Cardiac Services at North Shore Hospital are Safe
11 April 2000
Review Confirms Cardiac Services at North Shore Hospital are Safe and Appropriate
A review of cardiology services at North Shore Hospital has shown that patients in north-west Auckland are gaining access to cardiac services and on-going referral in an appropriate clinical manner.
Dunedin cardiologist, Dr Gerry Wilkins was commissioned by the Ministry of Health and Waitemata Health to investigate cardiology services at North Shore hospital, following the death of Mr Alan McKenzie who was a patient at North Shore hospital. The circumstances of his death was the subject of recent report on the 20/20 television programme which raised serious concerns about cardiology services at North Shore.
The Ministry of Health and Waitemata Health express their sympathies to the family.
Chief Advisor, Medical, Dr Colin Feek says the review has shown quite clearly that cardiac services provided at North Shore are appropriate and safe considering North Shore Hospital is a secondary provider.
This means that North Shore Hospital provides immediate care for heart patients in its region. It does not provide a tertiary service such as coronary surgery and angioplasty. These services are provided at Greenlane, Waikato, Wellington, and the South Island Cardiac service.
"Whilst we don't want to diminish what has happened, we believe that the public of north-west Auckland can have absolute confidence in the cardiac services provided by North Shore Hospital."
"However, this does not mean that the patients interviewed by media do not have complaints. Their concerns should be dealt with by the Health and Disability Commissioner."
"Patients and the public have a right to expect the highest quality of service at the Hospital, however the public need to understand that Cardiac surgery is important to relieve symptoms but unfortunately does not always extend life. When measured on a long term basis (over 12 years) surgery compared to medical treatment can only extend life by 2 - 19 months on average."
He said the new booking system for cardiac surgery details the estimated benefit in relation to the clinical priority score.
Dr Feek said it is difficult diagnosing patients with heart disease.
"Patients presenting with pain in the chest account for 20-30 percent of emergency hospital admissions. Yet fewer than half will have a final diagnosis of a heart attack or unstable angina."
He said a range of blood and cardiogram tests are used to try and determine who has heart disease. The treadmill exercise test is widely internationally as well as in New Zealand to select patients for coronary angiography after a myocardial infarction.
"Unfortunately this test is far from perfect. It has limitations and may miss up to 20-50 percent of the patients with a problem with their coronary arteries and also diagnose patients who don't have problems in their coronary arteries in up to 12 percent of the cases."
Coronary angiography (x-ray) of the coronary arteries in the heart is employed to detect blockages that may be reversible by angioplasty or coronary artery surgery. This test is only of use if angioplasty or surgery is being considered. This depends on the severity of the symptoms.
"Internationally all doctors have a problems in selecting patients for further surgery and the process is by no means foolproof. Nevertheless, this is the best that current medicine can provide."
Mr McKenzie case will be reviewed by the Auckland coroner, Mate Frankovich. Both the Health and Disability commissioner and the Auckland coroner will receive copies of this report. It is not the Ministry role to comment on individual cases.
Attached is the full report by Dr Wilkins along with an article from the Lancet detailing current evidence of the benefits of cardiac surgery. (The Lancet stories haven't been attached, but if you would like a copy, please call)
For more information: Internet address: http://www.moh.govt.nz/media.html
The inquiry by Dr Gerry Wilkins began on March 30 and was completed by April 7.
The findings were:
· Clinical practice appears to be similar with other public hospitals. · There is an acceptably low death rate (7.2 %) for patients suffering myocardial infarctions (heart attack) in the coronary care unit · There is a moderate rate (25%) of in hospital coronary angiography for patients with unstable angina admitted to coronary care unit. · There is a high level of non-invasive diagnostic test utilisation, suggesting high level of clinical activity within the cardiology service. · There is a high level of patient throughput by the two members of the cardiology staff. · Death rates for coronary artery disease are somewhat lower in the North Shore region (164 / 100,000) compared to the national rate of 212 per 100,000. · Utilisation of angiography at North Shore Hospital is 127 /100,000 and remarkably comparable to the average of 123 /100,000 at other secondary hospitals. · Utilisation of angiography at tertiary centres is higher (mean 182 / 100,000) · Utilisation of coronary artery surgery at North Shore Hospital is 48.5 / 100,000 and is considerable higher than the mean for other secondary hospitals at 35.3 / 100,000. The North Shore rate is more in line for rates of tertiary institutions in New Zealand (49 / 100,000)
The terms of reference for the inquiry were to determine whether:
· clinical decisions concerning diagnosis and treatment of patients with cardiac disease at North Shore hospital are consistent with other secondary hospitals in New Zealand; and whether · referral patterns and rates for coronary angiography and coronary artery by-pass surgery at North Shore Hospital are consistent with other secondary hospitals in New Zealand.
FULL COPY OF THE REPORT
Review of Cardiology Services at North Shore Hospital Gerard T Wilkins, Consultant Cardiologist, Senior Lecturer in Medicine, CPG Leader Dunedin Hospital, University of Otago Summary:
Terms of reference (in brief):
Is clinical decision making at North Shore Hospital consistent with other secondary hospitals? Are referral rates for angiography and coronary artery surgery consistent with other secondary hospitals?
North Shore Hospital is a secondary care hospital providing clinical cardiology services to a potential catchment of 390,000 people Referral patterns have been substantially altered by population growth and Health Funding Authority directives
Clinical practice appears to be consistent with other similar hospitals There is an acceptably low death rate (7.2%) for patients suffering myocardial infarction in the coronary care unit There is a moderate rate (25%) of in-hospital coronary angiography for patients with unstable angina admitted to the coronary care unit. There is a high level non-invasive diagnostic test utilisation, suggesting high levels of clinical activity within the cardiology service. There is a high level of patient throughput by the two members of the cardiology staff Death rates for coronary artery disease are somewhat lower in the North Shore region (164/100,000) compared to the national rate of 212/100,000. Utilisation of angiography at North Shore Hospital is 127/100,000 and remarkably comparable to the average of 123/100,000 at other secondary hospitals Utilisation of angiography at tertiary centres is higher (mean 182/100,000) Utilisation of coronary artery surgery at North Shore Hospital is 48.5/100,000 and is considerably higher than the mean for other secondary hospitals at 35.3/100,000. The North Shore rate is more in line with rates for tertiary institutions in New Zealand (49/100,000)
Cardiology service development is dependent upon staff recruitment and retention, which in-turn is related to the nature of the professional cardiology career the hospital offers. The definition of cardiac catheterisation facilities as a tertiary service requires review, in the context of large secondary hospital.
Review of Cardiology Services at North Shore Hospital
Gerard T Wilkins, Consultant Cardiologist, Senior Lecturer in Medicine, CPG Leader Dunedin Hospital, University of Otago.
This review was requested by Dr Feek of the Ministry of Health following publicity alleging inappropriate management of a cardiology patient at North Shore Hospital. It is not the brief of this short enquiry to examine that case, as this issue is ongoing, but rather to report on possible systemic issues concerning the cardiology service at North Shore Hospital. The terms of reference were to determine whether:
clinical decisions made concerning diagnosis and treatment of patients with cardiac disease at North Shore Hospital are consistent with other secondary hospitals in New Zealand and whether referral patterns and rates for coronary angiography and coronary artery bypass surgery at North Shore Hospital are consistent with other secondary hospitals in New Zealand.
This document is prepared following a visit to North Shore Hospital, interviews with related medical, administrative, nursing and technical staff, review of clinical activity markers, numbers of diagnostic tests performed and comparisons to the National Health data set for comparison data.
North Shore Hospital is the major Hospital of the Waitemata Health region and acts as a secondary hospital serving a large population. Cardiology services are provided for a region with a population of around 390,000. When North Shore Hospital was opened in 1984 cardiology services and the coronary care unit were established with three physician/cardiologists providing non-invasive diagnostic services and patient management. The hospital served a drainage area of 170,000 and there was direct access to Greenlane Hospital's specialty cardiology unit and coronary care unit for patients from the North Shore area.
By 1995 the drainage area had significantly increased in size to an estimated 250,000 with no increase in medical staff. However, a vocationally trained cardiologist was recruited and appointed in 1998.
About this time a Health Funding Authority directive to General Practitioner's in the area required them to refer patients with cardiology problems to their regional hospital (North Shore Hospital) resulting in a further increase in the drainage area served to around 390,000 effectively taking much of Greenlane Hospitals cardiology catchment area into North Shore Hospital. These changes have resulted in a further major change in workload. Clinical and administrative staff sought to increase the medical manpower available. Appropriately trained cardiology specialists have not been easy to recruit, however recently two further cardiologists have been appointed but presently have not commenced work.
Clinical Decision Making
The model of care for cardiology patients that has developed at North Shore Hospital is one common to many secondary care hospitals in New Zealand. Patients are admitted under the general medical team of the day or if there is appropriate need, to the coronary care unit where they are under the immediate care of a cardiologist. At discharge from the coronary care unit they return to the care of a general physician team until the time of discharge. Appropriate non-invasive cardiac testing is performed on patients on site at North Shore Hospital and results used in management decisions in a standard manner.
In the 98-99 year there were 450 confirmed infarcts and 682 patients admitted with chest pain (total 1132 admissions/year) managed in the CCU. Analysis of the data for the first 8 months of the current year to date shows a similar level of activity. In this period there have been 236 patients with confirmed myocardial infarction. Management within the CCU has resulted in an acceptably low mortality rate of 7.2% ( 17 deaths with an advanced average age). Through the same eight month period 121 patients were managed in the CCU with unstable angina resulting in a transfer rate of over 25% to another hospital (the vast majority presumed to be for coronary angiography at Greenlane Hospital). This would suggest a relatively high rate of invasive investigation as part of clinical management when compared to other secondary hospitals within New Zealand.
The utilisation of non-invasive testing within the hospital also seems to be relatively high. These tests (exercise testing and echocardiography) are generally used to clarify a cardiology diagnosis and stratify risk, and thus guiding management. In this context they can be used as an index of clinical activity. For the most recent eight month period 1537 exercise tests (yearly projected 2300), and 1434 echocardiograms (yearly projected 2150) have been performed at North Shore Hospital. For comparison, Middlemore Hospital, a similarly equipped secondary care hospital in the Auckland region performed 1500 exercise tests and 1832 echocardiograms for the year ending February 2000. Although both Hospitals are clearly performing high numbers of tests, comparisons suggest approximately 25% more non-invasive testing is being performed at North Shore Hospital and that levels of clinical activity and diagnostic testing are at least comparable to other secondary care hospitals.
A review of cardiology outpatient activity also confirms large numbers of patients are seen by the two cardiology staff members. Over the last six months the two senior medical staff combined have averaged 165 new patient consultations/month and 202 follow-up consultations/month. At last review there were about 175 patients waiting for appointments, a number comparable to other New Zealand outpatient services in cardiology.
This information suggests that clinical decision making and treatment at North Shore Hospital is consistent with other similar hospitals. The high levels of clinical activity achieved by two dedicated senior medical staff members confirms that there is a need to expand the number of cardiologists to better cope with the demand. As noted two further appointments have been made.
Referral Rates for Coronary Angiography and Coronary Artery Surgery:
A review of referral rates for coronary angiography and coronary artery surgery was undertaken comparing rates for Waitemata Health (North Shore Hospital) to other New Zealand regional hospitals. In general, differences in referral rates could reflect difficulties with access or provision of these services, or different standards of clinical practice. In comparison with other similar western countries, New Zealand has relatively low rates of coronary angiography and coronary artery surgery. It is generally agreed that a move towards higher levels of invasive investigation and management reflects best practice trends for New Zealand. Invasive management strategies (particularly coronary surgery) have consistently been shown to provide superior clinical and natural history outcomes for appropriately selected patients with ischaemic heart disease.
Information from the National Health Data Set allows these comparisons. Appendix A shows utilisation rates for angiography, coronary artery surgery and death rates (per 100,000) for coronary artery disease collated according to hospital health service regions in New Zealand for the 1996 year. Such comparisons should be viewed in the context of regional coronary heart disease mortality rates. Note a relatively low death rate from coronary artery disease in the Waitemata Health area (164/100,000) compared to the National figure (212). This lower rate of coronary artery disease mortality may reflect a younger population structure, higher socio-economic class or other factors.
Utilisation rates for coronary angiography suggest Waitemata Health is comparable with average rates in New Zealand. Rates for angiography at Waitemata Health are 127/100,000 compared to the national average of 157. The five tertiary care cardiac centres with on-site angiography (Auckland, Waikato, Wellington, Christchurch and Dunedin) have a higher angiography rate on average (182) but rates range enormously from 97 (Wellington) to 280 (Christchurch).
The North Shore Hospital rate (127/100,000) is remarkably comparable to the average rate for other secondary hospitals in New Zealand (123). The rates for the utilisation of angiography at North Shore Hospital are therefore consistent with other regions and hospitals in New Zealand.
A similar finding is noted for coronary artery surgery utilisation. Waitemata rates are 48.5/100,000 compared to a national rate of 42.2. Tertiary centres (in 1996 Auckland, Waikato, Wellington, Dunedin) averaged 49, but once again rates ranged enormously from a low of 23 in Wellington to 65 in Dunedin. The Waitemata rate for coronary surgery (48.5) is highly comparable with other Auckland regions (Auckland 53.5, South Auckland 43.7) and is considerably higher than other secondary hospitals in New Zealand (35.3). Very low rates of coronary surgery utilisation are seen in several regions (Tairawhiti 9, Wanganui 17.7, Mid Central 18, and also the tertiary centre of Wellington (Capital Coast 23).
In these data, the most current available to me, rates of coronary artery surgery for the North Shore region are highly favourable compared to other secondary care hospitals and apparently more in line with average tertiary hospital utilisation rates.
There is no evidence from these data of a systematic under-utilisation of invasive cardiac management strategies.
The review and analysis of these data strongly suggests that clinical cardiology practice at North Shore Hospital is comparable to standard practice in New Zealand. There are, however, problems in meeting the growing demand for cardiology services (as a consequence of a growing population and increased referral area) and changing standards of practice in this field. Criticism levelled at the Hospital has focused on the availability of specialist cardiologists and the use of invasive diagnostic tests. North Shore Hospital faces a dilemma in the provision of such a service. Categorised as a secondary hospital, despite its large catchment, it has developed its cardiology service according to the usual secondary hospital model of a strong general medical base and relatively few cardiologists. Invasive diagnostic studies (considered tertiary level care) have always been centralised for the Auckland region at Greenlane Hospital. Waiting lists are managed in common for the greater Auckland area and patient acce ss is generally ranked as satisfactory and comparable to other regions in New Zealand. Centralisation of services likely offers enhanced efficiency and expertise, especially when procedural numbers are low, however, as procedural numbers increase some of these advantages may be less compelling. As a consequence of a centralised invasive service, there are flow-on effects to North Shore (and other) hospitals. Cardiology practice at North Shore Hospital without the full range of diagnostic and therapeutic options on-site, is therefore more limited in the professional sense. It has therefore been difficult to recruit and retain cardiology staff who view such jobs as less desirable and professionally limited. The availability of invasive diagnostic facilities would greatly alter that perception.
The view that cardiac catheterisation facilities should only be available in tertiary level hospitals may require review as such tests become increasingly common-place and form the core activity of cardiology practice in the area of ischaemic heart disease management. It should be noted that a number of smaller hospitals have developed cardiac catheterisation facilities (Tauranga, Hastings and Nelson). The view that Publicly funded heart catheterisation facilities should remain centralised for a population of over 1.2 million may be difficult to sustain.