Ischaemic Heart Disease (IHD)
A Pathway to Prioritisation
March 2014
1
Executive Summary
In Strategic Overview: Cardiovascular Disease in New Zealand, the National Health Committee
(NHC) identified Ischaemic Heart Disease (IHD) as a cardiovascular disease in which there
exists a significant potential to improve health outcomes and efficiency. This report explores the
pathway of care for Ischaemic Heart Disease (IHD) to identify areas within the pathway that
may require investment, targeting, or service reconfiguration to deliver health and efficiency
gains.
The report maps out the pathway of care for IHD including health system indicators, costs and
flows of patients. A horizon scan of IHD technologies is presented along with results from a
survey of stakeholders on options to improve the pathway of care. Our preliminary analysis
suggests a discussion may be required around access to IHD services for Māori and highly
deprived populations. Horizon scanning has thus far yielded more than 80 options for change
(investment, targeting, and reconfiguration) to improve the pathway of care. Our survey of
stakeholder’s views yielded 50 options for improvement (with some overlap). Ultimately, the
NHC only has capacity to consider up to five interventions for assessment. Where the NHC
executive does not have the capacity to advance a promising assessment, it will endeavour to
share information, where appropriate, with relevant decision makers, such as the Ministry of
Health and PHARMAC.
Table of Contents
1
Executive Summary ............................................................................................................ 1
2
Purpose............................................................................................................................... 3
3
Introduction ......................................................................................................................... 3
4
Background ......................................................................................................................... 4
5
Overview of IHD health outcomes and cost ......................................................................... 5
6
IHD Pathway of Care........................................................................................................... 8
7
Interventions...................................................................................................................... 14
8
Health Innovation Partnership IHD Expression of Interest Assessment ............................. 26
9
NHC Executive Perspective .............................................................................................. 26
10
Limitations ..................................................................................................................... 31
Appendix 1: Cost Tables .......................................................................................................... 32
Low-deprivation Non-Māori ...................................................................................................... 34
Appendix 2: Full Methodology .................................................................................................. 34
2 Purpose
The purpose of this report is to explore the pathway of care for IHD patients and identify
potential areas for investment, targeting, or service reconfiguration to deliver better health
outcomes and improved efficiency.
3 Introduction
The National Health Committee (NHC) is tasked with improving health outcomes whilst
maintaining or reducing costs through the prioritisation of the most cost effective new and
existing health technologies. It does this by assessing ‘value for money’ in terms of health
outcomes and cost to the health sector.
The NHC’s goal is to improve health outcomes and
health sector sustainability through better investment and targeting of technologies and service
reconfiguration. With this goal in mind, the NHC identified cardiovascular disease as a priority
area as it affects a large number of people and results in a significant spend in Vote: Health –
the Government’s health expenditure.
In October 2013, the NHC published Strategic Overview: Cardiovascular Disease in New
Zealand.(1) That document explored the burden of cardiovascular disease from a
prevalence/incidence, health outcomes, utilisation and cost perspective in order to identify
which cardiovascular disease the NHC should focus further work on in 2013/14. Based on the
evidence presented in that report, the NHC identified Ischaemic Heart Disease (IHD) as fitting
best with its decision-making criteria and has agreed to conduct further assessment as per its
tiered assessment approach.
This report takes a pathway of care approach to assessing where value may be added to the
care of IHD patients. This report maps out the pathway of care for IHD including health
outcomes, health system indicators, costs and flows of patients. Advice from a cardiovascular
working group and a survey of sector representatives is incorporated to derive a short list of five
interventions for further assessment.
4 Background
4.1
4.1.1
IHD description and overview of management
Description
IHD is a condition in which there is insufficient blood and oxygen flow to heart muscle
(myocardium), as a result of a mismatch between supply and demand (ischaemia). This is most
commonly a result of coronary artery disease (CAD) due to atherosclerosis (the process of
inflammation, lipid deposition and progressive narrowing of medium to large blood vessels)
reducing the blood supply to the myocardium. These narrowings are called atheroscheloric
plaques. IHD is more common in males and in Māori. The mortality rate due to IHD has been
steadily declining across all subgroups since a peak in the 1960s and 1970s (2).
4.1.2
Risk factors and symptoms
A number of societal and individual risk factors contribute to the development of IHD, including
tobacco smoking, western diet, diabetes mellitus, high cholesterol, obesity, hypertension,
chronic renal failure and a family history of IHD. Sufferers will most often have symptoms
resulting from lack of oxygen to the myocardium. This can begin with breathlessness, sweating
and chest discomfort associated with exertion (angina pectoris) but may progress until these
symptoms are present on minimal exertion or at rest. Alternatively sufferers may present with a
sudden onset of prolonged symptoms at rest indicating myocardial infarction (MI), the death of
myocardium due to lack of blood supply. This is usually due to the sudden formation of a blood
clot over existing vulnerable atheroschlerotic plaque in a specific coronary artery. If sufficient
cardiac muscle dies, or if there is an accumulation of damage over time, this can lead to heart
failure through the process of left-ventricular (LV) remodelling. Areas of myocardial scar tissue
or Ischaemic myocardium may also act as a substrate for electrical disturbances of the heart
(arrhythmia), particularly ventricular tachycardia (VT), and may even lead to cardiac arrest from
ventricular fibrillation (VF). Other arrhythmias such as atrial fibrillation and conduction block may
also occur as a consequence of IHD.
4.1.3
Prevention
Primary prevention of IHD is partially through public health measures to increase awareness,
reduce smoking, encourage exercise, and improve diet. Prevention also includes the targeting
of individuals to treat modifiable factors, such as hypertension and high cholesterol, with
appropriate medications to pre-specified targets. The identification of high-risk individuals allows
aggressive preventative strategies to be implemented early. These measures seek to prevent,
slow or reverse the changes associated with IHD.
4.1.4
Diagnosis
The diagnosis of IHD is made based on clinical findings, the 12-lead electrocardiogram (ECG),
cardiac stress testing/imaging, and coronary angiography/CT coronary angiography. There are
different types of stress test used in routine clinical practice with varying sensitivity for stable
IHD; ECG-based exercise tolerance testing, exercise/dobutamine stress echocardiography and
stress-perfusion cardiac MRI. Also in a few centres around NZ, nuclear stress imaging is
performed.
CT coronary angiography allows direct tomographic imaging of the coronary
arteries but at lower resolution than traditional angiography. Coronary angiography remains the
gold standard investigation to diagnose and delineate the severity of stable or unstable coronary
disease. In those that have unstable symptoms or symptoms at rest, measurement of troponin T
or I in the blood facilitates the diagnosis of MI (3).
4.1.5
Treatment
Once IHD is established, treatment is aimed at reducing symptoms, lengthening life and
preventing complications of the disease. Anti-anginal medications such as nitrates, calciumchannel blockers and beta-blockers are used for managing symptoms. Statins and antiplatelet
agents are commenced to prevent disease progression and future events such as MI. If there
are severe narrowings on angiography, an attempt to either open or bypass the diseased vessel
can be made. This is done through percutaneous coronary intervention (PCI) or by surgical
coronary artery bypass grafting (CABG). Following PCI, antiplatelet agents are introduced to
maintain stent patency and prevent myocardial infarction (MI). After MI, medications such as
beta-blockers and angiotensin-converting-enzyme (ACE) inhibitors are commenced to prevent
ventricular remodelling and progression to heart failure. Cardiac rehabilitation programmes are
important to educate patients and reinforce lifestyle changes that are important to maximise
recovery after a cardiac event.
5 Overview of IHD health outcomes and cost
Before examining the IHD pathway of care (Figure 5) it is worth viewing IHD in its wider health
and cost context. The wider health context is that mortality rates for IHD have been steadily
declining in New Zealand since their peak in the late 1960’s largely due to reductions in three
risk factors – systolic blood pressure, total blood cholesterol and cigarette smoking
(4)
. Age-
standardised IHD mortality rates decreased by over two-thirds (69.5 percent) between 1980 and
2010 (5). In 2010, however, IHD remained the second largest cause of death, behind cancer,
accounting for 18.8 percent of deaths. Significant disparities remain with Māori males having the
highest age-standardised IHD mortality rate in 2010, being 55.6 percent higher than the rate for
non-Māori males. The rate for Māori females was nearly twice as high (99.0 percent) as the rate
for non-Māori females (5).
Rates of IHD are higher in more deprived areas, with about seven percent of people living in the
most deprived areas (quintile 5) being diagnosed with IHD, compared with a little over four
percent in the least deprived areas (quintile 1)
(6)
. After adjusting for age, sex and ethnic group,
people in the most deprived areas are 1.9 times more likely to have been diagnosed with IHD
compared to people in the least deprived areas. Māori have 1.8 times the rate of diagnosed IHD
(age-standardised) compared with non-Māori (6).
Overall we estimate that the cost of IHD to the health system is about $287 million per annum.
Cost is largely driven by hospitalisations, accounting for about 65 percent of total cost.
Pharmaceuticals account for 18 percent of cost, followed by general practice and out-patient
and emergency department expenditure, accounting for about eight percent of total cost
respectively (Figure 1).
Figure 1: IHD Cost by Service Area 2011/12
Total IHD Cost
Pallitive
0.0%
Troponin
0.1%
Angiography
0.3%
Pharmaceuticals
18.0%
GPs
8.3%
Hospitalisations
65.0%
Outpatient ED
8.2%
Source: 2014 NHC analysis of 2011/12 New Zealand Health Tracker data
Hospitalisation costs have grown significantly since 2001. Between 2001/02 and 2012/13
nominal IHD hospitalisation costs nearly doubled to $184 million. At the same time IHD hospital
admissions declined 13 percent (Figure 2).
Figure 2: IHD Hospitalisation Costs and Volumes of Admissions 2001/02 - 2012/13Error! Reference source not
ound.
Hospital admissions
27000
$200,000,000
$180,000,000
$160,000,000
$140,000,000
$120,000,000
$100,000,000
$80,000,000
$60,000,000
$40,000,000
$20,000,000
$0
26000
25000
24000
23000
22000
21000
IHD Hospitalisation Cost
2001/2002
2002/2003
2003/2004
2004/2005
2005/2006
2006/2007
2007/2008
2008/2009
2009/2010
2010/2011
2011/2012
2012/2013
20000
Volume of hospital admissions
Source: 2014 NHC analysis of 2011/12 New Zealand Health Tracker data
In 2011/12 84 percent of IHD patients did not have a hospital admission, and accounted for less
than a third (28 percent) of total cost (Figure 3). By contrast nine percent of patients had at least
one hospitalisation and accounted for nearly two-thirds (64 percent) of total cost. Seven percent
of IHD patients died, accounting for eight percent of total cost.
Figure 3: Costs and Flows of IHD Patients 2011/12
Persons with IHD 2011/12
Hospitali
sed IHD
9%
IHD Costs 2011/12
Death
7%
Death
8%
Nonhospitalis
ed IHD
84%
Nonhospitalis
ed IHD
28%
Hospitali
sed IHD
64%
Source: 2014 NHC analysis of 2011/12 New Zealand Health Tracker data
Disparities in health outcomes are reflected in a greater average cost of treatment for Māori
compared to Non-Māori and a greater average cost for high deprivation patients compared with
lower deprivation patients (Figure 4). Overall, the average cost of treating Māori IHD patients is
about 18 percent greater than treating Non-Māori IHD patients. The average cost of treating
high deprivation IHD patients is about 22 percent greater than low deprivation patients.
Figure 4: Average Cost of Treating IHD Patients by Ethnicity and Deprivation Level
2500
$/patients
2000
1500
Maori
1000
Non-Maori
500
Total
0
High Deprivation
(Quintile 5)
Moderate
Deprivation
(Quintile 2-4)
Low Deprivation
(Quintile 1)
Total
Source: 2014 NHC analysis of 2011/12 New Zealand Health Tracker data
Lastly, the pathway of care presented in Figure 5 below does not communicate the important
effect on health outcomes or cost of comorbidities. To estimate this effect would be a major
statistical exercise. Nevertheless, excluding IHD, we found that nearly two-thirds (65 percent) of
IHD patients have one of thirteen comorbidities we have looked at (lung cancer, colorectal
cancer, (female) breast cancer, prostate cancer, other cancer/s, chronic obstructive pulmonary
disease, asthma, ever-hospitalised stroke, anxiety and/or depression (past 12 months),
dementia, gout, diabetes, heart failure.) Thirty-five percent of these patients had one
comorbidity, 20 percent had two, 8 percent had three, 2 percent had four and less than 1% had
five or more comorbidities.
6 IHD Pathway of Care
Figure 5 depicts a simplified pathway of care for IHD. The pathway provides a general picture of
IHD care, but not every patient will travel through it in the same way nor will they receive the
same interventions along the pathway of care. It presents a static picture rather than a dynamic
model of a patient’s experience. The pathway has been condensed into five phases progressing
from prevention, early management of IHD, non-hospitalised IHD, to hospitalised IHD and lastly
death. Further information on how these phases have been defined is provided in Appendix 2.
Due to an absence of useful data some important components of the pathway of care are
missing. For example, the pathway does not include diagnosis indicators for a number of
significant interventions, and we have limited access to primary care data.
The pathway maps IHD prevalence, primary outcomes, modifiable risk factors, health targets,
secondary care indicators, significant IHD interventions, and the costs and flows of patients.
Primary outcomes include Disability Adjusted Life Years (DALY) lost to IHD and IHD mortality.
Modifiable risk factors include the percentage of adults (aged over 15) who are daily smokers,
the percentage of obese adults (Body Mass Index, BMI, greater than 30), the percentage of
adults with medicated high blood pressure, and the percentage of adults with medicated high
cholesterol. Of these risk factors high blood cholesterol, high systolic blood pressure, and
tobacco use account for at least 70 percent of the burden of IHD
(7)
. Health targets include the
‘support for smokers to quit’ target, and the ‘heart and diabetes checks’ target. The secondary
care indicators are MI mortality rate at 30 days, MI readmission rate at 30 days, and IHD
hospital discharges per 100 IHD population. The IHD interventions mapped include the
percentage
of
adults
on
triple
therapy
(defined
as
taking
aspirin
or
other
antiplatelet/anticoagulant agent, a beta blocker and a statin), age standardised rate of coronary
artery bypass grafts (CAGB), and age standardised rate of angioplasty.
Figure 5: IHD Pathway of Care
Prevention
Early Management
Non-hospitalised IHD
Hospitalised IHD
Death
IHD Prevalence
Health Target: Heart and diabetes checks
Triple Therapy
Triple Therapy
IHD Mortality (Age Standardised)
• 4.9% 2012/13 (5.3% in 2006/07)
• 69% of eligible pop had cardiovascular
risk assessed in past 5 years Q1 2013/14
• Māori 1.8 times prevalence
• 46% of non-hospitalised IHD patients on
triple therapy 2011/12
• 75% of hospitalised IHD patients were on
triple therapy
• In 2010 IHD accounted for 5389 deaths, or
about 19 percent of all deaths.
• 49% had been assessed in Q4 2011/12
• IHD Mortality rates declined 71% between
1980 and 2010.
• 89,000 DALYs lost : 9.3% of total DALYs
lost in 2006
• 70-80% is avoidable.
Risk Factors (Age Standardised)
Costs and flows
Costs and flows
MI Indicators (Age Standardised)
• 15.5% of adults daily smokers 2012/13
(18.3% in 2006/07)
• 81,000 people diagnosed
• 145,000 patients or 84% of identified
people with IHD
• MI mortality rate at 30 days = 3.0 % of MI
discharges
• 36% of Māori smoke 2012/13
• Total cost (troponin, community referred
tests, cardiology first referrals and
angiographies): $46 million
• Average cost = $550 per person
• MI readmission rate at 30 days = 1.2 % of
MI discharges
• 14,000 DALYs lost from smoking
attributable to IHD in 2006
• 31.3% of adults had a BMI > 30 in 2012/13
(26.5% 2006/07)
• 28,000 DALYs lost from BMI > 30
attributable to IHD in 2006
• 48% of Māori & 68% Pacific 2012/13
• 15.9% of adults had (medicated) high
blood pressure in 2012/13
• 39,000 DALYs lost from high BP attributable
to IHD in 2006
• 11% of adults had (medicated) high
cholesterol in 2012/13 (8.4% 2006/07)
• 28,000 DALYs lost from high cholesterol
attributable to IHD 2006
• Average cost $570 per person
• Total Cost = $80 million
• Māori men have 1.5 times age
standardised mortality rate non-Māori.
Mortality rates for Māori women are about
twice as high as Non-Māori women.
• No significant difference Māori/Non-Māori
for either
Hospital discharges (Age Standardised)
Costs and flows
• Discharges per IHD prevalent population
= 16%
• 12,000 people or 7% of identified people
with IHD
• Māori = 14%, Non-Māori = 17%
• Average cost = $1,900 per person
• Total cost = $22 million
Procedures (Age Standardised)
• CABG per MI discharges = 13 %
• Māori = 9%, Non-Māori = 14%
Health Target: Support for Smokers to quit
• Angioplasty per MI discharges = 66%
• 60% of patients are offered advice and
support to quit Q1 2013/14
• 34% in Q4 2011/12
• Māori = 39%, Non-Māori = 67%
Costs and flows
Costs and flows
• 240,000 people screened or receiving
pharmaceuticals for at-risk patients
• Average cost = $132 per person
• Total cost = $32 million
• 15,000 patients or 8.6% of identified
people with IHD
• Average cost $12,600 per person
• Total cost = $185 million
Source: MoH. NZ Health Survey: Annual update of key findings 2012/13. 2013; MoH. NZ Burden of Disease, Injuries and Risk Factors Study, 2006-2016. 2013; MoH. Mortality and Demographic Data 2010. 2013.; MoH. Health Targets. 2014. Costs and flows data,
discharges data, and procedures data derived from NHC analysis of the 2011/12 New Zealand Health Tracker, Pharmaceutical Collection, National Minimum Dataset, and 2010 Mortality Collection.
The costs and flows data provide an estimate of the number of people at each phase of the
pathway, the average cost of interventions, and the total cost to the health system. Here price
has been used as a proxy for cost as it is more readily available and is correlated with the cost
of the services being summarised. Cost has been measured over the 12 month period 2011/12
and thus does not reflect the expected costs of individual patients as they transition through
disease states. With the exception of the early management phase, the phases presented are
mutually exclusive. The diagnostic costs contained in the early management phase are also
counted in the later phases. Further information on the costs and flows data are contained in
Appendix 2.
6.1
Prevention
For adults aged over 15 the pathway shows an improvement from 2006/07 to 2012/13 in IHD
prevalence (5.3 percent to 4.9 percent), smoking rates (18.3 percent to 15.5 percent), and
greater support for patients to quit smoking
(8-10)
. The target sits across the pathway of care but
is included in early management for ease of illustration. The target is for 90 percent of Primary
Health Organisation (PHO) enrolled patients who smoke to be seen by a health practitioner in
general practice and offered brief advice and support to quit smoking, and for 95 percent of
hospitalised patients to be offered advice by a health practitioner in public hospitals. The target
also includes 90 percent of pregnant women (who identify as smokers at the time of
confirmation of pregnancy in general practice or booking with Lead Maternity Carer) being
offered advice and support to quit.
Obesity rates have increased since 2006/07 (26.5 percent) with nearly a third (31.3 percent) of
New Zealand adults obese in 2012/13. Obesity rates have also increased for children aged 2-14
years from eight percent in 2006/07 to 10 percent in 2011/12 (11). Obesity rates are higher
among Māori (17%) and Pacific (23 %) children, and children living in the most deprived areas
(19%). If not addressed a higher obesity rate in children may lead to a rise in heart disease in
the future. Māori have nearly twice the IHD prevalence of Non-Māori; more than double the
smoking rate, and almost half of Māori adults are obese (8). About 16 percent of adults have
medicated high blood pressure, and 11 percent have medicated high blood cholesterol.
IHD was responsible for the loss of 89,000 DALYs in 2006, or about 9.3 percent of total DALYs
lost
(5)
. About 39,000 DALYs were lost from high blood pressure attributable to IHD.
Approximately 28,000 DALYs were lost from high cholesterol and an equivalent number of
DALYs were lost from obesity attributable to IHD. About 14,000 DALYs were lost due to
smoking attributable to IHD1. Note the lost DALYs from the IHD risk factors are not mutually
exclusive and thus not additive.
We estimate that about 240,000 people were subject to primary prevention for IHD in 2011/12.
The primary prevention population is estimated based on the ‘at-risk’ group defined by the
Primary Health Care Handbook cardiovascular risk assessment criteria
(12)
; or anyone taking
three IHD related pharmaceuticals including a statin and an antiplatelet or anticoagulant who
has not been included in the IHD prevalent population. We estimate the total cost of this ‘at-risk’
population is about $32 million per annum or $132 per person.
6.2
Early management
Sixty-nine percent of the eligible population had had their cardiovascular risk assessed in the
past 5 years in the first quarter of 2013/14
was 49 percent
(9)
. In quarter 4 of 2011/12 the corresponding figure
(13)
. The national target is to achieve 90 percent coverage. We estimate that
about 81,000 people had an IHD diagnostic test in 2011/12, with an average cost of about $570
per person and total cost of $46 million per annum, some of these tests were for monitoring
purposes, rather than initial diagnoses, and some of them did not result in any IHD diagnosis.
6.3
Non-hospitalised IHD
We estimate that there were about 145,000 people with IHD who did not have a hospital
admission in 2011/12. Nearly half (46 percent) of non-hospitalised IHD patients were on triple
therapy in 2011/12. This estimate corroborates reasonably well with the Health Quality and
Safety Commissions estimate of CVD patients on triple therapy. We estimate that 47 percent of
all IHD patients receive triple therapy, while the HQSC atlas of variation estimates that 53.5
percent of CVD patients receive triple therapy
(14)
. Average costs for non-hospitalised patients
were about $550 per patient, or a total of $80 million per annum.
6.4
Hospitalised IHD
We estimate that there were about 15,000 people with IHD who had at least one hospital
admission in 2011/12. The average cost per patient was $12,600 with a total cost of $185
million per annum. The national MI mortality rate at 30 days of hospital discharge was 3.0 per
100 MI discharges. The MI readmission rate at 30 days of hospital discharge was 1.2 per 100
MI discharges. There was no significant2 difference between Māori and Non-Māori in these
1
The DALYs lost from Smoking is unpublished NZ Burden of Disease data obtained from the Ministry of Health
Health and Disability Intelligence Unit.
2
Significant differences in this report refer to statistical significance to the 5% level. Ninety-five percent confidence
intervals have been calculated for the data presented. They are not presented as data collection anomalies
rates, and no clear correlation with deprivation. Nationally there were 16 hospital discharges per
100 IHD prevalent population. Māori had a significantly lower rate of hospital discharge at 14
compared with Non-Māori at 17 per 100 IHD prevalent population, again, however, there is no
clear pattern relating to deprivation.
Three quarters of hospitalised IHD patients were on triple therapy in 2011/12. Age standardised
rates of Coronary Artery Bypass Graft (CABG) surgery and angioplasty stand at 13 and 66 per
100 MI patients respectively. Overall Māori have significantly lower rates of CABG (8.7 vs 13.7)
and Angioplasty (38.4 vs 66.9) than Non-Māori (Figure 6).
Figure 6: Age standardised Rates of CABG and Angioplasty by ethnicity and deprivation
ASR CABG per 100 MI discharges
18
16
14
12
10
8
6
4
2
0
Maori
Non-Maori
Total
ASR Angioplasty per 100 MI discharges
90
80
70
60
50
40
30
20
10
0
Deprivation quintile
Maori
Non-Maori
Total
Deprivation quintile
Source: 2014 NHC analysis of 2011/12 New Zealand Health Tracker data
Māori have 1.8 times the rate of diagnosed IHD (age-standardised) compared with non-Māori
(6)
. After adjusting for age, sex and ethnic group, people in the most deprived areas are 1.9
times more likely to have been diagnosed with IHD compared to people in the least deprived
areas. Given this and assuming equivalent drivers for admission and procedures, we might
expect to see higher age-standardised rates of hospital discharge, CABG and angioplasty than
illustrated for Māori and the least deprived.
(which can emerge in later investigation) are not accounted for in confidence intervals which can distort summary
statistics giving the reader a false impression of accuracy.
6.5
Death
About 12,000 people with IHD died in 2011/12, with the average cost per patient about $1,900
per patient and a total cost of $22 million. IHD mortality, including myocardial infarction, has
declined more than 70 percent since 1980 and accounted for 19 percent of all deaths in 2010 (5).
The age standardised mortality rate is 88 per 100,000 population for men and 47.5 per 100,000
population for women. Māori men have 1.5 times the age standardised mortality rate of nonMāori. Mortality rates for Māori women are about twice as high as Non-Māori women.
7 Interventions
The NHC executive undertook a review of the Cochrane systematic review database and the
HealthPACT database to identify technologies and models of care to improve the pathway of
care for IHD patients. The search was supplemented by numerous other papers relating to IHD
known to the NHC executive. Appendix 3 contains more than 80 IHD Investment, Targeting or
Service Reconfiguration options. This horizon scan was subsequently shared with stakeholders
in a two phase engagement process to elicit options to improve the IHD pathway of care.
Stakeholders included:
1. Ambulance New Zealand
2. The National Heart Foundation
3. The Royal New Zealand College of General Practitioners
4. The Pharmaceutical Society of New Zealand
5. The PHO Service Agreement Amendment Protocol Group
6. The New Zealand College of Public Health Medicine
7. The National Nursing Organisations
8. The Royal Australasian College of Physicians
9. The Royal Australasian College Surgeons
10. DHB Planning and Funding (representative)
11. DHB Chief Operating Officer (representative)
The NHC executive requested a representative from each body to undertake an online survey
eliciting options to improve the IHD pathway of care, and the same or a different representative
to sit on a cardiovascular working group (CWG). The CWG was established to provide the NHC
executive with a realism lens on the state of IHD care, provide technical feedback on specific
interventions, and offer general advice on where the NHC might add the most value in its
assessments.
The online survey elicited options for:

Better service configuration

Better targeting of existing technologies and services

Better investment in cost-effective technologies
Service configuration, targeting and investment are explained in Figure 7 as articulated to
stakeholders. Elicited options from the survey were incorporated in an earlier draft of this
document, which was then discussed at the first Cardiovascular Working Group (CWG) meeting
in February 2014. Full results from the survey are presented below (see Table 1).
Figure 7: Terminology - Service Configuration, Targeting, Investment
Better service configuration
Options for better service configuration involve thinking about where there may be hold-ups in existing
services and opportunities for better management of a patients care. Cues for better service
configuration include:

Over-reliance on inpatient care due to insufficient focus on an earlier phase of a patients care
pathway including preventative care.

Unexplained variation in patient care pathways across regions, or outdated or poorly adhered to
patient care pathways.

Poor quality patient outcomes including mortality, quality of life, and patient experience through
the health system.
Better Targeting
Options for better targeting involve thinking about the relative value of current technologies and services
for patients. Cues for better targeting opportunities include:

Safety – is a commonly used and/or high cost intervention’s safety profile unacceptable in
some patient groups?

Effectiveness – does a commonly used and/or high cost intervention deliver little or no benefit
in some patient groups? Or is there little evidence to justify its use?

Cost-effectiveness – is a commonly used and/or high cost intervention cost-ineffective in some
patient groups? Do, for example, alternative cost-effective interventions exist that render the
intervention obsolete?

Indication creep – has a commonly used and/or high cost intervention expanded into areas of
practice where there is little evidence base? Alternatively, does an emerging technology in the
health system require evidence based leadership to contain potential indication creep?

Unexplained variation – is there large regional variation in a commonly used and/or high cost
intervention which cannot be explained by variation in need? Similarly, are we over supplying
certain health services relative to other developed countries?
Better Investment
Options for better investment involves thinking about where most value for money can be gained from the
next dollar spent on IHD patients. Cues for better investment opportunities include:

Safety and effectiveness – Is the technology safe and effective for the population group for
which it is proposed?

Cost effectiveness and budgetary impact – Is the technology affordable and does it represent
value for money in a fiscally constrained environment
7.1
CWG options for improving IHD care
The CWG indicated priority for the following assessment options:
1. Investment into cardiac rehabilitation to prevent hospital readmission. The evidence
base is already well established for cardiac rehabilitation, so this option may be more
about implementation than evidence assessment. There may be opportunity, especially
in smaller DHBs, to combine cardiac rehabilitation with pulmonary rehabilitation3.
2. Management of chest pain pathways for:
a. ‘low risk’ patients with an accelerated pathway. This may be a case of rolling out
models currently available in the NZ health system rather than exhaustive HTA.
b. ‘intermediate risk’ patients with CT angiography.
3. Implantable Cardiac Defibrillators (ICD), possibly including an assessment of the
Microvolt t-wave alternans (MTWA) for better targeting of patients suitable. It was
recommended that the NHC approach NZPEG (cardiac electrophysiology) for their
perspective on ICDs.
4. Avoiding unnecessary interventions - The CWG agreed that it was important to avoid
unnecessary interventions, and several options were discussed. It was agreed that
further discussion was warranted with the health sector. Here it was suggested the NHC
either go to the National Cardiac Network for endorsement of a set of internationally
recognised, evidence based, unnecessary interventions, or run an additional survey of
the sector of things doctors/patients should think twice about (i.e. a Choosing Wisely
style approach4). It was noted that nothing on the UK National Institute for Health and
Care Excellence Do-Not-Do list relating to IHD were common practice in New Zealand
except ECG-based stress testing to diagnose or exclude stable angina for people
without known coronary artery disease5.
3
The NHC is also investigating opportunities for assessment in the area of chronic obstructive pulmonary disease,
COPD.
4
The Choosing Wisely Initiative was established by the American Board of Internal Medicine to focus on encouraging
physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that
may be unnecessary, and in some instances can cause harm. The initiative is voluntary and medical speciality
society led, it centres on the formation of short lists of five tests or procedures doctors and patients should think
twice about before choosing: http://www.choosingwisely.org/
5
http://www.nice.org.uk/usingguidance/donotdorecommendations/
Table 1: Summary of feedback on investment, targeting and service reconfiguration options for the pathway
of care in IHD
Option
Type of Option
Description / Evidence
National Nursing Organisation
Cardiac
Rehabilitation
Investment
Current investment is limited; increasing the uptake of ’gold
standard’ cardiac rehabilitation has the potential to reduce
cardiac-related readmissions and deliver significant financial
savings.
Nurse-led
services/clinics
Investment
New Zealand cardiology departments have been slow to
respond in recognising the value of nurse led services outside
the CCU/ICU. The funding at a national level to support nurses
and cardiologists to develop new models of care for New
Zealand would be minimal but would have a significant impact
on waiting times and patient outcomes.
Ambulance Association
Lifenet (from
Physio Control)
Investment
Allows live transmission of the 12-lead ECG from the patient's
location to the cardiologist in the case of ST elevation
myocardial infarction to alert and prepare hospital staff for
percutaneous coronary intervention or thrombolysis in the field.
Nationwide
Destination
policies
Service
reconfiguration
In the Wellington Region, patient’s suffering ST-elevation
myocardial infarction are fast-tracked to the regional cardiac
centre, by-passing district hospitals (with the exception of North
Wairarapa). This has markedly reduced time to percutaneous
coronary intervention in these patients. The ambulance sector
would like to extend this system more widely but destination
policies would need to be in place nationwide. Cardiac
conditions appropriate for treatment at local hospitals should be
agreed.
Management of
Narrow complex
Tachycardia
Service
reconfiguration
St John ambulance has implemented a national guideline
allowing paramedics to treat selected patients with
supraventricular tachycardia to be treated on scene with
adenosine. In the absence of complicating factors, the patient
can be left at home when the treatment is successful. This
guideline should be extended nationwide. Apart from patient
benefit, transport to hospital is avoided in many cases.
DHB COO
Process of care
Investment
There is a very sound evidence base for most of the
interventions currently available to prevent, detect and manage
IHD at each level. Work is underway in the sector in each of
these areas to improve practice and outcomes eg tobacco
control, CVD risk assessment and smoking cessation advice and
management (national targets), work by cardiac networks to
increase intervention rates.
Smoking
cessation
Investment
Despite the apparently excellent (hospital) and improving
(primary care) target results we are probably not taking smoking
cessation seriously enough.
Unchecked
Obesity
Investment
NHC assessment of what works for obesity management /
prevention.
Option
Type of Option
Description / Evidence
Rapid
Diagnosis and
Retrieval
Service
reconfiguration
Extending the ambulance/helicopter rapid diagnosis and retrieval
system in place for example in the Wellington/Hutt/Kapiti for
primary angioplasty patients to the Wairarapa/Manawatu sub
region to support more timely access to care and better
outcomes.
Intervention
rates
Service
reconfiguration
Continue to support regional DHBs with below target intervention
rates with support staff, frequent rate reporting and education.
Acute patient
referral system
Service
reconfiguration /
investment
Constructing a region-wide web-based acute patient referral
system visible to all referrers to improve wait-time visibility
access and overall communication.
Chest pain
pathways
Service
reconfiguration
Development and Introduction of standardised chest pain
pathways to expedite the assessment and diagnosis of IHD in
the community and therefore appropriate management in the
right setting.
Anti-Platelet
therapy
Target
Continuing to reduce the administration of high cost anti-platelet
therapy (iv abciximab) in the acute patient
Thrombolysis
Target
Continuing to move away from thrombolysis (1.5 percent risk of
cerebral haemorrhage) to primary angioplasty
Referral to
angiography
Target
Minimising delay from referral to angiography (currently well
within 72 hour target)
Shared Care
Record
Investment
Reduce clinical risk by having access to most recent patient
information as well as history
IT Training
Opportunities Online and or
via CME/CNE
with CME points
attached
Investment
Increase provider IT knowledge to support identification and
management of patients. Increase training and awareness of
Decision Support tools to identify at risk patients.
Asynchronous
online training
Investment
Training Opportunities for clinicians to facilitate information
sharing outside the constraints of time and place among a
network of people.
Point of Care
Testing
Investment
Easy to use technology is available for patients to self-monitor
within the General Practice environment. Increase availability
and education to utilise this equipment where appropriate and
clinically indicated.
Increase self-awareness and self-management in an appropriate
environment without cost implications for patient. Reduce burden
of routine screening at General Practice.
Improve Health
Literacy and
Prevention
Service
reconfiguration
Identify the different needs of populations, whether they be rural,
urban, low socio-economic, high prevalence and cater to the
specific needs of the community.
What do the patients say they need? Can we afford to provide
that? Can we afford not to provide that?
Programmes
targeted at
Service
reconfiguration /
More support for Rheumatic Fever programmes. Smoking -
Option
Type of Option
Description / Evidence
youth
Investment
needs to be non-affordable.
Empower children to make healthy choices around food and
activity. For example, get all school children to grow a garden
and educate on how to eat the food they grow, and the benefits
of healthy eating.
Obesity
management
Service
reconfiguration
Ban super sizing of meals.
Increase involvement of dieticians - both for one on one and selfmanagement groups.
Improve access
to services f or
urgent care.
Service
reconfiguration
Closer to home care for the acutely ill as transportation delays
care.
GP's and nurses need to be on site and skilled in the use of
Streptokinase (or other treatment as indicated) and advanced
resuscitation.
Rural proofing
services
Investment /
Service
reconfiguration
DHB GM Planning and Funding
Renal
denervation
Investment
For control of resistant hypertension.
Hypertension one of the major risk factors that is poorly treated.
This procedure advances health care in this field
Split DHBs
would benefit
from one
service two site
model
Service
reconfiguration
Blenheim's traditional approach of insisting that all cardiology
FSA are assessed by general physicians rather than a
cardiologist (as occurs with Nelson patients) leads to
unnecessary FSA activity and unnecessary utilization of
investigations.
Blenheim's model is justifiable if it is geographically isolated but
not when 1.5h away from Nelson.
Increased use
of specialised
nurse
practitioners in
primary care
Service
reconfiguration
Unnecessary patient follow up occurs on secondary care especially with heart failure due to an inability of primary care to
adequately meet this demand. Specialist nurses that facilitate
ongoing follow up drug titration and advanced care planning
would reduce unnecessary FU and readmissions.
Increased
movement of
patients around
networks to
meet critical
time lines
Service
reconfiguration
If an angiogram needs to occur within 72 h why can’t patients
move between DHBs on a Network model to allow the patient to
receive the earliest treatment?
Royal Australasian College of Physicians
Wider use of
rapid access
nurse led chest
pain clinics
Investment
1) Chest pain referrals >50 percent elective cardio referrals
2) Development of clear community chest pain assessment
pathways to guide GP referrals
Option
Type of Option
Description / Evidence
2) Rapid access to Cardiac Nurse Specialist (CNS) led chest
pain clinics for immediate assessment, exercise testing and
cardiac imaging if fitting the protocol
3) Plethora of literature from the UK since 2000. Established in
the NICE guidelines.
4) Practised to various degrees within the NZ environment but
emphasis still on basic treadmill testing and escalation to
physician clinics defeats the purpose. The physician is likely to
request an imaging test which if the population is carefully
selected could have been done by the CNS
5) Net result is to reduce waiting time, improve access to
definitive tests, free up specialist assessment resource f or more
complex management issues.
Virtual
Specialist
Clinics
Investment
If GPs do not feel the community pathways are adequate in
helping them decide on patient management there should be a
virtual clinic access to specialist advice. This is done informally
by GP's "phoning for advice" but can be streamlined with
dedicated specialist time to receive such queries.
Hypertension
clinics
Investment
1) Hypertension is undertreated (NZ and worldwide data)
2) Every 10mmHg drop in BP halve CVS risk including stroke
3) 8000 strokes each year in NZ at $50,000 per stroke and only
1/3 alive and independent at 12 months (NZ data, stroke
foundation)
4) GP's treat hypertension very w ell, but issues with patient
attendance (cost and compliance)
5) Some hypertension can be refractory (5 percent) and needs
specialist hypertension services (choice of drugs and regimens)
6) Very limited models of care in NZ: most extensive is a WDHB
established through the renal department with success over the
last 5 years: average 4 visits with nurse specialist and physician
input.
Promoting Day
Case
angioplasty
Service
reconfiguration
1) Plenty of literature on safety
2) Variably practised in NZ
3) Unnecessary overnight admission
4) Can be used f or a select few on case by case basis
Length of stay
after
uncomplicated
myocardial
infarction and
successful
stenting could
be standardised
as far as
Service
reconfiguration /
targeting
1) Varies between 3-5 days
2) The evidence is predates wide use of primary PCI
3) Guideline support f or the shorter 3 days
Option
Type of Option
Description / Evidence
Stress testing
after myocardial
infraction to
guide treatment
of further
severe disease
could be
abolished
Targeting
1) variable practice in NZ
Encouraging
Nurse-cardiac
technologist led
general clinics
Service
Reconfiguration
possible
2) some would keep the patient for a few days then perform a
stress test pre discharge that may be repeated a few weeks later
before a decision is made on treating the non-infract related
artery (wasteful)
2) enough evidence to treat the severe lesions without this delay
(shortens hospital stay and reduces testing)
1) Specialist-GP development of community assessment of
heart failure, palpitations and murmurs
2) Rapid access to CNS led cardiac testing (echo, holter, event
monitors)
(echo,
arrhythmia
testing) in
favour of
specialist clinics
3) Open access from community to echo for instance proved to
have a low pick up rate (8-30 percent newly diagnosed heart
failure). Patient selection through established pathways and brief
assessment by CNS may streamline such services
4) selective referral to secondary assessment by specialist
5) Again multiple studies with varying results from the UK since
2000
National
Guidelines for
secondary care
Service
Reconfiguration /
targeting
1) There are numerous international guidelines on the
management of all CV conditions
2) There are no simple agreements for example on frequency of
reviews for heart failure or echo follow up of stable valve disease
(3 vs 6 monthly vs yearly vs guided by symptoms)
3) may be helpful to rationalize these pathways locally and
nationally
Indication
creep: Renal
Sympathetic
Denervation
Investment /
Targeting
1) Required f or <5 percent of severe hypertension
2) Recent randomized trail Simplicity HTN3 contradicts HTN1
and 2. Data not available
3) Needs critical appraisal (limited availability in NZ)
Indication
creep:
Structural heart
disease devices
Investment /
Targeting
All useful but need close monitoring to ensure appropriate
patient selection f or the most benefit
1) Left atrial appendage occluders: limited availability in NZ
2) Mitraclip for severe mitral valve regurgitation (mixed results):
not available in NZ yet
3) Transcutaneous aortic valves
4) PFO closure
New Zealand College of Public Health Medicine
Option
Type of Option
Population
disease register
with clinical
action
indicators/
reminders that
is electronically
integrated with
primary and
secondary care
IT system
Description / Evidence
Papers provided to the NHC
Use of MOH
data to provide
feedback to
reduce clinical
variations
Service
reconfiguration /
targeting
Highlighting potential treatment gaps.
Updating the
current CVD
guidelines to
lower treatment
thresholds (with
a view f or
electronic
implementation)
Service
reconfiguration /
targeting
Jackson R, Marshall R, Kerr A, Riddell T, Wells S. QRISK or
Framingham f or predicting cardiovascular risk? BMJ
2009;339:115
Paper noted based on Framingham equation: For men: 50
percent of CVD events in 10 years would come from people with
high risk, and for women only 17 percent would come from high
risk, indicating there is scope to lower threshold, and a potential
number of events could be prevented if the treatment threshold
is lower. This may be an reasonable option to explore, as CVD
medicine is of very low cost, and the side-effects are well
tolerated.
In order to improve usability of the guidelines, the guidelines
should incorporate common associated conditions such as
metabolic syndrome, and common co-morbidities.
The development of the guidelines should be informed by local
NZ data as well as latest cost effectiveness data.
Electronic implementation of such guidelines (with autopopulation), and supported by clinical actionable data from the
whole of system, (primary and secondary and MOH admin data,
local regional repository).
Pharmaceutical Society of New Zealand
Pharmacist-led
services
Investment
There is considerable evidence demonstrating pharmacist-led
services or in collaboration with general practitioners or nurses
improves management of CVD risk factors in the primary care
setting. Services have included medication adherence and
education, CVD risk screening, smoking cessation, optimisation
of medication therapy (in collaboration with prescribers),
identification & prevent of drug related problems and treatment
plan optimisation (with prescribers), pharmacological and nonpharmacological education and advice. Some of these (eg.
medication adherence services) are beginning to be funded by
some DHBs in New Zealand but to varying degrees. Service
functions could be expanded to assist burden on primary care.
Option
Type of Option
Description / Evidence
Health literacy
interventions
Investment
There is building evidence health literacy significantly impacts on
health outcomes. Pharmacists have a key role in patient's
understanding of the purpose of their medications, how to take
these, and how to identify and manage drug-related problems.
How poor health literacy impacts on the assessment and
treatment of our populations needs to be addressed.
Improve
secondaryprimary care
sharing of
medication
plans
Service
reconfiguration
Notification of medication changes to community pharmacy and
general practice at discharge. Adherence and education support
for a pharmacist to reconcile and synchronise patient
medications following discharge with removal of
discontinued/changed medications from the patient's home. To
improve medication management and reduce drug errors.
CV risk
screening/monit
oring by
pharmacies
integrated with
general practice
Service
reconfiguration
Greater collaboration for pharmacies to conduct CVD screening
and monitoring - linking information into the general practice.
Currently occurs in an uncoordinated and isolated manner.
Evidence of collaborative screening improving management of
risk factors.
Health literacy
Targeting /
Investment
Need to target those populations with poor health literacy to
better understand cardiovascular disease prevention and its
nonpharmacological and pharmacological management - to
improve effectiveness of these interventions.
The Royal New Zealand College of General Practice
Review model
of care at
specialist/ GP
interface
Service
reconfiguration
Synchronous specialist advice/virtual clinics.
-CME/CQI/pathway development
-Direct access to diagnostics in accordance with agreed patient
pathways (echo/nurse led exercise ECG/holter/event monitor).
-Where appropriate change terminology from refer to “consult
with”
Shift towards
more patient
centric
approaches
Investment /
service
reconfiguration
- Cardiopulmonary rehab.
- Consultation skills training to promote shared decision making
- Patient centred decision support (eg Option Grids).
- Change terminology primary care guidelines/secondary care
guidelines to “guideline for care of patients with.....”
- Advanced care planning / palliative care services
Set some
quality
expectations
Investment /
service
reconfiguration
- Quality of communication between providers.
- Access to care / maximum wait times
- Providers given & review their data /patient outcome measure
Enhance the
capacity and
capability of the
General
Investment /
service
reconfiguration
- Promote continuity of care and teamwork
- Invest in education / CME / CQI
Option
Practice
medical home
Type of Option
Description / Evidence
- Invest in change management to improve the way we work.
Source: 2014 NHC Survey Monkey Results for IHD
8 Health Innovation Partnership IHD Expression of Interest
Assessment
The Health Innovation Partnership (HIP) was created 2013 between the Health Research
Council and the NHC to support a coordinated investment in translational research for health
and disability related technologies. It is anticipated that research supported through this
partnership will gather evidence to inform the NHC’s recommendations regarding the cost
effectiveness and prioritisation of new and existing technologies. Research will also identify the
conditions and/or knowledge translation strategies that would be needed to support
implementation of findings and ways to restructure existing investment to optimise patient
outcomes.
The HIP conducted an Expression of Interest (EOI) process for translational research into IHD
in late 2013. The first round was concluded in January 2014, with 6 of 10 contenders invited to
submit full research applications. In addition to the IHD EOI process the CWG is able to make
recommendations for HIP research through the NHC. No assessments where recommended to
HIP in the first meeting of the CWG.
9 NHC Executive Perspective
The NHC executive’s current view, subject to revision with ongoing engagement and research,
is that there is potential value in five assessments. These are:
1. Cardiac rehabilitation
2. Management of low and intermediate risk chest pain pathways
3. Avoiding unnecessary interventions
4. Elective angioplasty with same day discharge
5. Early extubation and discharge of low risk patients for CABG
In addition we include below a possible assessment of Implantable Cardiac Defibrillators, but it
is the executive’s assessment that this option is less likely to be landed in timely fashion (and
more the domain of PHARMAC) than the other options presented.
Investment into cardiac rehabilitation to prevent hospital readmission
The benefits of a cardiac rehabilitation programme have been extensively documented
(15)
;
however, overall uptake by the sector has been variable and many patients do not attend
rehabilitation programmes. The CWG noted that current New Zealand guidelines from 2002
require updating. They considered current investment to be limited, where increasing the uptake
of ’gold standard’ cardiac rehabilitation has the potential to improve medication adherence,
reduce cardiac-related readmissions and improve health outcomes for IHD patients. It was
suggested there may be opportunity, especially in smaller DHBs, to combine cardiac
rehabilitation with pulmonary rehabilitation.
From a brief review of the literature, factors that could be improved include free transportation to
programme venue, increasing the number of programmes available and putting more resources
into disadvantaged/special groups. Apart from symptomatic benefit, cardiac rehabilitation has
been shown to reduce mortality, decrease recurrent MI and the requirement for
revascularisation procedures
(16, 17)
- thus reallocation of resources into this area is likely to
result in material health gain. An assesment performed by the NHC may be valuable in
documenting cardiac rehabilitation uptake, identifying a comprehensive set of barriers to
rehabilitation and making recommendations for improving the uptake of this service.
Management of chest pain pathways for “low risk” patients with an accelerated chest
pain pathway.
Chest pain is one of the most frequent presentations to the emergency department and places a
significant cost burden on existing services(18) . Current strategies for managing acute chest
pain often necessitate hospital admission even though a significant proportion of patients do not
have an important medical cause for their symptoms
(19)
. The Accelerated Diagnostic Pathway
(ADP) developed by Dr Martin Than at Christchurch Hospital uses the TIMI score and troponin I
at 0 and 2 hours to risk-stratify patients presenting with possible acute coronary syndrome
(ACS)
. Those who are deemed “low risk” are discharged at two hours without further
(20)
investigation. The pathway has been used in an observational study (the ADAPT study)
a randomised controlled trial
(21)
(20)
and
which compared the ADP with standard care. Numerous other
accelerated chest pain pathways have been developed overseas
(22)
. A standardised national
guideline could be developed to target patients at low risk of ACS if the NHC were to undertake
further assessment of this intervention in collaboration with the sector.
Early discharge plans for low risk chest pain patients were discussed in some depth by the
CWG. A new model at Waitemata DHB was noted where low risk patients are directed to come
back the next day for a booked test such as treadmill test, stress echo or CT coronary
angiography (CTCA). It was noted that some patients appearing at hospital with chest pain
might be better managed in the community by GPs.
The CWG noted that identification of low risk patients may be done using a risk screening
algorithm but close attention is required to the algorithm’s sensitivity, specificity and negative
predicative value. We were advised that regional differences in workforce capability and
resources need to be accounted for regarding the roll out of any low risk chest pain pathway.
Management of chest pain pathways for ‘intermediate risk’ patients with CT angiography.
The CWG suggested that this option be combined with the ‘low risk’ option above. Another
important area is the management of patients who are at intermediate risk of ACS, without
biomarker or ECG changes. The recent development of computed tomography coronary
angiography (CTCA) provides a high spatial and temporal resolution imaging technique to
evaluate the coronary arteries non-invasively. The CWG saw CTCA as a good tool that may be
underutilised in the health system with regional inequity in access. Nationally some CT
scanners lack the “cardiac package” needed for CT-angiography – including the necessary
software and technical support. The test is recognised by the American Heart association to
have a high diagnostic accuracy and negative predictive value in many populations; however its
application in the emergency department setting has been limited (23). A Korean study looked at
the application of this method to real world patients in the emergency department and found that
it had a 96.6 percent negative predictive value (24). Further systematic assessment of this
imaging technique may be helpful in identifying its role in acute chest pain management in the
NZ setting and assessing whether further investment in this technology is desirable.
Implantable Cardiac Defibrillators (ICD), possibly including an assessment of the
Microvolt t-wave alternans (MTWA) for better targeting of patients suitable.
Sudden cardiac death (SCD) is a devastating consequence of both Ischaemic and nonIschaemic cardiomyopathy. ICD implantation is well established in reducing SCD and thus
indications for ICD implantation are growing and, in parallel, the economic burden of these
devices (25).
Our brief assessment of cost data shows that ICDs are a rapid area of growth, growing
consistently above 14 percent per annum (compounding) over the past decade - where annual
cost now exceeds $15 million. A cursory review of cost-effectiveness studies shows ICDs are
cost-ineffective by standard measures. New and more costly ICD devices are coming to market.
The CWG advised that any assessment of ICDs would require careful engagement with
stakeholders, specifically the New Zealand Pacing and Electrophysiology Group. The CWG
were more focused on ICDs than the MTWA test, judiciously so as the test is not a major cost
pressure but ICDs are. The MTWA test has been shown in a recently published meta-analysis
to be a useful technology to risk-stratify those who are at greatest risk of SCD
(26)
. In
combination with abnormal heart rate turbulence (HRT), the predictive performance in patients
with left ventricular ejection fraction less than 40 percent after acute MI was strengthened
markedly (27). So, it appears from a cursory review of the literature, that this may be a promising
technology to help target patients who would most benefit from ICD implantation after an
Ischaemic event. If after systematic and sector review, the use of MTWA and HRT is found to
be a reliable technology for risk stratification of patients after acute MI, there could be an overall
cost-benefit. The costs of investing in this technology could be outweighed by a reduction in ICD
implantation.
ICDs are likely to be PHARMAC’s business longer term, but there may be an opportunity for the
NHC to get a relatively short term return on investment through an assessment of ICD use in
New Zealand, including the MTWA test.
Avoiding unnecessary interventions
The CWG recommended that the NHC further engage with the sector to identify unnecessary
interventions. Several interventions where raised through the CWG and online survey (Table 1
above) as potential candidates for improved targeting including:

Abolition of stress testing after myocardial infraction to guide treatment of further severe
disease.

Stop doing ECG-based stress testing to diagnose or exclude stable angina for people
without known coronary artery disease

Continuing to move away from thrombolysis (1.5 percent risk of cerebral haemorrhage)
to primary angioplasty.

Continuing to reduce the administration of high cost anti-platelet therapy (iv abciximab)
in acute patients.
Elective angioplasty with same-day discharge
Historically, prolonged bed rest after femoral sheath removal and monitoring for complications
have been key drivers for overnight hospital stays after PCI. The vast majority of patients in NZ
undergo transradial PCI, and during the past decade there have been rapid advances that have
dramatically improved safety and reduced complications
in the literature
(29, 30)
(28)
. There is now prospective evidence
to suggest that same day discharge is a safe and feasible option for a
carefully selected group of patients. Criteria that have been proposed in the trials are extensive
and include (30):
Pre-procedure factors:
5. Aged under 75 years, with a BMI less than 40, a preserved ejection fraction, normal
renal function, normal bleeding indices (INR, Hb, platelets), more than 14 days postacute MI, and adequacy of social support post discharge
Peri-procedure factors:
6. No target vessels occluded, no dissection, side branch occlusion, angiographic
thrombus and perforation, Thrombolysis in Myocardial Infarction (TIMI) 3 flow in all
vessels, no vein graft/left main/triple vessel involvement, procedure duration, 3 hours,
reasonable contrast use, no need for vasopressors or pacing, no concerns over sedation
Post-procedure factors:
7. Stable blood pressure without ongoing treatment, afebrile, no symptoms e.g. chest pain,
no access site issues (haematoma, aneurysm, bleeding, limb ischemia), need for blood
transfusion, ambulatory within day stay unit, discharge before 10 pm,
Targeting these patients in interventional centres across New Zealand may be an effective
strategy to decrease the overall cost associated with coronary revascularisation.
Early extubation and discharge of low risk patients for CABG
The NHC executive where informed at the first CWG meeting of Canterbury DHB’s early
extubation (at 2 hours) and early discharge of "low risk" patients undergoing CABG. The cases
that are likely to be low risk (as per euroscore6 and anaesthetic assessment) are done in the
morning. The system reportedly reduces intensive care unit stay to less than one day and
hospital stay from 6-7 days to 3 days. District nurse community support facilitates early
discharge.
6
A method of calculating predicted operative mortality for patients undergoing cardiac surgery.
10 Limitations
The number of people we have included in our analyses from Health Tracker is lower than that
estimated by the New Zealand Health Survey. As outlined in the methodology (Appendix 2) the
majority of people included in our definition have had a health system diagnosis, so there may
be a bias towards higher needs. There is, however, also a chance we may have captured
patients who do not have IHD but were prescribed one of the pharmaceuticals for another
condition or that a patient had been given a comorbid diagnosis of IHD in a hospital without a
full investigation.
The IHD costs from ED attendances may be overestimated since many IHD patients have
other co-morbidities which could have brought them to ED. There are other costs associated
with IHD some diagnostics, and aged care that have not been accounted for due to lack of
available data. Because our patient cohorts are defined by their service utilisation, they should
not be viewed as clinically grouped cohorts but rather service-use cohorts.
Given the breadth of IHD technologies available the Horizon-scan presented in Appendix 3 is
not exhaustive and it is possible that some important technologies have been excluded. This
risk has been mitigated somewhat through our survey of stakeholder options for improving the
IHD pathway of care.
In summary while the figures provided in this report are not a fully comprehensive picture of IHD
they do provide an indicative basis for understanding the burden associated with the IHD
pathway of care.
Appendix 1: Cost Tables
Total NZ
Disease
Count
Percent
Total Cost ($)
Average Cost ($)
Non-hospitalised IHD
Hospitalised IHD
Death
Total
144,667
14,716
12,019
171,402
84.4
8.6
7.0
100.0
79,664,300
185,094,300
22,320,000
287,078,600
550
12,580
1,860
1,670
Count
13,429
1,507
1,084
16,020
Percent
83.8
9.4
6.8
100.0
Total Cost ($)
8,910,600
19,819,900
2,579,800
31,310,200
Average Cost ($)
660
13,150
2,380
1,950
Count
Percent
Total Cost ($)
Average Cost ($)
131,238
13,209
10,935
155,382
84.5
8.5
7.0
100.0
70,753,700
165,274,500
19,740,200
255,768,400
540
12,510
1,810
1,650
Disease
Count
Percent
Total Cost ($)
Average Cost ($)
Non-hospitalised IHD
Hospitalised IHD
Death
Total
29,433
3,070
2,521
35,024
84.0
8.8
7.2
100.0
18,453,700
41,000,300
5,091,100
64,545,000
630
13,360
2,020
1,840
Count
Percent
Total Cost ($)
Average Cost ($)
91,927
9,378
7,807
109,112
84.3
8.6
7.2
100.0
50,397,800
116,981,600
14,066,000
181,445,400
550
12,470
1,800
1,660
Total Māori
Disease
Non-hospitalised IHD
Hospitalised IHD
Death
Total
Total Non-Māori
Disease
Non-hospitalised IHD
Hospitalised IHD
Death
Total
Deprivation
High-deprivation
Moderate-deprivation
Disease
Non-hospitalised IHD
Hospitalised IHD
Death
Total
Low-deprivation
Disease
Count
Percent
Total Cost ($)
Average Cost ($)
Non-hospitalised IHD
Hospitalised IHD
Death
Total
23,307
2,268
1,691
27,266
85.5
8.3
6.2
100.0
10,812,800
27,112,500
3,162,900
41,088,200
460
11,950
1,870
1,510
Count
Percent
Total Cost ($)
Average Cost ($)
6,267
686
553
7,506
83.5
9.1
7.4
100.0
4,429,800
9,431,500
1,280,900
15,142,200
710
13,750
2,320
2,020
Count
Percent
Total Cost ($)
Average Cost ($)
6,429
736
487
7,652
84.0
9.6
6.4
100.0
4,087,900
9,357,000
1,234,900
14,679,800
640
12,710
2,540
1,920
Count
Percent
Total Cost ($)
Average Cost ($)
733
85
44
862
85.0
9.9
5.1
100.0
392,900
1,031,300
64,000
1,488,200
540
12,130
1,460
1,730
Disease
Count
Percent
Total Cost ($)
Average Cost ($)
Non-hospitalised IHD
Hospitalised IHD
Death
Total
23,166
2,384
1,968
27,518
84.2
8.7
7.2
100.0
14,023,900
31,568,800
3,810,200
49,402,800
610
13,240
1,940
1,800
Ethnicity and Deprivation
High-deprivation Māori
Disease
Non-hospitalised IHD
Hospitalised IHD
Death
Total
Moderate-deprivation Māori
Disease
Non-hospitalised IHD
Hospitalised IHD
Death
Total
Low-deprivation Māori
Disease
Non-hospitalised IHD
Hospitalised IHD
Death
Total
High-deprivation Non-Māori
Moderate-deprivation Non-Māori
Disease
Non-hospitalised IHD
Hospitalised IHD
Death
Total
Count
Percent
Total Cost ($)
Average Cost ($)
85,498
8,642
7,320
101,460
84.3
8.5
7.2
100.0
46,309,800
107,624,600
12,831,200
166,765,600
540
12,450
1,750
1,640
Low-deprivation Non-Māori
Disease
Count
Percent
Total Cost ($)
Average Cost ($)
Non-hospitalised IHD
Hospitalised IHD
Death
Total
22,574
2,183
1,647
26,404
85.5
8.3
6.2
100.0
10,420,000
26,081,100
3,098,800
39,599,900
460
11,950
1,880
1,500
Appendix 2: Full Methodology
This appendix outlines the full methodology used to inform the contents of this report: pathway
of care, prevalence, costs and patient stratification.
IHD pathway volume and cost measurement methodology
Prevalence
The New Zealand Health Tracker (NZHT) is a health census of resident New Zealanders
created through the linkage of data in the Ministry of Health’s national collections and other data
sources. It was established and is maintained by the Ministry of Health’s Health and Disability
Intelligence (HDI) unit and is currently up-to-date to 2011/12.
To be included as a prevalent case, a person had to be alive on 30 June 2011 and must have
been enrolled in a primary health organisation (PHO) at that time, or had a contact event in a
PHO in 2011/12 or a recorded event in the NMDS. This method excludes most people who
have emigrated. A case had to meet the relevant diagnostic criteria outlined below.
The definition for a prevalent IHD case used here is the same as that used in the New Zealand
Burden of Diseases, Injuries and Risk Factors Study, 2006–2016 (NZBDS)(31) aside from the
age limitation which was amended retrospectively to 25 years in the NZBDS. The hospital
records for this analysis go back to 1988. The IHD definition used here is outlined in Table 2.
Table 2, Definition criteria for New Zealand Health Tracker IHD indicator
Any one of these
Description
Definition
Ischaemic heart disease
ICD-9: 410–414
Description
diagnoses or
Definition
ICD-10: I20–I25
procedures when
aged 25 years or
over:
Presence of aortocoronary
ICD-9: V45.81
bypass graft
ICD-10: Z95.1
Presence of coronary angioplasty
ICD-9: V45.82
implant and graft
ICD-10: Z95.5
Percutaneous angioplasty or stent
ICD-9: 36.01–36.07
intervention
ICD-10: 3530400, 3530500, 3531000,
3531001, 3531002
Coronary Artery Bypass Graft,
ICD-9: 36.10–36.16
including reconstruction
ICD-10:
3849700–3849707, 3850000–3850004,
3850300–3850304,
3863700,
9020100–9020103
Aged 25 years or
Nitrate
Glyceryl trinitrate
over and had any
Isosorbide Dinitrate
two dispensings of
any of these
Isosorbide mononitrate
pharmaceuticals in
Nicorandil
the previous 12
months
Calcium Channel Blockers
Perhexilin maleate
Source: 2011/12 New Zealand Health Tracker
Of the 171,402 people identified as prevalent cases of IHD, the majority (94.8 percent), were
identified through a record of a relevant diagnosis or procedure code. This leaves 5.2 percent
who were diagnosed via their pharmaceutical history alone. It should be noted that there are
limitations to using the pharmaceutical data for a prevalence measure. There are some reasons
why some people may be dispensed these pharmaceuticals in one year and not a subsequent
year for example an indication such as end-stage liver disease, or for a therapeutic trial(32). It is
also acknowledged that the use of medications to identify cases of IHD is less specific than use
of hospitalisation codes. Upon assessing the IHD population from 2010/11 to 2011/12 it was
found that approximately 235 people (0.1 percent
of the IHD prevalent population) were
‘prevalent’ in 2010/11 and still alive, but no longer ‘prevalent’ in 2011/12.
Costs
Hospital events
Hospitalisation event (inpatient and day patient) data from the National Minimum Data Set for
2011/12 were used with filtering to exclude non-publically funded and/or non-casemix
purchased events. The diagnosis code used was either the primary diagnosis or the secondary
diagnosis if the primary diagnosis was a ‘Z’ code (Factors influencing health status and contact
with health services). The ICD-10-AM codes I20 to I25 were used to define IHD-related hospital
events.
Price has been used as a proxy for cost as it is more readily available and is correlated with the
cost of the services being summarised. Each (filtered) hospitalisation event has a resourcebased volume measure of the relative resources used in the delivery of inpatient heath care
based on the diagnosis code (derived using Weighted Inline Equivalent Separation
methodology). For this analysis the WIESNZ10 caseweight has been multiplied by the national
unit price for 2011/12 ($4567.49).
Pharmaceuticals
The Pharmaceutical Collection was used to identify the IHD-relevant pharmaceuticals listed in
Table 3. Identified drugs are not necessarily only indicated for the management of IHD but in
the presence of IHD would be an appropriate part of clinical management.
New Zealand’s Pharmaceutical Management Agency (PHARMAC) receives rebates from some
pharmaceutical companies for some of the pharmaceuticals it purchases. To account for these
rebates the pharmaceutical ‘cost’ has been calculated based on the average price for each
chemical and formulation for August 2013. The reimbursement cost of the pharmaceuticals is
included, and is the cost from the supplier, the mark-up and the dispensing fee minus the
patient contribution. Goods and Services Tax (GST, 15 percent) was removed from the
reimbursement cost.
Table 3, IHD-related pharmaceuticals included in cost-estimates
Description 1
Statins
Description 2
Lipid Modifying agents
Chemical name
Acipimox
Atorvastatin
Bezafibrate
Cholesterol
Description 1
Description 2
Beta-blockers
Beta Adrenoceptor Blockers
Antiplatelet/anticoagulant
agents
Antithrombotic agents
Angiotensin-converting
enzyme (ACE) inhibitors
or Angiotensin receptor
blockers (ARB)
Agents affecting the reninangiotensin system
Diuretics
Diuretics, Beta-adrenoceptor
blockers with diuretics, ACE
inhibitors with Diuretics
Chemical name
Cholestyramine with aspartame
Clofibrate
Colestipol hydrochloride
Ezetimibe
Ezetimibe with simvastatin
Fluvastatin
Gemfibrozil
Nicotinic acid
Omega 3 Fish Oil
Pravastatin
Probucol
Simvastatin
Acebutolol
Acebutolol with hydrochlorothiazide
Alprenolol
Atenolol
Atenolol with chlorthalidone
Bisoprolol fumarate
Carvedilol
Celiprolol
Labetalol
Metoprolol succinate
Metoprolol tartrate
Nadolol
Oxprenolol
Pindolol
Pindolol with clopamide
Propranolol
Sotalol
Timolol (tablet form only)
Timolol maleate (tablet form only)
Anagrelide
Aspirin
Clopidogrel
Dipyridamole
Prasugrel
Tinzaparin sodium
Benazepril
Candesartan
Captopril
Captopril with hydrochlorothiazide
Cilazapril
Cilazapril with hydrochlorothiazide
Enalapril
Enalapril with hydrochlorothiazide
Lisinopril
Lisinopril with hydrochlorothiazide
Losartan
Losartan with hydrochlorothiazide
Perindopril
Quinapril
Quinapril with hydrochlorothiazide
Trandolapril
Acebutolol with hydrochlorothiazide
Amiloride
Amiloride with frusemide
Amiloride with hydrochlorothiazide
Atenolol with chlorthalidone
Description 1
Description 2
Nitrates
Nitrates
Antiarrhythmics
Antiarrhythmics
Calcium Channel
Blockers
Dihydropyridine Calcium Channel
Blockers (DHP CCBs)
Other Calcium Channel Blockers
Vasodilators
Vasodilators
Chemical name
Bendrofluazide
Bumetanide
Captopril with hydrochlorothiazide
Chlorothiazide
Chlorthalidone
Cilazapril with hydrochlorothiazide
Cyclopenthiazide
Enalapril with hydrochlorothiazide
Furosemide
Indapamide
Lisinopril with hydrochlorothiazide
Methyclothiazide
Pindolol with clopamide
Quinapril with hydrochlorothiazide
Spironolactone
Triamterene with
hydrochlorothiazide
Glyceryl trinitrate
Isosorbide dinitrate
Isosorbide mononitrate
Nicorandil
Amiodarone hydrochloride
Digoxin
Disopyramide phosphate
Flecainide acetate
Lignocaine hydrochloride
Mexiletine hydrochloride
Procainamide hydrochloride
Propafenone hydrochloride
Amlodipine
Felodipine
Isradipine
Nifedipine
Diltiazem hydrochloride
Perhexiline maleate
Verapamil Hydrochloride
Hydralazine
Minoxidil
Nicorandil
Source: 2012 Pharmaceutical Collection
General Practitioner (GP) visits
Regression analysis was carried out on the 2011/12 New Zealand Health Survey to estimate
the mean number of GP visits an IHD patient would have had. The model was run on those in
the survey who were 25 years or older and had IHD. Gender, age group, ethnicity and
deprivation were all included in the original model, however the only significant predictor (using
an alpha of 0.05) was deprivation quintile. The weighted mean from the survey was 5.92 visits,
compared to a predicted mean of 5.97 from the 2011/12 IHD NZ Health Tracker population.
Table 4 provides the predicted mean no. of visits by deprivation quintile.
Table 4, Predicted average number of GP visits for patients with IHD by NZDep2006 quintile, 2011/12
Deprivation quintile
Mean no. of GP
visits by IHD
patients
Mean no. of GP
visits by IHD
patients attributed
to IHD
1 (least deprived)
4.62
1.41
2
5.10
1.56
3
5.58
1.70
4
7.10
2.17
5 (most deprived)
6.74
2.06
Source: 2014 HDI analysis of 2011/12 NZ Health Survey and 2014 NHC analysis of NZ Health Tracker
Analysis of the 2011/12 NZ Health Survey also showed that IHD patients had 1.44 times the
number of GP visits in the previous twelve months as those who did not have IHD. For the
purposes of our analysis we adjusted the predicted mean number of GP visits related to IHD
accordingly (Table 4). It is assumed that the excess GP visits in those with IHD compared to
those with no IHD are attributable to the presence of IHD.
GP visits are funded by a combination of government capitation-based (per capita) payments
and (private) patient fees. The government funding is based on the age, sex, ethnicity and
deprivation level of patients enrolled with a primary health organisation7. The Burden of Disease
Epidemiology, Equity and cost-Effectiveness Programme (BODE3) have analysed the
government capitation funding formulae to produce some figures on the average government
cost per GP visit for each of the relevant age groups(33) (Table 5). These are the ‘costs’ we have
included for each GP visit.
Table 5, Average total cost per GP visit for enrolled patients by age (excluding GST)
Age group
Average total government cost
per visit ($)
25 to 44 years
36.92
45 to 64 years
35.43
65 years and over
32.96
7
See http://www.health.govt.nz/our-work/primary-health-care/primary-health-care-services-and-projects/capitationfunding for further information on capitation funding.
Source: Protocol for Direct Costing of Health Sector Interventions for Economic Modelling (Including Event
Pathways): Burden of Disease Epidemiology, Equity and cost-Effectiveness Programme (BODE3)(33)
There are four main limitations to the method we have used to allocate the likely annual costs of
a patient’s GP visits. We have only included the average capitation ‘costs’ for visits made by a
patient enrolled at a primary health organisation attending the practice they are enrolled with.
Survey data is self-reported and relies on people remembering back over a 12 month period.
Most GP visits may not be so eventful that they are particularly memorable. However, the NZ
Health Survey is a population based survey and the self-report effect is unlikely to differ
substantially by different population groups. The regression model used is fairly simple only
taking into account key demographics, further analysis may be able to add other variables into
the model at a later stage. It has been assumed the ‘excess’ number of GP visits solely relates
to the presence of IHD, however the difference in visits between IHD and non-IHD patients does
not take into account comorbidities. It may be for example, that a significant proportion of IHD
patients are suffering from chronic obstructive pulmonary disease (COPD) and much of the
excess ‘cost’ is therefore not due to their IHD, but their COPD.
The clinical reality is that patients’ attendance may be related to multiple clinical issues, that
may be inter-related, and it is not feasible to definitively allocate consultation time to a specific
condition.
Outpatient and Emergency Department visits
The National Non-Admitted Patient Collection (NNPAC) includes data on outpatient and
emergency department (ED) visits. ED visits that result in an admission are priced as part of the
hospital admission using the WIESNZ10 caseweight described in Section 0 above.
The Nationwide Service Framework Library Purchase Unit Data Dictionary Version 18, 2012/13
was reviewed for IHD-relevant purchase unit codes, including ED visits and palliative care.
These are outlined in Table 6.
For two services (palliative care M80005, and cardiac education and management M10004),
these costs were counted once per patient per year as they contain a yearly purchase unit price
as opposed to one applied per visit.
Analysis of the 2010 Mortality Collection (the most recent available) showed that of IHD patients
who died, approximately 40 percent IHD designated as the cause of death. As palliative care
could be provided for comorbid conditions, only 40 percent of the palliative care costs
(COPL0001, M80004, M80005) were included in this analysis.
It is important to note that not all the purchase unit codes are mandatory for DHBs to report
(Table 6). This means that for some purchase units which we have data for, the data may not
be complete as only some DHBs may have reported on these purchase units.
Each of the DHBs has a Production Plan (previously known as a Price Volume Schedule) which
shows the planned price and volume for each purchase unit code for the coming year. These
prices were mapped to each of the NNPAC events by DHB. Where no price was available from
the production plan for a DHB the price used was as follows:

the national price

the modal planned price of DHBs which had that purchase unit where there was no
national price

the average planned price of DHBs which had that purchase unit

the bulk price divided by the number of patients recorded as accessing the service.
Table 6, IHD-relevant purchase unit codes, national prices and number of IHD patients, 2011/12
Purchase
Descriptiona
Definitiona
a
unit code
ED02001
Mand
atory
Emergency Dept
Emergency service in small hospital
- Level 2
with designated assessment and
Price
($)
b
No. of
c
visits
No. of
IHD
to
patient
report
sc
Yes
265.66
533^
722
Yes
260.41
1140^
2280
treatment areas. Minor injuries and
ailments can be treated.
Resuscitation and limited stabilisation
capacity. Nursing staff available to
cover emergency presentations.
Visiting medical officer is on call. May
be local trauma service.
ED03001
Emergency Dept
As for level 2 plus: designated nursing
- Level 3
staff available on 24-hour basis. Has
unit manager. Some registered nurses
have completed or are undertaking
relevant post-basic studies. 24-hour
access to medical officers on site or
available within 10 minutes. Specialists
in general surgery, anaesthetics,
paediatrics and medicine available for
consultation. Full resuscitation
Purchase
Descriptiona
Definitiona
a
unit code
Mand
atory
Price
($)
b
No. of
c
visits
No. of
IHD
to
patient
report
sc
facilities in separate area. Access to
allied health professionals and liaison
psychiatry.
ED04001
Emergency Dept
As for level 3 plus: can manage most
- Level 4
emergencies. Purpose-designed area.
Yes
260.41
5543^
7508
Yes
349.18
1331^
2061
Yes
326.45
3484^
5275
Yes
122.89
10248
4392
Full-time director, experienced medical
officer(s) and nursing staff on site 24
hours. Experienced nursing staff on
site 24 hours. Specialists in general
surgery, paediatrics, orthopaedics,
anaesthetics and medicine on call 24
hours. May send nursing and medical
teams to disaster site. Participation in
regional adult retrieval system is
desirable. May be an area trauma
service.
ED05001
Emergency Dept
As for level 4 plus: can manage all
- Level 5
emergencies and provide definitive
care for most. Access to specialist
clinical nurse is desirable. Has
undergraduate teaching and
undertakes research. Has designated
registrar. May have neurology service.
ED06001
Emergency Dept
As for level 5 plus: has neurosurgery
- Level 6
and cardiothoracic surgery on site.
Sub-specialists available on rosters.
Has registrar on site 24 hours. May be
a Regional Trauma Service.
AH01001
Dietetics
Dietician services provided in an
outpatient or domiciliary setting.
Purchase
Descriptiona
Definitiona
a
unit code
Mand
atory
COPL000
Palliative
Initial assessment to determine the
1
Assessment &
need for or level of Palliative Care a
Care
client requires.
Price
($)
b
No. of
c
visits
No. of
IHD
to
patient
report
sc
No
116.01
64.8*
56
Yes
277.5
7805
5839
Yes
351.39#
546
309
Yes
448.75
7787
7420
Yes
288.96
31541
20960
Yes
254.9
6415
6415
Yes
413.92
351
130
Yes
400+
438
137
coordination
CS04001
Community
Cardiology tests referred by a general
referred tests -
practitioner or private specialist. eg
cardiology
ECG, stress tests, echocardiograph.
Includes interpretation and reporting of
the test. Excludes tests referred by
DHB staff.
CS04009
Community
Regular pacemaker maintenance
referred tests -
checks for clients that have had a
Pacemaker
pacemaker implanted.
physiology tests
M10002
Cardiology - 1st
First attendance to cardiologist or
attendance
medical officer at registrar level or
above or nurse practitioner for
specialist assessment.
M10003
M10004
Cardiology -
Follow-up attendances to cardiologist
Subsequent
or medical officer at registrar level or
attendance
above or nurse practitioner.
Cardiac
Cardiac education and case
Education and
management by multi-disciplinary
Management
teams in hospital or community-based
setting.
M10008
Cardiac
CHF project to provide support to
Outreach Service
prevent readmission and lower length
of stay. There is a Service Spec &
reporting requirements, Integration
project.
M10009
Cardio-vascular
Integration Project - General Practice
models of care
teams, providing in the community,
services for patients with Chronic
Cardio-Vascular Disease
Purchase
Descriptiona
Definitiona
a
unit code
M10012
Mand
atory
Pacemaker
Pacemaker maintainence checks for
Checks
clients that have had a pacemaker
Price
($)
b
No. of
c
visits
No. of
IHD
to
patient
report
sc
No
245.31
8469
3832
Yes
444.67
514
511
Yes
357.43
1194
1030
No
411.69
66
57
Yes
172.15
46*
74
Yes
1198.71
94.4*
236
impanted.
S15002
Cardiothoracic -
First attendance to general surgeon or
1st attendance
medical officer at registrar level or
above or nurse practitioner for
specialist assessment.
S15003
Cardiothoracic -
Follow-up attendances to
Subsequent
cardiothoracic surgeon or medical
attendance
officer at registrar level or above or
nurse practitioner.
S25008
Multifaceted
Multi-faceted specialist clinics for first
Specialist Clinics
and follow up assessments for
complex cardiac or respiratory clients
where client can be seen at a number
of outpatient units in one visit.
M80004
Palliative Care -
First attendance to palliative care
Outpatient
medicine specialist or medical officer
Services
at registrar level or above or nurse
practitioner for specialist assessment.
M80005
Palliative Care -
Programme of community-based care
Community
for people assessed as requiring
Services
specialist palliative care.
Source: a) The Nationwide Service Framework Library Purchase Unit Data Dictionary Version 16.3, 2011/12
b) National/Modal/Average price as defined in Section 0
c) 2013 NHC analysis of 2011/12 National Non-admitted Patient Collection
Notes:
* Two-fifths of the visits have been apportioned to the patients’ IHD
^ Half of the visits have been apportioned to the patients’ IHD
#
This is the 2012/13 national price
+ Preliminary
estimated price
A limitation of the non-admitted ED data is that there is no description of diagnosis associated
with it. This means that IHD-specific non-admitted ED visits cannot be measured. However, IHD
patients are significantly more likely to have had a non-admitted ED visit than people not in the
IHD-prevalent population (odds ratio = 2.0, 1.97–2.03) (
Figure 8). For the purposes of this analysis 50 percent of the ‘cost’ of all non-admitted ED visits
have been included as attributable to IHD (the proportion of ED visits above a comparable, nonIHD population).
Figure 8: Number of non-admitted emergency department visits for IHD and Non-IHD-prevalent populations,
2011/12
Percent
100
Non-IHD patients
90
IHD patients
80
70
60
50
40
30
20
10
0
0
1
2
3+
Number of visits
Source: 2013 NHC analysis of 2010/11 NZ Health Tracker and NNPAC data
Troponin
A key diagnostic tool for IHD is a laboratory test for troponin, the average estimated cost of a
troponin test in 2011/12 is $12.14. The Laboratory Claims collection was used to find whether
and how many troponin tests a person had had. There are limitations with the Laboratory
Claims collection not being comprehensive and the prices involved being estimates.
Angiography
Coronary angiography is another IHD diagnostic tool, carried out in a hospital setting. While
many of these were captured and included in the hospital costs, we also included coronary
angiographies where the primary diagnosis was not IHD, but one of the secondary diagnoses
was IHD. We assessed the casemix price of a standard day-stay angiography to be $1941.63.
Total patient costs
Each patient’s pharmaceutical (total = $51.7M), GP ($23.9M), outpatient, ED (outpatient & nonadmitted ED = $23.6M), hospital ($186.7M), palliative ($48,400), angiographic ($953,300), and
troponin test ($171,000) ‘costs’ have been summed to create a cost-per-patient.
Where a cost was associated with a bulk contract, and there is no direct record of the particular
IHD patients who received the treatment (eg, health promotion, physical activity, cardiovascular
screening) then this has not been included here.
There are other costs to the health system that are attributed to the patient identified with IHD.
These are costs that may not all directly result from IHD. The presence of co-morbidities
alongside the IHD have an impact on the need for services, such as needing community
services such as home help, physiotherapy or occupational therapy, and outcomes such as
length of stay. To provide an indication of the IHD cost data in a timely manner, only the costs
mentioned above (pharmaceutical, GP, ED and the outpatient costs listed in Table 6) have been
included. While these are not comprehensive, they are IHD focused and provide enough
information to assess the IHD pathway in terms of the interventions that should be assessed to
improve health outcomes for New Zealanders.
Private patient fees
It is important to note that private patient fees are not included in our cost analyses, GP patient
fees, fees for collecting prescriptions, and any medical treatment paid for directly by the patient,
or the patient’s insurer are not included. The prescription and GP fees can be a barrier to
patients accessing public health services, with 8% of adults not collecting a prescription and one
in seven (14%) not going to a GP because of the cost in 2011/12. This was even more of a
barrier to Māori and more deprived patients(34). While these fees have not been included in our
cost analysis they should be considered in any pathway of care as patients not taking
pharmaceuticals they have been prescribed, or not seeing a GP when they need to can have
flow on effects in terms of a patient attending ED, which has no patient fee. Barriers to patients
not managing their condition in the best way leads to a poorer quality of life, or increased risk of
a myocardial infarction, and earlier death than if they had accessed the care needed.
Patient Stratification
Patients have been included in mutually exclusive groups based on whether they had a
hospitalisation with an IHD-related ICD primary diagnosis code in 2011/12. Anyone in the IHD
prevalent population who died in 2011/12 has been included in the 'death' category regardless
of whether their death was IHD-related or not. All three categories are part of the identified total
prevalent IHD population.
New cases
New cases of IHD were identified by assessing which patients were newly identified from
2010/11 to 2011/12 using New Zealand Health Tracker. These patients will overlap with the
patient stratification mentioned above.
The at-risk population
There is a health target, before 1 January 2012 this was “90 percent of the eligible adult
population would have had their CVD risk assessed in the last five years” (35). This target is to be
achieved in stages with 60 percent to have been done by July 2012. To assess if someone
should have had their risk assessed we have applied the age, gender and ethnic group criteria
of asymptomatic people(36). These people may be at risk, however it should be noted that
without other risk factors (diabetes, smokers, obesity, high blood pressure, family history of
premature IHD, previous other cardiovascular disease, genetic lipid disorders) then the risk is
likely to be mild (less than 10 percent)(36).
We have also included people who have been dispensed a statin and an antiplatelet or
anticoagulant as well as a pharmaceutical from one of the other
cardiovascular
pharmaceuticals: beta blockers, ACE or ARBs, diuretics, nitrates, calcium blockers, or
vasodilators. People who are taking one of these combinations of three pharmaceuticals are
likely to be taking them to prevent IHD in the longterm.
People in the ‘prevention’ section of the pathway of care (Figure 5) were identified as anyone
being in the ‘at-risk’ group as defined by the age, gender and ethnic group criteria for CVD
screening, or who are not in this group, but are taking a combination of the three
pharmaceuticals outlined above (N = 5415) who have not already been diagnosed with IHD
according to the NZ Tracker definition. This group will include patients with non-IHDcardiovascular disease, for which drug therapy will be appropriate for secondary prevention of
CVD. Some individuals identified at higher risk may not receive all the preventative drug types.
The cost we have associated with this group is an estimate of the cost to screen this population.
In essence this is the cost of a GP appointment (as outlined in Table 5 above), the average
price of a lipids test ($7.64) and an HBA1C test ($10.18), these were summed and divided by
five, as the screen is carried out once every five years. As well as this we have included the
cost of any related pharmaceuticals if the patient is taking a combination of the three
pharmaceuticals outlined above. This is a rough estimate that provides some context around
the IHD cost of the non-prevalent population.
Diagnostics
Cardiology first referral visits, cardiology community referred tests, angiography, and troponin
tests are all used to diagnose IHD and are measurable. This is not a comprehensive list,
however other items eg, risk factor assessment or echocardiograms are difficult to quantify from
the data available. Not everyone who has these things will have IHD, but presenting information
on the overall costs for these provides some information on who receives them and some of the
cost involved.
Events
A patient was identified as having had a coronary artery bypass in 2011/12 if during that period
they had any ICD-10 procedure code in any of these ranges: 3849700–3849707, 3850000–
3850004, 3850300–3850304, 3850500, 3863700, 9020100–9020103. Note this includes
reconstruction.
A patient was identified as having had angioplasty in 2011/12 if during that period they had any
ICD-10 procedure code in any of these ranges: 3530306–3530307, 3530400–3530401,
3530500–3530501, 3530906–3531005, 3533500, 3533800–3533801, 3534100, 3534400–
3534401, 3830000–3830001, 3830300–3830301, 3830600–3830605, 3830900, 3831200–
3831201, 3831500, 3831800–3831801. This includes both open and percutaneous angioplasty
and excludes peripheral angioplasty.
A patient who has had a primary diagnosis in 2011/12 of I21 has been identified as having had
an acute myocardial infarction.
The 2010 Mortality Collection has been used to quantify IHD and of those, acute myocardial
infarction deaths. Note that this data is older than the majority of the other data presented.
Rates
Age-standardised rates have been standardised to the 2011/12 NZ Health Tracker population.
Note the denominator population (who the rate is out of) is different for different measures,
some of the populations used are the New Zealand population, the IHD prevalent population
and the population of people discharged with a myocardial infarction.
Comorbidities
As mentioned above if a person is hospitalised with a condition it may be the presence of
another condition that results in an extended length of stay, or higher costs. To provide some
insight into the comorbidities of people with IHD we appraised the list of conditions with the
highest disability-adjusted life years and years lived with disability in New Zealand(31) alongside
available data and clinical advice. From this a list of potential comorbidities was selected to
investigate among IHD patients for 2010/118:
8

lung cancer

colorectal cancer
2010/11 has been used due to the availability of New Zealand Cancer Registry data, this is a year older than the
majority 2011/12 data analysed and presented in this report.

(female) breast cancer

prostate cancer

other cancer/s

chronic obstructive pulmonary disease

asthma

ever-hospitalised stroke

anxiety and/or depression (past 12 months)

dementia

gout

diabetes

heart failure.
The methods and limitations of how each of these diseases have been measured are outlined
below.
Cancer
“The New Zealand Cancer Registry (NZCR) is a population-based register of all primary
malignant diseases diagnosed in New Zealand, excluding squamous and basal cell skin
cancers.”(37) NZCR data (including preliminary 2011 data) have been used to provide 2010/11
measures with an effective cure time of five years9. The ICD-10 codes used for colorectal
cancer were C18 to C21, lung cancer were C33 and C34, breast cancer was C50 and was
limited to females and prostate cancer was C61 and limited to males. Other cancer/s was made
up of the residual C-codes.
Chronic Obstructive Pulmonary Disease
This New Zealand Health Tracker indicator is still in development. COPD is defined as any
person aged 35 years or older who has any history (from 2001 to 2011) of being prescribed
ipratropium bromide, salbutamol with ipratropium bromide or tiotropium bromide; or any history
of being prescribed theophylline or aminophylline and has no prior (since 1988) admission
diagnosis of asthma; or has a history of any admission with any diagnosis of COPD (Table 7).
Table 7, Diagnoses codes used to define COPD
ICD-9 codes
9
ICD-10 codes
This is a parsimonious approach and does not necessarily reflect the actual cure time of all cancers.
ICD-9 codes
ICD-10 codes
490 Bronchitis, not specified as acute or chronic
J40 Bronchitis, not specified as acute or chronic
4910 Simple chronic bronchitis
J410 Simple chronic bronchitis
4911 Mucopurulent chronic bronchitis
J411 Mucopurulent chronic bronchitis
49120 Obstructive chronic bronchitis without
mention of acute exacerbation
J418 Mixed simple and mucopurulent chronic
bronchitis
49121 Obstructive chronic bronchitis with acute
exacerbation
J42 Unspecified chronic bronchitis
J430 MacLeod's syndrome
4918 Other chronic bronchitis
J431 Panlobular emphysema
4919 Unspecified chronic bronchitis
J432 Centrilobular emphysema
4920 Emphysematous bleb
J438 Other emphysema
4928 Other emphysema
J439 Emphysema, unspecified
496 Chronic airway obstruction, not elsewhere
classified
J440 Chronic obstructive pulmonary disease with
acute lower respiratory infection
J441 Chronic obstructive pulmonary disease with
acute exacerbation, unspecied
J448 Other specified chronic obstructive
pulmonary disease
J449 Chronic obstructive pulmonary disease,
unspecified
Ever-hospitalised Stroke
Ever-hospitalised stroke includes anyone who has had one of the diagnoses outlined in Table 8
since 1988.
Table 8, Diagnoses codes used to define ever-hospitalised stroke
ICD-9 codes
ICD-10 codes
430 Subarachnoid hemorrhage
G45 Transient cerebral ischaemic attacks and
related syndromes
431 Intracerebral hemorrhage
432 Other and unspecified intracranial
hemorrhage
G46 Vascular syndromes of brain in
cerebrovascular diseases
I60 Subarachnoid haemorrhage
433 Occlusion and stenosis of precerebral
arteries
I61 Intracerebral haemorrhage
434 Occlusion of cerebral arteries
I62 Other nontraumatic intracranial haemorrhage
435 Transient cerebral ischemia
I63 Cerebral infarction
436 Acute but ill-defined cerebrovascular disease
I64 Stroke, not specified as haemorrhage or
infarction
437 Other and ill-defined cerebrovascular
disease
I65 Occlusion and stenosis of precerebral
arteries, not resulting in cerebral infarction
438 Late effects of cerebrovascular disease
I66 Occlusion and stenosis of cerebral arteries,
not resulting in cerebral infarction
I67 Other cerebrovascular diseases
I68 Cerebrovascular disorders in diseases
classified elsewhere
I69 Sequelae of cerebrovascular disease
Source: World Health Organization ICD-10 Version: 2010 http://apps.who.int/classifications/icd10/browse/2010/en;
http://www.icd9data.com/
Heart Failure
This is a New Zealand Health Tracker indicator. To meet the definition for heart failure a person
has to have had a diagnosis of heart failure (ICD-10: I50, ICD-9: 428) since 1988.
Diabetes
This is a robust New Zealand Health Tracker indicator. This includes people who have either
type 1 or type 2 diabetes as well as a small number of people with diagnoses where diabetes is
coded to unspecified or other specified diabetes (not type 1, 2, or gestational).
A person is counted as having showed an indication of diabetes type 1 or 2 if they meet at least
one of the conditions specified below (from any data collection):
1) IC9-CMA diagnosis codes: 250, 6480; ICD-10-AM diagnosis codes: E10, E11, E13, E14,
O240, 0241, O242, O243, O249
2) One or more outpatient attendances for services with the following purchase unit codes:
M20006 (Diabetes education and management), M20007 (Diabetes – Fundus Screening),
M20010 (High risk type I diabetes support), M20015 (High risk type I diabetes support for up to
18 year olds).
3) More than one dispensing of:

insulin

oral hypoglycaemics

metformin where the person is not a female aged between 12 to 45 years.
4) Where the person is female and aged 12–45 years: more than one dispensing of metformin
and one of the following outpatient attendances: M20004 (Diabetes 1st attendance), M20005
(Diabetes subsequent attendance), MAOR0106 (Diabetes management - Māori).
5) Laboratory claims: Four or more Hba1c tests undertaken for an individual during a two year
period from 1 July 1996 to present, and one or more Albumin Creatinine Ratio tests during the
same two year period.
6) National Needs Assessment and Service Coordination Information System (Socrates): One
or more diagnoses of insulin or non-insulin dependent diabetes (2801)
A person is not counted as having type 1 or type 2 diabetes as at a particular point in time if one
of the above criteria is first present in an episode of documented gestational diabetes events,
though diabetes type 2 can occur after a documented episode of gestational diabetes.
If someone has one or two type I diagnoses and none for type II, no oral hypoglycaemic /
metformin dispensings, and no insulin dispensings then they are specifically excluded (because
there isn't evidence of insulin treatment for someone with a type I diagnosis - possible coding
error).
Asthma
This is a New Zealand health Tracker indicator that is still in development. A person is counted
as having shown an indication of asthma if they have one of the diagnosis codes specified
below or two or more dispensings from the Pharmaceutical Collection for asthma preventer
within three years (as the condition is reversible). People identified as having COPD (see
above) are excluded from this indicator.
ICD 8 & 9 codes: 493 (Asthma); ICD9CMA codes: 49300 (Extrinsic asthma without mention of
status asthmaticus), 49301 (Extrinsic asthma with status asthmaticus), 49310 (Intrinsic asthma
without mention of status asthmaticus), 49311 (Intrinsic asthma with status asthmaticus), 49320
(Chronic obstructive asthma, without mention of status asthmaticus), 49321 (Chronic
obstructive asthma, with status asthmaticus), 49390 (Asthma, unspecified, without mention of
status asthmaticus), 49391 (Asthma, unspecified, with status asthmaticus). ICD 10 codes: J450
(Predominantly allergic asthma), J451 (Nonallergic asthma), J458 (Mixed asthma), J459
(Asthma, unspecified), J46 (Status asthmaticus).
Pharmaceuticals: Beclomethasone Diproprionate (excluding allergy prophylactics); Budesonide
(excluding antidiarrhoeals and allergy prophylactics); Fluticasone; Budesonide w/ Eformoterol;
Eformoterol Fumarate; Salmeterol; Fluticasone w/ Salmeterol.
Gout
This is a robust New Zealand Health Tracker indicator. A person is counted as having shown an
indication of gout if they have had a diagnosis of ICD-10 code M10 or ICD-9 code 274, or they
have been dispensed colchicine, or allopurinol. Dispensing of Allopurinol alone is only taken as
an indication of gout if there is no diagnosis of malignant neoplasms of lymphoid,
haematopoietic and related tissues (ICD-10 codes C81-C96) recorded in either the NZCR or
NMDS in the 24 months before the period end date.
Anxiety or Mood disorder
This is a New Zealand Health Tracker indicator which is classified as ‘partial capture’. There are
likely to be people with an anxiety or mood disorder who are untreated, or treated via nonpharmaceutical methods privately.
A person is counted as having shown an indication of a mood disorder if they have one of the
codes specified below from the NMDS, Programme for the Integration of Mental Health Data
(PRIMHD), Socrates, or Pharmaceutical collections, or three of the tests specified for
Laboratory Claims within the past twelve months:
ICD-10_AM diagnosis codes: F30-F39 Mood (affective) disorders
ICD 9 CM(A) diagnosis codes: 296 Affective psychoses; 3004 Neurotic depression; 30113
Cyclothymic disorder; 311 Depressive disorder, not elsewhere classified
DSMIV diagnosis codes: 296 Mood disorders; 3004 Dysthymic Disorder; 30113 Cyclothymic
Disorder; 311 Depressive Disorder NOS
Pharmaceuticals: amoxapine, dothiepin hydrochloride, doxepin hydrochloride, lithium
carbonate, mianserin hydrochloride, mirtazapine, nefazodone, phenelzine sulphate,
tranylcypromine sulphate, trimipramine maleate.
Laboratory Claims Collection: Three or more tests for Lithium in the 12 month period.
Socrates (Disability): Tier 2 diagnosis code: 1303 Bipolar disorder (manic depression); 1304
Depression.
Other diagnosis free text: BIPOLAR', 'DEPRESSION', 'MOOD DISORDER'.
The free text diagnosis was not used if the field also contained 'POSSIBLE', 'QUERY', 'SOME',
'SYMPTOMS'.
A person is counted as having shown an indication of an anxiety disorder if they have one of the
codes specified below (from any data collection) within the past 12 months:
ICD-10-AM diagnosis codes: F400 - F48; ICD 9 CM-A diagnosis codes: 30000 - 30015, 30020 3003, 3005 - 3009, 3060 - 30650, 30652 - 3069, 30780, 30789, 3080 - 3091, 30922 - 30982,
30989, 3099; ICD 9 diagnosis codes: 3000-3003, 3005-3009, 306,3078, 3080-3094,3099.
DSMIV diagnosis codes: 30000-30015, 30021 - 3003, 3006 - 3009, 30780, 30789, 3083, 3090,
30924 - 3099.
Pharmaceuticals: bromazepam, buspirone hydrochloride, meprobamate.
Socrates (Disability): Tier 2 diagnosis code: 1302 Anxiety disorder.
Other diagnosis free text: ANXIETY DISORDER', 'PTSD', 'OCD', 'OBSESSIVE COMPULSIVE',
'POST TRAUMATIC STRESS', 'PHOBIA'.
The free text diagnosis was not used if the field also contained 'POSSIBLE', 'QUERY', 'SOME',
'SYMPTOMS'.
A person was included as having an indication of a mood or anxiety disorder if they fitted either
the mood or anxiety disorder definitions given above, or if they had been dispensed one of the
following pharmaceuticals in the past twelve months:
Alprazolam, citalopram hydrobromide, escitalopram, maprotiline hydrochloride, moclobemide,
sertraline, sertraline Hydrochloride, venlafaxine.
If the person had shown an indication of dementia during the same period, a dispensing of
citalopram alone was not taken as an indication of mood / anxiety disorder (though note the
person may still be picked up through any of the other inclusion criteria for mood / anxiety
disorder).
Dementia
This New Zealand Health Tracker indicator is ‘in development’, previous work has found that
this counts approximately one-third of the estimated cases. While this is limited it was decided
that this indicator should still be included due to the burden it is having upon our ageing
population.
A person is counted as having shown an indication of dementia if they have one of the codes
specified below (from any data collection):
ICD10 diagnosis codes: F000 - F03, G30; ICD 9 CM diagnosis codes: 2900 - 2909, 2941, 3310;
ICD 9 diagnosis codes: 290, 2941, 3310.
DSMIV diagnosis codes: 2900 - 29043, 2941, 2948.
Pharmaceutical Collection: Donepezil hydrochloride, rivastigmine.
Socrates (Disability): Tier 2 diagnosis code: 1405 Vascular dementia, 1499 Other dementia.
Other diagnosis free text: ‘DEMENTIA’.
The free text diagnosis was not used if the field also contained 'POSSIBLE', 'QUERY', 'SOME',
'SYMPTOMS'.
Appendix 3: IHD Horizon Scan
Reading the table from left to right:

Population describes the population for which the technology is suggested

Efficacy / effectiveness - a quick assessment of whether an intervention is
efficacious/effective, ineffective, or of questionable effectiveness. This is a quick
judgment based on the literature referenced, and is subject to change based on proper
assessment.

Volume is the number of patients the intervention may be used for. We have conducted
quick queries using the national minimum data set to give rough numbers of patients for
some common procedures. Mostly, however, it is difficult to define volume with any
degree of certainty and hence estimates are not provided for most technologies.

Our rough cost estimates either come from international literature (converted to New
Zealand dollars) or from Ministry of Health datasets.

CEA is cost-effectiveness analysis; we have not conducted any CEA ourselves. Instead
we present a count of CEA studies from the Centre for Reviews and Dissemination NHS
EED database.

Growth figures are rough estimates derived from Ministry of Health data sets, or
international literature.

Evidence: Low = No RCT in CENTRAL database (or otherwise evident), Moderate = at
least 1 RCT in CENTRAL (or known by other means), High = at least one Cochrane
Systematic Review. Other reviews such as DARE systematic reviews or NICE reviews
will be listed as such. Diagnostic Evidence: Low = No randomised trial in CENTRAL (or
otherwise evident), Moderate = at least 1 Randomised trial in CENTRAL (or known by
other means), High = at least 2 randomised trials in CENTRAL.

Value of assessment - a subjective valuation accounting for the materiality (cost and
health impact) of the option, feasibility of assessment (is there sufficient evidence to
evaluate), and whether others were already working on it.
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
$NZ
Intervention
Service
Smoking cessation(38-43)
Multiple interventions
– multiple
interventions.
Reccomended
throughout pathway of care.
Smokers
Effective
High
Multi-pronged
approach in
New Zealand
Moderate
Risk assessment(38)
Risk
assessment
for
most
asymptomatic men is recommended
from the age of
General pop
Effective
NZGG
Optimality
current
practice
unclear
Moderate
45 (or from the age of 35 if they have
risk factors). Risk assessment for most
of
Cochrane review
underway (44)
asymptomatic women is recommended
from the age of 55 (or from the age of
45 if they have risk factors).
• Mäori should be assessed for
cardiovascular risk 10 years earlier
than non-Mäori.
There is an urgent need to focus
intervention programmes on Mäori,
who bear the greatest burden of
cardiovascular
disease
in
New
Zealand. The ‘outcome gap’ between
Mäori and non-Mäori is widening.
Multiple
risk
factor
interventions for primary
prevention of coronary
heart disease(45)
Increased consumption
of fruit and vegetables for
the primary prevention of
cardiovascular
diseases(46)
Multiple risk factor interventions using
counselling and educational methods
assumed to be efficacious and costeffective in reducing coronary heart
disease (CHD) mortality and morbidity
and that they should be expanded.
General population
Interventions
using
counselling and education
aimed at behaviour change
do not reduce total or CHD
mortality or clinical events in
general populations but may
be effective in reducing
mortality
in
high-risk
hypertensive and diabetic
populations.
Evidence
suggests
that
health
promotion interventions have
limited use in general
populations.
High
Multiple
programmes
Moderate
General population
There are very few studies to
date examining provision of,
or advice to increase the
consumption of, fruit and
vegetables in the absence of
additional
dietary
interventions or other lifestyle
interventions for the primary
prevention of CVD. The
limited evidence suggests
advice to increase fruit and
vegetables as a single
intervention has favourable
effects on CVD risk factors
but more trials are needed to
confirm this.
High
Multiple
programmes
Low
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
$NZ
Intervention
Service
Reduced or modified
dietary fat for preventing
cardiovascular
disease(47)
Reduction and modification of dietary
fats
have
differing
effects
on
cardiovascular risk factors (such as
serum cholesterol), but their effects on
important health outcomes are less
clear.
General population
There is a small but
potentially
important
reduction in cardiovascular
risk on modification of dietary
fat, but not reduction of total
fat, in long term trials.
High
Low glycaemic index
diets for coronary heart
disease.(48)
The glycaemic index (GI) is a
physiological measure of the ability of a
carbohydrate to affect blood glucose.
Interest is growing in the low GI
carbohydrate concept for the clinical
management of people at risk of, or
with
established
coronary
heart
disease.
People at risk of IHD
(primary prevention)
and
with
IHD
(secondary prevention
There is no evidence from
RCTs to show an effect of
low GI diets on coronary
heart disease. The combined
evidence from the studies
suggests that any beneficial
effect of low glycaemic index
diets on CHD and its risk
factors is small.
High
Wholegrain cereals for
coronary
heart
disease(49)
There is increasing evidence from
observational studies that wholegrains
can have a beneficial effect on risk
factors for coronary heart disease
(CHD).
General population
There is a need for welldesigned,
adequately
powered,
longer
term
randomised
controlled
studies in this area.
High
Low
Dietary advice given by a
dietitian versus other
health professional or
self-help resources to
reduce
blood
cholesterol(50)
The average level of blood cholesterol
is an important determinant of the risk
of coronary heart disease. Blood
cholesterol can be reduced by dietary
means. Although dietitians are trained
to provide dietary advice, for practical
reasons it may be given by other health
professionals
or
using
self-help
resources.
People at risk of IHD
Dietitians were better than
doctors at lowering blood
cholesterol in the short to
medium term, but there was
no evidence that they were
better
than
self-help
resources. There was no
evidence
that
dietitians
provided better outcomes
than nurses.
High
Low
MRA(51)
Do not use magnetic resonance (MR)
coronary angiography for diagnosing
stable angina.
Patients
angina
Ineffective for patient group
Ultrafast
single-photon
emission
computer
tomography (SPECT)(52)
Multiple technologies employing more
sophisticated ultrafast cameras and
software to produce better resolution of
the heart more quickly with a lower
dose of tracer
Patients with IHD
with
stable
Reportedly safe and effective
In patients:
49
people
2010-12 (10
of whom had
be
diagnosed
with IHD) 4
subsequently
diagnosed
with IHD
18 studies in
NHS EED 19962013 – appear to
be
assessing
older
SPECT
technologies.
Cardiovascular
magnetic
Resonance
imaging found to
be more costeffective
in
diagnosing CHD
New
Low
Unclear
(NICE)
Optimality
current
practice
unclear
Unclear – many
non-randomised
studies
Unclear
Low
of
High
High
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
One
DARE
systematic review
Unlikely to be
in use
High
$NZ
Intervention
Service
than SPECT (53)
Cardiovascular Magnetic
Resonance (CMR)(54)
For the diagnosis of coronary heart
disease (CHD) as an alternative to
other imaging modalities such as non‐
invasive
single‐photon
emission
computed tomography (SPECT) and
invasive X‐ray angiography.
Patients suspected of
IHD
Reportedly effective
$1.5-2.5
million
per
CMR
machine
1 hit in NHS EED.
CEA
Ontario
Canada: SPECT
dominated CMR
with lower costs
and more QALYs.
And
Stress
echocardiography
dominates both
SPECT and CMR
for stable chest
pain, but only
CMR
is
dominated
for
acute chest pain.
Japanese
CEA
found the costeffectiveness of
SPECT and CMR
similar.
CT angiography(55)
The accuracy of diagnosing
coronary artery stenosis was
the
highest
in
CTCA,
followed
by
myocardial
SPECT and stress ECG.
CEA
between
CTCA
and
myocardial
SPECT indicated
that CTCA was
the cost-effective
test
Delayed
enhancement
MRI(56, 57)
Delayed
enhancement
magnetic
resonance imaging (DE-MRI) aims to
assess cardiac viability in patients who
have experienced an acute myocardial
infarction.
Patients with MI
DE-MRI
correlates
and
agrees well with both PET
and SPECT in the detection
of scar tissue and cardiac
viability
Transmyocardial
laser
revascularisation(58, 59)
Transmyocardial
laser
revascularisation (TMLR) for refractory
angina pectoris should not be used
IHD patients
Ineffective for patient group
Point
of
care
Ultrasonography (60)
Vscan - Miniaturisation of current
ultrasound technology, use at bedside.
Heart failure, acute
coronary syndrome?
Unknown
Implantable
monitor for
MI(60)
Telemedicine - An implantable cardiac
device intended to detect rapid ST
segment changes through EKG to alert
patients through a series of vibration,
Patients with MI
Unknown
10
chest
Korean study:
Patients
pain
cardiac
detecting
with
Korean study:
CT coronary angiography for the
diagnosis of Ischaemic heart disease in
patients with chest pain
Low
Moderate
Unknown
High
(NICE)
Not used in
New Zealand
according to
NMDS
Low
New
Low
Can purchase
in
New
Zealand
Moderate
New
Low
Unlikely to be
in use
Low
DE-MRI can
be conducted
on
a
conventional
MRI scanner
$5,00010
Price as advertised on anunico, March 2014: http://www.anunico.co.nz/search/cat-0/ge+vscan+ultrasound+scanner+for+sell+price+5+000
High
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
No hits in NHS
EED
New
Moderate
Not in use
Low
New
Low
Unlikely to be
in use
Low
Moderate
Unknown
Moderate
$NZ
Intervention
Service
sounds and visual warnings.
Point of care genetic
testing
to
determine
antiplatelet regimen after
PCI(61, 62)
Patients who carry a loss-of-function
allele CYP2C19*2 are at increased risk
of major adverse CVD events if treated
with clopidogral (Plavix). Where this is
the case patients should be treated
with Prasugrel instead.
Patients undergoing
PCI who will be placed
on dual antiplatelet
therapy
Effective
NZ CEA: ICER
$9,000
per
QALY(62)
The Spartan RX CYP2C19 test may
identify such patients in less than an
hour without need for laboratory tests.
U.S. CEA: cost
saving
for
patients
with
Acute coronary
syndrome
undergoing PCI,
compared
with
empiric
approaches
to
treatment(63)
The frequency
of the *2 allele varies by ethnicity and
the Māoris, Asians and Pacific
Islanders
of New Zealand have a relatively high
incidence(62).
Over 15 months,
total costs were
$18 lower with a
gain of 0.004
QALY
in
the
genotype-guided
strategy
compared
with
empiric
clopidogrel, and
$899 lower with a
gain of 0.0005
QALY compared
with
empiric
prasugrel.
KIF6
p.Trp719Arg
genetic testing for IHD(64)
Genetic screening for
familial
hypercholesterolaemia(65,
66)
The current body of evidence
shows imprecise, and in
some
cases,
conflicting
results
Familial hypercholesterolaemia one of
the most common genetic disorders,
affecting 1 in 500 individuals worldwide.
Genetic screening of FH is achieved by
the molecular identification of mutations
within the LDLR or apoB gene.
People suspected of
Familial
hypercholesterolaemia
FH appears to be efficacious
in increasing the proportion
of FH patients receiving
adequate medical treatment.
But the ability of current
genetic testing techniques to
identify mutations within the
LDLR gene is somewhat of a
concern (20% to 80%
mutation detection rate in
clinically
diagnosed
FH
patients), especially if they
are utilised to identify index
UK costs: regular
screening
FH
using the clinical
criteria
ranged
from
$260
(cascade
screening)
to
19,000(universal
screening). genetic
confirmation
ranged
from
$3,700 (cascade
screening)
to
$140,000(universal
Dutch /
USA
ICER: $11,000 –
$50,000
per
QALY compared
with conventional
clinical diagnosis
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
Non-Cochrane
Meta-analysis of
randomised
controlled trials.
Was offered
privately
through
Medtel NZ Ltd
in 2008
High
$NZ
Intervention
cases.
Microvolt
t-wave
alternans (MTWA) test
(67)
A prognostic tool used to risk stratify
patients
who
are
suitable
for
implantation with an ICD, and in whom
the defibrillator will be required to
discharge.
Patients suggested for
ICD
Service
screening)
A meta-analysis and a
number of large prospective
studies have demonstrated
the effectiveness of MTWA
testing in predicting future
arrhythmic events across a
variety of patient populations.
$40,000
$50,000
HearTwave®
II
Cardiac
Diagnostic
System in NZ
in 2009
$400 per test
$55,000
net
PA
NHS EED 2 hits.
Potentially cost
saving in terms of
reducing
ICD
use.
USA CEA: Risk
stratification
of
patients
for
suitability of ICD
implant improve
ICD ICER from
110,000
per
QALY to 60,000
per QALY.
The MTWA test measures small beatto-beat fluctuations in the t-wave not
detectable through routine ECG and
therefore requires specialised sensors
combined with computer algorithms to
evaluate results.
A Canadian CEA
found
only
marginal
improvements in
ICD
costeffectiveness
using the test
Autologous
progenitor
cell treatment for IHD(68)
Progenitor cell treatment is a promising
therapy with the potential to benefit a
large population of patients with
Ischaemic heart disease
Patients with IHD
Cochrane review found high
degree of
heterogeneity
amoung RCTs but moderate
improvement in global heart
function is significant and
sustained long-term. (68). But
there is no evidence of
reduced mortality.
New
High
Unknown but
unlikely
Moderate
Combination intracardiac
echocardiography
and
ultrasound
system
(ICE)(52)
ICE uses a miniaturized transducer
mounted on a wire, or catheter that is
advanced inside the heart during a
catheter ablation procedure. The
system provides clear pictures of the
cardiac anatomy and of the effects of
ablation treatment in real-time
Patients undergoing
cardiac ablation ?
Reportedly
efficacious
New
Low
Unlikely to be
in use
Low
Ultrasound cardiac output
monitor
for
patients
requiring haemodynamic
monitoring(69)
The USCOM device is a non-invasive,
ultrasound cardiac output monitor
designed to measure and record
changes in the haemodynamic status
of critically ill patients transcutaneously.
The USCOM utilises continuous-wave
Doppler ultrasound and can measure
both left and right cardiac output.
Patients
requiring
haemodynamic
monitoring
USCOM device appears to
be safe and efficacious for
the measurement of cardiac
output in critically ill patients.
New
Low
Unknown
Moderate
safe
and
$40-45,000
There are no
recurring
costs, such
as disposable
consumables,
apart
from
standard
ultrasound
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Low
Optimality
current
practice
unclear
Value
of
assessment
$NZ
Intervention
Service
conducting
gel.
Echocardiograms(70)
Avoid using stress echocardiograms on
asymptomatic patients who meet “low
risk” scoring criteria for coronary
disease
Patients at low risk of
coronary disease
Ineffective for patient group
ablation
A minimally invasive radiofrequency
ablation technology that isolates a
target section of the epicardium
employing
a
vacuum-assisted
stabilization system.
Patients
arrhythmias
with
Reportedly
efficacious
Elective
ablation(71)
cardiac
Identified in the UK as an effective
intervention that should be considered
only after cost-effective alternative
alternatives have been tried.
Patients
arrhythmias
with
Not cost-effective in patient
group
Use
of
Myocardial
Perfusion Imaging in the
Diagnosis
of
Acute
Coronary Syndrome
Myocardial Perfusion Imaging is used
in the diagnosis of IHD. Here the
technology is used in a more acute
setting.
Patients
presenting
with acute symptoms,
without ECG changes
of
MI,
and
at
intermediate risk of
IHD
Similar
sensitivity
to
Troponin, less specificity.
Reduced
hospital
admissions?
Use of nuclear imaging
techniques for diagnosis
of heart failure
Radionuclide ventriculography
myocardial perfusion scintigraphy
Diagnosis of heart
failure
with
nondiagnostic
echocardiogram
Not first line investigation(74,
Elecsys®
proBNP
Immunoassay: For the
diagnosis of congestive
heart failure(76).
Tests for the diagnosis of congestive
heart failure.
Patients suspected to
have heart failure
Unclear effectiveness
Point of care testing for
ACS-troponin T, heart
failure pro-BNP (77, 78)
Delivery of trop T and pro BNP at
patient side and access to faster result
– miniaturised tests
Risk of IHD and Heart
failure
Systematic review of early
POC moderate PPV/NPV for
ACS including multi-test (79)
and H FABP(80) Varied
reduction in time attending
ED and limited impact on inpatient resources(81, 82)
POC for IHD(84)
Moderate
Low
Unlikely to be
in use
Moderate
Low
Optimality
current
practice
unclear
of
Moderate
Choosing Wisely:
American Society
of
Echocardiography
Epicardial
system(52)
and
of
safe
New
and
(Corydon
List
repeated
in
London
Health
Observatory
“Save to Invest”)
Patients at risk of IHD
$1200
75)
There is insufficient evidence
to
support
that
POC
cholesterol
testing
can
replace
conventional
laboratory
testing
for
diagnosis of CHD, monitoring
response to therapy, or that it
will
result
in
overall
comparable
clinical
effectiveness.
12 Hospital
labs NZ (out
of
hours/back
up)
for
Troponin (83)
Cost
per
assay $40
4 studies in NHS
EED
Moderate (72, 73)
In
use
–
scope change
proposed
Moderate
1 study in NHS
EED
Sourced
guidelines
In use
Low
Moderate
Unclear
Moderate
Moderate
Restricted use
Moderate
Restricted use
Moderate
4 studies in NHS
EED
Stable 200711.
Current
usage for out
of hours.
Systematic review
– not Cochrane
Systematic review
in DARE
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
new
Low
epidemiological
studies
Not in use for
this role
Moderate
$NZ
Biomarkers to improve
CVD risk prediction(85, 86)
(87)
Addition of CRP/ troponin T , BNP to
traditional risk factors for CVD risk
assessment
Selected
population
for
CVD
risk
assessment
IHD risk prediction
Nil
Intervention
Service
CRP-$6
Not more than
currently as would
be additional tests
to
current
procedure
BNP $80
Troponin $12
Cystatin
$80
Cardiovascular
risk
assessment in primary
care (88).
Risk factors considered Included:
Ankle-brachial
index,
C-reactive
protein, Carotid intima media thickness,
Electron beam computed tomography,
Fasting
glucose,
Homocysteine,
Lipoprotein(a), Periodontal disease,
White blood cell count.
CVD testing
health target
C
General population
Analysis indicates that Creactive
protein
measurement could play an
important role in improving
the prediction of CHD risk in
a large segment of the US
male population with 10–
20%10-year risk of first CHD
events.
U.S. Preventive
Services
Task
Force systematic
review
of
epidemiological
studies
NZ CVD risk
assessment
tool
developed in
2003.
Guideline
recommended
against
the
use of CRP
for screening
Moderate
Evidence to 2009
Screening
exercise
electrocardiogram testing
in individuals who are
asymptomatic and at low
risk for coronary heart
disease (89)
Do not obtain screening exercise
electrocardiogram testing in individuals
who are asymptomatic and at low risk
for coronary heart disease
General Population
Ineffective for patient group
Choosing Wisely
recommendation
from
the
American College
of Physicians
Optimality
current
practice
unclear
of
Moderate
Chest x-ray for acute
coronary syndrome(90)
In emergency patients suspected of
acute coronary syndrome but without
other symptoms, signs or pathology,
chest x-ray gave low yield of
unexpected pathology and its need is
questionable in this group.
ED patients suspected
of acute coronary
syndrome but without
other symptoms, signs
or pathology
Ineffective for patient group
Low
Optimality
current
practice
unclear
of
Moderate
Exercise
Resting and exercise ECGs are of
limited
incremental
value,
more
effective risk assessment is needed in
ambulatory suspected angina patients
Patients
ECG
undergoing
Ineffective for patient group
Low
Optimality
current
practice
unclear
of
Moderate
Exercise tolerance testing can provide
risk information but its usefulness for
asymptomatic patients is unclear(92).
Asymptomatic patients
with suspected angina
Ineffective for patient group
Systematic review
for the technical
support for the
U.S. Preventive
Services
Task
Force
Optimality
current
practice
unclear
of
Moderate
Do not use exercise electrocardiogram
(ECG) to diagnose or exclude stable
angina for people without known
coronary artery disease
Patients
angina
Ineffective for patient group
(NICE)
Optimality
current
practice
unclear
of
Moderate
electrocardiogram
(ECG) for Angina
ECG(51)
(51, 91)
with
stable
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
$NZ
Intervention
Troponin
testing
for
elevation of heart attack /
heart injury
Introduction of a Troponin Testing
Algorithm in Canada improved care by
reducing patients stay and costs
without adversely affecting patient
outcomes(93).
Service
Patients suspected of
MI
Ineffective for patient group
Low
Optimality
current
practice
unclear
Patients subject
Troponin testing
Moving from routine troponin
to high sensitivity troponin
tests has the advantage of
earlier diagnosis, but has the
disadvantage of increased
uncertainty as to whether
raised troponin levels are
due to MI or other conditions.
Low
In use
Ineffective for patient group
Low
Optimality
current
practice
unclear
of
High
Optimality
current
practice
unclear
of
High
Optimality
current
practice
unclear
of
High
Optimality
current
practice
unclear
of
Moderate
Optimality
current
practice
of
High
of
High
Troponin I provides little additional
benefit to ECG in identifying patients
with syncope due to AMI in the ED.
Troponin I should not be used to rule
out AMI in patients presenting with
syncope(94).
High sensitivity troponin
testing(95)
Stress testing(96)
Do not perform routine annual stress
testing after artery revascularization
to
Patients who have
undergone
revascularisation
High
Choosing Wisely:
Society
of
Nuclear Medicine
and
Molecular
Imaging
Stress Cardiac Imaging
or advanced non-invasive
imaging(97)
Do not perform stress cardiac imaging
or advanced non-invasive imaging in
the initial evaluation of patients without
cardiac symptoms unless high-risk
makers are present
General population
Do not perform annual stress cardiac
imaging or advanced non-invasive
imaging as part of routine follow-up in
asymptomatic patients.
General population
Ineffective for patient group
Low
Choosing Wisely:
American College
of Cardiology
Ineffective for patient group
Low
Choosing Wisely:
American College
of Cardiology
Diagnostic tests (98)
Computed Tomography
Non-invasive diagnostic tests for
patients with a pre-test probability of
coronary disease that is above 90% or
below 10% should be discontinued as
they add little or nothing to diagnostic
precision
General population
Don’t use coronary artery calcium
scoring for patients with known
coronary artery disease (including
Patients with IHD
Ineffective for patient group
Low
BMJ
opinion
Ineffective for patient group
Low
Expert
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
$NZ
Intervention
Service
stents and bypass grafts).
New
Generation
Computed
Tomography(99, 100)
unclear
Don’t order coronary artery calcium
scoring for screening purposes on low
risk asymptomatic individuals except
for those with a family history of
premature coronary artery disease.
Low risk IHD patients
Don’t
routinely
order
coronary
computed tomography angiography for
screening asymptomatic individuals.
General population
Don’t
use
coronary
computed
tomography angiography in high risk
emergency
department
patients
presenting with acute chest pain.
Patients with
chest pain
Multiple CT technologies - using
Discovery CT750 HD (GE Healthcare),
Brilliance iCT (Philips Healthcare),
Somatom Definition Flash (Siemens
Healthcare) or Aquilion ONE (Toshiba
Medical Systems)
Patients with IHD
Choosing Wisely:
Society
of
Cardiovascular
Computed
Tomography
acute
NGCCT may be sufficiently
accurate
to
diagnose
clinically significant IHD in
some or all difficult-to-image
patient groups.
64 slice CT
scanners with
cardiac
capabilities
cost
about
$1.5
million(100)
May
be
cost
saving
for
patients
with
known
CAD
subject
to
invasive coronary
angiography
compared
with
invasive coronary
angiography
alone.
DARE Systematic
Review
Unknown
High
Low
Unclear
Low
High
2004 review
of
Cardiac
rehab found a
need improve
referral
High
For
radiation
exposure
only,
the
ICER
for
NGCCT
compared
with
64-slice CT in
congenital heart
disease ranged
from £521,000 for
the
youngest
patients
to
£90,000
for
adults.
WHITE BLOOD CELL
COUNT TESTING TO
PREDICT CORONARY
ARTERY DISEASE(101)
Cardiac
(102-104)
rehabilitation
Compared with usual care, in medium
to longer-term follow-up (12 or more
months)
exercise-based
cardiac
rehabilitation was found to be effective
in reducing overall and cardiovascular
People at risk of IHD
Unclear: A number of studies
reported
a
correlation
between WBC and coronary
artery inflammation, however
there are many markers
currently available and in use
for the prediction of coronary
artery disease.
Patients with IHD
Effective
About $20 per test
2001: $80.45
per purchase
unit, national
spend $1.34
million. Wide
3 Hits NHS EED
Irish
Study
-
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
$NZ
Intervention
Service
variation(105)
mortality in patients with CHD, and
appeared to reduce the risk of hospital
admissions in the shorter term (<12
months follow-up).
ICER:
$12,500
per
life
year
gained (106).
processes,
promotion,
provision,
delivery and
monitoring of
cardiac
rehabilitation
services (108).
UK
Study
–
ICER: $4,000 per
life year gained
(107)
.
Heart
Foundation
sponsoring
research into
cardiac
rehabilitation
in
New
Zealand
currently.
NHC
executive in
contact with
researcher
Home versus centrebased
cardiac
rehabilitation (109, 110)
Home- and centre-based cardiac
rehabilitation appear to be equally
effective in improving the clinical and
health-related quality of life outcomes
in acute MI and revascularisation
patients.
Patients with IHD
Effective
High
High
Psychological
interventions for coronary
heart disease (111)
Psychological
treatments
appear
effective in treating psychological
symptoms of CHD patients.
Patients with IHD
Effective
High
Optimality
current
practice
unclear
of
Moderate
Psychological
interventions
for
symptomatic
management of nonspecific chest pain in
patients (112)with normal
coronary anatomy
Recurrent chest pain in the absence
of coronary artery disease is a
common problem that sometimes leads
to excess use of medical care.
Patients with nonspecific chest pain
A modest to moderate
benefit for psychological
interventions,
particularly
those using a cognitivebehavioural
framework,
which was largely restricted
to the first three months after
the intervention
High
Optimality
current
practice
unclear
of
Moderate
Service organisation for
the secondary prevention
of
ischaemic
heart
disease
in
primary
care(113)
While the benefits of individual medical
and
lifestyle
interventions
is
established, the effectiveness of
interventions which seek to improve the
way secondary preventive care is
delivered in primary care or community
settings is less so.
Patients with IHD
There is weak evidence that
regular planned recall of
patients for appointments,
structured monitoring of risk
factors and prescribing, and
education for patients can be
effective in increasing the
proportions of patients within
target levels for cholesterol
control and blood pressure.
High
Various
Yoga
for
secondary
prevention of coronary
heart disease(114)
Yoga has been regarded as a kind of
physical activity as well as stress
management
strategy.
Growing
evidence suggests the beneficial
Patients with IHD
The effectiveness of yoga for
secondary prevention in
CHD remains uncertain.
Large RCTs of high quality
High
High
Low
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
New
Various
trials
NZ Status
Value
of
assessment
$NZ
Intervention
effects of yoga on various ailments.
Service
are needed.
New Stents(52)
New drug-eluting, bioresorbable, selfapposing, self-expanding stents
Patients with coronary
occlusion
Unknown
Stents(115, 116)
There is no evidence to suggest that
primary stenting reduces mortality
when compared to balloon angioplasty
Patients with coronary
occlusion
Ineffective for patient group
High
Optimality
current
practice
unclear
of
Low
Stents(97)
Do not perform stenting of non-culprit
lesions during percutaneous coronary
intervention
for
uncomplicated
haemodynamically stable ST-segment
elevation myocardial infarction.
Patients with coronary
occlusion
Ineffective for patient group
Low
Optimality
current
practice
unclear
of
Low
Drug-eluting stents(117)
There is no evidence of significant
effect for drug eluting stents, versus
bare metal stents, on rates of death MI
or thrombosis
Patients with coronary
occlusion
Ineffective for patient group
High
Optimality
current
practice
unclear
of
Low
Angioplasty
versus
stenting for subclavian
artery stenosis(118)
There is currently insufficient evidence
to determine whether stenting is more
effective than angioplasty alone for
stenosis of the subclavian artery.
Patients
subclavian
stenosis
Ineffective for patient group
High
Optimality
current
practice
unclear
of
Low
Percutaneous
transluminal
coronary
angioplasty with stents
versus coronary artery
bypass
grafting
for
people with stable angina
or
acute
coronary
syndromes(119)
CABG is associated with reduced rates
of major adverse cardiac events
compared with PCI, mostly driven by
reduced repeat revascularisation.
Patients with stable
angina
or
acute
coronary syndromes
CABG appears to be more
effective than PCI for people
with stable angina or acute
coronary syndromes
High
Optimality
current
practice
unclear.
of
Moderate
Patients undergoing
angioplasty
Reportedly
efficacious
compared with plain balloons
in reducing mortality but no
significant
difference
compared with drug eluting
stents (121)
Moderate
Unlikely to be
used
Low -
Drug eluting balloons in
angioplasty(120)
Low
clinical
Choosing Wisely:
American College
of Cardiology
with
artery
With a DARE
systematic review
Early invasive versus
conservative strategies
for unstable angina and
non-ST
elevation
myocardial infarction in
the stent era. (122)
Available data suggest that an invasive
strategy (early stent or CABG) may be
particularly useful in those at high risk
for recurrent events.
Patients with coronary
occlusion and non-ST
elevation myocardial
infarction
Effective
High
Optimality
current
practice
unclear
of
Low
Coronary
revascularisation (123)
Coronary revascularisation should not
be routinely considered in patients with
heart failure due to systolic left
ventricular impairment, unless they
have refractory angina
Patients with heart
failure due to systolic
left
ventricular
impairment,
Ineffective for patient group
NICE
Optimality
current
practice
unclear
of
High
Robotic assisted totally
endoscopic
coronary
artery
bypass
The da Vinci telemanipulation robotic
system enables totally endoscopic
Patients with IHD
Appears safe and efficacious
Low
Unlikely
$2 million
$550K
costs
annual
Low
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
High
Undertaken in
New Zealand
High
Low
Unknown
–
limited use in
Australia
Moderate
$NZ
Intervention
surgery(124)
CABG
Bariatric surgery(38)
To be used when all other measures
have failed
Microbial
sealant
to
reduce
surgical
site
infections
following
coronary artery bypass
graft(125)
Obese people
Effective
Patients
CABG
Reportedly safe and possibly
efficacious , but unclear if
significant
reductions
in
infections
undergoing
Service
$35
per
application
(25cm
*25cm)
Fast-track interventions
(low-dose opioid based
general anaesthesia and
early tracheal extubation)
are
safe
in
adults
undergoing
cardiac
surgery(126)
Fast-track interventions reduced the
time to extubation and shortened the
length of stay in the intensive care unit,
but did not reduce the length of stay in
the hospital.
Patients undergoing
cardiac surgery
Effective
High
Optimality
current
practice
unclear
of
Moderate
Cardiopulmonary bypass
during CABG(127, 128)
Cardiopulmonary bypass found not to
improve a 12 month primary composite
measure compared with a beating
heart (off-pump) technique. The
composite outcome included death,
myocardial infarction, stroke, or new
renal failure requiring dialysis
Patients undergoing
heart surgery
Ineffective for patient group
Moderate
Optimality
current
practice
unclear
of
High
Minimally
invasive
cardiopulmonary bypass
system
(mini-CPB
system)(129)
An alternative to off-pump and
conventional cardiopulmonary bypass
(CPB) (where blood flow and oxygen
circulation are maintained while the
heart is stopped for a period of time),
using
a
minimally
invasive
cardiopulmonary bypass system to
avoid complications of CPB. Mini-CPB
systems include: a closed circuit,
centrifugal
pump,
hollow-fibre
oxygenator, biocompatible surfaces,
reduced membrane surface area,
separation of the pericardial shed blood
suction and reduced priming volume
Patients undergoing
heart surgery
mini-CPB appears to present
a viable alternative to
conventional CPB
Moderate
Unknown
Fractional flow reserveguided stenting(52)
FFR is a physiological index that
determines the severity of blood flow
blockages in the coronary arteries and
is measured using a Pressure Wire
technology. The pressure wire is
placed over the lesion of interest
inducing a state of maximal blood flow,
to enable the physician to determine if
the narrowing is tight enough to cause
ischemia. FFR measurement may help
better identify which specific lesion or
lesions are responsible for a patient’s
ischemia.
Patients with coronary
occlusion
Reportedly efficacious
Moderate
Optimality
current
practice
unclear
2 studies in NHS
EED
(older
technologies)
More
recent
study Identified
outside EED (130)
– PCI guided by
FFR
compared
with
optimal
medical therapy
with
stable
angina – ICER
$45,000
per
New
and
existing
Moderate
of
Moderate
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
New
Low
Not in use as
of 2012(131)
Low
New
Low
Unlikely to be
in use
Low
High
Optimality
current
practice
unclear
High
New
Low
Unlikely to be
in use
Moderate
Unclear
Low
Unknown
Moderate
High
Unknown
Moderate
Unknown
Moderate
$NZ
Intervention
Service
QALY
Guided
medical
positioning system(52)
MediGuide – a guided medical
positioning system enabling clear
navigation for intra-cardiac devices
Patients
requiring
cardiac catheterisation
and
interventional
cardiology procedures
Unkown
Robotic
assisted
coronary angioplasty(52)
Robotic angioplasty allows physicians
to work away from the patient,
protecting them from radiation during
angioplasty
Patients with coronary
occlusion
Unknown
Carotid endarterectomy
for carotid stenosis in
patients
selected
for
coronary artery bypass
graft surgery (133)
Cochrane review found no evidence
from RCTs by which to assess the
benefits and risks of prophylactic
carotid surgery before CABG surgery
Patients undergoing
prophylactic
carotid
surgery before CABG
surgery
Ineffective for patient group
Extracorporeal
shockwave
myocardial
revascularisation
(ESMR)(52)
Cardiospec
–
a
non-invasive
technology using a shock wave
generator designed to deliver lowintensity, focused shock waves to preselected locations in the patient heart.
The shock waves are reported to
increase local blood flow reducing
angina symptoms not treatable by
conventional
revascularization
methods.
Patients with Angina
Early evidence suggests safe
and efficacious but small
studies(134)
TherOx® AO System(135)
The TherOx® AO System is a form of
hyberbaric oxygen therapy. The
System controls Cartridge operation,
wherein SSO2 solution is created and
mixed with the patient’s blood to create
SuperOxygenated blood for delivery to
the coronary arteries. The SSO2
Therapy procedure is a one-time, 90minute infusion that is initiated in the
cardiac catheterization lab
Patients after MI
May be safe and efficacious
for subgroup of patients after
MI
Hypothermia
for
neuroprotection in adults
after
cardiopulmonary
resuscitation(136).
Good neurologic outcome after cardiac
arrest is hard to achieve. Interventions
during the resuscitation phase and
treatment within the first hours after the
event
are
critical.
Experimental
evidence suggests that therapeutic
hypothermia is beneficial
Patients who have
had a cardiac arrest
Conventional
cooling
methods to induce mild
therapeutic
hypothermia
seem to improve survival and
neurologic outcome after
cardiac arrest.
Hypothermia to reduce
neurological
damage
following coronary artery
Coronary artery bypass surgery
(CABG) may be life-saving, but known
side effects include neurological
damage and cognitive impairment. The
Patients
CABG
There is insufficient data to
date to draw any conclusions
about the use of mild
undergoing
Price
specifics are
unavailable
but
similar
robotic
platforms,
such
as
remote
catheter
navigation,
cost upwards
of
$2
million.(132)
$42,500
$2,500 disposable
per patient
of
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
$NZ
Intervention
Service
bypass surgery(137)
temperature
used
during
cardiopulmonary bypass (CPB) may be
important with regard to these adverse
outcomes, where hypothermia is used
as a means of neuroprotection
Hyperbaric
oxygen
therapy
for
acute
coronary syndrome(138)
Acute coronary syndrome (ACS),
includes acute myocardial infarction
and unstable angina, is common and
may prove fatal.. After Hyperbaric
oxygen therapy (HBOT) may improve
oxygen supply to the threatened heart
and may reduce the volume of heart
muscle that perishes. The addition of
HBOT to standard treatment may
reduce death rate and other major
adverse outcomes
Patients with Acute
coronary syndrome
There is some evidence from
small trials to suggest that
HBOT is associated with a
reduction in the risk of death,
the volume of damaged
muscle, the risk of MACE
and time to relief from
ischaemic pain. However, as
evidence base is limited The
routine application of HBOT
to these patients cannot be
justified.
High
Unknown
Moderate
Oxygen therapy for acute
myocardial infarction(139)
Oxygen is widely used in people with
acute myocardial infarction (AMI)
although it has been suggested it may
do more harm than good.
Patients having had a
an acute myocardial
infarction
There is no conclusive
evidence from randomised
controlled trials to support
the routine use of inhaled
oxygen in people with AMI.
High
Unknown
High
Primary
angioplasty
versus
intravenous
thrombolysis for acute
myocardial infarction(140)
Intravenous thrombolytic therapy is the
standard care for patients with acute
myocardial infarction, based upon its
widespread availability and ability to
reduce
patient
mortality
well
demonstrated in randomised trials.
Despite
its
proven
efficacy,
thrombolytic therapy has limitations.
Many patients are ineligible for
treatment with thrombolytics. Of those
given thrombolytic therapy, 10 to 15
percent have persistent occlusion or
reocclusion of the infarct-related artery.
Consequently, primary angioplasty
(primary PTCA) has been advocated as
a better treatment of myocardial
infarction
Patients having had a
an acute myocardial
infarction
Angioplasty provides a shortterm clinical advantage over
thrombolysis which may not
be
sustained.
Primary
angioplasty when available
promptly at experienced
centres, may be considered
the preferred strategy for
myocardial reperfusion. In
most situations, however,
optimal thrombolytic therapy
should still be regarded as
an excellent reperfusion
strategy.
High
Unknown
High
Intra-aortic balloon pump
counterpulsation (IABP)
for myocardial infarction
complicated
by
cardiogenic shock(141)
Intra-aortic
balloon
pump
counterpulsation (IABP) is currently the
most commonly used mechanical
assist device for patients with
cardiogenic shock due to acute
myocardial infarction. Although there is
only limited evidence by randomised
controlled trials, the current guidelines
of
the
American
Heart
Association/American
College
of
Cardiology and the European Society
of Cardiology strongly recommend the
use of the intra-aortic balloon
counterpulsation in patients with
infarction-related cardiogenic shock on
the
basis
of
pathophysiological
considerations as also non-randomised
trials and registry data
Patients with patients
with cardiogenic shock
due
to
acute
myocardial infarction
Available evidence suggests
that IABP may have a
beneficial effect on the
haemodynamics,
however
there is no convincing
randomised data to support
the use of IABP in infarct
related cardiogenic shock.
High
Unknown
Moderate
hypothermia.
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
TMLR
appears not to
be used in
New Zealand,
but
cannot
know
for
certain
Low
High
Unknown
Moderate
new
Moderate
with
Cochrane review
in progress
Been trailed in
NZ
Moderate
No growth
Moderate
No
certified
hospital
in
New Zealand.
One
in
Sydney
Low
No
growth
over
past
decade.
Potential for
growth with
technological
advance
Moderate
Very limited
volumes over
past 10 years
Moderate
$NZ
Intervention
Transmyocardial
laser
revascularization versus
medical
therapy
for
refractory angina (142).
Transmyocardial
laser
revascularization (TMLR) has been
proposed to improve the clinical
situation of these patients. TMR uses a
laser beam to improve blood flow to
heart muscle.
Patients with IHD
There is insufficient evidence
to conclude that the clinical
benefits of TMLR outweigh
the potential risks. The
procedure is associated with
a significant early mortality.
Percutaneous
transluminal
rotational
atherectomy for coronary
artery disease(143)
Percutaneous transluminal coronary
rotational
atherectomy
(PTCRA)
debulks atherosclerotic plaque from
coronary arteries using an abrasive
burr. On rotation, the burr selectively
removes hard tissue. PTCRA has been
used both as an alternative to and in
conjunction with balloon angioplasty to
open up blocked coronary arteries.
Patients with IHD
When
adjunctive
percutaneous
transluminal
coronary
angioplasty
is
feasible, PTCRA appears to
confer no additional benefits.
There is limited published
evidence and no long-term
data to support the routine
use of PTCRA in in-stent restenosis.
Compared
to
angioplasty
alone,
PTCRA/PTCA did not result
in a higher incidence of
major
adverse
cardiac
events, but patients were
more likely to experience
vascular spasm, perforation
and
transient
vessel
occlusion
Patients suspected of
heart failure
Reportedly efficacious
BNP test for diagnosis of
heart failure (144)
Total Artificial Heart
(52,
SynCardia’s temporary
145)
End
Stage
Failure
Heart
Reportedly efficacious as a
bridging device to heart
transplant
2005
HealthPACT
estimate less
than
7
patients
in
Australia –
so unlikely to
be a feasible
services in
NZ
End
Stage
Failure
Heart
May be efficacious for some
high risk surgical candidates
2 (2012/13)
artificial heart (TAH) is the only device
that
replaces
both
ventricles.
SynCardia’s TAH
has been used as a bridge to transplant
since 2004 in the United States (146).
Ventricular assist devices
(52, 147, 148)
Service
BNP $80
10 hits NHS EED
per test
Australia
CEA:
cost
saving
compared
with
no BNP through
reduced
hospitalisations
for home based
nursing care
$114,000
$143,000
-
$187,000
35%
65%
$700,000
5 hits in NHS
EED
Continuous-flow
VADs
ICER
=
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
New
Low
Unlikely to be
in use NZ
Moderate
New
Low
Unlikely to be
in use
Low
Reportedly cost
saving from a US
Medicare
perspective
compared with IV
diuretic therapy
New
Moderate
Unknown use
in NZ – limited
use
in
Australia
Moderate
7 hits in NHS
EED
4.9%
pa
2003/042012/13
High
Standard
treatment
Moderate
Low
Not in use
Low
Moderate
Standard
treatment
Moderate
Moderate
Pharmac
longer term
$NZ
Intervention
Service
$NZ200,000
(DLA Piper)
Optimizer III(60, 149, 150)
A device implant intended to treat
patients with refractory HF not eligible
for cardiac resynchronisation. Unlike
pacemakers and ICD’s it is intended to
increase the strength of the heart beat
through
Cardiac
Contractility
Modulation (60).
Patients
with
refractory heart failure
Unknown
Catheter-based
ventricular
restoration
implant (60)
A percutaneous device for the left
ventricle partitioning the damaged
portion of the heart from the functional
heart segment with a view to improving
geometry and function of the heart.
Patients
with
Ischaemic heart failure
Unknown
Ultrafiltration(151)
The Aquadex FlexFlow system uses a
simplified approach to ultrafiltration for
the removal of salt and water in
patients with fluid overload. The device
is smaller and more portable than
conventional ultrafiltration technologies.
The system consists of a console,
disposable circuit and disposable
venous catheter that can be placed in
either a central or peripheral location.
Heart failure patients
Appears efficacious in some
patients, but results require
confirmation by larger RCTs
(underway)
Patients
with
arrhythmias or heart
failure
Effective
Pacemakers(52, 152)
.
Hardware =
$30,000 per
device.
Disposable
UF circuit and
haematocrit
sensor
=
$1,500
per
patient
1754
(2012/13)
37%
63%
$3,500
$6,000
$13.2 million
in CUBE for
implantation or
replacement
2012/13
4.5% pa
2007/082012/13
Wireless
stimulator(52)
Implantable
cardiac
A wireless pacemaker employing
pulses of ultrasound to regulate the
heart
Patients
with
arrhythmias or heart
failure
Phase 1
underway
Arrhythmias
Effective
and
2
trials
Cardioverter
Defibrillator(52)
508
(2012/13)
66%
34%
$22,000
$11,000
$14.4 million
in the CUBE
for
implantation or
replacement
2012/13
6 hits in NHS
EED
14.2% pa
2003/042012/13
European study:
ICER =
$70,000/QALY
gained compared
with the no ICD
14.5% pa
2007/082012/13
(153)
Subcutaneous
implantable
defibrillator(52, 150)
ICS
Arrhythmias Patients who do not also
require a pacemaker or
$60,000
EFFORTLESS
study underway –
primary
completion date
New
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
$NZ
Intervention
Service
January 201411
pacing therapy
IHD
and
arrhythmias
comorbid
Wearable
vest (52)
Reportedly efficacious
more than 23,000 patients
have worn the wearable
defibrillator.
New
Low
Patients with AV and
HF
Effective
New
Moderate
Patients
arrhythmias
Some applications may be
efficacious
New
Moderate
Multiple
technologies.
New
technology –
unlikely to be
in use but
may
have
been trialled
in
New
Zealand
High
defibrillator
A vest with a portable battery and
control system for monitoring the heart
and delivering shock treatment for lifethreatening arrhythmias
Bridge
to
implantation
Biventricular
(BiV)
pacingfor atrioventricular
(AV) 12 (60, 154)
Biventricular pacing (also called CRT
pacing) using cardiac resynchronization
therapy-pacemakers and –defibrillators
for atrioventricular block and heart
failure approved by FDA.
Next generation balloon
ablation technologies(52)
Multiple balloon ablation technologies
for the treatment of arrhythmias
employing cryoenergy(intense cold
energy) or high intensity focused
ultrasound (HIFU), or laser-based
ablation therapy.
ICD
with
Cryoablation =
$6000
Vs
radiofrequency
ablation
=
(155)
$4000
Average cost per
successfully
treated
patient
was $6,600 with
cryoablation
vs
$4,300
with
radiofrequency
ablation(155)
Unlikely to be
in use
Moderate
Moderate
1 study in NHS
EED on surgical
(not
percutaneous)
HIFU
Balloon pumps: Extraaortic balloon counterpulsation heart assist
device for heart failure(60)
C-Pulse device – A electronically
controlled balloon device that wraps
around the outside of the aorta to
increase blood flow to the arteries.
Inserted using minimally invasive
surgery.
Patients
with
refractory heart failure
Unknown
New
Low
Have
been
undertaken in
Auckland
hospital(156)
High
Vagus nerve stimulation
for treatment of heart
failure – CardioFit (60)
Percutaneous device, similar to a pace
packer,
that
stimulates
the
parasympathetic nervous system, with
a view to rebalancing activity between
the sympathetic and parasympathetic
nervous system in order to lower heart
rate, reduce workload, and reduce HF
symptoms.
Patients
failure
with
heart
Unknown
New
Low
Unlikely to be
in use
Low
Autologous bone marrow
cell transplantation(157)
An alternative to heart transplantation
for patients with heart failure.
Autologous
bone
marrow
cell
transplantation is designed to improve
cardiac function and inhibit cardiac
Patients
failure
with
heart
As of 2007, long term safety
and effectiveness unclear
New
Low
Unlikely to be
in use
Moderate
11
See the Cameron Health Post Market S-ICD Registry (EFFORTLESS), NCT01085435: http://clinicaltrials.gov/ct2/show/NCT01085435?term=EFFORTLESS&rank=1
12
Medtronic press release: http://newsroom.medtronic.com/phoenix.zhtml?c=251324&p=irol-newsArticle&id=1862765
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
$NZ
Intervention
Service
remodelling by replacing the fibrous
scar tissue (created by myocardial
infarction) with viable myocardium.
Early warning system to
reduce
hospital
readmission for Heart
Failure(60)
Healthy Recovery Solutions – an
integrated e-health system for keeping
HF patients out of hospital. Patients
provided
with
evidence
based
behavioural prompts loaded on tablets.
Patient data readily available to
clinicians through electronic medical
record. Web monitoring and smart
phone applications to reinforce healthy
lifestyles.
Patients
failure
with
heart
Reportedly efficacious
New
Low
Various
initiatives
underway on
adhoc basis
Moderate
Wireless
monitoring
system for management
of
heart
failure
(Champion system by
CardioMEMS)(60)
A percutaneously delivered paper clip
sized device in the pulmonary artery
that monitors left atrial pressure. An
external hand held electronic sensor
collects
pressure
data
using
radiofrequency energy.
Patients
failure
with
heart
Reportedly efficacious
New
Moderate
Unlikely to be
in use
Moderate
BodyGuardian
Remote
Monitoring system
The
BodyGuardian®
Remote
Monitoring System employing a
discreet body-worn sensor that adheres
to the patient’s skin. The bandage-like
patch carries a small battery operated
monitor sensor, so the patient has
complete mobility, allowing patients to
go about their normal life without
restrictions. Real time patient data is
delivered by smartphone to a cloud
based platform to health professionals
to monitor alerts at any time via the
web.
Patients
with
pacemakers,
ICDs
and
cardiac
resynchronisation
therapy
Unknown
New
Low
Unlikely to be
in use
Moderate
ICD,
pace-marker
and
cardiac
resynchronization therapy devices have
extensive diagnostic abilities in addition
to being therapeutic devices. Remote
monitoring (RM) allows patients to
transmit clinical data from their devices
to clinicians at home, and potentially
avoid hospitalisation and reduce the
need for patient follow up. A number of
RM systems have been studied
including the ‘Care Link Network’,
‘Home Monitoring’, and ‘Home Call 11’.
Patients with IHD
New
Moderate
Unknown
–
survey of ehealth
underway. If
in
use,
unlikely to be
mainstream
High
for
patients
with
pacemakers, ICDs and
cardiac resynchronisation
therapy(52)
Internet-based
deviceassisted
remote
monitoring
of
cardiovascular
Implantable
electronic
devices(158)
Costs
depends
on
the model of
care but may
be divided into
physician
costs, hospital
or clinic costs,
and network or
data system
costs.
Data
support
system costs
may
be
covered
by
industry.
NHS EED results
appear to be
focused
on
broader
telemetering
systems
for
cardiac patients.
OHTAC analysis
in
Ontario
Canada
found
ICD and CRT
device
remote
monitoring could
be cost saving
from
reduced
physician visits.
With
an
incremental
annual saving of
$115
per
patient.(158)
Intervention / Model of
Care
Description
Population
Efficacy / effectiveness
Volume
Cost $NZ
Total Cost
CEA
Growth
Evidence
NZ Status
Value
of
assessment
New
Low
May
be
isolated cases
of innovation.
Survey of ehealth
application
currently
underway
Low
New
Moderate
Unlikely
Moderate
New
Low
Unclear
if
competing
integrated
models
of
care in New
Zealand
High
$NZ
Intervention
Service
But
analysis
included
only
physician related
costs.
enabled
Remote monitoring, including blood
pressure, ECG monitoring, and vital
signs
employing
smartphone
technology
Patients with IHD
Unknown
Health
Buddy
–
telemonitoring device(160)
An electronic interactive device for
monitoring patients health (weight
blood pressure, diet, other vital signs)
data may be linked to clinicians via the
web. Educational feedback provided.
Used
for
chronic
conditions
management and has been assessed
in relation to heart failure and following
CABG
Patients with heart
failure or following
CABG
Reportedly efficacious
The Regional Approach
to
Cardiovascular
Emergencies
(RACE)
project13(60)
The RACE project (North Carolina) is a
system for providing rapid coordinated
care of cardiovascular emergencies. It
incorporates
quality
improvement
efforts of over 119 hospitals, 540
emergency medical agencies and
thousands of health care providers
working in a coordinated manner to
provide timely and lifesaving care.
Interventions include, but not limited to,
placing ECG and transmittal equipment
on EMS vehicles, having a single
telephone number to get access to a
PCI hospital, educational symposia,
creating system compatible intravenous
tubing and pumps, eliminating need for
IV pumps.
Patients with MI
Reportedly effective
Smart phone
monitoring (159)
13
Further information regarding the RACE project is available here: updathttps://racecars.dcri.duke.edu/
$600
Ongoing
costs
$60-250 per month
References
1.
NHC. Strategic Overview: Cardiovascular Disease in New Zealand2013. Available
from: http://nhc.health.govt.nz/strategic-overview-cardiovascular-disease-new-zealand.
2.
Hay DR. Cardiovascular Disease in New Zealand, 2001: A Summary of Recent
Statistical Information: National Heart Foundation of New Zealand; 2002.
3.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al. Third
Universal Definition of Myocardial Infarction. Journal of the American College of Cardiology.
2012;60(16):1581-98.
4.
Tobias M, Taylor R, Yeh LC, Huang K, Mann S, Sharpe N. Did It Fall or Was It
Pushed? The Contribution of Trends in Established Risk Factors to the Decline in Premature
Coronary Heart Disease Mortality in New Zealand. Australian and New Zealand journal of
public health. 2008;32(2):117-25.
5.
MoH. Mortality and Demographic Data 2010. Wellington: 2013.
6.
MoH. The Health of New Zealand Adults 2011/12: Key Findings of the New Zealand
Health Survey. Wellington: 2012.
7.
Tobias M, Turley M, Paul S, Sexton K. Debunking the ‘Only 50%’Myth: Prevalence of
Established Risk Factors in New Zealanders with Self‐Reported Ischaemic Heart Disease.
Australian and New Zealand journal of public health. 2005;29(5):405-11.
8.
MOH. New Zealand Health Survey. Annual Update of Key Findings 2012/13.
Wellington: 2013.
9.
MoH. How Is My Pho Performing? 2013/14 Quarter One Results2014. Available
from: http://www.health.govt.nz/system/files/documents/pages/pho-ht-q1-2013-14-3.pdf.
10.
OECD. Oecd Health Statistics 20132013. Available from:
http://www.oecd.org/health/health-systems/oecdhealthdata.htm.
11.
MoH. The Health of New Zealand Children 2011/12: Key Findings of the New
Zealand Health Survey. Wellington: MoH, 2012.
12.
Mann J, Arroll B, Carryer J, Group NZG. The Assessment and Management of
Cardiovascular Risk. The assessment and management of cardiovascular risk. 2003.
13.
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National Health Committee (NHC) and Executive
The National Health Committee (NHC) is an independent statutory body which provides
advice to the New Zealand Minister of Health. It was reformed in 2011 to establish
evaluation systems that would provide the New Zealand people and health sector with
greater value for the money invested in health. The NHC Executive is the secretariat that
supports the Committee. The NHC Executive’s primary objective is to provide the
Committee with sufficient information for them to make recommendations regarding
prioritisation and reprioritisation of interventions. They do this through a range of evidencebased reports tailored to the nature of the decision required and time-frame within which
decisions need to be made.
Citation: National Health Committee.2014. Ischaemic Heart Disease (IHD): A Pathway to
Prioritisation Wellington: National Health Committee.
Published in March 2014 by the National Health Committee
PO Box 5013, Wellington, New Zealand
ISBN: 978-0-9922623-1-0
HP 5851
This document is available on the National Health Committee’s website:
http://www.nhc.health.govt.nz/
Disclaimer
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