a strategy for tackling cardiovascular disease in southland · 2018-11-08 · a strategy for...

A Strategy for tackling Cardiovascular Disease inSouthland

December 2004 Quality and Humanity in Health 1

PROJECT DETAILSProject Title Cardiovascular Disease Management Strategy

Project Sponsor Dr Gershu Paul, CEO

Project Manager Leanne Liggett, Policy Analyst

Project Team members Internal: Cardiac Rehabilitation Nurse, Clinical Director ofGeneral Medicine, Allied Health Manager, GM Māori Health,Director of Nursing & Midwifery.

External: Heart Foundation, Public Health South, Push PlayNetwork, Rural Health Advisory Network, Smokefree Murihiku,Pharmacist, South Link Health, Stroke Foundation.

DOCUMENT CONTROLVersion number 06 Date: 6/12/04Associated projects SDHB Health Needs Assessment

PHO Health Promotion programmesSmokefree HospitalPublic Health South InvestigationHealthy Eastern Southland InvestigationHealthy Eating Health Action StrategySDHB Diabetes Strategy

Confidentiality The information contained within this document is confidential to SDHB. It may not beused, reproduced, or disclosed to any others except employees who have the need toknow for the purpose of this project.

DEFINITIONSBackground to project In 2003, a joint project between Planning & Funding, SDHB and

SISSAL entitled Cardiovascular Health Needs Assessment andrecommendations for action was tabled at the November 03board meeting. This document was the initial first step requiredto defining a process or framework that SDHB can follow inorder to address the New Zealand Health Strategy Priority ofreducing the incidence and impact of cardiovascular diseasewith the region.

The primary purpose of the above document was to understandthe cardiovascular health and disability needs of the Southlandcommunity during 2003, document the findings and presentrecommendations to the board. Numerous recommendationswere outlined and these were summarised under six keyheading. These being 1) information, 2) health promotion, 3)primary care, 4) secondary service, 5) Maori and 6) ruralpopulations. See Appendix 1 for further details.

Appendix 2 moulds together these recommendations with thoseoutlined for immediate action as reported in the 04/05 DistrictAnnual Plan (DAP). Additional variables such as financialimpact and evaluation were incorporated, ensuring that each oftheses determinants are not considered in isolation but insteadon merit and health gains associated. These health gains arenot always easy to quantify and the majority of preventiveactivities need to be evaluated using qualitative methodologies



and often require a change in philosophy for both the healthproviders and population they are targeting. Examples includethe implementation of the Primary Health Care Strategy and theamendments to the Smoke-free Environments Act 1990.

SDHB has also been approached by the Heart Foundation todevelop a formal relationship based on agreed principles ofassociation and a Memorandum of Understanding or Co-operation. See Appendix 3.

Cardiovascular disease is the leading cause of death in peoplewith diabetes and as such, strategies need to be closely linkedto ensure the best outcome for the Southland population and beimplemented within the funding available. The board hasrecently approved a significant investment in the DiabetesStrategy and this CVD Strategy further aligns the two healthpriorities.

It is also acknowledged that there needs to be an increase indisease prevention interventions whether this be at a primarylevel (pre disease state) or at a secondary level (post diseasestate) and therefore lifestyle modification programmes andcollaborations need to be promoted.

Project Goal To develop a framework for a robust Cardiovascular DiseaseManagement Strategy for the people of Southland with anemphasis on both short and long-term goals.

Project Objectives Initially

• Formalise an agreement between the Heart Foundation andSDHB through a Memorandum of Co-operation orUnderstanding.

• Form a CVD advisory group incorporating key stakeholders.See Appendix 4.

Annually:1. Identify 3 or 4 projects/tasks to be accomplished within the

coming financial year.

2. Consult with CVD advisory group and plan accordingly.

3. Identify and engage with key stakeholders specifically wherethe project/task falls outside of secondary care.

4. Incorporate monitoring and evaluation into eachprojects/task both at process and outcome stages.

5. Continuously monitor long term goals.

6. Reconvene CVD advisory group during DAP planningprocess to review and update the strategy.

Deliverables (includingmeasures or indicators ofsuccess)

1. Signed MOU between SDHB and Heart Foundation.

2. Formation of CVD advisory committee.

3. Identification of three to four realistic projects to beundertaken in collaboration with other key stakeholdersduring each financial year until 2007. It is expected that they



will fall under the following headings:- Health Promotion;- Risk Assessment; and- Acute Care.

4. Plan and outputs incorporated into 2005/06 – 2007/08 DAP.

Appendix 5 outlines a proposed monitoring templates that will befollowed.

Benefits of project(including measures ofknown benefits whichrelate to deliverables aswell as less tangiblebenefits)

1. Increased community awareness of CVD issues and serviceprovision providing a platform that embraces self-ownership /community.

2. Improved linkages between and across different healthproviders servicing the Southland region.

3. Potential improved understanding of a) health promotion b)risk assessment c) acute care from within providersdepending on topics chosen.

Scope (areas affected byproject)

The scope of the project is very large and is ultimatelydetermined by the projects chosen annually depending onwhere they fall within the disease control continuum.

See table below.

STAKEHOLDERSKey stakeholders SDHB, Public Health South, Sport Southland, Stroke

Foundation, Heart Foundation, Territorial Local Authorities, GoreHealth Limited, Maori Health Providers, PHOs, South LinkHealth, Local Diabetes Team.

Other stakeholders Community Trusts, South Link Health Inc., Public HealthDirectorate, Local Runanga, YMCA, Community NetworkingTrust, Ministry of Social Development, Schools.

PROJECT MANAGEMENT APPROACHProject strategy (broadstatement of how projectwill be approached)

The key internal owner of this project is the CEO. The ProjectManager will report directly to this individual and provide regularupdates.

Project start date January 05 Project completion date 30 June 2007Milestones Date

Sign Memorandum of Co-operation February 2005

CVD advisory board formed and initial meeting held February 2005

05/06 priorities identified February 2005

Progress report July 2005

APPROACHES STRATEGY IMPACT OF STRATEGYPreventative activities Health promotion

Disease preventionIncidence reduction

Acute care,rehabilitation andchronic care services

Diagnostic and treatment servicesRehabilitationOngoing care for chronic disease

Impact reduction

Information andanalysis

Monitoring and surveillanceResearch

Optimised implementation,planning and evaluation.



06/07 priorities identified January 2006

Progress report July 2006

07/08 priorities identified January 2007

New Cardiovascular Strategy written 2007

RISKS MITIGATION• Buy-in from key

stake holders.

• Availability offunding.

• Apathy ofpatients.

Information /database

PHO database

• Need to ensure face to face meetings occur and that all sectors(public, primary and secondary) are continually informed throughadvisory group members and that these individuals candisseminate information in both directions.

• Education of the community is essential to ensure buy-in fromother key stakeholder and community funders in joint projects.

• Proactive approach to raise awareness of the seriousness ofcardiovascular disease and the importance of modifying lifestyleregimes and taking a wellness approach to healthcare to improvequality of life for individuals and their whanau. Targetedpopulation uptake is one approach to consider.

• SDHB is purchasing a new Integrated Patient ManagementSystem with an aim to provide an improved capacity ofinformation sharing ability across primary and secondary healthcare sectors.

• Southland’s Health Needs Analysis in 2001 was notable for thelack of information from the primary care sector. South LinkHealth has indicated that they are intending to create diseaseregisters in the form of a database to assist PHO improvecapturing this information.

INVESTMENT1. $10K Annual contribution to the Healthy Eastern Southland Coordinator’s salary

2. $150K Total costs associated with piloting the Heart Manual (3 year project)

3. $10K Workforce development (annual expense)

4. $2K CVD Advisory Group meeting (annual expense)

TOTAL (annual expenses) = $22KTOTAL (pilot expenses) = $150K

ADDITIONAL INFORMATIONAppendix 6 contains the proposal received from the Heart Foundation regarding the HeartManual, which will be referred to as “Heart Guide Aotearoa” in New Zealand.

Appendix 7 contains a short summary on Cardiovascular Disease Morbidity in the Southlandregion.



Appendix 1

Excerpts from the 2003 Southland District Health Board report -“Cardiovascular Health Needs Assessment and Recommendations for Action”.

Executive SummaryThe purpose of this paper is to understand the cardiovascular health and disability needs of theSouthland community within the scope of information readily available to the authors during themid to late months of 20031. This data is also supported at a local level by key stakeholderinterviews with an overall objective of determining how the Southland District Health Board canapproach the New Zealand Health Priority of Reducing the Incidence and Impact ofCardiovascular Disease within the region.

This paper is the first step for the Southland District Health Board in addressing this key healthpriority and together with the recent Draft Diabetes Action Plan provides timely direction fortackling these health priorities. As described above, necessary population statistics are notreadily available therefore further investigations will be required to justify funding for many ofthe proposed recommendations described.

Four key recommendations of this report are:• Support the increase of hours for the Cardiac Rehabilitation nurse, expanding the scope of

the service• Improve information collection across all health care sectors• Support the employment of a community dietitian• Support the proposed pilot of the heart manual

Current cardiovascular care in New Zealand demonstrates the inverse care law whereby thosemost in need receive the least. The trend in Southland is no different and reducing inequalitiesand barriers to accessing care are pivotal in creating health gains for the region.

A reduction in the cardiovascular disease incidence will only be achieved through a populationbased or health promotion approach. This methodology is a long-term approach to reducingthe burden of disease on individuals, communities and health services and the benefits will notbe immediate. Therefore a combination of high risk and population based strategies arerequired by the Southland District Health Board.

Key Areas for recommendations.1. Information and Cardiovascular HealthTo improve information collection regarding cardiovascular health status and risk factors inSouthland.

2. Health Promotion and Cardiovascular HealthTo support and develop the planning and coordination of health promotion activities inSouthland that aim to reduce the incidence of cardiovascular disease.

3. Primary Care and Cardiovascular HealthTo support the primary health care sector to reduce the incidence and impact of cardiovasculardisease.

1 The 2001 Southland Health Needs Assessment was notable for the lack of information from the primary caresector and this status has remained constant



4. Secondary Services and Cardiovascular HealthTo support secondary services to reduce the incidence and impact of cardiovascular disease.

5. Māori and Cardiovascular HealthTo reduced the incidence and impact of cardiovascular disease for Māori in Southland.

6. Rural Populations and Cardiovascular HealthTo reduced the incidence and impact of cardiovascular disease for rural populations inSouthland.

Further details can be found in the 2003 report tabled at the November 03 board meeting.



Appendix 2

logos

Memorandum of Cooperation

The Southland District Health Board and the National Heart Foundation of New Zealand holdcommon interests in relation to the health and wellbeing of the Southland population. Inrecognition of this a Memorandum of Cooperation has been developed to formally record thebasis upon which our future relationship will be founded.

We agree to

Acknowledge our respective organisations roles and responsibilities

Agree common goals in light of respective strategic plans

Focus on agreed priorities across population and personal heart health

Share resources and knowledge

Work together to improve workforce training

Work together on projects which are able to be evaluated and replicated

Review progress with the above on a regular basis

………………………………

………………………………

Norman SharpeMedical DirectorThe National Heart Foundation of New Zealand

…………… 2004



Appendix 3

OBJECTIVE 1: REDUCE THE INCIDENCE AND IMPACT OF CVDStrategy: Continue to work towards ensuring prevalence rates, and all key indicators reflect nationally acceptable guidelinesDeliverable Outcome (Timeframe) Financial Impact EvaluationPREVENTATIVE ACTIVITIES

Promote and collaboratewith communityorganisation’s deliveringpopulation healthinitiatives. Ensure that individualswith cardiovasculardisease, and at risk groupshave access to timely andaccurate educationprogrammes.

Promote PHO enrollment.

(a) Reduce the smoking rates inSouthland from 25% to 20%,target population is Maori andyouth (5 years).

(b) Support the development ofintersectoral initiatives, inparticular the HealthyEastern Southland initiativethat is in its developmentstage and has obtainedpreliminary support from keystakeholders.(immediate ongoing).

(c) Encourage alignment of PHOHealth Promotion plans andprogrammes with risk factorsassociated with CVD(1 year ongoing).

(a) Within current budget and includesTobacco Control funding received from thePublic Health Directorate.

(b) Contribute $10K annually towards theappointment of a coordinator to beappointed by the intersectorial agencies(SDHB, GHL, GDC, PHS, Hokonui Runanga,PHO, Community Connection Trust, WINZ).Planning for establishing this coordinatingrole is underway.

(c) Within current budget and resources.

(a) Specific reporting requirements are attached toeach smoking cessation contract facilitated bySDHB and alignment will be made with MOHcontracts.

(b) As this is an intersectoral collaborationinitiative, success will be monitored in a numberof ways and this funding relates only tostrategic planning and not operational costs,which may be incurred when projects areidentified. Variables measured may include1)continued support from other key agenciesthrough funding or provisions of overheads forthe coordinators position, 2)increasedengagement between organisations,3)development of new relationships and4)increased awareness of services available topeople residing in the Eastern Southland region.Please note each specific project undertaken bysignatories will have their own evaluationattached and require their own funding source.

(c) PHOs will be assisted with the development oftheir Health Promotion plans and programmesand this will incorporate evaluation and reportingmethodologies which concur with best-practice.Quarterly reporting/six monthly reporting willbe attached to their contract.



Deliverable Outcome (Timeframe) Financial impact EvaluationACUTE CARE, REHABILITAION AND CHRONIC CARE SERVICES

Improve CVD risk factorpatient management inboth primary andsecondary care sectorsthrough the promotion andimplementation of the NZCardiovascular AdvisoryGroup Recommendationsand Guidelines (2003). Ensure that individualswith cardiovasculardisease, and at risk groupshave access to timely andaccurate educationprogrammes.

Expand Phase 3 cardiacrehabilitation services,supported dischargeprogrammes and Strokeclinic capabilities.

Establish a communityDietitian position. NB. Thismay or may not be a SDHBhoused position as littletime would be spent in anoffice environment butrather in Southlandcommunity at variouslocations.

(d) Increase the uptake of freeannual checks for people withDiabetes and reduce thenumber of patients with poorlycontrolled HbA1c by 10% -(baseline = 2004 nmds2

figures) (3 years).

(e) Increase the number ofcardiac and stroke patientsoffered evidence basedrehabilitation programmes by20% in this financial year anddetermines realistic targetsfor the next 5 years –(baseline = 2004/05 SDHBfigures) (1 year).

(f) Begin to plan and implementthe Heart Manual incollaboration with the HeartFoundation (2 years).

(g) Promote medical managementin collaboration withPharmacists and PHOs(1 year).

(h) Develop protocols for theadministration of pre-hospitalthrombolytics in ruralSouthland in collaborationwith Cardiologists servicingSouthland DHB (1 year).

(d) Within current budget.

(e) Investigate the expansion of Stroke clinicand supported discharge programmes, nocost attached. If the outcome is positivefunding will be sought following thedevelopment of a implementation plan,Cardiac Rehab nurse has recently become1.0 FTE providing a 40% increase in serviceprovision for Cardiac patients.

(f) Appendix 6 outlines a proposal receivedform the Heart foundation for this pilotproject. The salary for the CommunityFacilitator 0.5 FTE position should be metwithin the current budget and theprojected costs shown in Table 1 (Appendix5) will require to be adjusted accordingly.Adjusted expenses for the 3 year Pilotaverage to $50K with year 1 requiring alarger proportion and this reduces overyears 2 and 3. Total financial investment$150K.

(g) Within current budget.

(h) Within current budget.

(d) The Local Diabetes Team submits an annualreport which describes the current status ofFree Annual Checks delivered by South LinkHealth.

(e) Evaluation will be incorporated into thisinvestigation.

(f) A comprehensive evaluation is associated withthe development of the Heart Manual pilot andwill be provided by the Heart Foundation.

(g) A survey needs to be undertaken of both sectorsto determine how changes can be safelyimplemented and how these can be bestmeasured.

(h) Process evaluation would be a requirement in thedevelopment of the protocol and onceimplemented an outcome evaluation to beundertaken.

2 nmds = national minimum data set



Deliverable Outcome (Timeframe) Financial impact EvaluationACUTE CARE, REHABILITAION AND CHRONIC CARE SERVICES

Provide safe appropriateaccess to SpecialistCardiologist. Ensure sustainableresources are maintainedin the Wakatipu Basin.

(i) Ensure Southlander’s who havebeen identified as highcardiovascular or diabetesrisk have access to a dietitianand are provided with anexercise regime which willconsider both geography, workand social environment foreach client (1-2 year).

(j) Actively support professionalworkforce development(ongoing).

(k) Continue to investigateShared Service capabilitieswith ODHB (1-2 years).

(i) Funding for this position was given withinthe Diabetes Strategy. Activity costslinked to Care Plus and Green Prescriptionare within current budget.

(j) $10K.

(k) Within current budget.

(i) The Care Plus programme offered in Primarycare will need to have comprehensive reportingattached and ideally a survey undertaken ofboth clients and GPs who have had someinteraction with this programme. Thisprogramme is still in developmental stage.

(j) The new Health Practitioners Competency Actwill assist in this process.

(k) Evaluation will be incorporated into thisinvestigation.

INFORMATION AND ANALYSIS Improve the capture ofinformation across primaryand secondary carethrough technologicaladvancements and acuterecording.

(l) Work with South Link Healthto create an informationplatform that PHOs cancapture patient risk factorsdata and for this template tobe modified for secondarycare ensuring capability anddata sharing (2 years).

(m) Encourage and supportorganisation who undertakeany research within theSouthland region (ongoing).

(l) Within current budget.(m) Financial assistance will be considered on a

case by case basis and assessed using theSDHB prioritisation template.

(l) An extensive investigation into what platform ispurchased is required to ensure data capturedwill be in a format that can be analysed.

(m) Ensure proposals supported by SDHB containboth process and outcome evaluation.



OBJECTIVE 2: ENSURE IMPROVED COORDINATION AND INTEGRATION ACROSS CARDIAC ANDSTROKE SERVICESStrategy: Integrate public health, primary health and specialist hospital servicesDeliverable Outcome (Timeframe) Financial impact EvaluationPREVENTATIVE ACTIVITIES

Encourage the alignment ofstrategic planning andimplementation between SDHBand deliverers of communitybased health promotioninitiatives.

(n) Develop partnerships with key agenciessuch as but not limited to HeartFoundation, Sport Southland and PHOswhich take a broad chronic diseaseprevention perspective (ongoing).

(o) Ensure SDHB has the ability to influencethe content of Public Health South’sannual plan with respect to public healthfunding (Ministry of Health contract)(1 year ongoing).

(n) Within current budget.

(o) Within current budget.

(n) Has a formal partnership been formedand if so, have the aims of respectiveprogrammes been achieved.

(o) Evidence of service delivery changeshould be visible in monthly reporting.

ACUTE CARE, REHABILITAION AND CHRONIC CARE SERVICES Promote an increased associationbetween Diabetes managementand CVD management in Primaryand Secondary care settings.

(p) Investigate and promote theimplementation of risk factor clinics forpatients with known IHD or diabetes, orif possible, expand the targetedpopulation to include those who havepredisposed risk factors for eithercondition (1-2 years).

(p) Promotion expense falls withincurrent budget. Expenses forPrimary care have not beenconsidered. There is no costattached to secondary careinvestigating risk factor clinics.If the outcome is positive,funding will be sought followingthe development of aimplementation plan.

(p) Evaluation will be incorporated into thisinvestigation.

INFORMATION AND ANALYSIS Provide a Integrated PatientManagement System andStandardised IT platform.

(q) Establish a local steering committee todirect and comment on the CVD strategyas it is rolled out (immediate).

(r) Develop Patient Management System andStandardised IT platform (3 year).

(q) Meeting expenses andattendance fees estimated tobe $2K

(r) Within current budget

(q) Survey the committee capturinginformation on expectations and capabilityof members regarding the role of thecommittee.

(r) A comprehensive evaluation has alreadyoccurred regarding the PMS which isbeing purchased by SDHB.



OBJECTIVE 3: ENSURE THAT ACCESSIBLE AND APPROPRIATE PROGRAMMES ARE AVAILABLEFOR MAORI AND PI PEOPLE IN COLLABORATION WITH THE COMMUNITYStrategy: Continue to work towards ensuring Maori and Pacific Island prevalence rates are in line with nationally agreed targetsDeliverable Outcome (Timeframe) Financial impact EvaluationPREVENTATIVE ACTIVITIES

Eliminate barriers an improveaccess to health care Ensure strategic planning andservice delivery of MāoriProvider services aligns withSDHB priorities

(s) Work with PHOs who have upliftedfunding for Services to Improve Access(ongoing).

(t) Establish closer linkages with MāoriHealth Providers and with guidance fromKaitiaki Hauora (ongoing).

(s) Within current budget.

(t) Within current budget.

(s) A comprehensive reporting regime isattached to this funding line and PHOs.

(t) The Māori Health GM regularly updatesthe board and senior management.

ACUTE CARE, REHABILITAION AND CHRONIC CARE SERVICES Eliminate barriers to improveaccess to health care

(u) Support workforce development forMaori, PI and alongside mainstream healthprofessionals (ongoing).

(v) Investigate expanding communityoutreach services by 10% every year(1 year).

(u) Within current budget.

(v) Investigate the expandingcommunity outreach services, nocost attached. If the outcomeis positive funding, will besought following thedevelopment of aimplementation plan.

(u) The new Health Practitioners CompetencyAct will assist in this process.

(v) Outcome evaluation is required after thefirst year to determine the short-termbenefits of expanding the servicesthrough the measurement of morbidityand mortality rates.

INFORMATION AND ANALYSIS Ensure quality ethnicity datacollection in both primary andsecondary care settings

Facilitate a Provider Hui

(w) Work with South Link Health inestablishing a consistent framework forethnicity data alongside and not limited torisk factors (1-2 years).

(x) Promote increased awareness of Māoriprovider services both within health caresectors and for the community that theyserve (1 year).

(w) Within current budget.

(x) Within current budget.

(w) Survey primary and secondary carehealth workers to gauge theirinterpretation on the accuracy ofethnicity data collected within theirorganisation.

(x) Facilitate a focus group to captureinformation during this Hui.



Appendix 4

Proposed membership of CVD Advisory Group:

Internal• Cardiac Rehabilitation Nurse• Clinical Director of General Medicine• Consultant Cardiologist (ODHB)• Director of Nursing and Midwifery• Manager Allied Health• GM Māori Health• Project Manager

External• Heart Foundation – Southland Branch• Public Health South• Representative from Push Play Network• Representation from Rural Health Advisory Committee• Representative from Smokefree Murihiku• Pharmacy representative• South Link Health (GP &/or Practice Nurse Representative)• Stroke Foundation – Southland Branch• Representative from the Local Diabetes Team

Meeting frequencyFour meetings are recommended annually. The first and third to be held 6 months apart inthe months of January and July with a purpose to review and plan. The second and forthare to be held in the months of February and August and allow committee members time toconsult with the wider population with to the meeting content discussed at the precedingmeeting.



Appendix 5

Monitoring template:Project Activity Specifics Responsibility

& Time FrameDue Date Progress Notes

Prepare strategyfor Boardmeeting

Develop time frame andactivities

Leanne Liggett(Nov 04)

1 December 04 Completed for Octoberboard but pushed out toDecember – updatedfollowing DiabetesStrategy

SignMemorandum ofCo-operation

Form a formalrelationship with theHeart Foundation

Gershu Paul / DenisCairns / HF/Leanne Liggett(Feb 05)

28 February 05 Draft document receivedfrom HF

Identifypriorities for05/06

CVD Advisory BoardFormed3-4 small projects to beidentified

CVD AdvisoryBoard formed andconsensus ofprojects obtained(Feb 05)

28 February 05

CommunicationStrategy

Develop a process fordisseminatinginformation to a)thepublic and b)health careproviders

Leanne Liggett /Megan Grindlay(March 05)

18 March 05

CPHAC & BoardUpdate

Update CPHAC 6monthly & boardannually on: progress,time lines, key drivers,risks and mitigation’s

Leanne LiggettCPHAC (Feb & Aug05)Board (Nov 05)

1 February 051 August 0520 October 05

Dates of meetingscurrently unknown

Contractmonitoring

Review and consolidatequarterly reportssupplied by serviceproviders specific toCVD whether it behealth promotion,disease prevention ordisease management.Recommend adjustmentto contract delivery &reporting wherepossible.

P&F Team but co-ordinated byLeanne Liggett(ongoing)

3rd Quarter =April 054th Quarter –July 051st Quarter =October 052nd Quarter =January 06

SDHB Policies &Procedures

Monitor and reviewthese policies andprocedures to ensurethey align with the CVDStrategy.

Create where necessarynew policies such as aNutrition Policy

Richard Catto /Leanne Liggett(6 monthly -ongoing)

Lexie O’Shea(Feb 05)

March 05September 05

February 05



Appendix 6

Heart GuideAotearoa

A Partnership Proposal Between SouthlandDistrict Health Board, Te Hotu Manawa Māori

and the National Heart Foundation.

Te HotuManawa Māori



ContentsPage

1. Overview 17

2. Objectives 18

3. Background cardiac rehabilitation literature 18

3.1 Trials comparing home based cardiac rehabilitation 18

3.2 Cardiac Rehabilitation and New Zealand 19

3.3 Cardiovascular Disease Among Māori 20

3.4 Problems with the Existing Framework of Cardiac Rehabilitationfor Māori Patients 20

4.0 The United kingdom (UK) Experience of the Heart Manual 22

4.1 Communication Between Primary and Secondary Care 23

5.0 Audit Evaluation 23

5.1 Audit Tool 24

5.2 The Audit Tool and the Pilot 24

6.0 Financial Analysis 26

6.1 Investment 26

6.2 Southland DHB and the Heart Guide Aotearoa Program 26

6.3 Investment Return 29

6.4 Conclusion 30

References 31

Appendix A 34



1. Overview

The 2001 New Zealand Health Strategy developed by the Ministry of Health set out 13key population health objectives; reducing the incidence and impact of cardiovasculardisease is one of these objectives (MOH, 2001). However, five other key strategies aredirectly related to cardiovascular disease; these being improving nutrition, reducing levels ofobesity, reducing rates of smoking, reducing the incidence and impact of diabetes, andincreasing the level of physical activity.

This proposal describes a project which meets many of the key health objectives of theNew Zealand Health Strategy by improving access and use of cardiovascular rehabilitation(CR) services. Additionally, this program meets specific objectives of the Māori HealthStrategy (He Korowai Oranga) by providing a pathway to address the disparity among Māorireceiving the benefits of cardiac rehabilitation. Because of the poorer health outcomesexperienced by Māori, reducing disparity has become a priority for central government. Anequitable health system is a Treaty of Waitangi obligation and the New Zealand HealthStrategy has outlined the government’s commitment to reducing the unequal health status ofMāori, and reducing the impact of cardiovascular disease on this group (MOH, 2001).

The Heart Guide Aotearoa (HGA) project is a partnership between the National HeartFoundation, Te Hotu Manawa Maori, Ministry of Health and The North Island EnglishMasonic District Charitable Trust, to develop a home based cardiac rehabilitation program.Professor Bob Lewin, an internationally acclaimed expert in cardiac rehabilitation and theauthor of the ‘Heart Manual’ (1992) has been contracted to write a new programme drawingon his previous experience with the ‘Heart Manual’ combined with the latest research incardiovascular rehabilitation.

Heart Guide Aotearoa is a home based cardiac rehabilitation programme which aims toovercome the barriers of access to traditional secondary care rehabilitation. This project isdesigned to help with the development of an effective program that increases the uptake ofcardiac rehabilitation, especially for those groups of consumers presently disenfranchised(working men, Maori and Pacifica people, women and the elderly) by the present model ofcare. Processes for audit evaluation and quality assurance will be undertaken to assess theeffectiveness of HGA, patient usage, health outcomes and cost benefit analysis.



2. Objectives

The Objectives of the project are:

improve the quality of life for post myocardial infarction patients

improve the integration of care (improve links and support structures betweensecondary and primary care)

target people presently disenfranchised by the present model of care to helpreduce mortality and morbidity

improve self care

decrease hospital admissions rates for patients with related cardiac issues

3. Background Cardiac Rehabilitation Literature

Cardiac rehabilitation after an acute myocardial infarction (AMI) has historically beenmade up of three main components, exercise, psychosocial and education. Theeffectiveness of these programmes using meta-analysis has been shown to reduce mortalityand morbidity by between 20-26% over a one to three year time frame (Jolliffe et al, 2000.,Dusseldorp et al, 1999). These studies have shown that cardiac rehabilitation can improveblood pressure, serum cholesterol, patient understanding, and psychological wellbeing(Mullen, 1992). Despite these benefits it is clear that that many people who would be helpedby cardiac rehabilitation are not receiving it (Pell et al, 1996).

3.1 Trials Comparing Home-based Cardiac Rehabilitation

Home based cardiac rehabilitation studies preformed to date provide information aboutimproved exercise capacity, reduces anxiety levels, adherence to such programs andreduced systolic blood pressure (Lewin, 1992; Marchionni, 2003). While exercise-onlyrehabilitation program have been reported to significantly improve exercise capacity (Bell,1998., and Marchionni, 2003), systolic blood pressure and serum cholesterol, a reduction inhospital attendance during the first six months of follow-up is also noted (Bell, 1998).



3.2 Cardiac Rehabilitation in New Zealand

In New Zealand cardiac rehabilitation is divided into three phases. Phase 1 is the initialinterview with a cardiac rehabilitation nurse in hospital. Phase II is only provided bysecondary care, normally within the hospital grounds, involving a 6 – 12 weeks programmesome time after discharge (between 2 -12 weeks). Phase III is the maintenance phasebased in the community.

Phase II (hospital based programmes) traditionally offers an informative, didacticteaching method within a group session. Therefore, individual need is often not addressed,resulting in some aspects of the programme not being relevant to patient needs, which maybe a factor contributing to the low completion rate of the programme. Other factors identifiedby a NHF audit (Doolan-Noble, 2001) include:

Increasing equity and reducing inequality

Reduce post AMI GP visits

Reduce post AMI readmission

Reduce post AMI mortality and morbidity

Limited family involvement

Attendees are volunteers and generally well motivated, white and male

No formal individual assessment of need

No setting of individual goals and checking on attainment

No help immediately following discharge

Programmes frequently concentrate on exercise, which may not be the mainproblem for most patients

There are many factors that affect the uptake of cardiac rehabilitation by patients.These include the effectiveness of phase one in identifying appropriate patients. Referral bya cardiologist, who overtly supports and states the benefits of a cardiac rehabilitationprogram to the patient, along with the availability and accessibility of a program. Significantpredictors of patient uptake include level of education, being elderly, female, socio-demographic factors, ethnic minorities and spousal involvement.



Furthermore, there is a high degree of variability between facilities in the format of theservice, equipment, duration of programmes, the make up of the multidisciplinary team andsessions available.

Unfortunately in New Zealand there is very little formal evaluation, audit or monitoringof the clients satisfaction of CR programmes. The Cardiac Rehabilitation Guidelines (NewZealand Guidelines Group, 2002) state, “Audit, evaluation and patient feedback are integralaspects of quality improvement”. The main reason for this paucity of data collection isthought to be related to a lack of time as many cardiac rehabilitation nurses work only part-time.

Doolan-Noble’s (2004) audit of attendance to New Zealand cardiac rehabilitationprograms demonstrated that only 36% of eligible patients were referred to a program. Ofthose referred to a phase II program 58% did not attend and only 24% completed foursessions. In essence this means that less than 10% of eligible patients completed at leastfour sessions of a program, despite the proven benefits of attending cardiac rehabilitation.

3.3 Cardiovascular Disease Among MāoriPresently the burden of cardiovascular mortality and morbidity falls disproportionately

on Māori in New Zealand. For example, Māori die almost a decade earlier than non-Māori(MOH, 2001). Māori women are 2.3 times more likely to die from coronary heart diseasethan non-Māori women. Similarly, Māori men are 1.7 times more likely to die from coronaryheart disease than non-Māori males (Hay, 2002). Both Māori men and women have morethan 4 times the rate of hypertensive disease than non-Māori. Additionally, the coronaryheart disease mortality rate for Māori aged under 65 is more than 3 times higher than fornon-Māori in the same age group (Hay, 2002). Clearly, the over-representation of Māoriamong the negative indices of cardiovascular disease requires immediate attention.

3.4. Problems with the Existing Framework of Cardiac Rehabilitation for MāoriPatients

Unfortunately, Māori do not receive a level of medical intervention that is proportionalto their burden of cardiovascular disease. For example, Māori men have been shown toreceive less than half the age-standardised CABG and PTCA procedures that non-Māorimen receive. Māori women receive approximately 74% of CABG and 43% of PTCAinterventions that non-Māori women receive (Tukuitonga, 2002). These findings demonstratean ‘inverse care’ law, whereby those with the most need receive the least care (Hart, 1971).Unfortunately the inverse care approach appears to apply in cardiac rehabilitation also.

International research has demonstrated consistently low cardiac rehabilitationreferral rates for women, patients from low socioeconomic groups, and ethnic minorities



(Pell, 1996). Additionally, research in the United States has shown that ethnicity is a majorpredictor of access to health care (Bhopal, 1998).

An analysis of all New Zealand cardiac care centres in 2002 found that only 36% ofeligible patients were referred to Phase I of cardiac rehabilitation. Risk factors for non-referral included having a diagnosis of heart failure, being older or female. If patients werereferred to Phase II, factors contributing towards non-completion of the programme includedlow socioeconomic status and being younger than 65 or older than 74 (Doolan-Noble, 2003).Of particular relevance is that Māori tend to suffer cardiovascular disease at a younger agethan non-Māori. Additionally, Māori suffer twice the rate of hospital admissions for heartfailure as non-Māori and cardiac rehabilitation has been shown to be effective in themanagement of this disease (NZGG, 2002). Finally, Māori patients are clearly at risk of notreceiving the benefits of cardiac rehabilitation as people in lower socioeconomic groups aremost likely to lack transport (Wannamethee & Shaper, 1997).

The confinement of cardiac rehabilitation programs to the hospital environment is afurther factor that impedes access by Māori. A higher proportion of Māori live in rural areascompared with non-Māori, compounding transport issues to and from the hospital (Dept. ofStatistics, 2001). Also, hospital based cardiac rehabilitation programs are only availableduring working hours, this has been suggested as a reason for poor attendance for thoseunder the age of 65 who are still of working age.

The existing hospital-based cardiac rehabilitation framework does not incorporate akaupapa Māori approach to patient management. As stated, the existing programs have apatient-centred approach rather than a family-oriented framework; a Māori framework wouldbe inclusive of the important roles that whānau can provide in rehabilitation (HealthPromotion Forum, 2002). This approach is further emphasised in He Korowai Oranga (MāoriHealth Strategy) through Te Ara Tuatahi (Pathway 1); where a commitment to strengtheningMāori whānau and Māori models of health is recognised (MOH, 2002).

Lastly, many of the existing hospital-based cardiac rehabilitation programs do notincorporate Māori providers in service delivery. International studies have shown thatindigenous health services provide improved access, higher levels of compliance, and agreater sense of community ownership and participation (Waldrum, 1997). Similarly in NewZealand, Māori health care providers have been shown to be effective in providing healthcare services for Māori communities. Examples include higher rates of childhoodimmunisation, increased use of general practice services, and reduced disease morbidity(Ratima, 1999). In summary, despite the proven efficacy of indigenous health care providers,cardiac rehabilitation is only delivered by a non-Māori hospital-based system of providers atpresent.

The New Zealand government has made a commitment to improve Māori healthoutcomes and to reduce the impact of cardiovascular disease through the New Zealand



Health Strategy (MOH, 2001) and He Korowai Oranga (MOH, 2002). There is enormouspotential to achieve these goals in cardiac rehabilitation by including Māori health careproviders, Māori models of health, and a more accessible system of delivery in therehabilitation process.

In the SouthlandDHB area, cardiac rehabilitation is offered predominantly in thehospital environment during working hours (Monday-Friday, 8am-5pm). In a discussion withone of the team members, it was stated that the program worked well for those people ableto access the program at the hospital. However, it was obvious that those located in moredistant areas from the hospital were absent. Additionally, those who lacked transport or whohad poor English language ability were also likely to be missing from the program.

4. The United Kingdom (UK) Experience of the Heart Manual

Within the UK, the Heart Manual has been adopted to provide home basedcardiovascular rehabilitation. The development and contents of the Heart Manual are basedon a cognitive-behavioural model and have three major components (Lewin, 1992).

1. The Facilitator: during inpatient treatment the facilitator initiates enrolment byintroducing the Heart Manual to the patient and family following their AMI. Thisincludes an assessment of the patient’s ability to understand and complete the simpleexercise programme.

Post discharge follow-up involves completing semi-structured interviews either througha home visit or phone call at fortnightly intervals to monitor their progress.

2. The Workbook contains a six week phased programme of health education, homebased exercise and stress management, and a section on specific problems orconcerns relating to life post MI.

3. Audiotapes provide information in relation to relaxation training and a scriptedinterview between a doctor and patient targeted to assist family to understand what hashappened and what they can do to assist in care post discharge

At the end of the programme the patient completes a questionnaire pack to check theirneeds have been met. Some programmes offer a triage system with patients either,discharged with information about community facilities, referred to primary care, or referredback to the hospital for ongoing care. All patients are followed up at twelve months and thenpass into routine annual follow-up presently available in the UK for the care of people withcoronary heart disease (CHD).

Other benefits evident with this model of service delivery include:



• Increased liaison, referral and support across the primary/secondary care interface(Lewin and Thompson, 2002).

• Lowered levels of anxiety and depression at one year (Lewin, 1992)

• Reduced use of hospital services at six months and general practitioners visits atone year (Lewin, 1992)

• Improved uptake of secondary prevention medication (Dalal, 2003)

4.1 Communication Between Primary and Secondary Care.

The benefits of cardiac rehabilitation are dependant on the patient remaining adherentto lifestyle changes and medications. The communication between secondary care (thetraditional location for cardiac rehabilitation) and primary care is often poor, which can leadto a discontinuance of secondary prevention medications (Mudge, et al., 2000) andconfusion when the patient is given different advice following discharge. These difficultiesreflect the different cultures in the two sectors that result in a restriction in the free flow ofinformation (Clarke, et al., 2002). A facility audit of all formal cardiac rehabilitationprogrammes in 2000 showed that only 48% of those who returned the completed audit forms(n =33, 80% response rate) had a mechanism in place for communication with GeneralPractitioners (Doolan-Noble, 2001). A cardiac rehabilitation programme that is deliveredaround the use of a home-based programme has been shown to improve the communicationbetween primary and secondary care sectors (Creaser, 2002).

To address issues noted here The Heart Foundation and Te Hotu Manawa Maori haveinitiated and are overseeing the development of a home based cardiac rehabilitationprogramme called Heart Guide Aotearoa (HGA). As with the Heart Manual in the UK, HeartGuide Aotearoa is intended to increase the number of patients attending cardiacrehabilitation and deriving benefits from it. The writing of HGA and development of thetraining manuals is being undertaken by Professor Bob Lewin of York University (the authorof the Heart Manual, 1992). This part of the project is being funded by the Ministry of Healthand the North Island English Masonic District Charitable Trust.

The development of a home-based cardiac rehabilitation programme will be one way ofexpanding the service to increase equity of access, improve acceptability and contain costs.

5.0 Audit Evaluation



It is intended that an audit evaluation will be undertaken to compare the outcomes ofHeart Guide Aotearoa, with present cardiac rehabilitation programmes, as it is important todemonstrate that all cardiac rehabilitation programmes improve outcomes for the patientsthey serve. This is especially important when a new service is being piloted as in the HeartGuide Aotearoa programme, where there needs to be an assurance on behalf of theproviders that this programme helps improve services in terms of access, equity, quality andclinical outcomes. It also needs to be considered that a range of new providers of cardiacrehabilitation are being introduced, along with a new set of procedures which makes itimperative that services are evaluated, so that future implementation of programmes candevelop or maintain their effectiveness and efficiencies.

5.1 The Audit Tool

The audit tool for Heart Guide Aotearoa has yet to be defined as this will be developedin consultation with the pilot sites, though it would seem prudent for this to be based uponthe United Kingdom’s minimum data set. It went through a rigorous development process ofover a year involving a number of professional groups including the British Association ofCardiac Rehabilitation. It was also subject to national and international expert review andhas been adopted by the British Heart Foundation and the British Association of CardiacRehabilitation as the preferred audit tool for cardiac rehabilitation (see Appendix A).

It is suggested that the audit tool will need to encompass the following domains (seetable below) in order to meet minium quality assurance processes.

Domain Rationale

Uptake andcompletion

To access whether HGA helps increase the uptake and completionof cardiac rehabilitation

Demographics To access whether HGA improves the present inequities

ClinicalIndicators

To access whether the menu based format of the programmecompromises patient outcomes eg BP, Pulse, pharmocol therapy,quality of life, etc.

Referral Times To assess the effectiveness of referral processes, as historicalprocedures are being adapted to fit this new model



It is envisaged that this audit tool will be available online and the collected data bestored centrally, though each pilot site will be able to access their collected data.

5.2 The Audit Tool and the Pilot

The audit tool will be used as part of a quality assurance process to inform whether theHeart Guide Aotearoa project achieves it stated goal, which is to improve equity related tothe uptake and completion of cardiac rehabilitation for all patients suffering a cardiac event.Firstly a pre audit will be undertaken of existing services that will provide base line data fromwhich to evaluate the Heart Guide Aotearoa project.

Stage One

Stage one will consist of a three month pre implementation audit, involving all patientssuffering from a cardiac event (Troponin positive) within a given pilot site whether or not theyattend cardiac rehabilitation.

Patients who are identified as Troponin or CKMB positive will be approached by PhaseI cardiac rehabilitation nurse and invited, as part of their Phase I rehabilitation, to attendPhase II cardiac rehabilitation. With their consent, questionnaires and data will be collect forthe purpose of the audit on discharge from hospital, completion of the rehabilitation program.

Stage Two

Stage two will last for six months and will involve all patients suffering from a cardiacevent (Troponin positive) within a given pilot site. These patients will be approached by thePhase I cardiac rehabilitation facilitator and offered the choice of either home based cardiacrehabilitation or traditional secondary care based cardiac rehabilitation.

Patients choosing the home-based ‘Heart Guide Aotearoa’ option will become theStage Two cohort for evaluation.

It is hoped that larger pilot sites will achieve more than one hundred patients over thissix month period.

Overview of Audit Evaluation

Stage One Stage TwoPre Implementation Audit Implementation Audit

Initial Inclusion Initial Inclusion



All patients with positive troponin All patients

Phase IInvited to attend Phase 2 rehabprogramme

Phase IOffered either, present Phase 2 rehabprogramme or Heart Guide Aotearoa

Which patients are AuditedAudit evaluation of all troponin positivepatients

Which patients are AuditedAudit only Heart Guide Aotearoaparticipants

6.0 Financial AnalysisPresently, Southland DHB provides predominantly hospital-based cardiac

rehabilitation. As a result, at least 65% of acute myocardial infarction (AMI) survivors fail togain the benefits of rehabilitation (Doolan-Noble, 2001). A significant opportunity exists forSDHB to realise these benefits by providing a home-based rehabilitation program. The 65%of AMI survivors who currently miss out would have an accessible rehabilitation option madeavailable to them.

International research has shown cardiac rehabilitation to be a cost-effectiveintervention after acute myocardial infarction (AMI). Meta-analysis has shown rehabilitationto be more cost-effective than thrombolytic therapy, coronary bypass surgery, andcholesterol lowering drugs, though less cost-effective than smoking cessation programs(Ades, Pashkow, Nestor, 1997). Furthermore, in the United States calculations of thesavings from averted hospital readmissions revealed a cost-effectiveness value of 2,130$/YLS in the late 1980s, projected to a value of 4,950 $/YLS in 1995 (Ades, Pashkow,Nestor, 1997).

In addition to the comparative financial benefits, rehabilitation has been shown toimprove exercise tolerance, reduce blood pressure, increase medication compliance, reducedepression, and reduce the number of unnecessary GP visits in the first year after AMI(Lewin, 1992).

6.1 InvestmentThe investment required to provide a home-based rehabilitation resource, the Heart

Guide Aotearoa, has been calculated below. Expenditure may be divided into setup costsand maintenance costs. Initial setup costs include one-off items such as a project manager,auditor, and computer hardware and software.

6.2 Southland DHB and the Heart Guide Aotearoa ProgramThis proposal has been complied to provide information with regard to the cost of

setup, implementation, and ongoing costs for running the home based cardiac rehabilitation.



This proposal has been assisted by projections from a proposal designed for SDHB andfrom information available through the East Riding and Hull Cardiac Rehabilitation Programwebsite. Costs are based on the enrolment and maintenance of 200 patients per annumwithin home based rehabilitation. All costs are based on an average of four patients perweek.

The components of the program that require funds are staffing, resources in the form ofthe HGA booklet and overheads. The first year incurs extra costs associated with the startup of the project in the form of training, IT and computer equipment. The overall costpredications for the project are listed in Table 1.

Patient ContactThe costs related to patient contact can be divided into two main sections. These are

explained here.

Initially a cardiac rehabilitation nurse will introduce patients to the concept of HGAwhile in hospital. This person will act as a liaison and activate the process of follow-up for thepatient within the community. This initial interview will be the same as the present Phase Iprogramme, they will offer the Heart Guide Aotearoa and forward the patient details to theHGA facilitator.

Following discharge, patients are contacted four times within a six-week period tomonitor their progress through the HGA. This contact is either through face-to-face contactor by phone. The schedule and time allotment for these appointments are as follow:

• Visit 1 - person to person within 7-10 days post discharge - one hour (give the patientthe manual and walk them through the overview of programme)

• Visit 2 - by phone 2 weeks post-discharge, 10 minutes• Visit 3 - by phone 4 weeks post-discharge, 10 minutes• Visit four person to person 6 weeks post-discharge, one hour• Travel time- 1hour 20 minutes total• Data entry per individual patient - one hour (includes one year assessment)

This provides a time allowance of 3.4 hours, which when rounded up to a four hourallowance would require a maximum 16 hour time commitment per patient over the durationof their enrolment in the program. On a weekly basis this would equate to a timecommitment of 14 hours 40 minutes, this allows a weekly patient load of four new patients,four final visits to existing patients, and eight phone calls along with travel time to theappointments. In the cost prediction 0.5 FTE equivalent has been assigned to this task.Although a larger FTE than required this allows for time to be provided for administration anddata collection for one-year assessments.

For Maori, the time allowed for visits may differ to accommodate whanau inclusion andinvolvement in the rehabilitation process.



One hour has been allowed for the collection, completion, and entry of data into anaudit tool, which will be analysed at the end of the pilot.

Overall costThis cost analysis is based on the involvement of five pilot sites with costs for the

project coordinator and researcher being shared equally between these sites. The costsrelate to the first three years and include implementation and continuation costs.



Table 1. Cost projections over start-up and maintenance stages. Year 1 (Start-up and Pilot Year 1) Per Unit Units Cost Total

Team Community Facilitator (0.5 FTE) 45000 0.5 22500 Facilitator Training course 395 1 395 Project manager (1 FTE)8 60000 0.2 12000

Auditor (0.2 shared by 5 Pilot sites) 60000 2400 Hospital Liaison nurse (0.1 FTE) 45000 0.1 4500 41795

Resources Paper manual 30 200 6000 Cost of 2 Tapes 5 200 1000 7000

Overhead Car 14000 1 14000 Phone 3000 1 3000 Audit software (shared) 20000 0.2 4000 Computer 5000 1 5000 26000

Total

Expenses $ 74,795

Year 2 (Pilot Year 2) Per Unit Units Cost Total Team Community Facilitator (0.5 FTE) 45000 0.5 22500 Project manager (1 FTE) 60000 0.2 12000

Auditor (0.2 shared by 5 Pilot sites) 60000 0.04 2400 Hospital Liaison nurse (0.1 FTE) 45000 0.1 4500 41000

Resources Paper manual 30 200 6000 Cost of 2 Tapes 5 200 1000 7000 Overhead Car 14000 1 14000 Phone 3000 1 3000 17000

Total

Expenses $ 65,400



Table 1 (contd.). Cost projections over start-up and maintenance stages.

Year 3(Ongoing Maintenance Cost) Per Unit Units Cost Total Team Community Facilitator (0.5 FTE) 45000 1 22500 Facilitator Training course 395 1 395 Hospital Liaison nurse (0.1 FTE) 45000 0.1 4500 27395

Resources Paper manual 30 200 6000 Cost of 2 Tapes 5 200 1000 7000 Overhead Car 14000 1 14000 Phone 3000 1 3000 17000

Total

Expenses $ 51,395

Potential areas for cost increase:• Training of community facilitator. This projection is based on one facilitator being

trained who will continue with the project to completion of the one year audit.Training costs relate to time out of work for the 2-day training period.

• Type and level of facilitator used and related salary. Salary prediction does not fullyaddress potential salary negotiations currently underway with NZNO and DHBNZ.The DHB will assign the type and scale of salary to the position that has beendevised for their program. Two models suggested to date are, secondary care nursefacilitator with home visits and patient contact, or primary/ practice nurse facilitatorfollow-up.

6.3 Investment ReturnInternational research has revealed a substantial reduction in the rate of hospital

readmissions during the first year post-AMI in those who have taken part in a formalrehabilitation program. Typically, a readmission rate of approximately 50% can be expectedfor those who do not take part in rehabilitation (, Robertson, 2003; Tavazzi, 1999; Bell,2004). In contrast, a rate of approximately 25% has been observed in patients who take partin rehabilitation (Tavazzi, 1999; Bell, 2004). Consequently, a home based program has thepotential to reduce hospital readmission rates in the SDHB.



In summary, the benefits that would accrue to SDHB with the implementation of ahome-based rehabilitation program would include:

• A reduction in the number of hospital readmissions after AMI (reduction fromapproximately 50% to 25% of AMI survivors)

• A reduction in the number of Emergency Department presentations each year throughaverted readmissions (The cost of an admission through the emergency departmentis $679)

• Increased hospital bed-days saved through averted readmissions (the daily cost of a wardbed is $213 with an average length of stay of 5 days during readmission after AMI)

• Reduced demand on psychiatric and counselling services through decreased incidence ofpost-AMI depression and anxiety

• Reduction in the number of GP consultations sought by post-AMI patients

• Increased patient compliance with medications

• Improved population measures among AMI survivors including:o Decreased cigarette smokingo Increased exercise toleranceo Improved blood pressure

• With the Heart Guide Aotearoa resource engaging the entire family, lifestyle benefits arepossible for all family members. These lifestyle gains have potential savings forSDHB in future years.

6.4 ConclusionA home based rehabilitation resource, the Heart Guide Aotearoa holds many potential

benefits for SDHB and the people it cares for. These benefits can be measured financiallyand at a population level, and would be attained through increasing participation in cardiacrehabilitation. The home-based program Heart Guide Aotearoa is a resource which couldbring about a significant increase in participation for the groups which need it the most.



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Appendix A

Demographics (ethnic group by patient self completed questionnaire, as recorded for UK national census)Name: NHS Number: Prog. Name:Date of Birth: Postcode: Date of Death (if known):Gender: Not Known Male Female Unspecified Mortality: alive

deceased Marital Status: Single Married Permanent partnership Divorced Widowed

Unknown White (British) White (Irish) White (other) Mixed white/black Caribbean Mixedwhite/black AfricanMixed white/Asian Mixed other Indian Pakistani Bangladeshi Other Asian Black Caribbean Black African Black other Chinese Other Ethnic Group Not stated Initial Event (most recent event leading to referral to rehabilitation, dates, reasons for not attending programme)Myocardial Infarction Acute Coronary Syndrome Bypass Surgery Angioplasty CardiacArrestAngina Other Surgery Heart failure Pacemaker ICDCongenital Heart Transplant LV Assist Device Other UnknownDate of Initiating Event: Date Referred: Date Invited to Join:Agreed to Rehab Prog: Yes No Date Rehab Started: Date Completed:Patient not interested/refused Ongoing investigation Too far to travel Physical incapacity

Returned to workLocal exclusion criteria Language Barrier Holidaymaker Mental incapacity NotransportDied Not referred Other UnknownPrevious Events (any other acute events prior to the current reason for attending)Myocardial Infarction Acute Coronary Syndrome Bypass Surgery Angioplasty CardiacArrestAngina Other Surgery Heart failure Pacemaker ICDCongenital Heart Transplant LV Assist Device Other UnknownComorbidity (from case notes or patient completed questionnaire)Angina Arthritis (osteoarthritis) Cancer Diabetes Rheumatism (rheumatoidarthritis) Stroke Osteoporosis Chronic bronchitis Emphysema Asthma AIDS Claudication Chronic Back Problems Other Comorbid Complaint Admin. (assessment number 1 = pre rehab, 2 = 12 weeks after starting rehab, 3= 12 months after starting)Assessment Date: Assessment Number:Rehabilitation Type: Home based Hospital based Community based

Other Risk Assessment: Low Moderate High Rehab Programme Completed: No Yes

Partially Unknown

Percentage Completed: 0% 1-25% 26-50% 51-75% 76-99% 100%

Did not attend – unknown reason Returned to work Left this area Achieved aims Planned/emergency intervention Too ill Died Other

Unknown Menu / Sessions Attended / Onward Referral (record of the elements of rehab patient experienced, 50% attendance required toqualify)Group exercise classes Individual exercise programme Home exercise planLifestyle education – written Lifestyle education – talks/video Dietary – group classDietary - individual Relaxation training Psychological – group talkPsychological – individual counsellor Individual clinical psychology OT groups sessionsOT individual referral Vocational assessment Heart manualPapworth manual Angina plan Other home based programmeHome visits Other



Onward referral Phase 4 community exercise Primary care CHD clinicnurseGeneral Practitioner – medical treat Medical specialty – medical treat Patient support groupSmoking clinic Social Services Sexual problemsCommunity programme Voluntary body NoExaminations & Tests (as per protocol in your centre)Weight: kg Height:

cmBlood Pressure: / mm Hg Has patient smoked in last 4 weeks: Yes No Cholesterol: Total: HDL: LDL: Ratio: Triglycerides:Drugs (case record or patient self completion questionnaire)Aspirin or other antiplatelet agent ACE inhibitor Beta Blocker Statin

Psychological (HAD) & Physical Activity (Hospital Anxiety & Depression Scale, Modified brief leisure time questionnaire, NSFquestion)Anxiety Score: Depression Score: 1a. Vigourous: 1b. Moderate: 1c.

Mild2a. Often 2b. Sometimes 2c. Never/Rarely Physical Activity – 30 min duration 5 times a week: Yes

No

Qualify of Life (Dartmouth COOP charts and UK national Census data for economic activity )

Physical Fitness: Feelings: Daily Activities:

Social Activities: Pain: Change in Health:

Overall Health: Social Support: Quality of Life:

Employed full-time Employed part-time Self-employed full-time Self-employed part-timeUnemployed looking for work Gov. training course Looking after family/home RetiredPermanently sick/disabled Temporarily sick or injured Student Other reasons



Appendix 7

Cardiovascular Disease Morbidity Summary (2000-2004)

A data-set containing 4628 admissions with either a primary or secondary CardiovascularDisease (CDV) diagnosis to Southland Hospital between the 1 January 2000 and 31 August2004 was analysed. CVD admissions were defined using ICD10 coding for the subheadings Angina, Myocardial Infarction, Heart Failure, CVA and Transient IschaemicAttack. It is imperative to note that the intention of this appendix is to paint a picture or toget an indication of CVD secondary care and the associated admissions for the Southlandregion. It is not a comprehensive CVD dataset as it does not contain details about patientsadmitted to either Gore Hospital or Lakes District Hospital nor those managed by GeneralPractitioners for CVD conditions.

A. Patient Characteristics i. GenderThe total number of patients admitted during this period was 2695. Of these 1416 (52.5%)were males and the remaining 1279 (47.5%) were females. The majority of these patientspatients (69.6%) were found to have only one admission to hospital (see section B.i below)therefore details shown in this section, Patient Characteristics utilises data from their first oronly admission during the 44 month period that this information was captured from.

ii. AgeThe age of patients at their first admission during this time was very broad, ranging fromnewly born infants through elderly patients. The average age of individuals at the time oftheir first admission was 70.0 years (sd 13.7yrs); for males it was 67.8 years and 72.6 yearsfor females. Standard deviations were consistent with that shown in the total group. Thegraphs below shows ages against numbers for firstly the total group (n=2695) the total andsecondly for each sex.

These graphs show that there is a sharp increase in slope for at 40 and this is steeper formales than females and than there is a slight delay in onset of disease diagnosis forfemales showing a small shift in the female curve to the right for females. This incidencerate increases steadily for both sexes until the age of 80 where it drops dramatically formales and for females tapers slowly off until the age of 90 until it dramatically decreases.This can be explained by females outliving their male counterparts and for the prevalencerate for all CVD conditions to be higher for males.

age bands

>90 years80-89 years

70-79 years60-69 years



5-19 years<5 years

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age bands

>90 years80-89 years




5-19 years<5 years

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SEX

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iii. EthnicityEthnicity was also recorded on admission and these details have been summarised into 6Categories.

TOTAL MALE FEMALE

Frequency Percent Frequency Percent Frequency Percent

NZ European 2237 83.0 1146 80.9 1091 85.3Māori 115 4.3 69 4.9 46 3.6Pacific 18 0.7 11 0.8 7 0.5Asian 8 0.3 6 0.4 2 0.2Other European 244 9.1 143 10.1 101 7.9Other / Not Stated 73 2.7 41 2.9 32 2.5TOTAL N=2695 100 1416 100 1279 100

iv. LocalityLocality of patients has been described in two ways. Firstly by Territorial Local Authority(TLA) and secondly by Primary Health Organisation (PHO) catchment region. The secondof these is not as accurate and a couple of examples follow. Areas such as Dipton do notneatly fall into one PHO region, individuals may choose to access primary care from eitherLumsdem or Winton as there is no local GP. Both of the alternative town’s GPs areassociated with two different PHOs. Furthermore individuals living in Winton but working inInvercargill may again choose to access Invercargill clinics rather than their local clinicwhich again is associated with a neighboring PHO. Details on how locations weredistributed into PHO area’s are available on request. Figures show that there is a highermorbidity rate for those living in the ICC boundary and lower morbidity rates for the ruralTA’s as compared to the mapped population.

TOTAL MALE FEMALE

Frequency Percent Regionalpopulationpercent3

Frequency Percent Frequency Percent

ICC 1625 60.3 48.2 823 58.1 802 62.7SDC 480 17.8 27.8 264 18.6 216 16.9QLDC 161 6.0 12 90 6.4 71 5.6GDC 218 8.1 12 111 7.8 107 8.4Sub total 2484 92.2 100 1288 90.9 1196 93.6

Otago 54 2.0 N/A 28 2.0 26 2.0Other SthIsland

59 2.2 N/A 38 2.7 21 1.6

Nth Is +Intl.

98 3.6 N/A 62 4.4 36 2.8

TOTAL 2695 100 N/A 1416 100 1279 100

3 The projected population for Southland DHB at 30 June 2004 is 107, 735 people (Statistics New Zealandreproduced by Ministry of Health 2004) and these percentage outline are proportionate to the 4 TLA within thisboundary.



TOTAL MALE FEMALE


Invercargill PHO 1634 65.8 826 64.1 808 67.6Rural Sthland PHO 382 15.4 212 16.5 170 14.2Wakatipu PHO 161 6.5 90 7.0 71 5.9Eastern & Northern 307 12.4 160 12.4 147 12.3TOTAL 2484 100 1288 100 1196 100



B. Admissions i. Frequency

Some patients were admitted on multiple occasions during this 44-month period and thetable below describes these findings. The table is divided into three sections:

• those admitted with a Primary diagnosis of CVD (some of these patients may alsohave a secondary diagnosis of a CVD nature) and

• those admitted for a non-CVD condition such as a broken hip who had a secondarydiagnosis of CVD also received CVD management and

• a combined tally.A)

Primary diagnosis

(CVD)

B)

Primary diagnosis

(Non CVD)

TOTAL

(A+B)


1 admission 1744 73.5 131 40.7 1875 69.62-3 admissions 524 22.1 137 42.5 661 24.54-5 admissions 66 2.8 39 12.1 105 3.96-9 admissions 32 1.3 10 3.1 42 1.6≥10 admissions 7 0.3 5 1.6 12 0.4TOTAL N=2373 100 N=322 100 N=2695 100

The table shows that the majority of patients (≈ 95%; 3:1) were admitted either once or 2-3times with a CVD primary diagnosis or the combined total. Whereas for patients admittedwith a non-CVD primary diagnosis, there was an equal distribution between those admittedonce or 2-3 occasions with a lesser proportion of patients (83%) admitted between 1-3times.

ii. Length of stayA)

Primary diagnosis

(CVD)

B)

Primary diagnosis

(Non CVD)

TOTAL

(A+B)


<1 day 203 8.6 12 3.7 215 8.01-3 days 1058 44.6 99 30.7 1157 4294-10 days 974 41.0 147 45.7 1121 41.611-30 days 136 5.7 54 16.8 190 7.11-3 months inclusive 2 0.1 8 2.5 10 0.4≥4 months 0 0 2 0.6 2 0TOTAL N=2373 100 N=322 100 N=2695 100

The table shows that the majority of patients are admitted for between

N=2695; mean=4.8days; sd=10.4; min=0 ; max=474

N=2373; mean=4.1days; sd=3.9; min=0 ; max=45



iii. Disease DiagnosisThe table below describes crudely the proportion of patients admitted to Southland underthe 5 major disease categories.

TOTAL PRIMARY DIAGNOSIS SECONDARY DIAGNOSIS


ANGINA 1418 30.6 1227 34.8 191 17.3MI 1338 28.9 1132 32.1 206 18.7HF 1423 30.7 804 22.8 619 56.1CVA 254 5.5 190 5.4 64 5.8TIA 195 4.2 171 4.9 24 2.2TOTAL 4628 100.0 3524 100 1104 100

For example a lady was admitted for 8 days, primary diagnosis Myocardial Infarction;secondary diagnosis Heart Failure. The percent of patients diagnosed with each conditionis very similar when comparing the primary diagnosis with that of the total, with theexception of Heart Failure. Those patients recorded with a secondary CVD diagnosis mayor may not have a primary diagnosis of a CVD nature. After further investigation, findingsshow that 32% (n=353) of the 1104 with a secondary diagnosis of CVD also had a primarydiagnosis of CVD. The remaining 68% (n=751) had a non-CVD primary diagnosis. Thisdataset can be re-worked selected each of the 5 identified diagnosis and information foreach characteristic identified if required.

The graph below shows morbidity disease trend percentage by year. Data included in thisgraph includes both primary and secondary diagnosis data and therefore should be treatedwith some caution. Actual numbers are shown in the table above. It is worthy to note thatHeart Failure diagnosis has a higher incidence as a secondary diagnosis than a primarydiagnosis which is in contract to the other 4 disease states described. 2004 data is notshown in the graph below as the year is incomplete.

a strategy for tackling cardiovascular disease in southland · 2018-11-08 · a strategy for...

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