Journal of the New Zealand Medical Association, 15-February-2008, Vol 121 No 1269
Cardiovascular health in New Zealand: areas of concern and targets for improvement in 2008 and beyond
Chris J Ellis, Andrew W Hamer
Cardiovascular (CVS) disease accounts for 39% of mortality in New Zealand, the commonest cause of death.1 Ischaemic heart disease (IHD) which accounts for 22% of all deaths and cerebrovascular disease (10% of deaths) are essentially the result of an ageing process of the arterial system: atherosclerosis.
Although ‘age-standardised’ mortality has fallen, atherosclerosis still affects large numbers of younger individuals who suffer from decades of ‘life years’ lost as a result. Further, there has been more than a doubling of hospital discharges for a heart attack from 1989 to 2002/2003, indicating that a larger number of older New Zealanders have been diagnosed with IHD and have been hospitalised.2
A comprehensive strategy of prevention, treatment, and ongoing management of affected patients is clearly required to limit the effect of this epidemic.
A unique opportunity to assess how well we are doing as a nation comes from a paper by Stewart et al (http://www.nzma.org.nz/journal/121-1269/2931) published in this issue of the Journal. It uses data from the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) trial, which randomised 9014 stable IHD patients from Australia and New Zealand to either pravastatin 40 mg daily (which is approximately as potent as simvastatin [Lipex] 20 mg3) or a placebo medicine.
Overall, in the LIPID study published in 1998, there was a 25% reduction in cardiovascular (CVS) mortality over 6.1 years. The current analysis is from the extended follow up LIPID study and compares CVS risk factors, medical treatments, CVS mortality, and socioeconomic differences between our two countries.
Patients from both New Zealand and Australia, with remarkably similar baseline characteristics, were enrolled; the importance of this study is obvious as, of all countries, Australia has the closest mix of peoples, lifestyle, and diseases to New Zealand.
The findings are dramatic: there is a 35% greater chance of a New Zealander dying of CVS disease in the median follow-up period of 7.8 years, compared to an Australian. The 2784 New Zealanders were uncannily similar, although not identical, in baseline characteristics—including age, gender, risk factors (except total:HDL cholesterol ratio), and socioeconomic status—to the 5949 Australians enrolled in the study.
The two major differences seen in the studies analyses were that more Australians used ‘extra’ statin medication, outside of the trial, and that more Australian patients received revascularisation by coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI).
Other unknown factors may also be affecting these figures, but the clear implication from this important study is very clear: we are not managing heart disease as well as the Australians!
PHARMAC’s 15-year involvement in the New Zealand health care environment has been a difficult and sometimes dangerous experience for patients, although there has been a resultant, general awareness of the need to ration expensive medicines.
Access to a number of CVS medications in recent years has been delayed or remains limited. The benefits from such medications, which are generally well proven in robust clinical trials,4 are large but have often not been readily available to New Zealanders.
In terms of statin availability and use, PHARMAC’s delays in making available appropriate medications,5 has probably caused more unnecessary death and major morbidity to New Zealanders than any other of their policies.6
In the late 1990s, most New Zealand patients with heart disease simply could not access these life-saving medicines. The extra use of statins outside of the trial in Stewart et al’s study is likely to account for some of the mortality advantage for those Australian patients. The additional lost opportunity for hundreds of thousands of other New Zealanders denied access to a statin during this time has simply been ignored by PHARMAC.
From 1993 to 2007 there was a 35% increase in funding for PHARMAC.7 However, the compound inflation rate over these 14 years was 33%,8 the population grew by 17%,9 and hence per person in New Zealand, there was a 15% decrease in drug funding over these 14 years for every man, woman, and child.
New Zealand currently spends less than half of the amount that Australia spends on pharmaceuticals, per capita.10 See Figure 1.
PHARMAC’s pride in this achievement7 is misguided: spending less money on medicines may not be a good idea if the cost in patients’ health is too great. It is anomalous that expenditure is capped in this area of health care but not others. The increasing imbalance has inevitably led to cost-shifting and set us aside from most other developed countries. The effects on patient risk, health outcomes, and also the medical workforce have been negative.11
The importance of cost containment and achieving best value is well understood and the New Zealand taxpayer needs to rely on such an organisation to achieve this. However, there is wide agreement across the sector that the current model and funding policy should be reviewed for the future benefit of New Zealand. What is now desperately needed is a resetting of funding for pharmaceuticals in New Zealand, to allow a rapid change from one of rationing to one of facilitating access to medicines.
Figure 1. Comparison of expenditure on pharmaceuticals by New Zealand, Australia, and the United Kingdom from 1993 to 200510
There is a limited availability of cardiac surgery and percutaneous coronary intervention in New Zealand.12 However, the fact is that there are only a limited number of patients who would benefit from these life-saving and symptom-limiting procedures, each year. This is not a ‘bottomless pit’ of expense.
If resource were made available and the operations undertaken, there would be an ongoing benefit for the individuals concerned. There would also be financial savings to be made, as patients are returned to the (taxpaying) workforce, and are able to lead productive lives with their families. Further, there would also be cost savings in hospitals.
Patients currently have a prolonged wait in a hospital bed to access heart surgery at 1 of our 5 Public Cardiothoracic Centres, without which treatment they are unable to be discharged home. At an approximate cost of $2000 per day per patient for staying in a coronary care unit, if 20 patients are always waiting for 2 weeks in each region, a scandalous $40,000 daily is wasted, or $15 million dollars per year, or approximately 500 cardiac operations per year (at $30,000 per operation) per Centre, on unnecessary hospital in-patient charges.
Appropriate investment in Health, where it is needed, will result in remarkable cost efficiencies as well as improved health care. People requiring heart-preserving surgery should no longer be ignored.
Clinicians as a group, have a very real understanding of patient management structures, health costs and rationing, and societal and individual needs—and yet they are underutilised in decision-making. They spend their life in the health care environment and develop a unique understanding of this complex workplace.
The current management structure pays scant attention to this group of health professionals, instead relying on well intentioned, but transient managers, to make the majority of important decisions which control the structure, and hence outcomes of health care. That clinicians do not play a major role in the structural planning of the New Zealand health services is a key problem.
The Health Ministry must actively seek out busy clinicians, who are representative of the majority of clinicians across New Zealand, to positions of influence. These clinicians should be found by asking the doctors’ medical colleges and professional organisations, such as the Cardiac Society, to nominate such individuals.
Due to its small population New Zealand has a unique opportunity to develop a comprehensive and caring health service in CVS medicine and throughout all aspects of health care. With only 4.2 million people, it is small enough for a progressive, efficient management team to plan services.
At most, probably five regions (centred on Auckland, Hamilton, Wellington, Christchurch, and Dunedin) should efficiently and smoothly organise all CVS and other services in New Zealand. This would not, and must not, result in a ‘centralisation’ of service, but a structure with real ability to direct funding out to the regional centres, where it is clearly needed12—and also into key central services (e.g CABG operations), when needed.
Until this change occurs, we will continue to have extraordinary examples of health care waste. For example, in Auckland, which is divided into three health boards, a patient who is admitted to one hospital (e.g. Middlemore Hospital) close to where they may work, will have initial investigations in the emergency department to ensure that they are fit enough to be sent by ambulance to their ‘own’ hospital (e.g. North Shore Hospital) where they live! In the reverse direction, is another ambulance, transferring a ‘Middlemore’ patient back ‘home’.
Health inequalities. The second conclusion of the current paper reconfirms the well known fact that those in the lower socioeconomic groups suffer worse health, both CVS and in other areas. This is the crux of the matter. The challenge for New Zealand is to provide a comprehensive health service for all, because if we cannot adequately organise the health service, then the most vulnerable in our community will suffer most, a true indictment on the current state of play.
With the publication of Stewart et al’s important paper there is a unique opportunity for us to reassess our CVS health priorities. It represents a chance to change direction in the listed four key areas, whilst pursuing the already promoted and vital lifestyle campaigns.
All individuals working in CVS health care in New Zealand should refocus, following this report, and aim to improve how we use our limited health, and population resource. We have a new health minister and a new chief clinical advisor to the Health Ministry, a real chance for a new beginning.
Competing interests: None known.
Author information: Chris J Ellis, Cardiologist and Chairman of the Cardiac Society of New Zealand’s Acute Coronary Syndrome Audit Group, Green Lane Cardiovascular Services, Cardiology Department, Auckland City Hospital, Auckland; Andrew W Hamer, Cardiologist and Chairman of the Cardiac Society of New Zealand, Cardiology Department, Nelson Hospital, Nelson
Correspondence: Dr Chris Ellis, Cardiologist, Green Lane Cardiovascular Services, Cardiology Department, Auckland City Hospital, Auckland. Email: firstname.lastname@example.org
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