Call to action—the urgent need for a heart health plan in New Zealand
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Cardiovascular disease is responsible for a third of all deaths and is the leading cause of health loss in Aotearoa New Zealand. The current health system reform presents a once in a generation opportunity to address how our health system works for all. This includes addressing the gap in heart health outcomes[[1]] systematically and fairly to allow hundreds of thousands of affected New Zealanders to live longer and healthier lives.
When the Government released Te Pae Tata Interim New Zealand Health Plan 2022 it was disappointing that a clear commitment to reducing the burden of heart disease and stroke was not evident.[[2]]
In 2020, the Heart Foundation first called for a national heart health action plan. Since then, almost 30,000 New Zealanders have lost their lives to heart disease and stroke. We estimate 7,000 of those deaths were premature and avoidable.[[3]] These deaths could have been avoided through better prevention and improved and timely access to evidence-based healthcare.
The Heart Foundation is reiterating the urgent need for a national action plan for heart health, advocating for ambitious and achievable goals for better and more equitable heart health outcomes, by delivering a better heart health system. This starts with better prevention from early childhood and extends across the life course from assessing, understanding and managing heart disease risk, timely access to heart healthcare, improving survival following a heart event and planning for a sustainable skilled workforce delivering world-class care in a timely manner and where it is most needed.
In Aotearoa New Zealand there are huge and avoidable disparities in heart health outcomes. Māori, Pacific people and those living in the most deprived parts of the country are more likely to be exposed to risk factors such as smoking, and to face multiple barriers to accessing care including cost, transport, discrimination and systemic racism.[[4,5,6]] This results in under and delayed diagnosis and subsequent management and support. Urgent work is required to better understand and remove these barriers.[[7]]
Reasons for these disparities are complex, and include historical injustices, prejudice and mistrust in the health system, struggles for resources including health workforce, health literacy and geographical isolation.[[8]] In addition those regions with the greatest need for better heart healthcare are those with poorest access to healthcare, particularly delivered close to home.[[9]]
Progress on recommendations to improve heart health outcomes since 2020 has been poor. There have been some areas to celebrate including aggressive action towards a Smokefree 2025, some access to new drug treatments and the funding of a new centre of research excellence in heart health.[[10]] However, progress has been piecemeal, rather than bound by a clear and integrated strategy for achieving better outcomes.
Access to basic cardiovascular risk assessments and to cardiology services remains inconsistent and lacking for many New Zealanders. There are restrictions and limitations on access to cost-effective and evidence-based treatments, and cardiac arrest survival rates are hampered by inconsistent access to CPR and community defibrillators.[[11]]
Elements of the health system of Aotearoa New Zealand aimed at heart health are not currently working for everyone, especially for Māori, Pacific people, people living in areas of high deprivation and rural New Zealanders. About half of cardiovascular deaths in these populations are avoidable, meaning we could significantly reduce the impact of heart disease and stroke and improve health equity if our prevention and health care systems were working fairly for all.[[12]]
We have seen how ambitious targets can achieve results, in particular the substantial progress towards Smokefree 2025.[[13]]
The updated Heart Foundation white paper recommends that a national heart health action plan sets bold targets for better heart health and identifies six key areas that build on current strengths and have the potential to significantly reduce the impact of heart disease and stroke on all New Zealanders. It proposes that a national action plan has high level goals to reduce the rate of avoidable heart disease mortality and morbidity for all New Zealanders by at least 50% by 2050, and by 2040 for Māori and Pacific people.
Achieving these goals will require a life course approach with a balance between addressing outcomes for those at most immediate risk of heart disease by improving access to care and support, building a strong approach to heart disease risk screening and management, and ensuring better large-scale and sustainable outcomes longer term through effective prevention.
Our six priorities for a national heart health action plan are:
1. Reduce the risk of heart-related disease through prevention
Goal 1: reverse the declining trends in consumption of healthy food and physical activity and achieve minimal smoking for all populations by 2025.
A stronger prevention system needs to urgently address the personal and systemic financial and environmental barriers families face in accessing healthy food and undertaking regular physical activity.[[4,14]] A system where all children and families have the same access and rights to a healthy learning environment connected to their community is vital to set up young New Zealanders for heart-healthy lives.
2. Early detection and management of heart disease
Goal 2: 95% of eligible New Zealanders are risk assessed for cardiovascular disease (heart disease and stroke) and advised on appropriate risk management.
Manatū Hauora – Ministry of Health published the standard for cardiovascular disease risk assessment and management in primary care in 2018. It set out new guidelines recommending beginning cardiovascular risk assessments for men from age 45 and women from age 55. For Māori, Pacific and South Asian populations, risk assessment is recommended to start 15 years earlier than in other population groups.[[15]] Guidelines also set out standards for managing risk, and were accompanied by New Zealand’s own cardiovascular risk prediction equations for use in primary care.[[16]] Five years later, there is still no systematic approach to risk assessment, and management of cardiovascular risk.
For example, close to one in five adults have elevated blood pressure (>140/90mm Hg),[[15]] yet fewer than one in three New Zealanders with elevated blood pressure have it well controlled. This is well behind the OECD average.[[17]] Routine risk assessment, and identifying and managing those with risk—especially high blood pressure—is highly cost effective and will have an almost immediate impact on improving cardiovascular health in New Zealand.[[18]]
3. Timely access to evidence-based and effective care and support
Goal 3: reduce hospitalisations for acute cardiac presentations and stroke by 50% by 2040, with a particular focus on Māori, Pacific and South Asian populations.
People are often not able to access the heath system until forced to by an emergency, and even then delays in seeking and receiving care are common. A third of New Zealanders who had a heart attack in 2022 waited more than 2 hours to call for help.[[19]] A deterioration in timely access to angiography following an acute coronary syndrome presentation was also noted in 2022.[[20]]
There is significant regional variation in access to specialist opinion, diagnostic services including echocardiography, CT angiography, electrophysiology and invasive angiography with resultant variation in revascularisation, cardiac surgery and valve intervention.[[21]] Often these variations are inconsistent with need, with reduced access and longer wait times affecting communities at highest risk of poor heart health outcomes.
Aotearoa New Zealand is falling behind other countries with respect to access to effective evidence-based and recommended medicines. Current examples include restricted access to new diabetes drugs that improve heart health outcomes, which are currently only available to high-risk populations by special authority. SGLT-II inhibitors are a recommended foundation pillar of heart failure care in international guidelines[[22]] (Level I A) and are not currently funded for this indication in Aotearoa New Zealand. Sacubitril-Valsartan is a recommended foundation pillar for heart failure (Level I B) but is available with restricted access only.[[22,23]]
The delays in reaching care in the first place, delays in subsequent treatment and access to evidence-based care and medications are an entirely preventable failure of the health system. It requires a focus on early risk management and treatments, and on working with communities to remove the barriers to heart healthcare. Access to effective heart healthcare needs to match up with communities with the highest need, and the current situation where New Zealanders lack access to proven and cost-effective heart health medications must urgently be addressed.
4. Increase survival rates for out-of-hospital cardiac arrest
Goal 4: increase the survival rates for out-of-hospital cardiac arrest by 25% by 2030.
More than 2,300 people experienced a cardiac arrest in the community or at home in the year ending June 2022. Only one in 10 people who suffered an out-of-hospital cardiac arrest survived to hospital discharge compared to 1 in 7 in 2018.[[19]] We can reverse this trend by increasing access to life-saving CPR (cardiopulmonary resuscitation) and ensuring community defibrillators are where they are needed most, and by addressing regional and local disparities in access.[[11]] Aotearoa New Zealand should join nations like the United Kingdom, Germany, China, Norway, Sweden and the majority of states in the United States where teaching CPR in schools is mandatory. Teaching CPR and AED (automated external defibrillator) skills in schools is a simple addition to the curriculum that will increase rates of bystander CPR, improve access to early defibrillation and achieve better outcomes for people suffering out-of-hospital cardiac arrest.[[24]]
5. A more transparent and accountable health system
Goal 5: set clear accountable goals for heart disease risk management and outcomes and provide adequate resourcing and incentives to achieve them.
Currently, around one in eight health dollars are spent on heart disease and stroke, and the wider costs associated with disability and death reaches many hundreds of millions of dollars.[[25]] Acting on heart health is highly cost effective—just improving on the sub-optimal management of high blood pressure alone would reduce the lifetime cost to the health system by several million dollars.[[18]]
A transparent health system requires clear accountability to those most at risk of heart disease, and uses data systematically to measure and improve impact. While we can measure risks, such as smoking, and outcomes, such as hospitalisations and deaths, there are limited systematic measures of prevention and management of heart disease, with some areas of the heart health journey better covered than others. For example, Te Whatu Ora – Health New Zealand fund the All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI), collecting data from secondary care allowing for benchmarking of services provided, which also highlights quality improvement opportunities. Data on planned care wait times can be accessed, and drug dispensing is available via Pharmac.[[26,27]] However, these are reported largely independent of each other, and not in the context of an overarching strategy for cardiovascular disease. A heart health strategy must pull this together in order to cohesively drive and measure improvement across the health continuum, and be accountable and transparent to patients and the public. For example, drawing on the experiences from Aotearoa New Zealand’s world-leading COVID-19 reporting.[[28]]
Aotearoa New Zealand needs accessible, coordinated and quality national data that report accurate, timely information on the burden of heart disease, monitors and guides efforts and, in particular, increases transparency and accountability for closing the heart health equity gap.
6. Support a world-class health workforce to translate research into practice
Goal 6: attract and maintain a world-class health workforce delivering world-class heart healthcare in Aotearoa New Zealand.
Aotearoa New Zealand has world-class heart research programmes both domestically and through international collaborations. Developing and resourcing stronger pathways from research to practice and closing the evidence-to-action gap will ensure that New Zealanders are benefitting from research.
Putting research findings into action requires supporting and sustaining a high-quality workforce and providing resources for implementation. Currently New Zealand faces a future health workforce shortage and limited representation in our heart health workforce including doctors, nurses, cardiac physiologists and echosonographers. There are around 160 cardiologists practicing in Aotearoa New Zealand, of whom an estimated 2.5% are Māori or Pacific. Eighteen percent are women.[[29,30]] Māori and Pacific nurses are also under-represented in cardiac specialties.[[31]] There are also significant inequalities in FTE numbers of the heart health workforce across regions. More promotion of heart health as a career pathway, to build a sustainable, skilled and diverse workforce that represents the Aotearoa New Zealand population, is urgently required. It will build expertise for the future and create a workforce that is connected and relevant to patients.
In summary, cardiovascular disease remains responsible for a third of all mortality and is the leading cause of health loss in Aotearoa New Zealand. More New Zealanders are living with heart disease than ever before. There are huge disparities in timely diagnosis, treatment and outcomes in heart health, most of which is avoidable. Aotearoa New Zealand is a world leader in many aspects of heart research, but translation into outcomes for our population remains inconsistent, unequal and unfair, and is falling behind international best practice. Movement beyond the current disconnected and an ad hoc approach is needed.
Aotearoa New Zealand urgently needs an action plan to focus on reducing the avoidable and inequitable burden of heart disease. Health system reforms are a critical opportunity to address the lack of coherent strategy for heart health and bring together clinicians, health planners, policy makers, communities and Māori and Pacific health leaders to develop a roadmap for better outcomes.
This has been done for smoking, cancer, mental health and diabetes, among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda.
Summary
Abstract
Aim
Cardiovascular diseases are responsible for almost 10,000 deaths annually in Aotearoa New Zealand. Almost a quarter of these are avoidable, increasing to half of all cardiovascular deaths for Māori and Pacific people. Health system reforms are an opportunity to set clear ambitious goals for improved heart health. This has been done for smoking, a cancer plan, mental health and diabetes among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda.
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Te Whatu Ora – Health New Zealand. Mortality Web Tool: Māori/non-Māori population: Historical Mortality by selected cause of death and sex [Internet]. 2022 [cited 2023 Jun]. Available from: https://tewhatuora.shinyapps.io/mortality-web-tool/.
2) Te Whatu Ora – Health New Zealand, Te Aka Whai Ora – Māori Health Authority. Te Pae Tata Interim New Zealand Health Plan. Wellington, New Zealand; 2022.
3) Walsh M, Grey C. The contribution of avoidable mortality to the life expectancy gap in Māori and Pacific populations in New Zealand-a decomposition analysis. N Z Med J. 2019 Mar 29;132(1492):46-60.
4) Manatū Hauora – Ministry of Health. Annual Data Explorer [Internet]. 2022 [cited 2023 Jun]. Available from: https://minhealthnz.shinyapps.io/nz-health-survey-2021-22-annual-data-explorer/.
5) Espiner E, Paine SJ, Weston M, Curtis E. Barriers and facilitators for Māori in accessing hospital services in Aotearoa New Zealand. N Z Med J. 2021 Nov 26;134(1546):47-58.
6) Graham R, Masters-Awatere B. Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research. Aust N Z J Public Health. 2020 Jun;44(3):193-200. doi: 10.1111/1753-6405.12971.
7) Tane T, Selak V, Eggleton K, Harwood M. Understanding the barriers and facilitators that influence access to quality cardiovascular care for rural Indigenous peoples: protocol for a scoping review BMJ Open. 2022;12(12):e065685. doi: 10.1136/bmjopen-2022-065685.
8) Manatū Hauora – Ministry of Health. Health and Disability System Review – Final Report – Pūrongo Whakamutunga [Internet]. Wellington, New Zealand: Health and Disability System Review; 2020 [cited 2023 Jun]. Available from: https://www.health.govt.nz/system/files/documents/publications/health-disability-system-review-final-report.pdf.
9) Irurzun-Lopez M, Jeffreys M, Cumming J. The enrolment gap: who is not enrolling with primary health organizations in Aotearoa New Zealand and what are the implications? An exploration of 2015-2019 administrative data. Int J Equity Health. 2021;20(1):93. doi:10.1186/s12939-021-01423-4
10) Manaaki Manawa | The Centre for Heart Research [Internet]. [cited 2023 Jun]. Available from: https://www.manaakimanawa.ac.nz.
11) Dicker B, Garrett N, Wong S, et al. Relationship between socioeconomic factors, distribution of public access defibrillators and incidence of out-of-hospital cardiac arrest. Resuscitation. 2019 May;138:53-58. doi: 10.1016/j.resuscitation.2019.02.022.
12) Mazengarb J, Grey C, Lee M, et al. Inequity in one-year mortality after first myocardial infarction in Māori and Pacific patients: how much is associated with differences in modifiable clinical risk factors? (ANZACS-QI 49). N Z Med J. 2020 Sep 4;133(1521):40-54.
13) Manatū Hauora – Ministry of Health. Smokefree Aotearoa 2025 Action Plan - Auahi Kore Aotearoa Mahere Rautaki 2025. Wellington, New Zealand: Ministry of Health; 2021.
14) Te Tai Ōhanga – The Treasury. Living Standards Framework Dashboard [Internet]. [cited 2023 Aug]. Available from: https://lsfdashboard.treasury.govt.nz/wellbeing/.
15) Manatū Hauora – Ministry of Health. Cardiovascular Disease Risk Assessment and Management for Primary Care [Internet]. Wellington, New Zealand: Ministry of Health; 2018 [cited 2023 Jun]. Available from: https://www.health.govt.nz/publication/cardiovascular-disease-risk-assessment-and-management-primary-care.
16) Manatū Hauora – Ministry of Health. HISO 10071:2019 Cardiovascular Disease Risk Assessment Data Standard [Internet]. Wellington, New Zealand: Ministry of Health; 2019 [cited 2023 Jun]. Available from: https://www.moh.govt.nz/notebook/nbbooks.nsf/0/3DB32BADACD4F745CC258449000F2E03/$file/hiso-10071-2019-cardiovascular-disease-risk-assessment-data-standard-v2.pdf.
17) NCD Risk Factor Collaboration (NCD-RisC). Long-term and recent trends in hypertension awareness, treatment, and control in 12 high-income countries: an analysis of 123 nationally representative surveys. Lancet. 2019 Aug 24;394(10199):639-651. doi: 10.1016/S0140-6736(19)31145-6.
18) Wilson N, Cleghorn C, Nghiem N, Blakely T. Prioritization of intervention domains to prevent cardiovascular disease: a country-level case study using global burden of disease and local data. Popul Health Metr. 2023;21(1):1. doi:10.1186/s12963-023-00301-1.
19) Dicker B, Todd V, Callejas P, et al. Out-of-Hospital ST-segment Elevation Myocardial Infarction Registry: Aotearoa New Zealand, National Report 2021/22. Hato Hone St John; 2022.
20) Miller R, Nixon G, Turner RM, et al. Outcomes and access to angiography following non-ST-segment elevation acute coronary syndromes in patients who present to rural or urban hospitals: ANZACS-QI 72. N Z Med J. 2023 Apr 14;136(1573):27-54.
21) Buckley B, Farnworth MJ, Whalley G. Echocardiography service provision in New Zealand: The implications of capacity modelling for the cardiac sonographer workforce. N Z Med J. 2016 Jan 8;129(1428):17-25.
22) Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e876-e894. doi: 10.1161/CIR.0000000000001062.
23) Wilson K, Khan A. Pharmaceutical Schedule [Internet]. Pharmac; 2023 [cited 2023 Aug]. Available from: https://schedule.pharmac.govt.nz/2023/08/01/Schedule.pdf#page=49
24) Vetter VL, Griffis H, Dalldorf KF, et al. Impact of State Laws: CPR Education in High Schools. J Am Coll Cardiol. 2022;79(21):2140-2143. doi:10.1016/j.jacc.2022.03.359.
25) Blakely T, Kvizhinadze G, Atkinson J, et al. Health system costs for individual and comorbid noncommunicable diseases: An analysis of publicly funded health events from New Zealand. PLoS Med. 2019;16(1):e1002716. doi: 10.1371/journal.pmed.1002716.
26) Manatū Hauora – Ministry of Health. Elective Services Patient Flow Indicators Web Tool [Internet]. 2023 [cited 2023 Aug]. Available from: https://tewhatuora.shinyapps.io/ESPI_app/.
27) Te Whatu Ora – Health New Zealand. Pharmaceutical Data web tool [Internet]. 2023 [cited 2023 Aug]. Available from: https://tewhatuora.shinyapps.io/pharmaceutical-data-web-tool/.
28) Kerr A, Shuker C, Devlin G. Transparency in the year of COVID-19 means tracking and publishing performance in the whole health system: progress on the public reporting of acute coronary syndrome data in New Zealand. N Z Med J. 2020 Aug 21;133(1520):113-119.
29) Burgess S, Shaw E, Ellenberger KA, et al. Gender equity within medical specialties of Australia and New Zealand: cardiology's outlier status. Intern Med J. 2020 Apr;50(4):412-419. doi: 10.1111/imj.14406.
30) Te Kaunihera Rata o Aotearoa | Medical Council of New Zealand. Our data [Internet]. 2023 [cited 2023 Aug]. Available from: https://www.mcnz.org.nz/about-us/our-data/.
31) Te Kaunihera Tapuhi o Aotearoa Nursing Council of New Zealand. Te Ohu Mahi o Aotearoa/The New Zealand Nursing Workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2018-19. Wellington, New Zealand: Te Kaunihera Tapuhi o Aotearoa/Nursing Council of New Zealand; 2019.
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Cardiovascular disease is responsible for a third of all deaths and is the leading cause of health loss in Aotearoa New Zealand. The current health system reform presents a once in a generation opportunity to address how our health system works for all. This includes addressing the gap in heart health outcomes[[1]] systematically and fairly to allow hundreds of thousands of affected New Zealanders to live longer and healthier lives.
When the Government released Te Pae Tata Interim New Zealand Health Plan 2022 it was disappointing that a clear commitment to reducing the burden of heart disease and stroke was not evident.[[2]]
In 2020, the Heart Foundation first called for a national heart health action plan. Since then, almost 30,000 New Zealanders have lost their lives to heart disease and stroke. We estimate 7,000 of those deaths were premature and avoidable.[[3]] These deaths could have been avoided through better prevention and improved and timely access to evidence-based healthcare.
The Heart Foundation is reiterating the urgent need for a national action plan for heart health, advocating for ambitious and achievable goals for better and more equitable heart health outcomes, by delivering a better heart health system. This starts with better prevention from early childhood and extends across the life course from assessing, understanding and managing heart disease risk, timely access to heart healthcare, improving survival following a heart event and planning for a sustainable skilled workforce delivering world-class care in a timely manner and where it is most needed.
In Aotearoa New Zealand there are huge and avoidable disparities in heart health outcomes. Māori, Pacific people and those living in the most deprived parts of the country are more likely to be exposed to risk factors such as smoking, and to face multiple barriers to accessing care including cost, transport, discrimination and systemic racism.[[4,5,6]] This results in under and delayed diagnosis and subsequent management and support. Urgent work is required to better understand and remove these barriers.[[7]]
Reasons for these disparities are complex, and include historical injustices, prejudice and mistrust in the health system, struggles for resources including health workforce, health literacy and geographical isolation.[[8]] In addition those regions with the greatest need for better heart healthcare are those with poorest access to healthcare, particularly delivered close to home.[[9]]
Progress on recommendations to improve heart health outcomes since 2020 has been poor. There have been some areas to celebrate including aggressive action towards a Smokefree 2025, some access to new drug treatments and the funding of a new centre of research excellence in heart health.[[10]] However, progress has been piecemeal, rather than bound by a clear and integrated strategy for achieving better outcomes.
Access to basic cardiovascular risk assessments and to cardiology services remains inconsistent and lacking for many New Zealanders. There are restrictions and limitations on access to cost-effective and evidence-based treatments, and cardiac arrest survival rates are hampered by inconsistent access to CPR and community defibrillators.[[11]]
Elements of the health system of Aotearoa New Zealand aimed at heart health are not currently working for everyone, especially for Māori, Pacific people, people living in areas of high deprivation and rural New Zealanders. About half of cardiovascular deaths in these populations are avoidable, meaning we could significantly reduce the impact of heart disease and stroke and improve health equity if our prevention and health care systems were working fairly for all.[[12]]
We have seen how ambitious targets can achieve results, in particular the substantial progress towards Smokefree 2025.[[13]]
The updated Heart Foundation white paper recommends that a national heart health action plan sets bold targets for better heart health and identifies six key areas that build on current strengths and have the potential to significantly reduce the impact of heart disease and stroke on all New Zealanders. It proposes that a national action plan has high level goals to reduce the rate of avoidable heart disease mortality and morbidity for all New Zealanders by at least 50% by 2050, and by 2040 for Māori and Pacific people.
Achieving these goals will require a life course approach with a balance between addressing outcomes for those at most immediate risk of heart disease by improving access to care and support, building a strong approach to heart disease risk screening and management, and ensuring better large-scale and sustainable outcomes longer term through effective prevention.
Our six priorities for a national heart health action plan are:
1. Reduce the risk of heart-related disease through prevention
Goal 1: reverse the declining trends in consumption of healthy food and physical activity and achieve minimal smoking for all populations by 2025.
A stronger prevention system needs to urgently address the personal and systemic financial and environmental barriers families face in accessing healthy food and undertaking regular physical activity.[[4,14]] A system where all children and families have the same access and rights to a healthy learning environment connected to their community is vital to set up young New Zealanders for heart-healthy lives.
2. Early detection and management of heart disease
Goal 2: 95% of eligible New Zealanders are risk assessed for cardiovascular disease (heart disease and stroke) and advised on appropriate risk management.
Manatū Hauora – Ministry of Health published the standard for cardiovascular disease risk assessment and management in primary care in 2018. It set out new guidelines recommending beginning cardiovascular risk assessments for men from age 45 and women from age 55. For Māori, Pacific and South Asian populations, risk assessment is recommended to start 15 years earlier than in other population groups.[[15]] Guidelines also set out standards for managing risk, and were accompanied by New Zealand’s own cardiovascular risk prediction equations for use in primary care.[[16]] Five years later, there is still no systematic approach to risk assessment, and management of cardiovascular risk.
For example, close to one in five adults have elevated blood pressure (>140/90mm Hg),[[15]] yet fewer than one in three New Zealanders with elevated blood pressure have it well controlled. This is well behind the OECD average.[[17]] Routine risk assessment, and identifying and managing those with risk—especially high blood pressure—is highly cost effective and will have an almost immediate impact on improving cardiovascular health in New Zealand.[[18]]
3. Timely access to evidence-based and effective care and support
Goal 3: reduce hospitalisations for acute cardiac presentations and stroke by 50% by 2040, with a particular focus on Māori, Pacific and South Asian populations.
People are often not able to access the heath system until forced to by an emergency, and even then delays in seeking and receiving care are common. A third of New Zealanders who had a heart attack in 2022 waited more than 2 hours to call for help.[[19]] A deterioration in timely access to angiography following an acute coronary syndrome presentation was also noted in 2022.[[20]]
There is significant regional variation in access to specialist opinion, diagnostic services including echocardiography, CT angiography, electrophysiology and invasive angiography with resultant variation in revascularisation, cardiac surgery and valve intervention.[[21]] Often these variations are inconsistent with need, with reduced access and longer wait times affecting communities at highest risk of poor heart health outcomes.
Aotearoa New Zealand is falling behind other countries with respect to access to effective evidence-based and recommended medicines. Current examples include restricted access to new diabetes drugs that improve heart health outcomes, which are currently only available to high-risk populations by special authority. SGLT-II inhibitors are a recommended foundation pillar of heart failure care in international guidelines[[22]] (Level I A) and are not currently funded for this indication in Aotearoa New Zealand. Sacubitril-Valsartan is a recommended foundation pillar for heart failure (Level I B) but is available with restricted access only.[[22,23]]
The delays in reaching care in the first place, delays in subsequent treatment and access to evidence-based care and medications are an entirely preventable failure of the health system. It requires a focus on early risk management and treatments, and on working with communities to remove the barriers to heart healthcare. Access to effective heart healthcare needs to match up with communities with the highest need, and the current situation where New Zealanders lack access to proven and cost-effective heart health medications must urgently be addressed.
4. Increase survival rates for out-of-hospital cardiac arrest
Goal 4: increase the survival rates for out-of-hospital cardiac arrest by 25% by 2030.
More than 2,300 people experienced a cardiac arrest in the community or at home in the year ending June 2022. Only one in 10 people who suffered an out-of-hospital cardiac arrest survived to hospital discharge compared to 1 in 7 in 2018.[[19]] We can reverse this trend by increasing access to life-saving CPR (cardiopulmonary resuscitation) and ensuring community defibrillators are where they are needed most, and by addressing regional and local disparities in access.[[11]] Aotearoa New Zealand should join nations like the United Kingdom, Germany, China, Norway, Sweden and the majority of states in the United States where teaching CPR in schools is mandatory. Teaching CPR and AED (automated external defibrillator) skills in schools is a simple addition to the curriculum that will increase rates of bystander CPR, improve access to early defibrillation and achieve better outcomes for people suffering out-of-hospital cardiac arrest.[[24]]
5. A more transparent and accountable health system
Goal 5: set clear accountable goals for heart disease risk management and outcomes and provide adequate resourcing and incentives to achieve them.
Currently, around one in eight health dollars are spent on heart disease and stroke, and the wider costs associated with disability and death reaches many hundreds of millions of dollars.[[25]] Acting on heart health is highly cost effective—just improving on the sub-optimal management of high blood pressure alone would reduce the lifetime cost to the health system by several million dollars.[[18]]
A transparent health system requires clear accountability to those most at risk of heart disease, and uses data systematically to measure and improve impact. While we can measure risks, such as smoking, and outcomes, such as hospitalisations and deaths, there are limited systematic measures of prevention and management of heart disease, with some areas of the heart health journey better covered than others. For example, Te Whatu Ora – Health New Zealand fund the All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI), collecting data from secondary care allowing for benchmarking of services provided, which also highlights quality improvement opportunities. Data on planned care wait times can be accessed, and drug dispensing is available via Pharmac.[[26,27]] However, these are reported largely independent of each other, and not in the context of an overarching strategy for cardiovascular disease. A heart health strategy must pull this together in order to cohesively drive and measure improvement across the health continuum, and be accountable and transparent to patients and the public. For example, drawing on the experiences from Aotearoa New Zealand’s world-leading COVID-19 reporting.[[28]]
Aotearoa New Zealand needs accessible, coordinated and quality national data that report accurate, timely information on the burden of heart disease, monitors and guides efforts and, in particular, increases transparency and accountability for closing the heart health equity gap.
6. Support a world-class health workforce to translate research into practice
Goal 6: attract and maintain a world-class health workforce delivering world-class heart healthcare in Aotearoa New Zealand.
Aotearoa New Zealand has world-class heart research programmes both domestically and through international collaborations. Developing and resourcing stronger pathways from research to practice and closing the evidence-to-action gap will ensure that New Zealanders are benefitting from research.
Putting research findings into action requires supporting and sustaining a high-quality workforce and providing resources for implementation. Currently New Zealand faces a future health workforce shortage and limited representation in our heart health workforce including doctors, nurses, cardiac physiologists and echosonographers. There are around 160 cardiologists practicing in Aotearoa New Zealand, of whom an estimated 2.5% are Māori or Pacific. Eighteen percent are women.[[29,30]] Māori and Pacific nurses are also under-represented in cardiac specialties.[[31]] There are also significant inequalities in FTE numbers of the heart health workforce across regions. More promotion of heart health as a career pathway, to build a sustainable, skilled and diverse workforce that represents the Aotearoa New Zealand population, is urgently required. It will build expertise for the future and create a workforce that is connected and relevant to patients.
In summary, cardiovascular disease remains responsible for a third of all mortality and is the leading cause of health loss in Aotearoa New Zealand. More New Zealanders are living with heart disease than ever before. There are huge disparities in timely diagnosis, treatment and outcomes in heart health, most of which is avoidable. Aotearoa New Zealand is a world leader in many aspects of heart research, but translation into outcomes for our population remains inconsistent, unequal and unfair, and is falling behind international best practice. Movement beyond the current disconnected and an ad hoc approach is needed.
Aotearoa New Zealand urgently needs an action plan to focus on reducing the avoidable and inequitable burden of heart disease. Health system reforms are a critical opportunity to address the lack of coherent strategy for heart health and bring together clinicians, health planners, policy makers, communities and Māori and Pacific health leaders to develop a roadmap for better outcomes.
This has been done for smoking, cancer, mental health and diabetes, among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda.
Summary
Abstract
Aim
Cardiovascular diseases are responsible for almost 10,000 deaths annually in Aotearoa New Zealand. Almost a quarter of these are avoidable, increasing to half of all cardiovascular deaths for Māori and Pacific people. Health system reforms are an opportunity to set clear ambitious goals for improved heart health. This has been done for smoking, a cancer plan, mental health and diabetes among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda.
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Te Whatu Ora – Health New Zealand. Mortality Web Tool: Māori/non-Māori population: Historical Mortality by selected cause of death and sex [Internet]. 2022 [cited 2023 Jun]. Available from: https://tewhatuora.shinyapps.io/mortality-web-tool/.
2) Te Whatu Ora – Health New Zealand, Te Aka Whai Ora – Māori Health Authority. Te Pae Tata Interim New Zealand Health Plan. Wellington, New Zealand; 2022.
3) Walsh M, Grey C. The contribution of avoidable mortality to the life expectancy gap in Māori and Pacific populations in New Zealand-a decomposition analysis. N Z Med J. 2019 Mar 29;132(1492):46-60.
4) Manatū Hauora – Ministry of Health. Annual Data Explorer [Internet]. 2022 [cited 2023 Jun]. Available from: https://minhealthnz.shinyapps.io/nz-health-survey-2021-22-annual-data-explorer/.
5) Espiner E, Paine SJ, Weston M, Curtis E. Barriers and facilitators for Māori in accessing hospital services in Aotearoa New Zealand. N Z Med J. 2021 Nov 26;134(1546):47-58.
6) Graham R, Masters-Awatere B. Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research. Aust N Z J Public Health. 2020 Jun;44(3):193-200. doi: 10.1111/1753-6405.12971.
7) Tane T, Selak V, Eggleton K, Harwood M. Understanding the barriers and facilitators that influence access to quality cardiovascular care for rural Indigenous peoples: protocol for a scoping review BMJ Open. 2022;12(12):e065685. doi: 10.1136/bmjopen-2022-065685.
8) Manatū Hauora – Ministry of Health. Health and Disability System Review – Final Report – Pūrongo Whakamutunga [Internet]. Wellington, New Zealand: Health and Disability System Review; 2020 [cited 2023 Jun]. Available from: https://www.health.govt.nz/system/files/documents/publications/health-disability-system-review-final-report.pdf.
9) Irurzun-Lopez M, Jeffreys M, Cumming J. The enrolment gap: who is not enrolling with primary health organizations in Aotearoa New Zealand and what are the implications? An exploration of 2015-2019 administrative data. Int J Equity Health. 2021;20(1):93. doi:10.1186/s12939-021-01423-4
10) Manaaki Manawa | The Centre for Heart Research [Internet]. [cited 2023 Jun]. Available from: https://www.manaakimanawa.ac.nz.
11) Dicker B, Garrett N, Wong S, et al. Relationship between socioeconomic factors, distribution of public access defibrillators and incidence of out-of-hospital cardiac arrest. Resuscitation. 2019 May;138:53-58. doi: 10.1016/j.resuscitation.2019.02.022.
12) Mazengarb J, Grey C, Lee M, et al. Inequity in one-year mortality after first myocardial infarction in Māori and Pacific patients: how much is associated with differences in modifiable clinical risk factors? (ANZACS-QI 49). N Z Med J. 2020 Sep 4;133(1521):40-54.
13) Manatū Hauora – Ministry of Health. Smokefree Aotearoa 2025 Action Plan - Auahi Kore Aotearoa Mahere Rautaki 2025. Wellington, New Zealand: Ministry of Health; 2021.
14) Te Tai Ōhanga – The Treasury. Living Standards Framework Dashboard [Internet]. [cited 2023 Aug]. Available from: https://lsfdashboard.treasury.govt.nz/wellbeing/.
15) Manatū Hauora – Ministry of Health. Cardiovascular Disease Risk Assessment and Management for Primary Care [Internet]. Wellington, New Zealand: Ministry of Health; 2018 [cited 2023 Jun]. Available from: https://www.health.govt.nz/publication/cardiovascular-disease-risk-assessment-and-management-primary-care.
16) Manatū Hauora – Ministry of Health. HISO 10071:2019 Cardiovascular Disease Risk Assessment Data Standard [Internet]. Wellington, New Zealand: Ministry of Health; 2019 [cited 2023 Jun]. Available from: https://www.moh.govt.nz/notebook/nbbooks.nsf/0/3DB32BADACD4F745CC258449000F2E03/$file/hiso-10071-2019-cardiovascular-disease-risk-assessment-data-standard-v2.pdf.
17) NCD Risk Factor Collaboration (NCD-RisC). Long-term and recent trends in hypertension awareness, treatment, and control in 12 high-income countries: an analysis of 123 nationally representative surveys. Lancet. 2019 Aug 24;394(10199):639-651. doi: 10.1016/S0140-6736(19)31145-6.
18) Wilson N, Cleghorn C, Nghiem N, Blakely T. Prioritization of intervention domains to prevent cardiovascular disease: a country-level case study using global burden of disease and local data. Popul Health Metr. 2023;21(1):1. doi:10.1186/s12963-023-00301-1.
19) Dicker B, Todd V, Callejas P, et al. Out-of-Hospital ST-segment Elevation Myocardial Infarction Registry: Aotearoa New Zealand, National Report 2021/22. Hato Hone St John; 2022.
20) Miller R, Nixon G, Turner RM, et al. Outcomes and access to angiography following non-ST-segment elevation acute coronary syndromes in patients who present to rural or urban hospitals: ANZACS-QI 72. N Z Med J. 2023 Apr 14;136(1573):27-54.
21) Buckley B, Farnworth MJ, Whalley G. Echocardiography service provision in New Zealand: The implications of capacity modelling for the cardiac sonographer workforce. N Z Med J. 2016 Jan 8;129(1428):17-25.
22) Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e876-e894. doi: 10.1161/CIR.0000000000001062.
23) Wilson K, Khan A. Pharmaceutical Schedule [Internet]. Pharmac; 2023 [cited 2023 Aug]. Available from: https://schedule.pharmac.govt.nz/2023/08/01/Schedule.pdf#page=49
24) Vetter VL, Griffis H, Dalldorf KF, et al. Impact of State Laws: CPR Education in High Schools. J Am Coll Cardiol. 2022;79(21):2140-2143. doi:10.1016/j.jacc.2022.03.359.
25) Blakely T, Kvizhinadze G, Atkinson J, et al. Health system costs for individual and comorbid noncommunicable diseases: An analysis of publicly funded health events from New Zealand. PLoS Med. 2019;16(1):e1002716. doi: 10.1371/journal.pmed.1002716.
26) Manatū Hauora – Ministry of Health. Elective Services Patient Flow Indicators Web Tool [Internet]. 2023 [cited 2023 Aug]. Available from: https://tewhatuora.shinyapps.io/ESPI_app/.
27) Te Whatu Ora – Health New Zealand. Pharmaceutical Data web tool [Internet]. 2023 [cited 2023 Aug]. Available from: https://tewhatuora.shinyapps.io/pharmaceutical-data-web-tool/.
28) Kerr A, Shuker C, Devlin G. Transparency in the year of COVID-19 means tracking and publishing performance in the whole health system: progress on the public reporting of acute coronary syndrome data in New Zealand. N Z Med J. 2020 Aug 21;133(1520):113-119.
29) Burgess S, Shaw E, Ellenberger KA, et al. Gender equity within medical specialties of Australia and New Zealand: cardiology's outlier status. Intern Med J. 2020 Apr;50(4):412-419. doi: 10.1111/imj.14406.
30) Te Kaunihera Rata o Aotearoa | Medical Council of New Zealand. Our data [Internet]. 2023 [cited 2023 Aug]. Available from: https://www.mcnz.org.nz/about-us/our-data/.
31) Te Kaunihera Tapuhi o Aotearoa Nursing Council of New Zealand. Te Ohu Mahi o Aotearoa/The New Zealand Nursing Workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2018-19. Wellington, New Zealand: Te Kaunihera Tapuhi o Aotearoa/Nursing Council of New Zealand; 2019.
For the PDF of this article,
contact nzmj@nzma.org.nz
View Article PDF
Cardiovascular disease is responsible for a third of all deaths and is the leading cause of health loss in Aotearoa New Zealand. The current health system reform presents a once in a generation opportunity to address how our health system works for all. This includes addressing the gap in heart health outcomes[[1]] systematically and fairly to allow hundreds of thousands of affected New Zealanders to live longer and healthier lives.
When the Government released Te Pae Tata Interim New Zealand Health Plan 2022 it was disappointing that a clear commitment to reducing the burden of heart disease and stroke was not evident.[[2]]
In 2020, the Heart Foundation first called for a national heart health action plan. Since then, almost 30,000 New Zealanders have lost their lives to heart disease and stroke. We estimate 7,000 of those deaths were premature and avoidable.[[3]] These deaths could have been avoided through better prevention and improved and timely access to evidence-based healthcare.
The Heart Foundation is reiterating the urgent need for a national action plan for heart health, advocating for ambitious and achievable goals for better and more equitable heart health outcomes, by delivering a better heart health system. This starts with better prevention from early childhood and extends across the life course from assessing, understanding and managing heart disease risk, timely access to heart healthcare, improving survival following a heart event and planning for a sustainable skilled workforce delivering world-class care in a timely manner and where it is most needed.
In Aotearoa New Zealand there are huge and avoidable disparities in heart health outcomes. Māori, Pacific people and those living in the most deprived parts of the country are more likely to be exposed to risk factors such as smoking, and to face multiple barriers to accessing care including cost, transport, discrimination and systemic racism.[[4,5,6]] This results in under and delayed diagnosis and subsequent management and support. Urgent work is required to better understand and remove these barriers.[[7]]
Reasons for these disparities are complex, and include historical injustices, prejudice and mistrust in the health system, struggles for resources including health workforce, health literacy and geographical isolation.[[8]] In addition those regions with the greatest need for better heart healthcare are those with poorest access to healthcare, particularly delivered close to home.[[9]]
Progress on recommendations to improve heart health outcomes since 2020 has been poor. There have been some areas to celebrate including aggressive action towards a Smokefree 2025, some access to new drug treatments and the funding of a new centre of research excellence in heart health.[[10]] However, progress has been piecemeal, rather than bound by a clear and integrated strategy for achieving better outcomes.
Access to basic cardiovascular risk assessments and to cardiology services remains inconsistent and lacking for many New Zealanders. There are restrictions and limitations on access to cost-effective and evidence-based treatments, and cardiac arrest survival rates are hampered by inconsistent access to CPR and community defibrillators.[[11]]
Elements of the health system of Aotearoa New Zealand aimed at heart health are not currently working for everyone, especially for Māori, Pacific people, people living in areas of high deprivation and rural New Zealanders. About half of cardiovascular deaths in these populations are avoidable, meaning we could significantly reduce the impact of heart disease and stroke and improve health equity if our prevention and health care systems were working fairly for all.[[12]]
We have seen how ambitious targets can achieve results, in particular the substantial progress towards Smokefree 2025.[[13]]
The updated Heart Foundation white paper recommends that a national heart health action plan sets bold targets for better heart health and identifies six key areas that build on current strengths and have the potential to significantly reduce the impact of heart disease and stroke on all New Zealanders. It proposes that a national action plan has high level goals to reduce the rate of avoidable heart disease mortality and morbidity for all New Zealanders by at least 50% by 2050, and by 2040 for Māori and Pacific people.
Achieving these goals will require a life course approach with a balance between addressing outcomes for those at most immediate risk of heart disease by improving access to care and support, building a strong approach to heart disease risk screening and management, and ensuring better large-scale and sustainable outcomes longer term through effective prevention.
Our six priorities for a national heart health action plan are:
1. Reduce the risk of heart-related disease through prevention
Goal 1: reverse the declining trends in consumption of healthy food and physical activity and achieve minimal smoking for all populations by 2025.
A stronger prevention system needs to urgently address the personal and systemic financial and environmental barriers families face in accessing healthy food and undertaking regular physical activity.[[4,14]] A system where all children and families have the same access and rights to a healthy learning environment connected to their community is vital to set up young New Zealanders for heart-healthy lives.
2. Early detection and management of heart disease
Goal 2: 95% of eligible New Zealanders are risk assessed for cardiovascular disease (heart disease and stroke) and advised on appropriate risk management.
Manatū Hauora – Ministry of Health published the standard for cardiovascular disease risk assessment and management in primary care in 2018. It set out new guidelines recommending beginning cardiovascular risk assessments for men from age 45 and women from age 55. For Māori, Pacific and South Asian populations, risk assessment is recommended to start 15 years earlier than in other population groups.[[15]] Guidelines also set out standards for managing risk, and were accompanied by New Zealand’s own cardiovascular risk prediction equations for use in primary care.[[16]] Five years later, there is still no systematic approach to risk assessment, and management of cardiovascular risk.
For example, close to one in five adults have elevated blood pressure (>140/90mm Hg),[[15]] yet fewer than one in three New Zealanders with elevated blood pressure have it well controlled. This is well behind the OECD average.[[17]] Routine risk assessment, and identifying and managing those with risk—especially high blood pressure—is highly cost effective and will have an almost immediate impact on improving cardiovascular health in New Zealand.[[18]]
3. Timely access to evidence-based and effective care and support
Goal 3: reduce hospitalisations for acute cardiac presentations and stroke by 50% by 2040, with a particular focus on Māori, Pacific and South Asian populations.
People are often not able to access the heath system until forced to by an emergency, and even then delays in seeking and receiving care are common. A third of New Zealanders who had a heart attack in 2022 waited more than 2 hours to call for help.[[19]] A deterioration in timely access to angiography following an acute coronary syndrome presentation was also noted in 2022.[[20]]
There is significant regional variation in access to specialist opinion, diagnostic services including echocardiography, CT angiography, electrophysiology and invasive angiography with resultant variation in revascularisation, cardiac surgery and valve intervention.[[21]] Often these variations are inconsistent with need, with reduced access and longer wait times affecting communities at highest risk of poor heart health outcomes.
Aotearoa New Zealand is falling behind other countries with respect to access to effective evidence-based and recommended medicines. Current examples include restricted access to new diabetes drugs that improve heart health outcomes, which are currently only available to high-risk populations by special authority. SGLT-II inhibitors are a recommended foundation pillar of heart failure care in international guidelines[[22]] (Level I A) and are not currently funded for this indication in Aotearoa New Zealand. Sacubitril-Valsartan is a recommended foundation pillar for heart failure (Level I B) but is available with restricted access only.[[22,23]]
The delays in reaching care in the first place, delays in subsequent treatment and access to evidence-based care and medications are an entirely preventable failure of the health system. It requires a focus on early risk management and treatments, and on working with communities to remove the barriers to heart healthcare. Access to effective heart healthcare needs to match up with communities with the highest need, and the current situation where New Zealanders lack access to proven and cost-effective heart health medications must urgently be addressed.
4. Increase survival rates for out-of-hospital cardiac arrest
Goal 4: increase the survival rates for out-of-hospital cardiac arrest by 25% by 2030.
More than 2,300 people experienced a cardiac arrest in the community or at home in the year ending June 2022. Only one in 10 people who suffered an out-of-hospital cardiac arrest survived to hospital discharge compared to 1 in 7 in 2018.[[19]] We can reverse this trend by increasing access to life-saving CPR (cardiopulmonary resuscitation) and ensuring community defibrillators are where they are needed most, and by addressing regional and local disparities in access.[[11]] Aotearoa New Zealand should join nations like the United Kingdom, Germany, China, Norway, Sweden and the majority of states in the United States where teaching CPR in schools is mandatory. Teaching CPR and AED (automated external defibrillator) skills in schools is a simple addition to the curriculum that will increase rates of bystander CPR, improve access to early defibrillation and achieve better outcomes for people suffering out-of-hospital cardiac arrest.[[24]]
5. A more transparent and accountable health system
Goal 5: set clear accountable goals for heart disease risk management and outcomes and provide adequate resourcing and incentives to achieve them.
Currently, around one in eight health dollars are spent on heart disease and stroke, and the wider costs associated with disability and death reaches many hundreds of millions of dollars.[[25]] Acting on heart health is highly cost effective—just improving on the sub-optimal management of high blood pressure alone would reduce the lifetime cost to the health system by several million dollars.[[18]]
A transparent health system requires clear accountability to those most at risk of heart disease, and uses data systematically to measure and improve impact. While we can measure risks, such as smoking, and outcomes, such as hospitalisations and deaths, there are limited systematic measures of prevention and management of heart disease, with some areas of the heart health journey better covered than others. For example, Te Whatu Ora – Health New Zealand fund the All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI), collecting data from secondary care allowing for benchmarking of services provided, which also highlights quality improvement opportunities. Data on planned care wait times can be accessed, and drug dispensing is available via Pharmac.[[26,27]] However, these are reported largely independent of each other, and not in the context of an overarching strategy for cardiovascular disease. A heart health strategy must pull this together in order to cohesively drive and measure improvement across the health continuum, and be accountable and transparent to patients and the public. For example, drawing on the experiences from Aotearoa New Zealand’s world-leading COVID-19 reporting.[[28]]
Aotearoa New Zealand needs accessible, coordinated and quality national data that report accurate, timely information on the burden of heart disease, monitors and guides efforts and, in particular, increases transparency and accountability for closing the heart health equity gap.
6. Support a world-class health workforce to translate research into practice
Goal 6: attract and maintain a world-class health workforce delivering world-class heart healthcare in Aotearoa New Zealand.
Aotearoa New Zealand has world-class heart research programmes both domestically and through international collaborations. Developing and resourcing stronger pathways from research to practice and closing the evidence-to-action gap will ensure that New Zealanders are benefitting from research.
Putting research findings into action requires supporting and sustaining a high-quality workforce and providing resources for implementation. Currently New Zealand faces a future health workforce shortage and limited representation in our heart health workforce including doctors, nurses, cardiac physiologists and echosonographers. There are around 160 cardiologists practicing in Aotearoa New Zealand, of whom an estimated 2.5% are Māori or Pacific. Eighteen percent are women.[[29,30]] Māori and Pacific nurses are also under-represented in cardiac specialties.[[31]] There are also significant inequalities in FTE numbers of the heart health workforce across regions. More promotion of heart health as a career pathway, to build a sustainable, skilled and diverse workforce that represents the Aotearoa New Zealand population, is urgently required. It will build expertise for the future and create a workforce that is connected and relevant to patients.
In summary, cardiovascular disease remains responsible for a third of all mortality and is the leading cause of health loss in Aotearoa New Zealand. More New Zealanders are living with heart disease than ever before. There are huge disparities in timely diagnosis, treatment and outcomes in heart health, most of which is avoidable. Aotearoa New Zealand is a world leader in many aspects of heart research, but translation into outcomes for our population remains inconsistent, unequal and unfair, and is falling behind international best practice. Movement beyond the current disconnected and an ad hoc approach is needed.
Aotearoa New Zealand urgently needs an action plan to focus on reducing the avoidable and inequitable burden of heart disease. Health system reforms are a critical opportunity to address the lack of coherent strategy for heart health and bring together clinicians, health planners, policy makers, communities and Māori and Pacific health leaders to develop a roadmap for better outcomes.
This has been done for smoking, cancer, mental health and diabetes, among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda.
Summary
Abstract
Aim
Cardiovascular diseases are responsible for almost 10,000 deaths annually in Aotearoa New Zealand. Almost a quarter of these are avoidable, increasing to half of all cardiovascular deaths for Māori and Pacific people. Health system reforms are an opportunity to set clear ambitious goals for improved heart health. This has been done for smoking, a cancer plan, mental health and diabetes among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda.
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Te Whatu Ora – Health New Zealand. Mortality Web Tool: Māori/non-Māori population: Historical Mortality by selected cause of death and sex [Internet]. 2022 [cited 2023 Jun]. Available from: https://tewhatuora.shinyapps.io/mortality-web-tool/.
2) Te Whatu Ora – Health New Zealand, Te Aka Whai Ora – Māori Health Authority. Te Pae Tata Interim New Zealand Health Plan. Wellington, New Zealand; 2022.
3) Walsh M, Grey C. The contribution of avoidable mortality to the life expectancy gap in Māori and Pacific populations in New Zealand-a decomposition analysis. N Z Med J. 2019 Mar 29;132(1492):46-60.
4) Manatū Hauora – Ministry of Health. Annual Data Explorer [Internet]. 2022 [cited 2023 Jun]. Available from: https://minhealthnz.shinyapps.io/nz-health-survey-2021-22-annual-data-explorer/.
5) Espiner E, Paine SJ, Weston M, Curtis E. Barriers and facilitators for Māori in accessing hospital services in Aotearoa New Zealand. N Z Med J. 2021 Nov 26;134(1546):47-58.
6) Graham R, Masters-Awatere B. Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research. Aust N Z J Public Health. 2020 Jun;44(3):193-200. doi: 10.1111/1753-6405.12971.
7) Tane T, Selak V, Eggleton K, Harwood M. Understanding the barriers and facilitators that influence access to quality cardiovascular care for rural Indigenous peoples: protocol for a scoping review BMJ Open. 2022;12(12):e065685. doi: 10.1136/bmjopen-2022-065685.
8) Manatū Hauora – Ministry of Health. Health and Disability System Review – Final Report – Pūrongo Whakamutunga [Internet]. Wellington, New Zealand: Health and Disability System Review; 2020 [cited 2023 Jun]. Available from: https://www.health.govt.nz/system/files/documents/publications/health-disability-system-review-final-report.pdf.
9) Irurzun-Lopez M, Jeffreys M, Cumming J. The enrolment gap: who is not enrolling with primary health organizations in Aotearoa New Zealand and what are the implications? An exploration of 2015-2019 administrative data. Int J Equity Health. 2021;20(1):93. doi:10.1186/s12939-021-01423-4
10) Manaaki Manawa | The Centre for Heart Research [Internet]. [cited 2023 Jun]. Available from: https://www.manaakimanawa.ac.nz.
11) Dicker B, Garrett N, Wong S, et al. Relationship between socioeconomic factors, distribution of public access defibrillators and incidence of out-of-hospital cardiac arrest. Resuscitation. 2019 May;138:53-58. doi: 10.1016/j.resuscitation.2019.02.022.
12) Mazengarb J, Grey C, Lee M, et al. Inequity in one-year mortality after first myocardial infarction in Māori and Pacific patients: how much is associated with differences in modifiable clinical risk factors? (ANZACS-QI 49). N Z Med J. 2020 Sep 4;133(1521):40-54.
13) Manatū Hauora – Ministry of Health. Smokefree Aotearoa 2025 Action Plan - Auahi Kore Aotearoa Mahere Rautaki 2025. Wellington, New Zealand: Ministry of Health; 2021.
14) Te Tai Ōhanga – The Treasury. Living Standards Framework Dashboard [Internet]. [cited 2023 Aug]. Available from: https://lsfdashboard.treasury.govt.nz/wellbeing/.
15) Manatū Hauora – Ministry of Health. Cardiovascular Disease Risk Assessment and Management for Primary Care [Internet]. Wellington, New Zealand: Ministry of Health; 2018 [cited 2023 Jun]. Available from: https://www.health.govt.nz/publication/cardiovascular-disease-risk-assessment-and-management-primary-care.
16) Manatū Hauora – Ministry of Health. HISO 10071:2019 Cardiovascular Disease Risk Assessment Data Standard [Internet]. Wellington, New Zealand: Ministry of Health; 2019 [cited 2023 Jun]. Available from: https://www.moh.govt.nz/notebook/nbbooks.nsf/0/3DB32BADACD4F745CC258449000F2E03/$file/hiso-10071-2019-cardiovascular-disease-risk-assessment-data-standard-v2.pdf.
17) NCD Risk Factor Collaboration (NCD-RisC). Long-term and recent trends in hypertension awareness, treatment, and control in 12 high-income countries: an analysis of 123 nationally representative surveys. Lancet. 2019 Aug 24;394(10199):639-651. doi: 10.1016/S0140-6736(19)31145-6.
18) Wilson N, Cleghorn C, Nghiem N, Blakely T. Prioritization of intervention domains to prevent cardiovascular disease: a country-level case study using global burden of disease and local data. Popul Health Metr. 2023;21(1):1. doi:10.1186/s12963-023-00301-1.
19) Dicker B, Todd V, Callejas P, et al. Out-of-Hospital ST-segment Elevation Myocardial Infarction Registry: Aotearoa New Zealand, National Report 2021/22. Hato Hone St John; 2022.
20) Miller R, Nixon G, Turner RM, et al. Outcomes and access to angiography following non-ST-segment elevation acute coronary syndromes in patients who present to rural or urban hospitals: ANZACS-QI 72. N Z Med J. 2023 Apr 14;136(1573):27-54.
21) Buckley B, Farnworth MJ, Whalley G. Echocardiography service provision in New Zealand: The implications of capacity modelling for the cardiac sonographer workforce. N Z Med J. 2016 Jan 8;129(1428):17-25.
22) Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e876-e894. doi: 10.1161/CIR.0000000000001062.
23) Wilson K, Khan A. Pharmaceutical Schedule [Internet]. Pharmac; 2023 [cited 2023 Aug]. Available from: https://schedule.pharmac.govt.nz/2023/08/01/Schedule.pdf#page=49
24) Vetter VL, Griffis H, Dalldorf KF, et al. Impact of State Laws: CPR Education in High Schools. J Am Coll Cardiol. 2022;79(21):2140-2143. doi:10.1016/j.jacc.2022.03.359.
25) Blakely T, Kvizhinadze G, Atkinson J, et al. Health system costs for individual and comorbid noncommunicable diseases: An analysis of publicly funded health events from New Zealand. PLoS Med. 2019;16(1):e1002716. doi: 10.1371/journal.pmed.1002716.
26) Manatū Hauora – Ministry of Health. Elective Services Patient Flow Indicators Web Tool [Internet]. 2023 [cited 2023 Aug]. Available from: https://tewhatuora.shinyapps.io/ESPI_app/.
27) Te Whatu Ora – Health New Zealand. Pharmaceutical Data web tool [Internet]. 2023 [cited 2023 Aug]. Available from: https://tewhatuora.shinyapps.io/pharmaceutical-data-web-tool/.
28) Kerr A, Shuker C, Devlin G. Transparency in the year of COVID-19 means tracking and publishing performance in the whole health system: progress on the public reporting of acute coronary syndrome data in New Zealand. N Z Med J. 2020 Aug 21;133(1520):113-119.
29) Burgess S, Shaw E, Ellenberger KA, et al. Gender equity within medical specialties of Australia and New Zealand: cardiology's outlier status. Intern Med J. 2020 Apr;50(4):412-419. doi: 10.1111/imj.14406.
30) Te Kaunihera Rata o Aotearoa | Medical Council of New Zealand. Our data [Internet]. 2023 [cited 2023 Aug]. Available from: https://www.mcnz.org.nz/about-us/our-data/.
31) Te Kaunihera Tapuhi o Aotearoa Nursing Council of New Zealand. Te Ohu Mahi o Aotearoa/The New Zealand Nursing Workforce: A profile of Nurse Practitioners, Registered Nurses and Enrolled Nurses 2018-19. Wellington, New Zealand: Te Kaunihera Tapuhi o Aotearoa/Nursing Council of New Zealand; 2019.
Contact diana@nzma.org.nz
for the PDF of this article
View Article PDF
Cardiovascular disease is responsible for a third of all deaths and is the leading cause of health loss in Aotearoa New Zealand. The current health system reform presents a once in a generation opportunity to address how our health system works for all. This includes addressing the gap in heart health outcomes[[1]] systematically and fairly to allow hundreds of thousands of affected New Zealanders to live longer and healthier lives.
When the Government released Te Pae Tata Interim New Zealand Health Plan 2022 it was disappointing that a clear commitment to reducing the burden of heart disease and stroke was not evident.[[2]]
In 2020, the Heart Foundation first called for a national heart health action plan. Since then, almost 30,000 New Zealanders have lost their lives to heart disease and stroke. We estimate 7,000 of those deaths were premature and avoidable.[[3]] These deaths could have been avoided through better prevention and improved and timely access to evidence-based healthcare.
The Heart Foundation is reiterating the urgent need for a national action plan for heart health, advocating for ambitious and achievable goals for better and more equitable heart health outcomes, by delivering a better heart health system. This starts with better prevention from early childhood and extends across the life course from assessing, understanding and managing heart disease risk, timely access to heart healthcare, improving survival following a heart event and planning for a sustainable skilled workforce delivering world-class care in a timely manner and where it is most needed.
In Aotearoa New Zealand there are huge and avoidable disparities in heart health outcomes. Māori, Pacific people and those living in the most deprived parts of the country are more likely to be exposed to risk factors such as smoking, and to face multiple barriers to accessing care including cost, transport, discrimination and systemic racism.[[4,5,6]] This results in under and delayed diagnosis and subsequent management and support. Urgent work is required to better understand and remove these barriers.[[7]]
Reasons for these disparities are complex, and include historical injustices, prejudice and mistrust in the health system, struggles for resources including health workforce, health literacy and geographical isolation.[[8]] In addition those regions with the greatest need for better heart healthcare are those with poorest access to healthcare, particularly delivered close to home.[[9]]
Progress on recommendations to improve heart health outcomes since 2020 has been poor. There have been some areas to celebrate including aggressive action towards a Smokefree 2025, some access to new drug treatments and the funding of a new centre of research excellence in heart health.[[10]] However, progress has been piecemeal, rather than bound by a clear and integrated strategy for achieving better outcomes.
Access to basic cardiovascular risk assessments and to cardiology services remains inconsistent and lacking for many New Zealanders. There are restrictions and limitations on access to cost-effective and evidence-based treatments, and cardiac arrest survival rates are hampered by inconsistent access to CPR and community defibrillators.[[11]]
Elements of the health system of Aotearoa New Zealand aimed at heart health are not currently working for everyone, especially for Māori, Pacific people, people living in areas of high deprivation and rural New Zealanders. About half of cardiovascular deaths in these populations are avoidable, meaning we could significantly reduce the impact of heart disease and stroke and improve health equity if our prevention and health care systems were working fairly for all.[[12]]
We have seen how ambitious targets can achieve results, in particular the substantial progress towards Smokefree 2025.[[13]]
The updated Heart Foundation white paper recommends that a national heart health action plan sets bold targets for better heart health and identifies six key areas that build on current strengths and have the potential to significantly reduce the impact of heart disease and stroke on all New Zealanders. It proposes that a national action plan has high level goals to reduce the rate of avoidable heart disease mortality and morbidity for all New Zealanders by at least 50% by 2050, and by 2040 for Māori and Pacific people.
Achieving these goals will require a life course approach with a balance between addressing outcomes for those at most immediate risk of heart disease by improving access to care and support, building a strong approach to heart disease risk screening and management, and ensuring better large-scale and sustainable outcomes longer term through effective prevention.
Our six priorities for a national heart health action plan are:
1. Reduce the risk of heart-related disease through prevention
Goal 1: reverse the declining trends in consumption of healthy food and physical activity and achieve minimal smoking for all populations by 2025.
A stronger prevention system needs to urgently address the personal and systemic financial and environmental barriers families face in accessing healthy food and undertaking regular physical activity.[[4,14]] A system where all children and families have the same access and rights to a healthy learning environment connected to their community is vital to set up young New Zealanders for heart-healthy lives.
2. Early detection and management of heart disease
Goal 2: 95% of eligible New Zealanders are risk assessed for cardiovascular disease (heart disease and stroke) and advised on appropriate risk management.
Manatū Hauora – Ministry of Health published the standard for cardiovascular disease risk assessment and management in primary care in 2018. It set out new guidelines recommending beginning cardiovascular risk assessments for men from age 45 and women from age 55. For Māori, Pacific and South Asian populations, risk assessment is recommended to start 15 years earlier than in other population groups.[[15]] Guidelines also set out standards for managing risk, and were accompanied by New Zealand’s own cardiovascular risk prediction equations for use in primary care.[[16]] Five years later, there is still no systematic approach to risk assessment, and management of cardiovascular risk.
For example, close to one in five adults have elevated blood pressure (>140/90mm Hg),[[15]] yet fewer than one in three New Zealanders with elevated blood pressure have it well controlled. This is well behind the OECD average.[[17]] Routine risk assessment, and identifying and managing those with risk—especially high blood pressure—is highly cost effective and will have an almost immediate impact on improving cardiovascular health in New Zealand.[[18]]
3. Timely access to evidence-based and effective care and support
Goal 3: reduce hospitalisations for acute cardiac presentations and stroke by 50% by 2040, with a particular focus on Māori, Pacific and South Asian populations.
People are often not able to access the heath system until forced to by an emergency, and even then delays in seeking and receiving care are common. A third of New Zealanders who had a heart attack in 2022 waited more than 2 hours to call for help.[[19]] A deterioration in timely access to angiography following an acute coronary syndrome presentation was also noted in 2022.[[20]]
There is significant regional variation in access to specialist opinion, diagnostic services including echocardiography, CT angiography, electrophysiology and invasive angiography with resultant variation in revascularisation, cardiac surgery and valve intervention.[[21]] Often these variations are inconsistent with need, with reduced access and longer wait times affecting communities at highest risk of poor heart health outcomes.
Aotearoa New Zealand is falling behind other countries with respect to access to effective evidence-based and recommended medicines. Current examples include restricted access to new diabetes drugs that improve heart health outcomes, which are currently only available to high-risk populations by special authority. SGLT-II inhibitors are a recommended foundation pillar of heart failure care in international guidelines[[22]] (Level I A) and are not currently funded for this indication in Aotearoa New Zealand. Sacubitril-Valsartan is a recommended foundation pillar for heart failure (Level I B) but is available with restricted access only.[[22,23]]
The delays in reaching care in the first place, delays in subsequent treatment and access to evidence-based care and medications are an entirely preventable failure of the health system. It requires a focus on early risk management and treatments, and on working with communities to remove the barriers to heart healthcare. Access to effective heart healthcare needs to match up with communities with the highest need, and the current situation where New Zealanders lack access to proven and cost-effective heart health medications must urgently be addressed.
4. Increase survival rates for out-of-hospital cardiac arrest
Goal 4: increase the survival rates for out-of-hospital cardiac arrest by 25% by 2030.
More than 2,300 people experienced a cardiac arrest in the community or at home in the year ending June 2022. Only one in 10 people who suffered an out-of-hospital cardiac arrest survived to hospital discharge compared to 1 in 7 in 2018.[[19]] We can reverse this trend by increasing access to life-saving CPR (cardiopulmonary resuscitation) and ensuring community defibrillators are where they are needed most, and by addressing regional and local disparities in access.[[11]] Aotearoa New Zealand should join nations like the United Kingdom, Germany, China, Norway, Sweden and the majority of states in the United States where teaching CPR in schools is mandatory. Teaching CPR and AED (automated external defibrillator) skills in schools is a simple addition to the curriculum that will increase rates of bystander CPR, improve access to early defibrillation and achieve better outcomes for people suffering out-of-hospital cardiac arrest.[[24]]
5. A more transparent and accountable health system
Goal 5: set clear accountable goals for heart disease risk management and outcomes and provide adequate resourcing and incentives to achieve them.
Currently, around one in eight health dollars are spent on heart disease and stroke, and the wider costs associated with disability and death reaches many hundreds of millions of dollars.[[25]] Acting on heart health is highly cost effective—just improving on the sub-optimal management of high blood pressure alone would reduce the lifetime cost to the health system by several million dollars.[[18]]
A transparent health system requires clear accountability to those most at risk of heart disease, and uses data systematically to measure and improve impact. While we can measure risks, such as smoking, and outcomes, such as hospitalisations and deaths, there are limited systematic measures of prevention and management of heart disease, with some areas of the heart health journey better covered than others. For example, Te Whatu Ora – Health New Zealand fund the All New Zealand Acute Coronary Syndrome Quality Improvement programme (ANZACS-QI), collecting data from secondary care allowing for benchmarking of services provided, which also highlights quality improvement opportunities. Data on planned care wait times can be accessed, and drug dispensing is available via Pharmac.[[26,27]] However, these are reported largely independent of each other, and not in the context of an overarching strategy for cardiovascular disease. A heart health strategy must pull this together in order to cohesively drive and measure improvement across the health continuum, and be accountable and transparent to patients and the public. For example, drawing on the experiences from Aotearoa New Zealand’s world-leading COVID-19 reporting.[[28]]
Aotearoa New Zealand needs accessible, coordinated and quality national data that report accurate, timely information on the burden of heart disease, monitors and guides efforts and, in particular, increases transparency and accountability for closing the heart health equity gap.
6. Support a world-class health workforce to translate research into practice
Goal 6: attract and maintain a world-class health workforce delivering world-class heart healthcare in Aotearoa New Zealand.
Aotearoa New Zealand has world-class heart research programmes both domestically and through international collaborations. Developing and resourcing stronger pathways from research to practice and closing the evidence-to-action gap will ensure that New Zealanders are benefitting from research.
Putting research findings into action requires supporting and sustaining a high-quality workforce and providing resources for implementation. Currently New Zealand faces a future health workforce shortage and limited representation in our heart health workforce including doctors, nurses, cardiac physiologists and echosonographers. There are around 160 cardiologists practicing in Aotearoa New Zealand, of whom an estimated 2.5% are Māori or Pacific. Eighteen percent are women.[[29,30]] Māori and Pacific nurses are also under-represented in cardiac specialties.[[31]] There are also significant inequalities in FTE numbers of the heart health workforce across regions. More promotion of heart health as a career pathway, to build a sustainable, skilled and diverse workforce that represents the Aotearoa New Zealand population, is urgently required. It will build expertise for the future and create a workforce that is connected and relevant to patients.
In summary, cardiovascular disease remains responsible for a third of all mortality and is the leading cause of health loss in Aotearoa New Zealand. More New Zealanders are living with heart disease than ever before. There are huge disparities in timely diagnosis, treatment and outcomes in heart health, most of which is avoidable. Aotearoa New Zealand is a world leader in many aspects of heart research, but translation into outcomes for our population remains inconsistent, unequal and unfair, and is falling behind international best practice. Movement beyond the current disconnected and an ad hoc approach is needed.
Aotearoa New Zealand urgently needs an action plan to focus on reducing the avoidable and inequitable burden of heart disease. Health system reforms are a critical opportunity to address the lack of coherent strategy for heart health and bring together clinicians, health planners, policy makers, communities and Māori and Pacific health leaders to develop a roadmap for better outcomes.
This has been done for smoking, cancer, mental health and diabetes, among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda.
Summary
Abstract
Aim
Cardiovascular diseases are responsible for almost 10,000 deaths annually in Aotearoa New Zealand. Almost a quarter of these are avoidable, increasing to half of all cardiovascular deaths for Māori and Pacific people. Health system reforms are an opportunity to set clear ambitious goals for improved heart health. This has been done for smoking, a cancer plan, mental health and diabetes among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda.
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Call to action—the urgent need for a heart health plan in New Zealand
Cardiovascular disease is responsible for a third of all deaths and is the leading cause of health loss in Aotearoa New Zealand. The current health system reform presents a once in a generation opportunity to address how our health system works for all.
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