa les worldwide and have the potential to prevent most premature cas

4.2.4. Impact of Diabet rdiac Diseas

While there is no specific in on on the inciden prevalence o iac disease in the New Zealand ulation, there is good or w he risk facto e similar (with the exception of

moking).

9.5%). Adverse trends were seen for physical activity, obesity, and diabetes .

3. A recent paper estimates life-years gained from cardiological treatments and cardiovascular risk factors in England and Wales between 1981 aconcludes that modest reductions in major

in life-years fourpressure levels) lead to gains policies to promote healthy diets and physical activity might achieve even greater gain .

The INTERHEART study28 establishein 52 countries, representing every inhabiteThe relation of risk factors to myocardial infarction was reported. Odds ratios and their 99% ConfIntervals for the association of risk factors to myocardial infarction and their population attributable (PAR) were calculated. The results showed that the facute myocardial infarction (p<0.0001 for all risk

■ 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

■ 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%).

conclud hat abnormal lipids, smoking, hypertension, diabetes, abdomina

ches to prevention can be based on similar principes of myocardial infarction.

es on Ca e

formati ce or f cardpops

data on diabetes f hich t rs ar

Table 7. Predicted increase in prevalence of adult diabetes patients 1996 - 201129

Predicted annual % increase in the prevalence of diabetics - 1996 - 2011

Male Female European 3.3% 2.9% Māori 5.7% 5.8% Pacific 6.3% 6.1% Total population 5.7% 5.9%



In 2002, the New Zealand P Health Intelligenc t of the M ublished Modelling Diabetes: A Summary29, which estimates en of diabetes ew Zealan m 1996 to 2011. The expected growth in prevalence of diagn etics (onset 25 years), by t ifferent risk factors, are shown in

bles 7 & 8. While this is not cardiovascular disease modelling, there is no indication that the factors

ublic e uni oH p the burd in N d froosed diab -89 he d

taaffecting 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 Female Obesity 31% 29% Population size 30% 30% Age 21% 19% Ethnicity 9% 13% Mortality 9% 9%

ThDe

■ o adulthood. Risk factors can be identified early in life and are cumulative through

life. Zealand children present prior to conception include socio-economic

ultiple mechanisms besides those resulting from

dent of nutrition and diet.

nd

■ v e general population.

e times that of

■ acific peoples have the highest discharge rates for both rheumatic fever and rheumatic

Thi unique to New Zealand with indigenous Australians also having higher rates of cardiac

services

e MoH also published An Occasional Paper in February 2005 entitled ‘Influences in Childhood on the velopment of Cardiovascular Disease and Type 2 Diabetes in Adulthood’30. This document contains rmation of specific activities and programmes that have shown benefit both within info 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 t

■ Risk factors for Newdisadvantage, 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 moverweight and obesity. While the effects of diet and physical activity on health often interact, there are additional health benefits from physical activity that are indepenThere 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 aPacific people. The Ministry of Health indicates:

Death from all cardio ascular diseases is higher among Maori than thCoronary heart disease is the leading single cause of death for Maori.

■ Maori have the highest rate of hospital admissions for heart failure (nearly threEuropeans/others). Maori and Pheart disease. s situation is not

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 to Māori, Pacific and lower socio-economic groups, where there is identified high risk of cardiac disease.



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 lon■ g-term government investment and national and local targets; e that addresses cumulative disadvantages throughout life;

levels including intersectoral and from national down to the

s that focus on the wider determinants of lifestyle risk behaviours and the

ntions that set a precedent for the strategy across population, personal health and disability support services;

2. evelopment has six categories that reflect the need for a multi-level, multi-sector approach to improving cardiovascular outcomes. The categories

de:

■ Policy development; ■ Improved information systems; ■ Needs assessm

■

publishe re for cludes a and

el. S

■ A lifecourse perspectiv■ Multiple interventions at multiple

individual; ■ Lifestyle intervention

environments; ■ Health sector interve

■ Research based on intervention studies should be an essential component of the strategy.

The Māori Cardiovascular Action Plan currently under d

inclu

ent; ■ Quality standards;

Māori workforce development■ Research agenda.

3. The New Zealand Guidelines groupMāori with diabetes

d a literature review and summary of the barriers to ca reference to work by S. Crengle that looks at barriers

ee Table 9

32. This paper insolutions for Māori at a primary care lev

Table 9. Barriers to care and solutions used in Māori primary care services (from 32)

Barrier Solution

Financial barriers Unable to afford user co-payment for GP

rescription co-payment

all children under 16 years free:

Unable to afford p

Markedly cheaper co-payments. E.g.reduced co-payments for adults. Agreements with local pharmacists

Geographic and transport barriers to reaching services(whether GP or health promotio

n / education)

ellite clinics to improve access and reduce

/ service.

Use of mobile clinics and satcost of accessing services for client. Transport of patients to site of clinic

Lack of knowledge of health issues, screening programmes, how to access health information. s e.g. on marae, at hui, sports grounds, childcare

institutions etc. Provide information that is easily understood and appreciated by Māori.

Providing these services in a wide variety of locations, venues and community activitie

BarrInabi

t

n; llite clinics or in mobile clinics;

Proactive outreach and follow-up;

iers within the healthcare system lity to receive healthcare at the time that it is needed;

and reach those at risk;

Flexibility with appointment systems; Ability to walk in and be seeProvision of services in sateFailure to effectively identify

Limited follow-up; Lack of confidence / inability to negotiate aspects of health sys em e.g. outpatient clinic appointments.

Integration of community health and general practice services with a focus on health promotion and education; Assistance with appointment, including staff attending clinics.

Cultural Barriers ure to provide information in wa

Delivery of services using Māori cultural practices and beliefs; Fail ys that are appropriate

Fail nd

Employment of Māori staff;

for use with the Māori community; f resources which are appropriate and acceptable for use with the

for use in Māori communities; ures to provide services that are appropriate a

Presentation of information in ways that are appropriate and acceptable

acceptable to clients. Use oMāori community.



4. The first draft report of a research project looking at Māori with heart disease and the perspective of the okerau / Northland has been published33.

ms to improve healthcare practice and Māori access and experience of health care. to date have indicated the following potential solutions:

ion to the Marae and involving Kaumatua and Kuia,

althy

ferral;

■ Whanau involvement – attendance at consultations, support for lifestyle modifications; ra mmunity in the problem and acting for change;

st for intervention and/or

aining and equipment in the community.

meet

ent of individuals with identified cardiac disease and cardiac

atients with

ss surgery they are generally referred for tertiary y care.

ects of ut

t that should be classified as being more

Māori patient, whānau, and healthcare practitioner in Te Tai TThe project aiInterviews

Māori participants: ■ Information sharing through taking informat

Māori health services and health professionals; ■ Health eating and physical activity health promotion activities, in particular to support he

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 re

Individual responsibility for own health; ■■ Support network e.g. sharing goals to change lifestyle. Practitioners

■ Ma e based health promotion involving the co■ 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 reque

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 tr 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 tothe 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, managemrehabilitation 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 pmyocardial infarction. It is important that treatment is delivered quickly when necessary. In particular, re-establishing 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 bypacare, although some intervention services (but not surgery) are becoming possible in secondar

Tertiary care delivers specialised investigation and treatment. This includes most aspelectrophysiology and intervention for coronary artery disease. In addition, cardiac surgery is carried oexclusively in tertiary centres. There are some forms of treatmen



special ed than that provided by the averis age tertiary centre. These include cardiac transplantation and the management of pulmonary hypertension.

els as necessary. Cardiology services are also involved in palliation of conditions that are not amenable to cure34.

ugh health promotion and risk assessment and management; ■ Acute coronary syndrome management ensuring timely treatment of acutely ill individuals;

da ices; and ■ Support across the sectors for those with chronic disease.

4.4. Private Ca ervices

In December 4% of New Zealande d by rance35 waiting lists for patients to see access ele treatment in ublic system m that it is likely that many cardiac , and continu access servic the private sec

NZHIS collect om private hospitals in aper-based s and the inf n is not readily available to all tification of the proportio cardiac servic rovided in the sector. Private hospital data ilable until 1995 and data relating to cardio cic services in c and private are

cluded in a report by Antony Raymont published in 200236. Relevant results from this report are included in

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 lev

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 thro

■ Secon ry prevention services following an acute episode, including rehabilitation serv

rdiac S

2003, 3 rs were covere health insu . The long a cardiologist and to ctive the p ean

patients would have e to, es in tor.

s data fr a p ystem ormatioow iden n of es p private

was ava thora publiinTable 10.

Table 10. Cardiothoracic surgical discharge ratio (weighted) 1995 – Public & Private, 2000 – Public only

Cardiothoracic 1995 1999/2000 Surgery

Region Public + Private Public Only Public Only Eastern Bay of Plenty 1.03 1.09 0.81 Western Bay of Plenty 1.29 1.25 0.81 Lakes 0.71 0.73 0.84 Tairawhiti 0.97 1.02 0.83 Taranaki 1.07 1.10 0.67 Waikato 1.09 1.16 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.

■ Bay of Plenty has one cardiologist working fulltime in private and three cardiologists provide private services on a part-time basis in Tauranga and Wha ane

■ Taranaki has one cardiologist providing services in p ate■ Tairawhiti has a physician w g in private o s 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.

CURRENT SITUATION

katriv

.

. orkin wh pr eovid

■



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

rovide data. not p

Table 11. Cardiac procedures undertaken at Mercy Hospital for Midland population.

PCI Cardiac Surgery

2002 666 99 2003 772 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.



5. Contracting and Funding

5.1. DHB Agreements

Table 12. Contract and actual volumes for cardiac service purchase units

Bay of Plenty Lakes* Tairawhiti Taranaki Waikato Midland

% Contract Achieved

2003 Cardiology Caseweight (CWD) Contract 1668 0 0 0 5814 7482 102.3% M10001 Actual 1442 0 0 0 6211 7653 Cardiology 1st assessment Contract 550 244 72 625 1400 2891 93.2% M10002 Actual 732 98 62 466 1335 2693 Cardiology subsequent assessment Contract 1101 207 165 2000 3000 6473 89.0% M10003 Actual 987 64 144 1710 2855 5760 Cardiology - Education and Management Contract 1495 839 2334 295.4% M10004 Actual 1495 1617 3783 6895 Cardiac Surgery Contract 0 0 0 0 4075 4075 89.2% S15001 Actual 0 0 0 0 3635 3635 2004 Cardiology Caseweight (CWD) Contract 1668 0 0 0 5859 7527 101% M10001 Actual 1617 0 0 0 5987 7604 Cardiology 1st assessment Contract 550 244 72 625 1610 3101 111.2% M10002 Actual 682 54 50 527 2136 3449 Cardiology subsequent assessment Contract 1100 207 165 2000 3450 6922 86.0% M10003 Actual 1306 59 124 1600 2865 5954 Cardiology - Education and Management Contract 1495 839 2334 293.9% M10004 Actual 1495 1511 3854 6860 Cardiac Surgery Contract 0 0 0 0 4075 4075 85.9% 3502 0 0 0 0 3502 2005 ytd 31 Dec extrapolated to full year Cardiology Caseweight (CWD) Contract 1633 0 0 0 5859 7492 112.0% M10001 Actual 1494 0 0 0 6894 8388 Cardiology 1st assessment Contract 550 244 65 635 2040 3534 88.9% M10002 Actual 825 67 74 532 1642 3141 Cardiology subsequent assessment Contract 1100 207 180 1730 2755 5972 98.1% M10003 Actual 1219 91 88 1258 3202 5858 Cardiology - Education and Management Contract 1495 839 2334 229.0% M10004 Actual 1416 3928 5344 Cardiac Surgery Contract 0 0 0 0 4075 4075 86.0% S15001 Actual 0 0 0 0 3505 3505

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.



5.2. Outpatient Clinics

Table 13. Cardiology first specialist assessment: subsequent attendance ratios

Bay of Plenty Lakes Tairawhiti Taranaki Waikato Midland 2003 Contract 2.0 0.9 2.3 3.2 2.1 2.2 Actual 1.4 0.7 2.3 3.7 2.1 2.1 2004 Contract 2.0 0.89 2.3 3.2 2.1 2.2 Actual 1.9 1.1 2.5 3.0 1.4 1.7 2005* Contract 2.0 0.9 2.8 2.7 1.45 1.7 Actual 1.5 1.4 1.2 2.4 2.0 1.9

* Extrapolated full year

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 12-month 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

0

50

100

150

200

250

300

350

400

450

Jul-0

3

Aug-

03

Sep-

03

Oct-0

3

Nov-0

3

Dec-0

3

Jan-

04

Feb-

04

Mar-0

4

Apr-0

4

May-0

4

Jun-

04

Patie

nt Nu

mber

s

FSAs > 6mths Patients Added to Waiting ListPatients Treated Total on Waiting List as at end of Linear (Total on Waiting List as at end of ) Linear ( FSAs > 6mths)



Figure 4. Waikato Hospital cardiology procedure waiting times as at June 2005

30

70

80

60

40

50

Numb

er of

Pati

ents

10

20

00-1 mths 1-3 mths 3-6 mths 6-12 mths 12-24 mths 24-36 mths 36-72 mths

Angiography Angioplasty Pacemaker Ablation

sho ital waiting list, as at June 2005 have been waiting for various procedures.

urrently there is no ability for DHB e ignific e in v ithou al workforce. t vo

Ca

cardiac te r p bo i e vi s

o exp t to prioritising where for futur c n

n in Figure 6.

Figure 4 ws the length of time patients on the Waikato Hosp

C providers to deliv r any s ant increas olumes w t additionresource, both facility and Current demand is greater han contract lumes or resource is able to deliver.

5.3. DHB Expenditure on rdiac Services

An estimate of the funding of disease rela d services fo each DHB is rovided in Ta le 13. Note this is a high level estimate only t

is made in relation tprovide an ndication of th funding pro ded to each ervice. No

conclusion enditure bu is provided to allow DHBs consider op ortunities in relation to p e spending ould be considered. A graph of this expe diture as a percent is show

Table 14. Expenditure on cardiac services by Midland DHB’s, 2004.

Bay of Plenty Lakes Tairawhiti* Taranaki Waikato Regional Public Health $ 626,899 $ 423,600 $ 257,056 $ 344,773 $ 1,144,721 Community laboratory $ 946,851 $ 470,700 $ 204,709 $ 561,981 $ 2,257,969 Community pharmaceuticals $ 10,607,095 $ 4,493,145 $ 2,068,215 $ 6,139,985 $ 15,398,691 Community Referred Cardiology Testing $ 115,742 $ 44,000 $ - $ 263,000 $ 150,346 Prim MS $ 1,966,232 $ 1,260,676 $ 606,341 $ 665,436 $ 2,978,445 ary Care Providers - Capitation, GDisease State Management Nursing $ 51,667 $ 20,000 $ - $ 60,000 $ 86,667 Oth $ - $ - $ - $ - $ 256,000 er - please specify Cardiac Education and Management $ 145,898 $ 77,000 $ - $ 81,287 $ 178,956 Cardiology IP $ 6,445,300 $ 2,212,282 $ 535,210 $ 2,662,616 $ 11,825,660 Cardiology OP $ 293,500 $ 45,400 $ 32,387 $ 342,784 $ 578,396 Cardiothoracic IP $ 2,875,960 $ 1,766,652 $ 504,944 $ 1,576,613 $ 5,874,281 Cardiothoracic OP $ 16,163 $ 7,185 $ 1,335 $ 6,875 $ 23,989 Total $ 24,091,307 $ 10,820,640 $ 4,210,197 $ 12,705,349 $ 40,754,121 * Missing data not provided by Tairawhiti DHB



Notes: ■ Health Promotion $’s - as provided by MoH; ■ Community Laboratory – 1% total spend (potential underestimate);

un HARMAC (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.

■ Comm ity Pharmaceuticals – provided by P

Figure 5. CVD expenditure by service, Australia, 200485

Inpatients41%

Other health professionals

1%

Specialists4%

Diagnostics4%

Pharmaceuticals26%

Research3%

Other 5%

GP6%

Aged care10%



Figure 6. Estimated percent of cardiac services expenditure by Midland DHB

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bay of Plenty Lakes Taranaki Waikato NZ tertiary DHB

Regional Public Health Community laboratory Community pharmaceuticalsCommunity Referred Cardiology Testing Primary Care Providers - Capitation, GMS Disease State Management NursingOther - please specify Cardiac Education and Management Cardiology IPCardiology 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



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.



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


http://www.heartfoundation.org.nz/


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 long-term 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.



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 12-month 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


http://www.orionhealth.com/news/MyPractice/

http://www.enigma.co.nz/framed_index.cfm?fuseaction=newsletter&newsletteraction= issuedisplay&Currentid=256&issueid=11

http://www.enigma.co.nz/framed_index.cfm?fuseaction=newsletter&newsletteraction= issuedisplay&Currentid=256&issueid=11


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.



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



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.



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 Waikato Tairawhiti

Facility Tauranga Whakatane Rotorua Taupo Gisborne New Plymouth

Hawera Waikato Thames T’s

Cardiologists 3 FTE - - - - 2 - 10 = 7.5 FTE

- -

Cardiac Educators

1.8 FTE 1 FTE 1.2 FTE 0.4 FTE 1.2 FTE 0.8 FTE 0.4 FTE 2.3 FTE - 3 FTE

Cardiac Surgeons

- - - - - - - 3 - -

CCU beds 5 4 4 - 3 4 - 6 - --

Cardiology dedicated Beds

- - - - - - 42 - -

Outreach Clinics

From Tauranga

and Waikato

Pacing

only

Pacing Clinics

Own service

From Tauranga

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

Read by

Waikato

Read by Waikato

Read by

Waikato

Read by

Waikato

Read by

Waikato T’s – Taumaranui, Te Kuiti, Tokoroa, Complex cases referred to Waikato, ♦ General Ultrasounds being used for cardiology

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.



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.

0

5

10

15

20

25

30

35

0.5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 19 25Days

Patie

nt N

umbe

rs

Tauranga Whakatane Lakes Gisborne Taranaki 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;



■ 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;



■ Phase I cardiac rehabilitation services are provided at Rotorua Hospital and Phase II in Rotorua and Taupo.


■ 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.


■ 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;



■ 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.


■ 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;



■ 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.


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



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;



■ 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.



Figure 8. Ischaemic heart disease admissions by Midland DHB of domicile and gender

0200400600800

1000

200020

01_0

2

2002

_03

2001

_02

2002

_03 4

2004

_05 2

2002

_03

2004

_05

2002

_03

2004

_05

1200140016001800

2003

_04

2004

_05

2002

_03

2003

_04

2004

_05

2001

_02

2003

_0

2001

_0

2003

_04

2001

_02

2003

_04

BoP Lakes Tair Taranak aikaawhiti i W to

Female Male

Figure 8 indicates ato a ran e a ase i numb pati mi ospital with is ic he se, w is s ious ay o nty kes ts and contin s to increa rawh eral wa % de in a ons n the Midland region bet 01_0 200 xtra d fro March ytd to 3 ).

that Waik nd Ta aki hav decre n the er of ents adand La

tted to h patienchaem art disea hile th trend is le s obv for B f Ple

ue se in Tai iti. Ov l, there s a 13 crease hospital dmissi for IHD iween 20 2 and 4_05 (e polate m 31 0 June

Table 1 Percent ischaemic heart admissions by Midlan of do ethnicity, and ge6. d DHB micile, nder

DHB European Maori PI A

Other/NotStated

Female Male Year

sian

2001_02 74.5% 9.5% 0.1% 0.3% 15.6% 35.6% 64.4%

2002_03 76.2% 10.9% 0.5% 1.0% 11.5% 35.6% 64.4% Bay of Plenty 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%

2002_03 75.7% 20.3% 1.4% 0.7% 1.9% 38.8% 61.1% Lakes 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% Tairawhiti 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% Taranaki 2003_04 86.3% 7.3% 0.5% 0.6% 5.2% 41.1% 58.9%

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% Waikato 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

ere 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 coding practices. Th



admissions occurred in Tairawhiti where female admissions increased from 111 in 2001_02 to 134 in 2002-03 (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

west two deprivation quintiles. Between 1988 and 2001, 86% of Waikato DHB and 70% arges were for those living in quintiles 1 to 3.

detailed analysis of hospital data across all e picture.

services. Taranaki Base aupo, and

patient and

ati o and Tauranga cardiologists provide services at Whakatane Hospital. Outreach services

nursing staff, RMO’s and physicians; levant to current practice;

ach service to enable these services to be workforce section of this plan. While acute

ended that outreach

rce requirements in n-specialist cardiac

d makes some ities as indicated here (paediatric services have been excluded):

SD), or O) closure;

ent; tudies and ablations;

raphy; magnetic resonance and nuclear studies;

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 loof New Zealand IHD disch

No conclusions are drawn from this information acardiac admissions would be required to provide the c

nd moreomplet

CURRENT SITUATION

Cardiologists at Tauranga and Waikato Hospitals provide secondary cardiologyHospital employs two general physicians with an interest in cardiology. Whakatane, Rotorua, TThames Hospitals utilise general physicians to treat acute cardiac patients and refer acute, inoutpatients to Cardiologists as per agreed protocols.

Waikato cardiologists provide outreach services to Lakes, Tairawhiti and pacing services to Taranaki DHB ents. Waikatp

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 ■ Ensure guidelines and protocols are up to date and re■ 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 outred in the delivered. An estimate of cardiologist resource is identifie

patients will continue to be transferred from Whakatane to Waikato, it is recommservices to Whakatane Hospital should be provided from one centre, ideally Tauranga.

The British Cardiac Society (BCS) released a paper in July 2005 entitled “Cardiac workfothe UK”43. This paper looks at service levels and workforce across specialist and nocare. This paper predicts significant increases in secondary and tertiary level care anassumptions about activ

Cardiac activities which are generally consultant-based: ■ Diagnostic cardiac catheterisation and angiography;

nterventions (PCI), carotid intervention, atrial septal defect (A■ Percutaneous Coronary Ipatent foramen ovale (PF

■ Device implantation and replacem■ Invasive cardiac electrophysiology s■ Trans-oesophageal and stress echocardiog■ Reporting cardiac resynchronization,



■ Management of rare conditions; inical director, service director, lead clinician,

ultant based but with consultant supervision:

■ Device follow-up; rdiology investigations, echocardiography.

sts include: electrocardiogram (ECG), echocardiogram, event recorder monitoring, exercise olter monitoring, myocardial perfusion scans, and tilt table tests.

c groups and age bands. For example

a heart failure, arrhythmias and other conditions f e func he heart. Cardiac technicians or cardiologists generally are physi thin the region who are competent in echocardiography.

it has sufficient funding, resources and staffing. The Guideline for the Management of Chronic Heart Failure indicates: “echocardiogram for the assessment of left

portan source eatment should

■ Formal clinical management e.g. cl

Cardiac activities which are generally non cons

■ Reporting non-invasive ca

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 tetolerance test (ETT), h

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. ethnipredictions 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 diagnostic tool for that require an understanding o th tion of tundertake these, although there cians wiCurrently the New Zealand Cardiology Guidelines for Primary Referral have noted that direct access echo is endorsed by the working party with proviso

ventricular function is an im t part of the investigation. However, if this is delayed due to local reconstraints, then tr continue on an empirical basis.”



The Canadian Cardiovascular Society has developed Guidelines for the Provision of Echocardiography in 44

the Midland region. Where a service is available the waiting lists are long e.g. Waikato may have over 500 patients on the

nd the waiting time or inpatient st actice recommending echos to clarify diagnosis of a

e gene e to access echos for these patients. Any normal working hours and this limits the ability

to tr ls.

e few qualified staff available in New Zealand and cruitment 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 to

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.

Canada . 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 Waikato – 3226 (9530 pmp), Bay of Plenty - 1036 (5206 pmp) ■ Stress echo Bay of Plenty – 105 (525 pmp) ■ Transoesophageal echo Waikato – 93 (275 pmp)

CURRENT SITUATION

Echocardiography is the diagnostic test with the most significant access issues across

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 astay may be prolonged; and despite be pr guidelinesspecific condition in primary care, ar rally unablGPs research protocols requiring echos are undertaken outside ofof the cardiologists to recruit patients in ia

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 arre

Auckland provide a visiting echo service while undertaking the employment process.



Figure 9. Patients waiting for echocardiography at Bay of Plenty and Waikato DHBs as at June 2005.

0

250

1250

750

1000

500

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

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 to Midla s through away’ lab test contr 54 - $75 each. Most B pro iders re rict acc ss to gistrars d sp ospital experienced a

owth tests ordered from 5 a ry 20 n er 2 with an average of oxim 400 nterbury

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

available nd GP the ‘send act at a cost of $DH in

v st e0 i

reua

an03

ecialists. Waikato H 323 in November 200rapid gr

Septembn J

apprn

atelyto

pe3, peaking at 545 i

r month in 2005. Waikato and Ca004,



Hospital La torie rt NP g gene e ‘send ay’ laborat ry test contract. Whak H tal la y 2004.

r deta DHB n able bre in of the Waikato tests has en incl d.

polatio th e d , ate ests undertaken for the Midland DHBs are xpected 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 as echocardiograms and

in order to include or exclude a diagnosis of heart failure.

bora s unde ake B testin for ral practice in the Midland region under thaw o atane ospi boratory began providing BNP tests in JulFurthe il by is see in T 17, although akdown of the DHB of orignot be ude

Extra n of e April y ar to ate data indic s BNP te

attached Appendix Five. Appropriate use of BNP should reduce the need forlocal cardiologists indicate this is the emphasis that is appropriate for primary care

Table 17. BNP tests and costs by Midland DHB 2003 - 2005

2003 2004 2005 Comment

$ # $ # $ 2005 – extrapolated full year # Eastern BoP 181 $12,670 360 $25,200Hospital requests only, GP included in Waikato Western BoP 116 $ 6,196 132 $7,026 138 $7,484Hospital requests only, GP included in Waikato Lakes 47 $3,290 114 $7,980Hospital requests only, GP included in Waikato Tairawhiti 13 $710 83 $4,688 207 $11,886GP & hospital requests Taranaki 87 $4,344 256 $13,666 258 $13,991GP & hospital requests Waikato 2142 $149,940 4488 $310,870 4803 $336,210Waikato hospitals plus Waikato, Lakes, & BoP GP requests Midland 2358 $161,189 5186 $352,124 5880 $394,771

Figure 10. BNP test volume and cost by laboratory 2003-05 (extrapolated full calendar year)

$394,771

1000

2000

3000

4000

5000

6000

7000

Numb

er

BNP

Tests

$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000

02003 2004 2005

$0$50,000

Canterbury Hospital Laboratory Waikato Hospital LaboratoryWhakatane Hospital 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.



Pacing and Electrop logy

Pacing

hysio

Cardiac well-established discipli nvolvin atmen tien brad dia related symptom as syncope, dizziness, dyspno , and tire is o increa gly used atients with advanced heart failure, often combined with a brillato he evidence accu ates sho g significant benefit in tients. Management involve lection able p ng mod implant of devices, and regu n specialised clinics. The ideal fa y for pa aker i ntation n operating theatre o cing laboratory in which the highe ndard erility can be main d. While is both feas ant p akers i neral ac cathe erisation la oratories (as

ato Hospital) or even in a general radiology department, as at Tauranga and Taranaki Base s can be maintained in such areas, which should be

ve at least two trained implanting

dland Region, see Table 18. In Taranaki and Lakes DHBs should also provide a pacing service for their populations,

pacing is a ne i g tre t of pa ts with ycars such ea dness. It als sin in p

defi r as t mul win these pa s se of suit aci es, ationlar follow-up i cilit cem mpla is ar dedicated pa st sta of st taineible and commonplace to impl acem n ge cardi t b

occurs at WaikHospitals, it is unlikely that operating theatre standard

46regarded as sub optimal for pacing . Ideally this service should hacardiologists, 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 Mitime it is likely thatproviding 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 2011 2016

@ 550pmp @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:

■ ■

yWh

■ 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 Pl mouth and Thames. Cardiologists from Tauranga Hospital provide pacing clinics at Tauranga and

akatane 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

undertaken in an opbe erating theatre. In 2004-05 Waikato implanted 228 pacemakers, which is a rate of 290 pmp, significantly below the current recommended rate of 550 pmp.



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

rtise outside the tertiary unit but this should be done in association with a specialist

of services for patients with heart disease47 as e UK has not predicted the total number of EP

s rocedures and the CCN of Ontario has made initial d ds.

■ 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 nsiv has proved to be

, these procedures are time consuming and in the absence of a dedicated laboratory, tie up valuable cardiac catheterisation time.

CURRENT S

EP is unde Waikato Hospital for Midland on. In 20 Waik Hospital rtook 63 EP and ablati dures (80 pmp), how r, the wa g list for EP services uded 50 tients, some having be list for 2 onths or er. The sons for the delays in atment in nsufficient catheter laboratory time, av iologists and technical sta ome tr ents are not urrently Waik (atrial fibrillation ab ) due source ations and patients are ansferred to Christchurch Hospital for this therapy.

Hospi

where there is expecentre.

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 being an important component of everyday cardiology. Thprocedure but has made recommendations for specific precommen ations based on achievable levels rather than nee

comprehe e electrophysiology service. The use of catheter electrode ablation extremely effective and cost efficient for the treatment of cardiac arrhythmias. However

ITUATION

rtaken aton proce

the regi 04_05 ato undeeve itin incl pa

en on the 4 m long rea tre clude iailability of trained card ff. S eatm

ctr

available at ato lation to re limit

Waikato tal implanted 32 ICDs (41 pmp) in 2004-05.



Figure 11. ital ablation waiting list @ June 2005 Waikato hosp

0

5

20

25

10

Patie

nts W

aiting

15

<1w eek 1-4 w eeks 1-3 months 3-6 months 6-12 months >12 months >2 y ears

Table 19. Predicted number of electrophysiology screenings by Midland DHB domicile population

pmp 100 250 250 250 350 700 DHB 2006 2006 2011 2016 2011 2016 Bay of Plenty 20 50 54 57 75 159 Lakes 10 26 26 26 37 74 Tairawhiti 5 11 11 11 16 30 Taranaki 10 26 25 25 36 69 Waikato 34 85 87 88 121 247 Midland Total 79 198 203 207 284 580

Table 20. Predicted number of ICD implants by Midland DHB domicile population

pmp 40 200 300 300 400 700 DHB 2006 2006 2011 2016 2011 2016 Bay of Plenty 8 40 64 68 86 159 Waikato 14 68 104 106 42 74 Tairawhiti 2 9 13 13 18 30 Taranaki 4 21 31 30 41 69 Lakes 4 20 31 32 139 247 Midland Total 32 159 244 248 325 580

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.



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

010203040506070

ing

8090

<1w eek 1-4 w eeks 1-3 months 3-6 months >6 months

Patie

nts W

ait

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.



Table 21. Predicted cardiac catheterisation and angiography by Midland DHB domicile population

Revascularisation Rate pmp 1750 2150 2150 2150 2550 2950 2006 2006 2011 2016 2011 2016

Bay of Plenty 883 1085 1153 1219 1367 1673 Lakes 447 549 561 569 665 781 Tairawhiti 197 242 238 234 282 321 Taranaki 456 560 547 531 648 729 Waikato 1488 1828 1865 1898 2212 2605 Total 3470 4263 4363 4452 5175 6108 -70% PCI 555 777 796 812 1023 1275 Midland Total 2915 3486 3568 4799 4152 4833 Tauranga Hospital 371 456 484 512 574 703 Taranaki Base Hospital 182 224 219 212 259 291 Waikato Hospital Total 2362 2807 2865 2916 3319 3839

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.



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.



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



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

2005 2006 2011

CCU

(Current) Cardiac

Care CCU Cardiac

Care CCU Cardiac

Care Bay of Plenty 9 14-18 8 12-16 9 14-18 Lakes 4 6-8 4 6-8 4 6-8 Tairawhiti 3 5-6 2 3-4 2 3-4 Taranaki 4 6-8 4 6-8 4 6-8 Waikato 6 9-12 14 21-28 14 21-28 Midland 26 40-52 32 48-62 32 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.



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

DHB of Domicile

Procedure 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% Bay of Plenty 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% Lakes 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% Tairawhiti 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% Taranaki 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% Waikato Heart Valve Replacements and Repair 0.82 0.86 1.02 24.4%

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.



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 1000 1400 1400 1400 1800 2200 2006 2006 2011 2016 2011 2016 Bay of Plenty 202 283 300 318 386 499 Lakes 102 143 146 148 188 233 Tairawhiti 45 63 62 61 80 96 Taranaki 104 146 142 138 183 217 Waikato 340 476 486 494 625 777 Midland Total 793 1110 1137 1159 1461 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.



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



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 Controls Outcome

N= 31 49 Age 63 61 Male 79% 60% F/Up median 12.5mths 16.3mths Deaths 1 1 Readmission with Chest Pain 26%(8) 27%(18) 30%↓ p=ns Symptomatic In Stent Restenosis 13%(5) 26%(14) 57%↓ p=0.12

Figure 13. Waikato Hospital stent use March – May 2005

020406080

100120140160

Angioplasty DES Multiple DES BMS Multiple BMS DES + BMS

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

Patient # % Total

DES = Drug Eluting Stent, 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.



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 2002/03 2003/04 Jul to Dec 04

DHB Patient Number

s

CWDs Patient Number

s

CWDs Patient Number

s

CWDs

Bay of Plenty 138 980 162 1199 73 490 Average CWD per patient 7.1 7.4 6.7 Lakes 78 611 71 509 32 252 Average CWD per patient 7.8 7.2 7.9 Tairawhiti 24 178 36 248 17 150 Average CWD per patient 7.4 6.9 8.8 Taranaki 68 549 44 365 32 214 Average CWD per patient 8.1 8.3 6.7 Waikato 333 2034 288 1845 146 989 Average CWD per patient 6.1 6.4 6.8 Totals 641 4352 601 4166 300 2095

Average CWD per patient 6.8 6.9 7.0



Table 27. Actual treatment thresholds, discharges and standardised discharge ratios by cardiac unit for CABG and angioplasty patients treated July 2002 – June 2003

Number of Discharges Standardised Discharge

Ratio (for ‘catchment’ DHBs)

Cardiac Unit

Actual Treatment

Threshold for CABG

Treated at Unit (from all

locations)

Treated at Unit (from catchment

DHB's) CABG Angioplasties 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 Dunedin 48 588 578 1.421 1.424

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 2003/04 Jul to Dec 04 Patient Numbers Patient Numbers Patient Numbers

DHB Acute Elective Acute Elective Acute Elective

Waikato 374 240 377 189 187 85 60.9% 39.1% 66.6% 33.4% 68.8% 31.3%

Av. CWD per Patient 6.7 6.9 7

Auckland 804 604 963 332 458 127 57.1% 42.9% 74.4% 25.6% 78.3% 21.7%

Av. CWD per Patient 7.1 7 7.1

Capital &Coast 301 544 347 431 150 223 35.6% 64.4% 44.6% 55.4% 40.2% 59.8%

Av. CWD per Patient 5.9 6.2 7

Canterbury 299 263 333 196 144 111 53.2% 46.8% 62.9% 37.1% 56.5% 43.5%

Av. CWD per Patient 6 6.3 5.4

Otago 254 147 263 166 149 73 63.3% 36.7% 61.3% 38.7% 67.1% 32.9%

Av. CWD per Patient 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.



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 2003/04 Jul to Dec 04 DHB Acute Elective Acute Elective Acute Elective

Bay of Plenty 81 57 102 60 50 23 58.7% 41.3% 63% 37.0% 68.5% 31.5% Lakes 46 32 49 22 23 9 59% 41.0% 69% 31.0% 71.9% 28.1% Tairawhiti 12 12 24 12 13 4 50% 50.0% 66.7% 33.3% 76.5% 23.5% Taranaki 41 27 31 13 21 11 60.3% 39.7% 70.5% 29.5% 65.6% 34.4% Waikato 212 121 188 100 98 48 63.7% 36.3% 65.3% 34.7% 67.1% 32.9% Midland Total 392 249 394 208 205 96 % Total 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 750 750 750 2006 2011 2016 Bay of Plenty 151 161 170 Lakes 77 78 79 Tairawhiti 34 33 33 Taranaki 78 76 74 Waikato 255 260 265 Midland Total 595 609 621

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.



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 co-morbidity 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, re-infarction 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;



– 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 Phase II Outpatient

Phase III Support

Heart Foundation Affiliation

Bay of Plenty Tauranga Three Yes Whakatane Two One Lakes Rotorua Two One Taupo intermittent Two Yes Tairawhiti Gisborne One Yes Taranaki New Plymouth Two Yes Hawera One No Waikato Hamilton Three Yes Matamata - One Yes Taumaranui One Yes Te Awamutu No One Yes Te Kuiti One No Thames No One Yes Tokoroa No One 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



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 2003 2004

Tauranga # % # % 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 Unknown Unknown

Total attendees 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 27.6%

Attended 4 or more sessions Unknown

Total clinic visits 755 93.8%

DNA any sessions 423 72.4%



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%

Victoria Australia63 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

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Euro

pean

Mao

ri

Othe

r

Pacif

ic Is

Unkn

own

Euro

pean

Mao

ri

Othe

r

Pacif

ic Is

Unkn

own

Euro

pean

Mao

ri

Othe

r

Pacif

ic Is

Unkn

own

2003 2004 2005

Western Bay of Plenty Eastern Bay of Plenty Lakes Tairawhiti Total



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 home-based.

■ 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 2006 2011 2006 2011

Current IHD Heart

Failure Total IHD

Heart Failure

Total

Expected numbers based on 0.4%

population >19 years + annual increase

Bay of Plenty 620 693 222 915 736 256 992 569 914

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

Waikato 1168 349 1516 1192 394 1585 941 1512

Totals 2724 876 3600 2787 990 3777 2207 3556 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



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.



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.



COPYRIGHT © MIDLAN

Figure 15. Acute Coronary Syndrome flow diagram

8.1.1. ST ElevatiWhen patients with acute coronary syndmanagement since presenting without Sangina from non-ST(STEMI).

The prognosis in Selectrical complicatihospital deaths from

STEMI NSTEACS

REPERFUSION NSTEMI UAP

Risk Stratify

PRIMARY PCI THROMBOLYSIS

LOW RISK HIGH RISK

Risk Stratify

HIGH RISK LOW RISK

ANGIOGRAPHY EXERCISE TEST

STEMI – ST Eleva

NSTEACS – Non

UAP - Unstable A

ACUTE CORONARY SYNDROME

REVASCULARISATION

- 88- D DHBS, 2005

on Myocardial Infarction (STEMI) acute chest pain are first seen, the working diagnosis is that they are suffering from an rome. The 12-lead electrocardiogram (ECG) is at the center of the decision pathway for it permits distinction of those patients presenting with ST-segment elevation from those T-segment elevation. Serum cardiac biomarkers are obtained to distinguish unstable -segment MI (NSTEMI)) and to assess the magnitude of an ST-segment elevation MI

TEMI is largely related to the occurrence of two general classes of complications: (1) ons (arrhythmias) and (2) mechanical complications ("pump failure"). Most out-of- STEMI are due to the sudden development of ventricular fibrillation. The vast majority

MEDICAL TREATMENT tion Myocardial Infarction

-ST Elevation Acute Coronary Syndrome

ngina Pectoris


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.



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



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.



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.



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



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;



■ 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.



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.



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



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

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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:



■ 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



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.



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.



Table 34. Acute Rheumatic Fever notifications 1995-2000

District Acute Rheumatic Fever 1995 - 2000

Cases Notified Annual Incidence (per 100,000)

Eastern Bay of Plenty 10 3.3 Tauranga 11 1.6 Rotorua 14 3.6 Taupo 1 0.5 Gisborne 36 13.1 Taranaki 4 0.6 Waikato 61 3.4 Ruapehu 5 5.0 Midland Total 142 3.8 New Zealand 608 2.8

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

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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



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

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Figure 19. Acute Rheumatic Fever hospital admissions in Midland DHBs per 100,000 population by ethnicity

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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.



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.



Table 35. Electrophysiology, defibrillation and pacing laboratory session and catheter laboratory requirements

Waikato 2006 2011 2016 2011 2016 Electrophysiology 198 203 207 284 580 Defibrillation 106 163 165 217 387

Pacing 191 173 175 260 350

Total sessions 495 539 547 761 1316 Session/lab/pa 460 460 460 460 460 Waikato Labs 1.1 1.2 1.2 1.7 2.9 Tauranga Pacing Sessions 27.5 50 53 75 106 Session/lab/pa 460 460 460 460 460 Tauranga Lab 0.1 0.1 0.1 0.2 0.2

Table 36. Coronary angiography and angioplasty laboratory requirements

Cath Labs Required 2006 2011 2016 2011 2016

PCI 1.0 1.0 1.0 1.3 1.6 Diagnostic procedures 1.6 1.6 1.6 1.8 2.1 Waikato 2.7 2.7 2.7 3.1 3.7 Tauranga 0.3 0.4 0.4 0.5 0.6 Taranaki 0.1 0.1 0.1 0.1 0.2

Table 37. Total Laboratory Requirements for Midland Region

Catheter Laboratories 2006 2011 2016 2011 2016

Waikato 3.8 3.9 3.9 4.8 6.6 Tauranga 0.4 0.5 0.5 0.7 0.8 Taranaki 0.1 0.1 0.1 0.1 0.2 Midland Total 3.3 3.5 3.5 5.6 7.6

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;



– 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

2006 2011 2016 2011 2016

BoP Pacing + Diagnostic angiography 0.31 0.41 0..5 0.48 0.61 As above plus - Lakes & Tairawhiti OP angiography 0.37 0..44 0..46 0.55 0.70

As above plus Lakes & Tairawhiti pacing x 80% 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 $ (millions)

Clinical Items $1.7 Information Systems $0.4 Fit out $1.0 Total $3.1



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;



■ 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.




Figure 20. Cardiologists per 100,000 population in 2000

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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

Taranaki Waikato

Urgent Next available 1-4 weeks 1-2 months Semi-urgent 2-3 months 9-10 months 2-9 months Routine 6-12 months Not appointing 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.


Table 41. Cardiologist Requirements for the Midland Region

Medical Cardiologist

Interventional Cardiologist

Electro-physiologist

Total Cardiologists

DHB 2006 2011 2006 2011 2006 2011 2006 2011 Bay of Plenty 4.6 4.9 1.0 1.1 0.4 0.4 6.1 6.4 Lakes 2.4 2.4 0.5 0.5 0.2 0.2 3.1 3.1 Tairawhiti 1.0 1.0 0.2 0.2 0.1 0.1 1.4 1.3 Taranaki 2.4 2.3 0.5 0.5 0.2 0.2 3.1 3.1 Waikato 7.8 8.0 1.7 1.7 0.7 0.7 10.2 10.4 Midland Total 18.2 18.7 4.0 4.1 1.6 1.6 23.9 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;



■ 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.



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 2011 2016

PCI/Dx EP/ Pacing

/Defib Total PCI/Dx EP/ Pacing /Defib Total PCI/Dx EP/ Pacing

/Defib Total

Waikato

Catheter Laboratories 2.49 (.43/.23/.41)

1.07* 2.49 2.55 (.44/.35/.38)

1.17 2.55 2.59 (.45/.36/.38)

1.19 2.59 Nurse 7.5 1.9 9.4 7.6 2.1 9.8 7.8 2.2 9.9 Medical Radiation Technologist 2.5 2.5 2.5 2.5 2.6 2.6 Radiographer 1.2 1.2 1.3 1.3 1.3 1.3 Technician 2.5 2.1 4.6 2.5 2.3 4.9 2.6 2.4 5.0 Cardiologist 2.5 1.1 3.6 2.5 1.2 3.7 2.6 1.2 3.8 Interventionalist 1.2 0.5 1.8 1.3 0.6 1.9 1.3 0.6 1.9 Clerical / Booking 1.2 0.5 1.8 1.3 0.6 1.9 1.3 0.6 1.9 Support – orderly 1.2 0.5 1.8 1.3 0.6 1.9 1.3 0.6 1.9 Support -Healthcare Assistant 1.2 0.5 1.8 1.3 0.6 1.9 1.3 0.6 1.9 Tauranga Catheter Laboratories 0.25 0.06 0.31 0.26 0.11 0.37 0.28 0.1 0.39 Nurse 0.7 0.1 0.9 0.8 0.2 1.0 0.8 0.2 1.1 Medical Radiation Technologist 0.2 0.2 0.3 0.3 0.3 0.3 Radiographer 0.1 0.1 0.1 0.1 0.1 0.1 Technician 0.3 0.1 0.4 0.3 0.2 0.5 0.3 0.2 0.5 Cardiologist 0.2 0.1 0.3 0.3 0.1 0.4 0.3 0.1 0.4 Clerical / Booking 0.1 0.0 0.2 0.1 0.1 0.2 0.1 0.1 0.2 Support – orderly 0.1 0.0 0.2 0.1 0.1 0.2 0.1 0.1 0.2 Support -Healthcare Assistant 0.1 0.0 0.2 0.1 0.1 0.2 0.1 0.1 0.2 Taranaki Catheter Laboratories 0.12 0.12 0.12 0.12 0.12 0.12 Nurse 0.4 0.4 0.4 0.4 0.4 0.4 Medical Radiation Technologist 0.1 0.1 0.1 0.1 0.1 0.1 Radiographer 0.1 0.1 0.1 0.1 0.1 0.1 Technician 0.1 0.1 0.1 0.1 0.1 0.1 Cardiologist 0.2 0.2 0.1 0.1 0.1 0.1 Clerical / Booking 0.1 0.1 0.1 0.1 0.1 0.1 Support – orderly 0.1 0.1 0.1 0.1 0.1 0.1 Support -Healthcare Assistant 0.1 0.1 0.1 0.1 0.1 0.1

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.



Table 43. Predicted cardiac catheter laboratory workforce requirements – option two

2011 2016

PCI/Dx EP/Pacing

/Defib Total PCI/Dx EP/Pacing /Defib Total

Waikato Catheter Laboratories 2.48 1.10 3.58 2.53 1.15 3.68 Nurse 7.4 2.0 9.4 7.6 2.1 9.7 Medical Radiation Technologist 2.5 2.5 2.5 2.5 Radiographer 1.2 1.2 1.3 1.3 Technician 2.5 2.2 4.7 2.5 2.3 4.8 Cardiologist 2.5 1.1 3.6 2.5 1.2 3.7 Interventionalist 1.2 0.5 1.8 1.3 0.6 1.8 Clerical / Booking 1.2 0.5 1.8 1.3 0.6 1.8 Support – orderly 1.2 0.5 1.8 1.3 0.6 1.8 Support -Healthcare Assistant 1.2 0.5 1.8 1.3 0.6 1.8 Tauranga Catheter Laboratories 0.31 0.13 0.44 0.34 0.2 0.49 Nurse 0.9 0.3 1.2 1.0 0.3 1.3 Medical Radiation Technologist 0.3 0.3 0.3 0.3 Radiographer 0.2 0.2 0.2 0.2 Technician 0.3 0.3 0.6 0.3 0.3 0.6 Cardiologist 0.3 0.1 0.4 0.3 0.2 0.5 Clerical / Booking 0.2 0.1 0.2 0.2 0.1 0.2 Support – orderly 0.2 0.1 0.2 0.2 0.1 0.2 Support -Healthcare Assistant 0.2 0.1 0.2 0.2 0.1 0.2

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 2011 Bay of Plenty 4.1 4.4 Lakes 2.1 2.2 Tairawhiti 0.9 1.0 Taranaki 2.2 2.2 Waikato 6.7 7.0 Midland Total 16.0 16.8



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

2006 2011 Bay of Plenty 0.8 0.9 Lakes 0.4 0.4 Tairawhiti 0.2 0.2 Taranaki 0.4 0.4 Waikato 1.4 1.4 Midland Total 3.2 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.



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.



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



■ 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.



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.



- 119- YRIGHT © MIDLAND DHBS, 2005 COP

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

The Heart Health Continuum

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§Health information

§Screening§Risk assessment

§Clinical care§Rehabilitation

District Health Boards

Cardiac Clinical Care and Rehabilitation

Smoking

Nutrition

Physical Activity

Cardiovascular Guidelines

NS 2004

Engagement with the Health Sector

Coalitions/Alliances


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



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.



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.



■ 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.



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.



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



■ 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.



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.



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



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



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.



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.



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.



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



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



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.



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.




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.



APPENDIX TWO. CHRONIC CONDITIONS PROGRAMMES OF CARE MODEL & FRAMEWORK - BOPDHB

Population withearly chronic

conditions and fewother conditions

Population withadvanced chronic

conditions and multipleother conditions

Population coping withsevere frailty and

terminal conditions

Generalpopulation at risk

of a chroniccondition

Populations of Increasing Need at risk of, or diagnosed with,Chronic Progressive Conditions

Act

iviti

es a

long

the

Car

eC

ontin

uum

Health education particularly aroundprevention of complications

Condition Progression: Increasing Proportion of Supportive & Palliative CareActivities to meet Population Care Needs

Diagnosis Dying Death

Populations with Chronic Progressive Conditions

Family/whanau &/or Caregivers

Support & griefservices forfamily/whanau&/or caregivers

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.

Promotive/Preventive/Detective

Care

supportive ,condition-specificand maintenance

care

Supportive(Palliative) Care

bereavementsupport

condition-specific andrestorative

ActiveCurative Care

Maintenance

BOPDHB Chronic Conditions Conceptual Model


Chronic Conditions Programmes of Care Framework - BOPDHB

POPULATIONS WITH INCREASING NEED AT RISK OF OR DIAGNOSED WITH CHRONIC PROGRESSIVE CONDITIONS

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

Prevention/ Promotion

• 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 interventions

• Age, gender and culturally appropriate health education

• Screening for five risk factors

• Self-management education, skills and tools to limit & slow progression of comorbidities and introduce condition-specific 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 ‘functional decline’1 including home-based programmes

- learning - competency - identification and removal of local

environmental hazards

• Self-management education, skills and tools to limit & slow progression of comorbidities

• Planned access to ‘specialist care’2 programmes to assist in stabilising comorbidities, slowing the rate of progression of the condition and ‘pre-empting’ treatment or management options

• Planned access to appropriate diagnostic tools

• Self-management education, skills and tools to limit & slow progression of comorbidities

• Planned access to ‘specialist care’3 programmes to assist in stabilising comorbidities and/or slowing the rate of progression of the condition

• Planned access to appropriate diagnostic tools

Act

iviti

es a

cros

s th

e C

ontin

uum

of c

are

Detection

• Public health programmes for early detection

• Public health diagnostic tools

• 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)

• Tools, skills & knowledge to aid in self-detection of comorbidities

• Regular ‘expert care’4 to assist in detection of comorbidities, symptoms and signs of progression &/or deterioration

• Diagnostic tools specific to potential complications

• Tools, skills & knowledge to aid in self-detection 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

• 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

1 Refer: Prevention of Functional Decline in Elderly Persons. NEJM vol. 347, No.14. 3Oct02.page1068-1074 www.nejm.org2 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’



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

Curative Care

• Ensure provision of population protection interventions around environmental regulation eg potable water supplies

• 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)

• 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

• 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

Continuity Mgmt.

• 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

• Case Management delivered by a Specialist Palliative Care team within an organised district network including formal mechanisms e.g. Whanau and Whakawhanuatanga

Recovery &/or Rehab

• 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.




Support for daily living

• Case managed multidisciplinary provision by a specialist health care team

• Intensive specialist support programmes that maximise independence

• Planned appropriate access to supportive technologies

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

Palliative Care

• 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

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

Care for Family / Whanau

• Appropriate planned access to supportive and palliative care programmes including respite 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 re-

integration of whanau /family following family member death


APPENDIX THREE. PURCHASE UNITS DATA DICTIONARY V9

PF Purchase Unit Code

PF Purchase Unit 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

As per the specifications for the calculation of Inlier Equivalent Separations version 8 (IES5) and Weighted Inlier Equivalent Separations version 8 (WIES8A).

S15002 Cardiothoracic - 1st attendance

See Appendix for a generic 1st specialist assessment definition. First attendance to general surgeon or medical officer at registrar level or above or nurse practitioner for specialist assessment.

Attendances Number of attendances to a clinic/department/acute assessment unit.

S15003 Cardiothoracic - Subsequent attendance

See Appendix for a generic subsequent specialist assessment definition. Follow-up attendances to cardiothoracic surgeon or medical officer at registrar level or above or nurse practitioner.


M10001 Cardiology - 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).

M10002 Cardiology - 1st attendance

See Section 32 for a generic 1st specialist assessment definition. First attendance to cardiologist or medical officer at registrar level or above or nurse practitioner for specialist assessment.


M10003 Cardiology - Subsequent attendance

See Section 32 for a generic subsequent specialist assessment definition. Follow-up attendances to cardiologist or medical officer at registrar level or above or nurse practitioner.


M10004 Cardiac Education and Management

Cardiac education and case management by multi-disciplinary teams in hospital or community-based setting.

Clients 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 assessment definition. First attendance to cardiologist, paediatrician, or medical officer at registrar level or above or nurse practitioner for specialist assessment.


M10007 Specialist Paediatric Cardiac - Subsequent Attendance

See Section 32 for a generic subsequent specialist assessment definition. Follow-up attendances to paediatric cardiac specialist or medical officer at registrar level or above or nurse practitioner.


M10008 Cardiac Outreach Service - WH

CHF project to provide support to prevent readmission and lower length of stay. There is a Service Spec & reporting requirements, Integration project.

Service Agreed lump sum amount. Service purchased in a block arrangement

M10009 Cardio-vascular models of care

Integration Project - General Practice teams, providing in the community, services for patients with Chronic Cardio-Vascular Disease

Service Agreed lump sum amount. Service purchased in a block arrangement



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.



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)




APPENDIX SIX. GUIDELINES FOR THE USE OF BNP IN DIAGNOSIS OF HEART FAILURE NB: BNP may be increased by AF, Renal

Failure, LVH, ACS, acute PE, COR Pulmonale, age.

HEART FAILURE UNLIKELY

(2%)

PATIENT PRESENTING WITH DYSPNOEA OR POSSIBLE CARDIAC OEDEMA

HISTORY EXAM CXR ECG

BNP < 40 PMOL/L

BNP > 220PMOL/L

HEART FAILURE LIKELY (95%)

BNP 40-220PMOL/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.

Begin treatment for failure. Specialist

opinion and echo may be appropriate for

determining aetiology:

BNP

IF DIAGNOSIS REMAINS UNCLEAR

G Devlin: Cardiologist Anglesea Heart & Health Waikato


APPENDIX SEVEN. AMBULANCE SUPPORT SERVICES – MIDLAND REGION

Note: St John Ambulance Midland Region does not include Taranaki

DHB Fire First Response Units

Fire Co Response Units Fire Station

PRIME Location

Bay of Plenty Maketu Greerton Edgecumbe Matakana Island Mt Maunganui Katikati Matata Ohope Kawerau Pukehina Papamoa Murupara Tauranga Airport Opotiki Tauranga Waihau Bay Whakatane Board Mills Whakatane Whakatane Lakes Mamaku Ngongataha Mangakino Rotorua Reporoa Taupo Tongariro Turangi Tairawhiti Patutahi Gisborne Te Puia Tokomaru Tologa Bay Tologa Te Araroa Waikato Putaruru Cambridge Bennydale Tahuna Chartwell Cambridge Hamilton Huntly

Matamata Kawhia

Morrinsville Matamata Otorohanga Morrinsville Pukete Mokau Te Aroha Otorohanga Te Awamutu Piopio Tokoroa Putaruru Raglan Taumaranui Te Anga Te Aroho Te Kaha Te Kauwhata Te Kuitu Tirau Tokoroa



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.



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.



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.



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.



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 B-type-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.



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.



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.



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.



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.



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.



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.



16. References

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11 Ministry of Health 2003. Healthy Eating – Healthy Action Oranga Kai – Oranga Pumau: A strategic framework. 2003. Wellington: Ministry of Health. URL: http://www.moh.govt.nz/moh.nsf/0/6088A42CFAA9AC6FCC256CE0000DAE66/$File/heha-strategicframework.pdf

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