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| Journal of the New Zealand Medical Association,
15-February-2008, Vol 121 No 1269
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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.
How well do we achieve this goal?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!
What are the major areas of concern for CVS patient management in New Zealand?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.
ConclusionWith 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: chrise@adhb.govt.nz
References:
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