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