CARDIAC SERVICES BC ANNUAL REPORT 2010

Transcription

1 CARDIAC SERVICES BC ANNUAL REPORT 2010

2 Contents Abbreviations Foreword Acknowledgements Executive Summary Annual Report Content and Highlights About Cardiac Services BC Contact Chapter 1 Community Profile Demographics: Age and Sex Demographics: Ethnicity Selected Cardiovascular Disease-Related Risk Factors Risk Factor Prevalence Risk Factors and AMI Hospitalizations Chapter 2 Coronary Artery Disease-Related Hospitalizations Coronary Artery Disease-Related Hospitalizations: AMI Coronary Artery Disease-Related Hospitalizations: AMI Re-admissions Coronary Artery Disease-Related Hospitalizations: AMI In-Hospital Mortality Cardiac Procedures and AMI Ratios Cardiac Procedures and AMI Rates Chapter 3 Cardiac Procedure Utilization Cardiac Procedure Utilization: Rates Cardiac Procedure Utilization: Where Patients Receive Care Chapter 4 Wait Times Wait Times: Isolated CABG Wait Times: Patients Waiting and Completed Surgeries Wait Times: Wait Times and EP Procedures Chapter 5 Outcomes Outcomes: 30-Day Mortality Chapter 6 Planning Priorities Revascularization Services Congestive Heart Failure (CHF) Electrophysiology Services Chapter 7 Financial Resources Financial Resources: Cardiac Procedures Volumes and Budget by Major Program Appendix Cardiac Services BC - Annual Report

3 List of figures Chapter 1 Community Profile 10 Figure 1.1 BC Health Authorities 11 Figure 1.2 Age Distribution (%) by Sex and Resident Health Authority, Figure 1.3 Ethnic Distribution (%) by Resident Health Authority, Figure 1.4 Prevalence of Selected Cardiovascular Disease-Related Risk Factor Rates (%) by Resident Health Authority, Figure 1.5 Diabetes Rates (%) by Resident Health Authority, Selected Years 15 Figure 1.6 Heavy Drinking Rates (%) by Resident Health Authority, Selected Years 16 Figure 1.7 Obesity Rates (%) by Resident Health Authority, Selected Years 16 Figure 1.8 Hypertension Rates (%) by Resident Health Authority, Selected Years 17 Figure 1.9 Smoking Rates (%) by Resident Health Authority, Selected Years 17 Figure 1.10 Physical Inactivity Rates (%) by Resident Health Authority, Selected Years 18 Figure 1.11 AMI Hospitalization and Risk Factor Distribution (%) by Resident Health Authority Chapter 2 Coronary Artery Disease-Related Hospitalizations 20 Figure 2.1 AMI Hospitalization Rates (age- and sex-standardized, per 100,000 population) by Patient Residence, 2002/ /09 21 Figure 2.2 Observed and Projected AMI Hospitalization Rates for Men by Age Group 22 Figure 2.3 Observed and Projected AMI Hospitalization Rates for Females by Age Group 22 Figure 2.4 Observed and Projected Decline in AMI Hospitalization Overall Rates 27 Figure 2.5 Diagnostic Catheterization to AMI Ratio by Patient Residence, 2008/09 28 Figure 2.6 Revascularization to AMI Ratio by Patient Residence, 2008/09 29 Figure 2.7 AMI Hospitalization and Cardiac-Related Procedure Rates (age- and sex-standardized per 100,000 population) by Patient Residence, 2008/09 Chapter 3 Cardiac Procedure Utilization 32 Figure 3.1 Diagnostic Catheterization Rates (age- and sex-standardized, per 100,000 population) by Patient Residence, 2002/ /10 33 Figure 3.2 PCI Rates (age- and sex-standardized, per 100,000 population) by Patient Residence, 2002/ /10 34 Figure 3.3 Isolated Coronary Artery Bypass Graft Rates (age- and sex-standardized, per 100,000 population) by Patient Residence, 2002/ /10 34 Figure 3.4 Total Open Heart Surgery Rates (age- and sex-standardized, per 100,000 population) by Patient Residence, 2002/ /10 36 Figure 3.5 Percentage of Residents in a Health Authority Undergoing Diagnostic Catheterization by Hospital, 2009/10 37 Figure 3.6 Percentage of Residents in a Health Authority Undergoing PCI by Hospital, 2009/10 38 Figure 3.7 Percentage of Residents in a Health Authority Undergoing Open Heart Surgery by Hospital, 2009/10 Chapter 4 Wait Times 41 Figure 4.1 Percentage of Isolated CABG Completed within FMM Benchmarks by Priority, Figure 4.2 Number of Waiting for and Completed Heart Surgeries by Hospital, Figure 4.3 Median Wait Time and Number of Completed Electrophysiology Procedures by Hospital, Cardiac Services BC - Annual Report 2010 Chapter 5 Outcomes 47 Figure Day All-Cause Mortality Rate (%) Post Isolated CABG in BC, Figure Day All-Cause Mortality Rate (%) Post CABG Plus Valve Surgery in BC, Figure Day All-Cause Mortality Rate (%) Post Isolated Valve Surgery in BC, Figure Day Mortality Rate (%) Post PCI in BC, Chapter 6 Planning Priorities 54 Figure 6.1 Actual and Projected Demand for PCI (Volume of Cases ) 55 Figure 6.2 Actual and Projected Demand for Heart Surgery (Volume of Cases ) 55 Figure 6.3 Provincial Summary of PCI and Heart Surgery Volumes and Capacity 2

4 List of tables Chapter 2 Coronary Artery Disease-Related Hospitalizations 23 Table 2.1 AMI Re-admission Rates (%) by Patient Residence, 2003/04 to 2008/09 25 Table Day AMI In-Hospital Mortality Rates (%) by Patient Residence, 2003/04 to 2008/09 Chapter 6 Planning Priorities 58 Table 6.1 Device Implants Pacemaker Projections (2008/ /16) 58 Table 6.2 Device Implants ICD Projections (2008/ /16) 58 Table 6.3 EP Planning Parameters (2008/ /12) Chapter 7 Financial Resources 63 Table 7.1 Cardiac Procedure Volumes by Major Program, 2009/ /11 63 Table 7.2 Cardiac Services BC Budget by Major Program, 2009/ /11 Abbreviations ACS AMI CABG CAD CSBC CSSC EP FH HF HSDA ICD IH KGH NH OHS PAPCH PCI PHSA RCH RJH SPH VCH VGH VIHA Acute Coronary Syndrome Acute Myocardial Infarction Coronary Artery Bypass Graft Coronary Artery Disease Cardiac Services BC Cardiac Services Steering Committee Electrophysiology Fraser Health Heart Failure Health Services Delivery Area Implantable Cardioverter Defibrillator Interior Health Kelowna General Hospital Northern Health Open Heart Surgery Provincial Advisory Panel on Cardiac Health Percutaneous Coronary Intervention Provincial Health Services Authority Royal Columbian Hospital Royal Jubilee Hospital St Paul s Hospital Vancouver Coastal Health Vancouver General Hospital Vancouver Island Health Authority Cardiac Services BC - Annual Report

5 Cardiac Services BC - Annual Report

6 Foreword Heart disease remains Canada s number one cause of death and despite huge gains in the prevention, diagnosis, and treatment of cardiovascular diseases, roughly one-third of the deaths in the nation this year will have heart disease as their root cause. According to the most recent statistics, the annualized rate of deaths per 100,000 British Columbians is 224, although that number has been declining over the last decade. 1 That decline, however, will come under increasing pressure as the population of BC ages, demanding thoughtful planning, research, and vision to ensure BC citizens have access to the best, evidence-based, medical care in a timely manner. Cardiac Services BC (CSBC), an agency of the Provincial Health Services Authority (PHSA), is responsible for the province-wide planning, coordination, monitoring, evaluation, and funding of adult specialized cardiac care services across the spectrum of cardiovascular disease. The CSBC 2010 Annual Report explores the demographics of British Columbians, wait times they face before undergoing major cardiovascular procedures, recent initiatives for reducing delays, rates of different measures of cardiovascular health, and finally a summary of milestones reached and plans for the future, including a detailed roadmap how funds will be allocated. Cardiac Services BC - Annual Report

7 David Babiuk Provincial Executive Director Acknowledgements Cardiac Services BC - Annual Report 2010 CSBC is very pleased to present the 2010 Annual Report on cardiac care in British Columbia. The majority of the data reports and tables were available as isolated reports and this marks the first time they have been presented in this consolidated Annual Report. The purpose of this report is to provide detailed and timely information on cardiac care in British Columbia. It is a resource for healthcare professionals and administrators to inform decisions about planning, organizing, and evaluating cardiac care. The preparation of this first Annual Report was led by Sharon Relova, Epidemiologist at CSBC. Sharon received continued guidance and direction from Dr Karin Humphries, Provincial Director, Data Services, Evaluation, and Research; Dr Min Gao, Director, Biostatistics and Data Management; and Dr Christopher Thompson, Medical Advisor. The Stats Team, in particular Aihua Pu, contributed to the data analysis and preparation of the data tables and graphs with all CSBC staff involved in the final editing and report preparation. Please refer to the Appendix for a listing of CSBC staff contributing to this report. A special thank you to the support received from the PHSA Communication staff for their timely advice, support, and layout of the report. CSBC would like to also acknowledge the healthcare professionals, administrative staff and data entry personnel located at the provider centres for the quality of their work and their continued efforts to improve upon the timeliness, completeness, and accuracy of the data entered into the CSBC Registry. The collective effort of all contributors has made it possible for CSBC to present this first Annual Report. Executive Summary This report is structured around the epidemiological principles of person, place, and time. Descriptions of the demographic and risk factor profile of British Columbians are essential to understanding the community of interest. Results are presented by hospital or health authority to understand better cardiac procedural patterns across the province. Time trends are also provided to illustrate changes over time. Finally, planning priorities and financial resources provide contextual information. Annual Report Content and Highlights Community Profile: This chapter describes population demographics and distribution of cardiovascular risk factors. Caucasians comprised the largest ethnic group among all health authorities. Among residents living in VCH, 26% were Chinese. According to the Canadian Community Health Survey conducted in 2007, 42% of British Columbians reported being physically inactive, while 19% reported being a smoker. Hypertension rates increased significantly from 13% in 2001 to 16% in British Columbians must adopt healthier lifestyles to decrease the risk of cardiovascular disease. Coronary Artery Disease-Related Hospitalizations: This chapter reports on AMI hospitalizations, re-admission, and mortality rates. AMI can be used as a marker of coronary artery disease in the population. From 2002/03 to 2008/09, AMI rates declined from 236 to 204 per 100,000 population. The decrease in hospitalization rates may indicate that there is increased early detection of heart disease or that people are better managing their health. Variation exists in revascularization to AMI ratios, ranging from 0.53 (East Kootenay) to 1.87 (Fraser North). Access to care or hospital practices may explain some of this variability. 6

8 Cardiac Procedure Utilization: This chapter describes utilization trends for cardiac-related procedures (diagnostic catheterization, PCI, isolated CABG and OHS), and where patients receive care. Overall, all cardiac procedure rates in BC have declined from 2002/03 to 2009/10. Residents tended to receive care within their health authority. For those British Columbians living in health authorities without invasive cardiac procedure programs, the majority went to either SPH or VGH. Wait Times: This chapter reports on wait times for selected cardiac procedures. From January 2009 to September 2010, over 94% of patients had an isolated CABG within the recommended First Minister s Meeting benchmark. The numbers of British Columbians waiting for OHS and completing OHS have been fairly constant between January 2009 and September 2010, suggesting that an equilibrium has been achieved. The median wait time and number of completed electrophysiology procedures continue to be monitored. Outcomes: This chapter describes the 30-day mortality rate for selected cardiac procedures. From 2005 to 2009, the 30-day risk-adjusted mortality rate post isolated CABG decreased from 2.13% to 1.79%, while the CABG plus valve surgery mortality rate increased from 4.09% to 5.62%. The 30-day risk-adjusted mortality rate post PCI remained relatively stable between 2004 and 2008 at around 1.85%. Overall, the mortality rates in BC compare favourably with the literature, 1 but there is room for improvement. Planning Priorities: This chapter reports on CSBC priorities for planning cardiac services in the province within the context of PHSA s strategic plan. Service Level Agreements outline CSBC s priorities and define roles, responsibilities, service deliverables and accountabilities between CSBC and the health authorities. In addition, CSBC has completed provincial plans for coronary revascularization services, electrophysiology services, and heart failure services. The plans have focused on defining service need and capacity, now and into the future, and provide direction to CSBC s overall priority setting. Financial Resources: This chapter reports on CSBC priorities for the funding of cardiac services in the province. Currently, CSBC manages an annual operating budget of approximately $165 million to support cardiovascular disease-related treatment services and secondary prevention. Funding is allocated to health authorities based upon a rate-based funding model. Cost savings from provincial tenders in 2009/10 allowed CSBC to allocate resources to fund additional procedures to manage wait lists and wait times while maintaining a neutral budget in 2010/11. About Cardiac Services BC CSBC was established by the PHSA following the transfer of the adult tertiary cardiac provincial mandate and funding from the Ministry of Health Services in The province-wide mandate includes responsibility for the planning, coordination, monitoring, evaluation, and funding of cardiovascular disease-related treatment services and more recently has been expanded to include secondary prevention. CSBC provides a service coordination role for British Columbians by determining and assessing service needs across all regions of the province and the most appropriate and cost effective means of meeting the needs. CSBC also provides direction and provincial leadership in: a. setting provincial standards for access to cardiac services and ensuring appropriate and timely triage of patients; b. standardizing practice protocols utilizing current evidence and best practices to improve the quality of patient care; c. establishing a provincial vision, goals, and objectives for the cardiac services program; d. determining priority and allocating sufficient life support resources within cardiac services to best meet patient needs; e. recommending future initiatives for cardiac services within the province; f. developing provincial cardiac service and capital requirement plans. Where substantive increases in volumes or new technologies require significant new investment in capital equipment or infrastructure, CSBC collaborates with the regional Health Authorities to secure the required resources; g. partnering with BC Transplant in the treatment of acute heart failure. Continued Cardiac Services BC - Annual Report Shahian et al. Ann Thorac Surg 2009,88:S2 22; O Brien et al. Ann Thorac Surg 2009,88:S23 42; Shahian et al. Ann Thorac Surg 2009,88:S43 62; Singh et al. J Am Coll Cardiol 2008; 51:

9 Cardiac Services BC - Annual Report 2010 CSBC maintains a cardiac patient Registry containing 20 years of high quality cardiac-related procedural data. It is a complex database with data entry and report generation interfaces located at the provider sites and clinical offices. The Registry collects clinical information on all open heart surgery, angiography, angioplasty, implantable cardioverter defibrillator, and pacemaker procedures performed in the province. The registry data is used in monitoring and analyzing access time to service, projecting and planning future service requirements, analyzing and reporting on patient outcomes, and supporting evaluation and research. There are five regional Health Authority cardiac centres providing cardiac services within the context of a provincial program. The five sites are St Paul s Hospital (SPH), Vancouver General Hospital (VGH), Royal Jubilee Hospital (RJH), Royal Columbian Hospital (RCH), and Kelowna General Hospital (KGH). The provider responsibilities are generally accepted to include: a. having an overall regional cardiac services plan in place including primary care/prevention, diagnosis, treatment, rehabilitation, and secondary prevention services that within available resources maximizes access for all residents of the region; b. providing programs and services to support the plan; c. providing the range of services as agreed to and as outlined in the annual funding letter from the funder; d. providing all capital resources, within available funding, including the necessary equipment required to deliver the services. Where substantive increases in volumes or new technologies require significant new investment in capital equipment or infrastructure, the parties will collaborate to secure required resources; e. adhering to standards of patient care adopted provincially or nationally by programs of similar scope and size; f. timely entry of all data to the CSBC Registry; g. having quality assurance processes established and operational. The Provincial Advisory Panel on Cardiac Health (PAPCH) is a standing expert advisory committee comprised of physician leaders in cardiovascular medicine in BC. It is responsible to and funded by CSBC and reports to CSBC through the Provincial Executive Director. Its mandate is to provide medically and scientifically expert advice and recommendations to CSBC on the full continuum of cardiac health. The PAPCH has been in place for nearly 20 years. In 2008/09 fiscal year, the Cardiac Services Steering Committee (CSSC) was established with senior administrative and clinical representation from the provider centres, the Ministry of Health Services and PAPCH. The CSSC is responsible for providing direction on, among other things, the cost accounting, funding methodology, and funding policy for cardiac services; service capacity; new technology/drugs; quality assurance; quality improvement; provincial capital equipment planning and funding under a joint provincial strategy; and generally to provide more transparency between the funder and the provider and ensuring equity across all Health Authorities. An annual Service Level Agreement between CSBC and the each provider details the respective roles and responsibilities, provider deliverables including procedure volumes and price. The agreement is performance based with monthly monitoring and year end reconciliation of funding to procedures performed. Contact To comment on this report, suggest topics for future reports, or to obtain an electronic copy of this report please contact Carmen Ng at Carmen.Ng@phsa.ca. Cardiac Services BC is located at Burrard Street, Vancouver, BC, V6Z 2H3. 8

10 Chapter 1 Community Profile Cardiac Services BC - Annual Report 2010 Chapter 1 9

11 Figure 1.1 BC Health Authorities Chapter 1 Cardiac Services BC - Annual Report 2010 Community Profile Cardiovascular disease is the leading cause of death in Canada, with coronary artery disease--a narrowing of the arteries that supply blood to the heart muscle--the most common cause of heart attacks and sudden cardiac death, as well as debilitating chest pain (angina), in hundreds of thousands of Canadians. The choices we make as individuals (to exercise daily and maintain a healthy body weight), as parents (to limit screen time and to encourage physical activity in our children), and as a society (to demand communities that include parks and walking routes, and public health policies that limit salt in processed foods) profoundly affect the amount of cardiovascular disease in our province. Many so-called modifiable factors can influence an individual s risk of developing cardiovascular disease including tobacco and alcohol use; body weight; and physical activity, blood pressure and cholesterol levels. There are also nonmodifiable factors including genetic make-up (including family history), age, sex, and ethnicity that put some population groups at higher risk of developing cardiovascular disease than others. Identifying populations with higher risk of developing cardiovascular disease can help streamline efforts to improve modifiable risk factors and minimize the impact of non-modifiable factors, through, for example, improving diets, decreasing salt consumption, encouraging smoking cessation, and increasing physical activity. Since cultural factors influence diet, physical activity, and tobacco and alcohol use, different ethnic groups have different cardiovascular risk profiles. A recent study from the Institute for Clinical Evaluative Sciences in Toronto, found striking differences in the cardiovascular risk profiles of South Asian, Chinese, white, and black ethnic groups 1. Studies have also shown socioeconomic status and level of education to exert a powerful influence on cardiovascular disease prevalence. Of note, however, the INTER- HEART study 2, the largest, global study of cardiovascular risk to date, found that while people from different ethnic backgrounds have different risks of developing coronary heart disease, more than 90% of the risk of heart attacks across all ethnic groups can be attributed to modifiable risk factors, meaning that appropriate dietary, behavioural, or pharmaceutical approaches can radically reduce cardiovascular risk. This chapter provides an overview of the demographics and selected risk factors of the populations of the health authorities across BC (Figure 1.1 shows the location of each health authority). Limited trend data are also provided to highlight changes in risk factors over time Institute for Clinical and Evaluative Studies Accessed January 31, Yusuf et al. Lancet 2004;364:

12 Figure 1.2 Age Distribution (%) by Sex and Resident Health Authority, years years years 75+ years FH IH NH VCH VIHA BC Female Male Definitions: Proportion of adults aged 20 years and over by age and sex group by resident health authority. Source: BC Stats, Population Estimates and Projections [P.E.O.P.L.E. 33], Demographics: Age and Sex Significance: Age is an important risk factor for many diseases and in general, risk increases with age. Planners utilize population age structure to help plan future healthcare services, such as projecting procedure volumes (e.g. heart surgery) and infrastructure requirements (e.g., community cardiac rehabilitation programs) that older populations may require. Findings: With the exception of NH (51.5% males vs. 48.6% females) there was a slightly higher proportion of females (51.0%) in comparison to males (49.1%) across BC in Females tend to live longer than males and, consequently, there was a higher proportion of females aged 65 and over compared to males (10.0% vs 8.4%). While this gender gap has existed for many years, the gap has been narrowing over the last several years since men s life expectancy has been improving faster than women s. Although women do tend to live longer, national data suggest that women aged 65 and over are more likely to live alone and to have low incomes, or to have chronic or degenerative health problems 3. IH (22.9%) and VIHA (22.3%) had the highest proportion of residents aged 65 and over, followed by VCH (16.5%) and FH (16.4%), while NH was much lower (13.7%). (Note: Population estimates are updated annually and numbers may vary.) CSBC in ACTION As part of a mandate to plan for cardiac services, CSBC has developed projection models that take into account population growth, aging, and sex specific rates of disease (such as heart attacks) and utilization of services. These projection models, which have proven accurate to date, indicate that there is adequate capacity in the system at present and with the development of heart centre services in Kelowna to support revascularization needs in this previously underserved area. Cardiac Services BC - Annual Report 2010 Chapter 1 3 Statistics Canada Accessed January 31,

13 Figure 1.3 Ethnic Distribution (%) by Resident Health Authority, % FH IH NH VCH VIHA BC Caucasian % Chinese South Asian Southeast Asian % Other % 20% 0% FH IH NH VCH VIHA BC Definitions: Proportion of self-reported ethnicity among participants who responded to the Canadian Census B (long form) by health authority. Only one in five households in the census sample is asked questions on ethnicity. Other includes respondents who reported as West Asian, Black, Latin American, Arab or multiple visible minorities. Southeast Asian includes respondents who reported as Japanese, Korean, Vietnamese, Cambodian, Malaysian or Laotian. South Asian includes respondents who reported as Filipino, East Indian, Pakistani or Sri Lankan. Source: Statistics Canada, Census of Population, Demographics: Ethnicity Significance: Certain ethnic groups, whether due to genetics or cultural behaviours, are at higher risk of developing heart disease. For example, First Nations people and those of South Asian descent are at greater risk of heart disease in comparison to the general population 4, while there is less heart disease but more stroke 5 in the Chinese population. As noted, while some of this risk is related to family history and genetics, much of it can be attributed to modifiable risk factors. Findings: The 2006 data show that Caucasians formed the largest group across all health authorities. IH reported the largest percentage of Caucasians (96.0%) followed by NH (95.8%) and VIHA (92.8%). VCH had the highest percentage of Chinese (25.5%) while FH had the highest proportion of South Asians (15.5%). (Note: Statistics Canada conducts a census every five years to gather information [e.g., demographics, health, healthcare and social issues] on people living in Canada. Information is used by the government and researchers to learn about the needs and opinions of Canadians.) Chapter 1 Cardiac Services BC - Annual Report 2010 CSBC in ACTION The Canadian Working Group on Dietary Sodium Reduction, recognizing that hypertension is a significant problem influenced by dietary salt intake, recommended Canadians aim to reduce their sodium intake from 3,400 to 2,300 milligrams per day by CSBC supports this target based on the belief that it will significantly reduce both the incidence of hypertension and the number of patients with hypertension who reach treatment targets Heart and Stroke Foundation. Accessed November 26, Public Health Agency of Canada, Tracking Heart Disease and Stroke in Canada (Ottawa, ON: Public Health Agency of Canada, 2009).

14 Figure 1.4 Prevalence of Selected Cardiovascular Disease-Related Risk Factor Rates (%) by Resident Health Authority, % 40% 30% 20% 10% 0% Diabetes Smoking Physical Inactivity Diabetes Heavy Drinking Obesity Heavy Drinking Obesity Hypertension Hypertension Smoking Physical Inactivity FH IH NH VCH VIHA BC Definitions: Population prevalence rates of selected self-reported cardiovascular disease-related risk factors by resident health authority. Diabetes is defined as respondents reporting yes to being diagnosed as having diabetes by a health professional. Heavy drinking is defined as respondents reporting yes to having more than nine drinks per week for women and more than 14 drinks per week for men. Obesity is based on a body mass index of more than or equal to 30 kg/m 2. Hypertension is defined as respondents reporting yes to having high blood pressure. Smoking is defined as respondents reporting yes to smoking daily or occasionally. Physical inactivity is a derived variable based on a respondent s average daily energy expenditure during transportation and leisure time physical activities in the past three months. Source: Statistics Canada, Canadian Community Health Survey, Selected Cardiovascular Disease-Related Risk Factors The nine modifiable risk factors for cardiac disease identified in the 2004 INTERHEART study were smoking, raised ApoB/ApoA1 ratio (i.e., abnormal lipids), history of hypertension, diabetes, abdominal obesity, psychosocial factors, daily consumption of fruits and vegetables, regular alcohol consumption, and regular physical activity. The Canadian Community Health Survey (CCHS), a national cross-sectional health survey conducted by Statistics Canada, collects data on some of these factors, based on self-reported responses. Data have been collected annually since 2007 and collected biannually prior to Lee has published data showing both provincial variability in risk factor prevalence and Canadian time trends in risk factor prevalence which provide appropriate provincial comparators to the data presented in this chapter 6. CSBC in ACTION CSBC is committed to Promoting Healthier Populations, in part through collaborations with the Heart & Stroke Foundation BC & Yukon Division, the UBC Faculty of Medicine, and BC Women s Hospital in the establishment of a Chair in Women s Cardiovascular Health, focused on gaps in care or unique needs of female cardiac patients, or preventive medical strategies specific to women (See Chapter 6, Strategic Plan 2). Cardiac Services BC - Annual Report 2010 Chapter 1 6 Lee CMAJ 2009; 181(3-4):E

15 Risk Factor Prevalence Significance: Significant opportunities exist to reduce the risk of cardiovascular disease by implementing prevention approaches related to the nine modifiable risk factors identified by INTERHEART. Smoking cessation, weight loss, salt reduction, and more active lifestyles can substantially reduce the burden of cardiovascular disease and increase the sustainability of our healthcare system. This requires that planners re-focus health system planning beyond treatment (e.g., planning of cardiac procedures) to include both primary and secondary prevention. Findings: Overall in BC, the most common risk factor was physical inactivity (42.2%), followed by smoking (19.3%), hypertension (16.1%), obesity (13.2%), heavy drinking (10.4%) and diabetes (5.8%). In five of the six factors measured, at least 10% of the population selfreported that they had a risk factor. NH had the highest diabetes (6.6%), obesity (21.7%), and smoking (24.8%) rates. In contrast, VCH had the lowest heavy drinking (8.7%), obesity (7.3%), hypertension (14.7%), and smoking (16.1%) rates. FH had the highest physical inactivity rate (46.3%) and the second highest diabetes rate (6.5%). VIHA had the highest hypertension rate (18.4%) but the lowest diabetes rate (4.7%) and physical inactivity rate (37.8%). IH had the highest heavy drinking rate (12.9%) and the second highest smoking and obesity rates (23.5% and 17.0%, respectively). The following figures provide further detail on the selected risk factors identified above for the period between 2001 and Chapter 1 Cardiac Services BC - Annual Report 2010 CSBC in ACTION Given the high incidence of heart disease in the South Asian population, CSBC is supporting FH in funding a research Chair/Epidemiologist to enhance research into risk factor reduction in South Asians, to attempt to decrease the negative impact of cardiovascular disease in this group. Given the importance of culturally sensitive care, CSBC has also created a Special Populations Working Group that is charged with developing and implementing strategies related to heart failure education and access to cardiovascular care in specialized communities (e.g., South Asians, Chinese, First Nations, frail elderly). Furthermore, over the next year CSBC is committed to working with the health authorities to better understand the variation in risk across different populations. 14

16 Figure 1.5 Diabetes Rates (%) by Resident Health Authority, Selected Years 7% 6% 5% 4% FH IH NH VCH VIHA BC % Source: Statistics Canada, Canadian Community Health Survey, The overall BC rate for diabetes increased from 4.4% (2001) to 5.8% (2007). There was an increasing trend for all health authorities with the exception of residents from VIHA that reported lower rates from 2005 onwards. VCH reported among the lowest diabetes rates across all health authorities. Residents of FH, IH, and NH reported diabetes rates of more than 6% of their population in Figure 1.6 Heavy Drinking Rates (%) by Resident Health Authority, Selected Years 14% 13% 12% 11% 10% 9% 8% 7% 6% Figure 1.6 Heavy Drinking Rates (%) by Resident Health Authority, Selected Years Source: Statistics Canada, Canadian Community Health Survey, The overall BC heavy drinking rate increased from 8.8% in 2001 to 10.4% in VIHA had among the highest rates in the province in the early reporting period, ranging from 11.4% in 2001 to 12.5% in 2003 while IH had the highest rates over the latter period: 12.7% in 2005 and 12.9% in FH had the lowest rate in 2001 (7.0%) and VCH had the lowest rates in the subsequent years (7.2%, 8.5%, 8.7%, respectively). FH IH NH VCH VIHA BC Cardiac Services BC - Annual Report 2010 Chapter 1 15

17 Figure 1.7 Obesity Rates (%) by Resident Health Authority, Selected Years 25% 20% 15% 10% FH IH NH VCH VIHA BC % Source: Statistics Canada, Canadian Community Health Survey, The BC obesity rate remained relatively stable from 2001 (12.5%) to 2007 (13.2%). VIHA showed a consistent increasing trend from 12.9% (2001) to 15.7% (2007). NH and IH had the highest obesity rates while VCH had the lowest rates. Figure 1.8 Hypertension Rates (%) by Resident Health Authority, Selected Years 20% 18% 16% Chapter 1 Cardiac Services BC - Annual Report % 12% FH IH NH VCH VIHA BC % Source: Statistics Canada, Canadian Community Health Survey, Figure 1.8 Hypertension Rates (%) by Resident Health Authority, Selected Years Source: Statistics Canada, Canadian Community Health Survey, The overall BC rate for hypertension increased between 2001 (12.9%) and 2007 (16.1%). Hypertension rates continually increased over the years in IH, VCH, and NH. FH and VIHA rates both peaked in 2003 and in

18 Figure 1.9 Smoking Rates (%) by Resident Health Authority, Selected Years 35% 30% 25% 20% FH IH NH VCH VIHA BC % Source: Statistics Canada, Canadian Community Health Survey, The BC smoking rate was highest in 2001 (21.8%), lowest in 2005 (18.9%), and increased marginally in 2007 (19.3%). VCH smoking rates continually decreased over the years. NH consistently had the highest rates among the health authorities followed by IH, VIHA, FH, and VCH. Figure 1.10 Physical Inactivity Rates (%) by Resident Health Authority, Selected Years 50% 45% 40% % 30% Source: Statistics Canada, Canadian Community Health Survey, Figure 1.10 Physical Inactivity Rates (%) by Resident Health Authority, Selected Years Source: ;Statistics Canada, Canadian Community Health Survey, The BC rate for physical inactivity was highest in 2001 (45.5%) and then remained relatively stable between 42% and 43%. FH consistently had the highest physical inactivity rates while VIHA consistently had the lowest. FH IH NH VCH VIHA BC Cardiac Services BC - Annual Report 2010 Chapter 1 17

19 Figure 1.11 AMI Hospitalization and Risk Factor Distribution (%) by Resident Health Authority VCH VIHA FH IH NH BC AMI Standardized Rate per 100, VCH VIHA FH IH NH BC Risk Factors (%) AMI Rate Diabetes 5.0 Hypertension 14.7 Obesity 7.3 Smoking 16.1 Heavy Drinking Definitions: Proportion of selected self-reported cardiacrelated risk factors for population aged 20 years and over by health authority. AMI hospitalization rates were age- and sexstandardized using population data from BC Stats, Population Estimates and Projections (P.E.O.P.L.E. 34), Source: Statistics Canada, Canadian Community Health Survey, 2007 [Risk factors]; and Canadian Institute for Health Information, Discharge Abstract Database, 2008/09 [AMI hospitalizations]. Risk Factors and AMI Hospitalizations Significance: Acute myocardial infarction or AMI (more commonly known as a heart attack) is an acute presentation of coronary artery disease (CAD). AMI can be used as a marker of CAD in the population. The following graph illustrates the relationship between selfreported risk factors and the burden of CAD, using AMI hospitalizations as a proxy. Rate of AMI hospitalizations per 100,000 population by health authority are shown here as a solid bar behind the risk factors. Findings: AMI hospitalization is lowest in VCH and much higher in IH and NH. It is evident that the rates of smoking and obesity are correlated with the rate of AMI hospitalization. Chapter 1 Cardiac Services BC - Annual Report 2010 CSBC in ACTION CSBC recognizes the importance of smoking cessation programs as part of both cardiac rehabilitation and primary and secondary prevention. CSBC is working with the Health Authorities and the Ministry of Health to maintain and enhance smoking cessation services to people looking to quit. 18

20 Chapter 2 Coronary Artery Disease-Related Hospitalizations Cardiac Services BC - Annual Report 2010 Chapter 1 19

21 Figure 2.1 AMI Hospitalization Rates (age- and sex-standardized, per 100,000 population) by Patient Residence, 2002/ / / / / / / / /09 Rate per 100, FH IH NH VCH VIHA BC / / / / / / /09 Definitions: Rates of AMI hospitalizations per 100,000 population in BC. Hospitalization codes were identified from the Discharge Abstract Database. Rates were age- and sex-standardized using data from BC Stats, Population Estimates and Projections (P.E.O.P.L.E. 34), Source: Canadian Institute for Health Information, Discharge Abstract Database, 2002/ /09. CAD-Related Hospitalizations Chapter 2 Cardiac Services BC - Annual Report 2010 Every seven minutes in Canada, someone dies from either heart disease or stroke. Data from the Heart and Stroke Foundation of Canada indicate that in 2006, 30% of all deaths in Canada were as a result of cardiovascular disease with 23% of these related to an acute myocardial infarction (AMI), more commonly known as a heart attack 1. AMI is a major cause of hospitalization and one of the leading causes of illness and death in Canada 2. Typically, hospitalization rates for AMI are considered to be a marker of coronary artery disease (CAD) in a community. Rates of AMI hospitalization vary across population groups and much of this variation is explained by the risk factors identified in Chapter 1. An important issue to consider is the relationship between access to care and higher rates of AMI. National and local prevention strategies have focused on decreasing risk factors for cardiovascular disease, while improving access to and sustainability of the healthcare system given the increasing demands of an aging population. In addition, regional variation is also driven by supplier induced demand, professional and patient preferences, and service capacity. This chapter describes AMI hospitalizations, re-admission, and in-hospital mortality rates. Analyses of cardiac procedure utilization rates in relation to AMI hospitalization are also presented Heart and Stroke Foundation of Canada. accessed on February 24, Statistics Canada, Leading Causes of Death in Canada accessed February 9, 2011.

22 Figure 2.2 Observed and Projected AMI Hospitalization Rates for Males by Age Group Crude Rate per 100, / / / / / / / / / / / / / / / / / / / / /16 Fiscal Year Years Years (O) Years Years (O) Years Years (O) 75 Years + 75 Years + (O) Definitions: Rates of AMI hospitalizations per 100,000 male population in BC. Rates are displayed by age group. Solid circles are observed rates and solid lines are projected rates. Source: Canadian Institute for Health Information, Discharge Abstract Database, 1995/ /09 [AMI hospitalization]; BC Stats, Population Estimates and Projections [P.E.O.P.L.E. 34], 2009 [population]. CAD-Related Hospitalizations: AMI Significance: The following AMI hospitalization rates describe the change in hospitalizations over time and provide insight into the prevalence of CAD in the population. Differences in rates between health authorities may be attributed to several factors, while decreasing hospitalization rates overall may be a reflection of a healthier population or may be a result of better managing the disease outside of the hospital, for example, through heart disease prevention programs. Tracking and understanding trends in hospitalizations is important for planning resources, be it capacity-planning for treatmentrelated procedures or for primary and secondary prevention programs. Findings: Figure 2.1 AMI hospitalizations in BC have declined from to per 100,000 (2002/03 and 2008/09, respectively). AMI rates declined significantly in NH, VCH, and VIHA (pvalue<0.05). NH and IH had the highest rates of AMI (above 235 per 100,000) while VCH had the lowest rates (below 210 per 100,000) in 2008/09. (Note: These numbers do not include people who were not admitted to a hospital, for example people who died before being admitted to hospital.) Findings: Figure 2.2 AMI hospitalizations in BC have declined in all age categories in males from 1995/96 to 2008/09; rates are projected to continue to decline. Cardiac Services BC - Annual Report 2010 Chapter 2 21

23 Figure 2.3 Observed and Projected AMI Hospitalization Rates for Females by Age Group Crude Rate per 100, / / / / / / / / / / / / / / / / / / / / /16 Fiscal Year Years Years (O) Years Years (O) Years Years (O) 75 Years + 75 Years + (O) Definitions: Rates of AMI hospitalizations per 100,000 female population in BC. Rates are displayed by age group. Solid circles are observed rates and solid lines are projected rates. Source: Canadian Institute for Health Information, Discharge Abstract Database, 1995/ /09 [AMI hospitalization]; BC Stats, Population Estimates and Projections [P.E.O.P.L.E. 34], 2009 [population]. Findings: AMI hospitalization rates in BC have declined in all age groups in females with the concerning exception of those aged 20 to 49 years who have experienced a slight increase from 1995/96 to 2008/09. These trends are projected to continue. Figure 2.4 Observed and Projected Decline in AMI Hospitalization Overall Rates Chapter 2 Cardiac Services BC - Annual Report 2010 Crude Rate per 100, / / / / / / / / / / / / / / / / / / / / /16 Fiscal Year Female Male Overall Female (O) Male (O) Overall (O) Definitions: Rates of AMI hospitalizations per 100,000 population in BC. Rates are displayed for males and females and for the population as a whole. Solid circles are observed rates and solid lines are projected rates. Source: Canadian Institute for Health Information, Discharge Abstract Database, 1995/ /09 [AMI hospitalization]; BC Stats, Population Estimates and Projections [P.E.O.P.L.E. 34], 2009 [population]. Findings: AMI hospitalizations in BC have declined in both males and females from 1995/96 to 2008/09 and are projected to continue this decline. 22

24 Table 2.1 AMI Re-admission Rates (%) by Patient Residence, 2003/04 to 2008/09 Health Region 2003/ /06 rate (%) and 95% CI 2004/ /07 rate (%) and 95% CI 2005/ /08 rate (%) and 95% CI 2006/ /09 rate (%) and 95% CI Canada British Columbia 6.2 ( ) 5.6 ( ) 5.3 ( ) 4.8 ( ) IH East Kootenay 4.9 ( ) 4.3 ( ) 6.4 ( ) 4.7 ( ) Kootenay Boundary 11.4 ( ) 10.5 ( ) 9.0 ( ) 7.9 ( ) Okanagan 6.7 ( ) 6.0 ( ) 5.9 ( ) 5.5 ( ) Thompson/Cariboo/Shuswap 7.9 ( ) 7.2 ( ) 6.2 ( ) 6.1 ( ) FH Fraser East 5.9 ( ) 4.9 ( ) 3.6 ( ) 3.3 ( ) Fraser North 7.0 ( ) 5.8 ( ) 4.4 ( ) 3.9 ( ) Fraser South 5.9 ( ) 5.6 ( ) 5.4 ( ) 4.8 ( ) VCH Richmond Suppressed 3.1 ( ) 3.7 ( ) 3.3 ( ) Vancouver 3.8 ( ) 3.4 ( ) 3.7 ( ) 4.1 ( ) North Shore/Coast Garibaldi 5.0 ( ) 4.2 ( ) 4.8 ( ) 3.8 ( ) VIHA South Vancouver Island 3.0 ( ) 3.0 ( ) 3.5 ( ) 2.9 ( ) Central Vancouver Island 7.7 ( ) 7.2 ( ) 6.6 ( ) 6.1 ( ) North Vancouver Island 6.7 ( ) 8.4 ( ) 6.6 ( ) 6.0 ( ) NH Northwest 7.8 ( ) 7.5 ( ) 6.0 ( ) 6.4 ( ) Northern Interior 8.3 ( ) 7.0 ( ) 6.8 ( ) 5.8 ( ) Northeast Not available 4.6 ( ) 7.0 ( ) 6.9 ( ) Blue font indicates that the rate is statistically significantly lower than the Canadian rate (p<0.05) Red font indicates that the rate is statistically significantly higher than the Canadian rate (p<0.05) CI stands for Confidence Interval Definitions: The three-year pooled risk-adjusted rate of select unplanned re-admission conditions within 28- days following a hospital discharge of an AMI. Full technical notes can be found on the Canadian Institute for Health Information website. Source: Reprinted with permission from the Canadian Institute for Health Information, Health Indicators e-publication. indicators. Accessed January 14, CAD-Related Hospitalizations: AMI Re-admissions Significance: Re-admission rates reflect the impact hospital care has had on the patient s condition up to the point of discharge, and also represent the efficiency of the service. Inpatient hospital care is a primary expense and repeat admission represents a potentially avoidable cost to the system. As such, re-admission rates can be viewed as a measure of the overall quality of care delivered. Improvements across the continuum of care--such as improvements in hospital processes, patient education, community support, and communication among hospital providers--are believed to reduce re-admission rates. Likewise, knowing that re-admission rates are higher in one community than another offers opportunities to identify and adopt best practices to improve care. That said, re-admission rates represent only one indicator and must be interpreted within the context of other outcome measures. For example, higher in-hospital AMI mortality rates may be correlated with lower re-admission rates. As a result, a more meaningful outcome indicator may be death at home or re-admission within 30 days. Improving re-admission rates requires careful investigation of the care provided within each hospital and requires an understanding of the pathways of care following an AMI from the acute phase of care, to the medical follow-up, to the community-based services and support. Findings: Re-admission rates following an AMI in Canada and BC have declined steadily in recent years. The most recent data indicate that BC s re-admission rate is almost equivalent to Canada s rate. Kootenay Boundary rates were significantly higher than the Canadian rate for four reporting periods and remain the highest in the province. Vancouver rates were significantly lower than the Canadian rate for three reporting periods, while South Vancouver Island rates were Cardiac Services BC - Annual Report 2010 Chapter 2 23

25 significantly lower for four reporting periods. Substantial variation in re-admission rates exist on the Island with South Vancouver Island reporting rates as low as 2.9% and Central and North Vancouver Island reporting rates around 6.0%. Health Service Delivery Areas in FH and NH did not have significantly different rates however, the rates generally declined in these areas over the study period. The data indicate that residents living in more urban communities have lower re-admission rates suggesting that more remote areas may have less access to specialty care. Variation in AMI re-admission rates exist across the province and also within individual health authorities. (Note: The risk-adjusted model is based on data from all provinces, excluding Quebec, and territories in Canada.) CSBC in ACTION CSBC is continually monitoring BC s overall performance on AMI hospitalizations, re-admissions, and deaths, with the aim of improving performance across the system. CSBC continues to allocate funds toward a campaign initially launched by the Canadian Patient Safety Council, known as Safer Healthcare Now that utilizes quality improvement methods to integrate evidence and best practices into patient care delivery for patients with AMI. The projects funded focus on: The development and standardization of order sets (to ensure that treatment and medication are delivered consistently regardless of the practitioner); The implementation of tracking systems to monitor patient care; Measurement of the completion rate of six important quality-of-care indicators at baseline and post-implementation; and, Implementation of new quality improvement methods. Chapter 2 Cardiac Services BC - Annual Report

26 Table Day AMI In-Hospital Mortality Rates (%) by Patient Residence, 2003/04 to 2008/09 Health Region 2003/ /06 rate (%) and 95% CI 2004/ /07 rate (%) and 95% CI 2005/ /08 rate (%) and 95% CI 2006/ /09 rate (%) and 95% CI Canada British Columbia 10.6 ( ) 10.4 ( ) 10.0 ( ) 9.4 ( ) IH East Kootenay 7.6 ( ) 8.3 ( ) 10.1 ( ) 9.3 (6.6-12) Kootenay Boundary 11.0 ( ) 11.4 ( ) 10.7 ( ) 9.5 ( ) Okanagan 10.8 ( ) 10.5 ( ) 10.7 ( ) 9.4 ( ) Thompson/Cariboo/Shuswap 11.3 ( ) 12.4 ( ) 11.3 ( ) 9.6 ( ) FH Fraser East 12.6 ( ) 12.2 ( ) 11.1 ( ) 8.9 ( ) Fraser North 13.0 ( ) 12.5 ( ) 11.8 ( ) 10.9 ( ) Fraser South 10.5 ( ) 10.0 ( ) 9.6 ( ) 9.3 ( ) VCH Richmond 12.7 ( ) 11.8 ( ) 11.4 ( ) 11.4 ( ) Vancouver 11.7 ( ) 9.8 ( ) 8.3 ( ) 7.9 ( ) North Shore/Coast Garibaldi 10.3 ( ) 10.4 ( ) 10.5 ( ) 9.4 ( ) VIHA South Vancouver Island 8.9 ( ) 9.4 ( ) 9.4 ( ) 9.8 ( ) Central Vancouver Island 8.2 ( ) 8.8 ( ) 8.3 ( ) 8.6 ( ) North Vancouver Island 6.6 ( ) 7.8 ( ) 6.5 ( ) 6.8 ( ) NH Northwest 11.6 ( ) 7.7 ( ) 8.2 ( ) 10.0 ( ) Northern Interior 7.7 ( ) 8.2 ( ) 9.4 ( ) 10.9 ( ) Northeast Not available 15.2 ( ) 14.6 ( ) 14.7 ( ) Blue font indicates that the rate is statistically significantly lower than the Canadian rate (p<0.05) Red font indicates that the rate is statistically significantly higher than the Canadian rate (p<0.05) CI stands for Confidence Interval Definitions: Data from the three-year pooled risk-adjusted rate of all-cause in-hospital death occurring within 30 days of the first admission to an acute care hospital with a diagnosis of an AMI. Full technical notes can be found on the CIHI website. Source: Reprinted with permission from the Canadian Institute for Health Information, Health Indicators e-publication. indicators. Accessed January 14, CAD-Related Hospitalizations: AMI In-Hospital Mortality Significance: In-hospital mortality rates are a well-used indicator of quality of care. Lower rates may indicate higher quality of care received in the hospital and the community. Similar to the re-admission indicator, higher rates may require investigations into hospital processes, patient care and community health services. Re-admission and mortality rates are typically interpreted together to provide an overall indicator of the quality of care delivered. Monitoring rates provides useful information on evaluating interventions and other best practices. Findings: Rates of 30-day in-hospital mortality following an AMI in Canada and BC have declined steadily in recent years and this is likely a result of primary and secondary prevention efforts: both better use of medications that reduce heart disease risk, as well as risk-factor reduction. For example, BC has the lowest smoking rate in the country and reduced its rate from 16% to 15% from 2003 to BC AMI in-hospital mortality rates for the last two study periods (i.e., 2005/ /08 and 2006/ /09) were significantly higher than the Canadian average rate. Within FH, Fraser North rates were significantly higher than the Canadian rate for all reporting periods, while Fraser East rates were significantly higher for two reporting periods. Within VCH, Richmond rates have remained relatively high over the entire reporting period with rates significantly higher than the Canadian rate in the latest period. Northeast rates were significantly higher for three consecutive reporting periods. (Note: The risk-adjusted model is based on data from all provinces (excluding Quebec) and territories in Canada.) Cardiac Services BC - Annual Report 2010 Chapter 2 3 Heart and Stroke Foundation of Canada. Accessed on February 24,

27 CAD-Related Hospitalizations and Cardiac Procedure Utilization The diagnosis and treatment of CAD is an important component of CSBC s overall mandate. Coronary revascularization, through Coronary Artery Bypass Grafts (CABG) and/or Percutaneous Coronary Interventions (PCI), plays a key role in the treatment of CAD. The choice of treatment and the rate of treatment varies substantially across the system. This section provides an overview of the relationship between AMI hospitalizations and cardiac procedure utilization, through the reporting of rates and ratios. CSBC in ACTION CSBC is currently engaging in a provincial review on regional variation to better understand the impact of these factors on revascularization practice in BC. Chapter 2 Cardiac Services BC - Annual Report

28 Figure 2.5 Diagnostic Catheterization to AMI Ratio by Patient Residence, 2008/09 Northwest Northeast < >=3.00 BC Ratio = 2.47 Catheterization Center Vancouver North Shore/ Coast Garibaldi Fraser North Richmond Fraser South HSDA Ratio Fraser East 2.83 Fraser North 3.55 Fraser South 3.06 East Kootenay 0.72 Kootenay Boundary 1.78 Okanagan 1.94 Thompson Cariboo Shuswap 1.79 Northeast 0.8 Northern Interior 2.27 Northwest 2.37 North Shore/ Coast Garibaldi 2.39 Richmond 2.98 Vancouver 2.44 Central Vancouver Island 2.29 North Vancouver Island 2.21 South Vancouver Island 2.95 North Vancouver Island Central Vancouver Island South Vancouver Island North Shore/ Coast Garibaldi North Shore/ Coast Garibaldi Northern Interior Thompson Cariboo Shuswap Fraser North Fraser East Fraser Okanagan South Kootenay Boundary East Kootenay Significance: As identified earlier, AMI can be viewed as a marker of CAD in the population. While not all cardiac procedures are performed on AMI patients (for example, some patients are managed medically) and not all patients who have a cardiac procedure had an AMI, the ratio provides information on the relationship between resource utilization and burden of disease. These indicators also show that there is wide variation in procedure practice patterns among the different health authorities that is not explained by disease prevalence. The ratios do not take into account differences in population characteristics (e.g., age, ethnicity). Although the measure is a crude ratio, it provides general information on the variation across the system. The numbers of procedures and AMI hospitalizations are based on events and not on the person. These rates are not linked by person and do not suggest that persons who experienced an AMI underwent a procedure. Definitions: The ratio of diagnostic catheterizations to AMI hospitalizations by patient residence. A ratio greater than one suggests that the number of procedures is greater than the number of AMI events. A ratio equal to one suggests that the number of procedures is equal to the number of AMI events. A ratio less than one suggests that the number of procedures is less than the number of AMI events. Source: Cardiac Services BC, Cardiac Services BC Registry, 2008/09; and Canadian Institute for Health Information, Discharge Abstract Database, 2008/09. Cardiac Procedures and AMI Ratios Findings: There is wide variation in the ratios among HSDAs. The East Kootenay (0.72) and Northeast (0.80) areas had the lowest diagnostic catheterization to AMI ratios in BC, meaning that there were less diagnostic catheterizations relative to AMI hospitalizations as compared to all other areas in the province. As both HSDAs are close to the border it is likely that some patients may have received care in Alberta. Note that these rates include British Columbians having a diagnostic catheterization in Alberta, and, consequently their care may be more reflective of care provided in rural Alberta than in BC. Fraser East (2.83), Richmond (2.98), Fraser South (3.06) and Fraser North (3.55, the highest ratio), all areas geographically close together, had ratios higher than BC (2.47). 27 Cardiac Services BC - Annual Report 2010 Chapter 2

29 Figure 2.6 Revascularization to AMI Ratio by Patient Residence, 2008/09 Northwest Northeast < >=1.75 BC Ratio = 1.26 Revascularization Center North Shore/ Coast Garibaldi Vancouver Richmond Fraser North Fraser South HSDA Ratio Fraser East 1.51 Fraser North 1.87 Fraser South 1.66 East Kootenay 0.53 Kootenay Boundary 0.77 Okanagan 0.81 Thompson Cariboo Shuswap 0.84 Northeast 0.67 Northern Interior 1.01 Northwest 1.08 North Shore/ Coast Garibaldi 1.11 Richmond 1.45 Vancouver 1.18 Central Vancouver Island 1.25 North Vancouver Island 1.29 South Vancouver Island 1.63 North Shore/ Coast Garibaldi North Vancouve r Island Northern Interior Definitions: The ratio of revascularization procedures to AMI hospitalizations by patient residence. A ratio greater than one suggests that the number of procedures is greater than the number of AMI events. A ratio equal to one suggests that the number of procedures is equal to the number of AMI events. A ratio less than one suggests that the number of procedures is less than the number of AMI events. Source: Cardiac Services BC, Cardiac Services BC Registry, 2008/09; and Canadian Institute for Health Information, Discharge Abstract Database, 2008/09. Central Vancouver Island South Vancouver Island North Shore/ Coast Garibaldi Thompson Cariboo Shuswap Fraser North Fraser East Fraser Okanagan South Kootenay Boundary East Kootenay Chapter 2 Cardiac Services BC - Annual Report 2010 Findings: East Kootenay (0.53), Northeast (0.67), and Kootenay Boundary (0.77) had the lowest revascularization to AMI ratios in BC. Again, two of these areas border Alberta. Note that these rates include British Columbians having a revascularization procedures performed in Alberta, and, consequently their care may be more reflective of care provided in rural Alberta than in BC. Richmond (1.45), Fraser East (1.51), Fraser South (1.66), and Fraser North (1.87, the highest ratio), all areas geographically close together, had ratios higher than BC (1.26). Several factors may influence the frequency and type of revascularization including the age and sex of the patient, presence of other co-morbidities (e.g., diabetes), anatomic extent and severity of CAD, indication for catheterization (e.g., acute vs. stable CAD), physician skill set, and hospital characteristics. (Note: PCI is performed currently in five hospitals: KGH, RCH, RJH, SPH, and VGH. KGH started performing PCI in November 2009 and is not included in the PCI analysis.) 28

30 Figure 2.7 AMI Hospitalization and Cardiac-Related Procedure Rates (age- and sex-standardized per 100,000 population) by Patient Residence, 2008/ AMI Standardized Rate per 100, VCH VIHA FH IH NH BC Procedure Standardized Rate per 100,000 AMI Rate CABG Rate PCI Rate CATH Rate VCH VIHA FH IH NH BC Definitions: Rate of cardiac procedure by health authority, shown separately for CABG, PCI and diagnostic catheterization (CATH). Rate of AMI hospitalizations per 100,000 population by health authority is shown as a solid bar behind the risk factors and cardiac-related procedures. AMI hospitalization rates were age- and sex-standardized using data from BC Stats, Population Estimates and Projections (P.E.O.P.L.E. 34), Source: Cardiac Services BC, Cardiac Services BC Registry, 2008/09 [Revascularization procedures]; and Canadian Institute for Health Information, Discharge Abstract Database, 2008/09 [AMI hospitalizations]. Cardiac Procedures and AMI Rates Significance: This graph illustrates the relationship between CAD diagnosis (using AMI hospitalizations as a proxy) and cardiac-related procedure rates. Findings: The data indicate a high degree of variation in both the procedure rates (i.e., CABG, PCI, and diagnostic catheterization rate) and the rate of AMI hospitalization. While IH reported one of the highest AMI hospitalization rates in the province, it reported the lowest revascularization rates in the province. Further analysis indicated that there was no association between CABG, PCI or diagnostic catheterizations, and AMI hospitalizations (all p-values >0.39), meaning that the volume of cardiac services is not likely explained by disease prevalence. Practice patterns may explain some of the difference. CSBC in ACTION Further analysis by CSBC into the factors that influence the frequency and type of revascularization will be studied in the upcoming year to better understand resource utilization across the province. Cardiac Services BC - Annual Report 2010 Chapter 2 29

31 Chapter 3 Cardiac Services BC - Annual Report

32 Chapter 3 Cardiac Procedure Utilization Cardiac Services BC - Annual Report 2010 Chapter 3 31

33 Figure 3.1 Diagnostic Catheterization Rates (age- and sex-standardized, per 100,000 population) by Patient Residence, 2002/ / / / / / / / / /10 Rate per 100, FH IH NH VCH VIHA BC / / / / / / / /10 Definitions: The number of diagnostic catheterizations per 100,000 population by patient residence. Rates were age- and sex-standardized using population data from BC Stats, Population Estimates and Projections (P.E.O.P.L.E. 34), Source: Cardiac Services BC, Cardiac Services BC Registry, 2002/ /10. Cardiac Procedure Utilization Progress in the diagnosis and treatment of coronary artery disease (CAD) over the past few decades, as well as improved access to care, means more people are surviving heart attacks, living with fewer symptoms, and enjoying a better quality of life. Changes to diet and habits can help improve the symptoms of CAD, while other treatment options may include medication, such as blood thinners or cholesterol-lowering drugs, and medical procedures, including PCI or heart surgery. This chapter focuses on the use of medical procedures for diagnosis and treatment over the last several years and investigates where patients receive care. Chapter 3 Cardiac Services BC - Annual Report 2010 Cardiac Procedure Utilization: Rates Significance: Diagnostic catheterization and coronary revascularization procedures are important elements in the diagnosis and/or treatment of individuals with cardiac-related conditions. Tracking the number of procedures performed over time provides information on changing trends in the management of CAD. For example, in the early 2000s, studies supporting the use of invasive procedures for patients with acute coronary syndromes (ACS) requiring more urgent treatment, encouraged the uptake of diagnostic catheterization and PCI. By mid-decade, however, other studies in patients with stable angina, most notably the COURAGE 1 trial suggested that in these non-urgent patients, medical treatments were often as good as revascularization procedures, while other studies raised concerns over the long-term benefit/risk ratio of drug-eluting stents. These developments served to temper the growth in diagnostic catheterizations and PCI. CABG surgeries have been steadily declining in many parts of the world as less invasive coronary revascularization procedures have become more widely available. Furthermore declining rates of CAD in the population (as suggested by AMI hospitalizations) have also had an impact on treatment rates Boden et al. N Engl J Med 2007; 356:

34 Figure 3.2 PCI Rates (age- and sex-standardized, per 100,000 population) by Patient Residence, 2002/ / Rate per 100, / / / / / / / /10 FH IH NH VCH VIHA BC / / / / / / / /10 Definitions: The number of PCI procedures per 100,000 population by patient residence. Rates were age- and sex-standardized using population data from BC Stats, Population Estimates and Projections (P.E.O.P.L.E. 34), Source: Cardiac Services BC, Cardiac Services BC Registry, 2002/ /10. These trends in procedure utilization can be applied in projection models to determine future system-wide cardiac requirements. This is particularly relevant to the development of the new cardiac surgical program at KGH. Utilization and market share data have and will continue to be applied to estimate the needs of the new centre based on the population it serves, as well as the impact on existing centres. Findings: Figure 3.1 BC rates for diagnostic procedures increased from per 100,000 population in 2002/03 to in 2005/06 before declining to in 2009/10. VIHA rates decreased significantly (p<0.0001) from to per 100,000 over the eight-year period. VCH rates also decreased significantly (p=0.04) from to per 100,000. FH consistently had higher rates whereas VCH and IH tended to have lower rates. NH rates were more variable, which is most likely due to their small population. (Note: Diagnostic procedures with or without subsequent interventions were included in the calculation.) Findings: Figure 3.2 BC rates for PCI increased slightly from per 100,000 population in 2002/03 to in 2005/06, dipping in 2007/08 to 205.6, and continuing to decline since then. The decline in PCI rates in 2007/08 may reflect the impact of the COURAGE study. VIHA rates decreased significantly (p=0.02) from to per 100,000 during the eight-year reporting period. IH and VCH consistently had the lowest rates, while FH had the highest rate for six consecutive years starting from 2004/05. Rates at FH decreased in 2009/10 while rates in IH increased. A new PCI program commenced in IH in November 2009/10 and may have had an impact on increasing rates in the region in that year. (Note: PCI with or without a prior diagnostic procedure were included in the calculation.) Cardiac Services BC - Annual Report 2010 Chapter 3 33

35 Figure 3.3 Isolated Coronary Artery Bypass Graft Rates (age- and sex-standardized, per 100,000 population) by Patient Residence, 2002/ / Rate per 100, / / / / / / / /10 FH IH NH VCH VIHA BC / / / / / / / /10 Definitions: The number of isolated CABG procedures per 100,000 population by patient residence. Rates were age- and sex-standardized using population data from BC Stats, Population Estimates and Projections (P.E.O.P.L.E. 34), Source: Cardiac Services BC, Cardiac Services BC Registry, 2002/ /10. Findings: BC rates for isolated CABG significantly decreased from 67.4 per 100,000 population in 2002/03 to 53.1 in 2009/10 (p<0.0001). FH, NH, IH and VIHA CABG rates significantly declined (all p<0.05). The NH rate spiked in 2003/04 to 90.5, despite the significant downward trend. VCH generally had the lowest rates, while NH and FH generally had the highest rates. Similar declining trends of CABG utilization have been identified in other jurisdictions across Canada. Figure 3.4 Total Open Heart Surgery Rates (age- and sex-standardized, per 100,000 population) by Patient Residence, 2002/ / Chapter 3 Cardiac Services BC - Annual Report 2010 Rate per 100, / / / / / / / /10 Findings: BC rates for heart surgery (including isolated CABG) procedures significantly decreased from to 98.2 per 100,000 population (p<0.0001) during the eight-year time period. FH, NH, VCH, and VIHA rates 2002/ / / / / / / /10 FH IH NH VCH VIHA BC Definitions: The number of all open heart surgery procedures (including isolated CABG) per 100,000 population by patient residence. Rates were age- and sex-standardized using population data from BC Stats, Population Estimates and Projections (P.E.O.P.L.E. 34), Source: Cardiac Services BC, Cardiac Services BC Registry, 2002/ /10. significantly decreased (all p<0.05). The NH rate spiked in 2003/04 to 153.4, despite the significant downward trend. VCH generally had the lowest rates, while NH and FH generally had the highest rates. 34

36 Cardiac Procedure Utilization: Where Patients Receive Care Understanding what populations are accessing cardiac services is an important component in planning coronary revascularization services into the future. Not all patients receive care at a hospital within their health authority. Patients may choose to receive service in a hospital outside of their health authority, be referred out as a result of historical referral patterns, or the service may not be available in a hospital in the patient s health authority. Significance: Procedure volume and distribution of services among the health authorities is important for estimating the expected number of cases to be performed by each hospital site per year, given that sites are funded based on the volume of procedures completed. Market share is also useful in planning services into the future. As new programs are developed, or services are provided in closer proximity to their residence, it is useful to investigate market share and some of its drivers. Some of the factors that may drive case distributions include the distance between the patient s residence and hospital, service demand, resources available, existing referral patterns, and patient preference. Cardiac Services BC - Annual Report 2010 Chapter 3 35

37 Figure 3.5 Percentage of Residents in a Health Authority Undergoing Diagnostic Catheterization by Hospital, 2009/10 100% VGH 20% 80% SPH 23% 60% 40% 20% KGH 0% OOP Patient Residence FH IH NH VCH VIHA BC N = RJH RCH 18% 26% 12% 1% Definitions: The percentage of patients from the health authority of patient residence receiving a diagnostic catheterization at each hospital. The total number of residents in a health authority undergoing a diagnostic catheterization is also provided. OOP = Out of Province. Source: Cardiac Services BC, Cardiac Services BC Registry, 2009/10. Chapter 3 Cardiac Services BC - Annual Report 2010 Findings: FH residents underwent the highest number of diagnostic catheterizations (n=6,929), which was almost double the number for that of VCH residents (n=3,546). NH residents, the only health authority with no diagnostic catheterization facilities, underwent the lowest number of diagnostic catheterizations (n=948). Most residents undergoing a diagnostic catheterization went to a hospital within their health authority: 95.2% of VIHA residents went to RJH, 95.2% of VCH residents went to either SPH or VGH, 66.5% of IH residents went to KGH, and 63.3% of FH residents went to RCH. Virtually all of FH patients received care within the Lower Mainland (i.e., RCH, SPH, VGH). The majority of NH patients (63.6%) went to SPH for care. Note that prior to November 2009, a proportion of IH patients may have been diverted from KGH to other revascularization centres as KGH did not offer PCI services. As such, KGH s market share for IH residents may increase in 2010/11. In terms of overall market share, KGH performed the least diagnostic catheterizations (12%) while RCH performed the most (26%). One percent of BC residents sought care outside of BC. (Note: The number of residents in a health authority undergoing a procedure is graphically illustrated according to the width of the bar. The wider the bar, the more residents undergoing a procedure.) 36

38 Figure 3.6 Percentage of Residents in a Health Authority Undergoing PCI by Hospital, 2009/10 100% VGH 23% 80% SPH 17% 60% RJH 25% 40% 20% 0% Patient Residence N = FH 2679 IH 1144 NH 373 VCH 1316 VIHA 1550 RCH KGH OOP BC % 4% 2% Definitions: The percentage of patients from the health authority of patient residence receiving PCI at each hospital. The total number of residents in a health authority undergoing PCI is also provided. OOP = Out of Province. Source: Cardiac Services BC, Cardiac Services BC Registry, 2009/10. Findings: NH had the least residents undergoing a PCI (n=373), which was approximately one seventh of FH residents (n=2,679, the highest number). Similar to diagnostic catheterizations, most residents undergoing a PCI went to a hospital within their health authority: 97.7% of VIHA residents went to RJH, 93.9% of VCH residents went to either SPH or VGH, and 71.4% of FH residents went to RCH. KGH did not start performing PCI until November 2009, and consequently only 24.7% of IH residents went to KGH in 2009/10. VGH had the largest market share in IH prior to the creation of the PCI program in KGH. In terms of overall market share, KGH performed the least PCIs (4%) while RCH performed the most (29%). Two percent of BC residents received care outside of BC. Cardiac Services BC - Annual Report 2010 Chapter 3 37

39 Figure 3.7 Percentage of Residents in a Health Authority Undergoing Open Heart Surgery by Hospital, 2009/10 100% VGH 25% 80% 60% SPH 25% 40% RJH 23% 20% 0% Patient Residence N = FH 1281 IH 615 NH 212 VCH 748 VIHA 664 RCH OOP BC % 3% Definitions: The percentage of patients from the health authority of patient residence receiving open heart surgery at each hospital. The total number of residents in a health authority undergoing open heart surgery is also provided. OOP = Out of Province. Source: Cardiac Services BC, Cardiac Services BC Registry, 2009/10. Findings: The number of residents undergoing OHS ranged from 212 (NH) to 1281(FH) in 2009/10. The number of residents from IH, VCH and VIHA undergoing the procedure was similar (n=615, 748, 664, respectively). Similar to diagnostic catheterizations and PCI, most residents undergoing OHS went to a hospital within their health authority: 95.1% of VCH residents went to either SPH or VGH, 94.0% of VIHA residents went to RJH, and 58.5% of FH residents went to RCH. IH and NH do not have OHS facilities, and therefore the majority of IH residents went to RJH, SPH or VGH. The majority of NH patients went to SPH, VGH, or to a hospital outside of BC (most likely Alberta). In terms of overall market share, RCH and RJH each performed 23% of OHS in BC and SPH and VGH performed slightly more at 25%. Three percent of BC residents received care outside of BC. Chapter 3 Cardiac Services BC - Annual Report

40 Chapter 4 Wait Times Cardiac Services BC - Annual Report 2010 Chapter 4 39

41 Wait Times Timely access to care has long been one of the most hotly debated healthcare topics for average Canadians and policy makers alike: while most Canadians are satisfied with their level of access to healthcare, many experience long waits to see a specialist, get diagnostic tests, and/or undergo treatments. Delay to testing or treatment can be a source of considerable anxiety for patients--even those in whom testing ultimately finds them clear of disease. For those who need treatment, the perception or reality that a disease has proceeded unchecked during the period of delay is a common criticism of Canada s healthcare system. In general, the system strives to achieve the minimal queue required to ensure that care is provided in a safe and reasonable time while resources are not wasted with idle facilities or staff. In an effort to address Canadians concerns regarding timely access to care, the First Ministers (premiers of each province and territory and the Prime Minister) approved the 10-Year Plan to Strengthen Healthcare at the First Ministers Meeting (FMM) in By signing this document, all provinces and territories committed to reduce wait times in five priority areas: cardiac, cancer, diagnostic imaging, joint replacements, and sight restoration. Pan-Canadian benchmarks were established in 2005 with the aim of each province and territory meeting these benchmarks by the end of This chapter provides a snap-shot look at access to care for isolated coronary artery bypass graft surgery (CABG) by hospital, with wait times taken at specific points in time. The numbers of patients waiting for other heart surgery and completed surgery are also presented. CSBC in ACTION CSBC has recently begun collecting wait time data on electrophysiology (EP) procedures, used to treat heart arrhythmias, and some initial data on median wait time and number completed are included in this chapter. Chapter 4 Cardiac Services BC - Annual Report Accessed January 17, 2011.

42 Figure 4.1 Percentage of Isolated CABG Completed within FMM Benchmarks by Priority, % Within FMM Benchmark Jan Mar 2009 Apr Jun 2009 Jul Sep 2009 Oct Dec 2009 Jan Mar 2010 Apr Jun 2010 Target 90% Jul Sep 2010 Priority l # Total Cases Priority ll # Total Cases Priority lll # Total Cases Jan Mar Apr Jun Jul Sep Oct Dec Jan Mar Apr Jun Jul Sep Definitions: Percentage of urgent and elective BC isolated CABG cases completed from the waitlist according to the First Ministers Meeting (FMM) priority categories, and the total number of cases in each priority group by calendar quarters. Priority I: cases should have surgery within two weeks from the time of booking. Priority II: cases should have surgery within six weeks. Priority III: cases should have surgery within 26 weeks. The target is to have 90% of cases completed in each Priority within the recommended time frame. Source: Cardiac Services BC, Cardiac Services BC Registry, Wait Times: Isolated CABG Significance: The federal government has mandated that wait times for isolated CABG be reported and that patients receive surgery according to the defined benchmarks--the assumption being that meeting these benchmarks will improve patient outcomes. Meeting the federal benchmarks requires striking a delicate balance between existing capacity and demand, taking into account staffing, competing demands for the operating room, and critical care beds/cardiac tertiary care. Of note, the FMM initiative currently focuses on the wait time for the procedure itself (i.e., from time of booking to the procedure date), but does not take into account the waits patients face in being referred to a specialist, or being assessed. Hospitals working to improve waiting times for isolated CABG have also had to ensure that their progress has not been at the expense of other important procedures not identified through the FMM process. As a result of this initiative, wait times for isolated CABG are now quantitatively measured and published and have resulted in decreased wait times. Patients now have the ability to obtain relatively current wait time information on both the hospital and surgeon expected to perform the surgery on a publicly published Surgical Wait Times website ( bc.ca/swt/). Findings: All priorities have surpassed the target for the past seven quarters. For the past three quarters, more than 98% of isolated CABG cases have been completed within the FMM benchmarks. Priority III cases, those with the longest allowable wait time and generally the group who has the longest delay, were virtually all done within the FMM benchmarks. Cardiac Services BC - Annual Report 2010 Chapter 4 41

43 Figure 4.2 Number of Waiting for and Completed Heart Surgeries by Hospital, # Patients on waitlist for site # Patients on waitlist in BC waiting RCH completed waiting RJH completed waiting SPH completed Jan Mar Apr Jun Jul Sep Oct Dec Jan Mar Apr Jun Jul Sep # Surgeries completed for site Jan Mar 2009 Apr Jun 2009 Jul Sep 2009 Oct Dec 2009 Jan Mar 2010 Apr Jun Jul Sep # Surgeries completed in BC waiting VGH completed BC waiting completed Definitions: The number of outpatients waiting for heart surgery (including isolated CABG) at the end of the each calendar quarter in BC and by hospital. Procedures included in this graphic include isolated CABG, valve replacement and valve repair, aortic procedures, and other heart surgery procedures. Source: Cardiac Services BC, Cardiac Services BC Registry, Wait Times: Patients Waiting and Completed Surgeries Chapter 4 Cardiac Services BC - Annual Report 2010 Significance: The number of patients waiting for surgeries and surgeries completed are influenced by several factors, including the demand for service versus hospital capacity/throughput, patient risk factors, and patient readiness for surgery, as well as the number of hospitals/surgeons with the necessary degree of specialization to provide the service. Findings: Overall, the numbers of British Columbians waiting for heart surgery and completing heart surgery have been fairly constant between January 2009 and September 2010, suggesting a relatively stable state. The number waiting in BC steadily declined from 149 persons on the waitlist in January through March 2009 to 133 in July through September Generally, SPH had the highest number of patients on the waitlist, while RCH had the lowest number of patients. The number of heart surgeries completed in BC continues to be steady. There were 306 surgeries completed in January through March 2009 and 286 surgeries completed in July through September While this provides information on the total number of heart surgery procedures conducted, it does not provide any indication of how long the patient waited for those specific procedures. It also shows an overview of the number of waitlisted patients over this period of time, but doesn t include patients waiting to be referred and/ or assessed. In general, the data suggest that heart surgery volumes are in a steady state, but of note, for some specialty procedures where volumes are currently limited due to the cost and level of specialization required to perform the surgery (e.g., transcatheter aortic valve implants), the overall waitlists and wait times are growing. (Note: The lower volumes for heart surgery completed in August and December are associated with summer vacations and Christmas holidays, respectively.) 42

44 Figure 4.3 Median Wait Time and Number of Completed Electrophysiology Procedures by Hospital, Median Wait Time (Days) for Site # Procedures Completed for Site Oct 2009 Nov 2009 Dec 2009 Jan 2010 Feb 2010 Mar 2010 Apr 2010 May 2010 Jun 2010 Jul 2010 Aug 2010 Sep 2010 Oct 2009 median wait 34 RJH completed 89 median wait 40 SPH completed 99 median wait 39 BC completed 188 Nov Dec Jan Feb 2010 Definitions: The median wait time from booking to procedure completed for electrophysiology (EP) procedures at the end of each month by hospital. The total number of EP procedures completed (diagnostic procedures, simple and complex ablations) at the end of each month by hospital. Source: Cardiac Services BC, Electrophysiology Database, Mar Apr May Jun Jul Aug Sep Wait Times: Wait Times and EP Procedures Significance: In early 2008, wait times for complex EP ablation procedures--used to treat abnormal heart rhythms--were estimated at approximately two years. Additional funding in 2008 helped increase the number of cases treated and decrease wait lists, specifically for complex ablation cases at the two EP treating sites, RJH and SPH. Illustrated (Figure 4.3) are wait times for an EP procedure. Note that these data do not include the waiting period before initial assessment and/or referral, which anecdotally has been identified as the longest wait. (Note: Patient triage and wait list management functions are an integral part of the overall EP program. CSBC has made providing appropriate resources to effectively manage the wait lists for EP a high priority. Throughout the past year staff at both RJH and SPH have worked diligently to contact, prioritize, and document those awaiting EP procedures and improve the quality of the overall wait list data.) Findings: The median wait time for an EP procedure in BC from October 2009 to September 2010 ranged from 29 to 62 days. The number of EP procedures in BC from October 2009 to September 2010 ranged from 153 to 203 cases. While the data suggest that the median wait time for an EP procedure has increased over this period, the increase may be related to improved data collection and documentation during this window of time. Cardiac Services BC - Annual Report 2010 Chapter 4 43

45 CSBC in ACTION As part of its commitment to improving quality outcomes and providing better value for patients, CSBC has provided funding for atrial fibrillation clinics to help reduce the patient wait time for a standardized assessment of the need for an EP procedure and to enhance management of the waitlist. In 2011/12, all five cardiac centres will operate an atrial fibrillation clinic. As a result of the investments in EP services, overall EP volumes have substantially increased with a need to further expand capacity in 2011/12 (See Chapter 6, Strategic Plans 1 and 2). Chapter 4 Cardiac Services BC - Annual Report

46 Chapter 5 Outcomes Cardiac Services BC - Annual Report 2010 Chapter 5 45

47 Outcomes Tracking patient outcomes is a crucial component of any healthcare system assessment. Although patients undergo procedures to improve their healthcare, they sometimes experience problems either immediately after the procedure or later. Unlike longer term outcomes, which can be influenced by factors such as new or pre-existing, unrelated disease, shorter term outcomes--those occurring within 30 days post procedure--are more likely to be directly related to the procedure itself or the ancillary care provided. This chapter describes four indicators: 30-day mortality post heart surgery (shown separately for isolated CABG, isolated valve, and CABG plus valve) and 30-day mortality post PCI. CSBC in ACTION The CSBC Registry currently contains limited data on patients after they leave the hospital and must rely heavily on linkages with other databases to determine longer term outcomes. CSBC has historically collaborated with the BC Ministry of Health to secure death and hospitalization data. Recently, CSBC initiated collaborations with PharmaNet for pharmaceuticals and the Provincial Blood Coordinating Office s Central Transfusion Registry for blood product transfusions to secure additional data. Outcomes: 30-Day Mortality Chapter 5 Cardiac Services BC - Annual Report 2010 Thirty-day mortality rates are applied as a quality of care indicator for surgical and less invasive procedures in many jurisdictions. Since some cardiac procedures are riskier than others, mortality rates are presented according to the type of procedure. While BC s mortality rates for cardiac procedures are low and compare favourably with the literature, 1 CSBC continues to work with the cardiac surgery and interventional programs to explore opportunities for improvement. Significance: Mortality rates reflect the quality of care across the continuum of care including: The underlying risk of the patients undergoing the procedure; Selection for the procedure; The quality of care received during the procedure, and subsequent hospital care; Patient adherence with the treatment plan; and, Care received in the community. Higher mortality rates prompt those delivering care and health administrators to explore each of these factors to determine if modification of any aspect of care is warranted to improve care given to patients Shahian et al. Ann Thorac Surg 2009,88:S2 22; O Brien et al. Ann Thorac Surg 2009,88:S23 42; Shahian et al. Ann Thorac Surg 2009,88:S43 62; Singh et al. J Am Coll Cardiol 2008; 51:

48 Figure Day All-Cause Mortality Rate (%) Post Isolated CABG in BC, Adjusted Event Rate (%) N= Year Definitions: The risk-adjusted all-cause mortality rate within 30-days for patients undergoing isolated CABG. Estimates of rates with 95% confidence interval are shown by year. The five-year BC average rate is shown in red. Source: Cardiac Services BC, Cardiac Services BC Registry, ; and British Columbia Vital Statistics Agency, British Columbia Vital Statistics Agency Vital Event Registry, Findings: The 30-day risk-adjusted mortality rate post isolated CABG decreased from 2.13% in 2005 to 1.50% in 2008 before increasing to 1.79% in The variation among years is not statistically significant, suggesting that the variation is due to random chance. The five-year BC average rate was 1.77%, which is significantly lower than the Society for Thoracic Surgeons (STS) reported rate of 2.3%. 2 The number of isolated CABGs decreased from 1,944 in 2005 to 1,834 in (Note: The purpose of risk adjustment is to take into account variation in patient outcomes due to different risk factor profiles among different groups. The model included risk factors such as age, sex, selected co-morbidities, and urgency status at the time of surgery). CSBC in ACTION CSBC, as part of its commitment to working with physicians to assess outcomes and to improve overall performance, reviews outcome data annually with cardiac surgeons and interventional cardiologists. Some of the outcome indicators reviewed include: Surgery: percentage of cases with evidencebased medication at discharge by surgeon red blood cell transfusion rate by surgeon 30-day mortality rate by surgeon 30-day stroke/death rate by surgeon PCI: pre-procedural renal function assessment by physician six month repeat revascularization rate by physician 30-day mortality rate by physician 30-day AMI/death rate by physician Cardiac Services BC - Annual Report 2010 Chapter 5 2 Shahian et al. Ann Thorac Surg 2009;88:S

49 Figure Day All-Cause Mortality Rate (%) Post CABG Plus Valve Surgery in BC, Adjusted Event Rate (%) N= Year Definitions: The risk-adjusted all-cause mortality rate within 30-days for patients undergoing CABG plus valve surgery. Estimates of rates with 95% confidence interval are shown by year. The five-year BC average rate is shown in red. Source: Cardiac Services BC, Cardiac Services BC Registry, ; and British Columbia Vital Statistics Agency, British Columbia Vital Statistics Agency Vital Event Registry, Findings: The 30-day risk-adjusted mortality rate post CABG plus valve surgery remained generally stable: the lowest rate was 4.07% (2007) and the highest rate was 5.62% (2009). The five-year BC average rate was 4.60%, which is significantly lower than the STS reported rate of 6.8%. 3 The number of CABG plus valve surgeries performed was lowest in 2008 (n=369) and highest in 2007 (n=468). (Note: The model included risk factors such as age, sex, body mass index, selected comorbidities, urgency status at time of surgery, and history of drug abuse.) Figure Day All-Cause Mortality Rate (%) Post Isolated Valve Surgery in BC, Chapter 5 Cardiac Services BC - Annual Report 2010 Adjusted Event Rate (%) N= Year Definitions: The risk-adjusted all-cause mortality rate within 30-days for patients undergoing isolated valve surgery. Estimates of rates with 95% confidence interval are shown by year. The five-year BC average rate is shown in red. Source: Cardiac Services BC, Cardiac Services BC Registry, ; and British Columbia Vital Statistics Agency, British Columbia Vital Statistics Agency Vital Event Registry, Findings: The 30-day risk-adjusted mortality rate post isolated valve surgery remained relatively stable from 3.18% in 2005 to 2.37% in The highest rate was 3.81% in 2008 but the rate decreased to 2.37% the following year. The five-year BC average rate was 2.82%, which is significantly lower than the STS reported rate of 3.4%. 4 The number of valve surgeries increased from 406 in 2005 to 544 in (Note: The model included risk factors such as age, selected comorbidities, NYHA class, pre-operative ventilation, and history of previous surgery.) 48 3 O Brien et al. Ann Thorac Surg 2009;88:S Shahian et al. Ann Thorac Surg 2009,88:S43 62.

50 Figure Day Mortality Rate (%) Post PCI in BC, Adjusted Event Rate (%) N= Definitions: The risk-adjusted all-cause mortality rate within 30-days for patients undergoing PCI. Estimates of rates with 95% confidence interval are shown by year. The five-year BC average rate is shown in red. Source: Cardiac Services BC, Cardiac Services BC Registry, ; and British Columbia Vital Statistics Agency, British Columbia Vital Statistics Agency Vital Event Registry, Findings: The 30-day risk-adjusted mortality rate post PCI has remained stable with rates ranging from 1.92% (2004) to 1.79% (2008). The five-year BC average rate was 1.85%, which is lower than a study that reported a 30-day mortality rate of 2.4% for patients undergoing a PCI at the Mayo Clinic Rochester between 1996 and The number of PCI procedures increased by 7.8% from 5567 in 2004 to 5999 in (Note: The model included risk factors such as age, sex, selected comorbidities, urgency status at time of PCI, and ejection fraction.) Cardiac Services BC - Annual Report 2010 Chapter Year CSBC in ACTION CSBC is committed to improving quality outcomes and better value for patients. Details on some of CSBC s activities, including research, monitoring and reporting initiatives, and access improvements, can be found in Chapter 6, Strategic Priority 1. 5 Singh et al. J Am Coll Cardiol 2008; 51:

51 Chapter 6 Cardiac Services BC - Annual Report

52 Chapter 6 Planning Priorities Cardiac Services BC - Annual Report 2010 Chapter 6 51

53 Planning Priorities As an agency of the PHSA, CSBC plans within the framework of the PHSA s strategic directions. The following highlights CSBC s main priorities and planning activities. Strategic Priority 1: Improving quality outcomes and better value for patients Monitor and report on data quality, utilization data, wait time data and outcome performance Annual Service Level Agreements in place between CSBC and regional health authorities Monthly data quality reports developed and reviewed with tertiary cardiac sites New cardiac registry under development to include the full continuum of cardiac care Annual CSBC Report developed and distributed Monitor and report on process and outcomes of care with clinicians Annual meeting with all cardiac surgeons and interventional cardiologists to review outcomes to promote improved quality of care and patient outcomes Regular reporting of comprehensive set of indicators for process and quality of care based on international standards Quality outcomes for electrophysiology management under development Chapter 6 Cardiac Services BC - Annual Report 2010 Generate new knowledge of application of evidence and leading practices Provincial Advisory Panel on Cardiac Health provides recommendations on new and emerging technologies, indications for use, utilization of services, etc CSBC Data Access and Research Review Board promotes research projects utilizing CSBC Registry data Cardiac research fellowship positions supported within CSBC Staff initiate and collaborate with clinicians on research papers Improve access to cardiac care for all BC residents Provincial plans in place for electrophysiology and revascularization Revascularization services expanded to IH decreasing patient travel time & expense; reducing bed days for patients waiting for transfer Wait times for CABG surgery and EP procedures actively monitored to ensure compliance with national standards Atrial fibrillation clinics established at all tertiary cardiac sites to improve service access 52

54 Strategic Priority 2: Promoting Healthier Populations Expanding from a treatment centered to a patient centered approach and extending the reach of CSBC into high risk areas of the population A three-year provincial heart failure plan implemented Collaborate with PHSA Population Health on primary care initiatives (obesity, chronic disease management) Chair in Women s Cardiovascular Health established in collaboration with UBC Faculty of Medicine, Heart & Stroke Foundation BC & Yukon Division, BC Women s Hospital and Providence Health Care Five atrial fibrillation clinics established across the province Strategic Priority 3: Contributing to a Sustainable Healthcare System Enhancing system accountability through collaborative planning with service providers Cardiac Service Steering Committee established in 2009 with senior leadership from each health authority and meets monthly Annual Service Level Agreements signed between CSBC and health authorities Funding rates establishing for cardiac procedures using activity-based costing model, adjusting for patient complexities and co-morbidities Funding rates and volumes established with funding recovered for all procedures not delivered Promoting delivery of evidence-based therapies (e.g., safer healthcare now, heart failure, secondary prevention) Enhancing scrutiny of procedure indications and regional variation in utilization rates Standardized indications for high-cost, low volume procedures (e.g., micro-axial pump, thoracic endovascular aortic stents) Regional variation in electrophysiology and PCI under review Enhancing bed utilization through provincial coordination of patient flow Daily teleconferencing with triage coordinators Reallocating supply cost savings achieved through standardization of cardiac medical/ surgical supplies and devices through Health Shared Services BC provincial procurement Provincial plans developed for Cardiac Revascularization Services (CR), Congestive Heart Failure Services (CHF), and Electrophysiology Services (EP). Cardiac Services BC - Annual Report 2010 Chapter 6 53

55 Figure 6.1 Actual and Projected Demand for PCI (Volume of Cases ) 9,000 8,000 7,000 Actual 0% growth Average = Planned Volumes AMI Trend = Expected Volumes 6,000 Volume 5,000 4,000 3,000 2,000 1, Year Source: Cardiac Services BC Registry, 2001 to 2008 [PCI counts]; and Canadian Institute for Health Information, Discharge Abstract Database, 1995 to 2008 [AMI trends]. Revascularization Services Chapter 6 Cardiac Services BC - Annual Report 2010 Planning of revascularization services commenced in 2004 and culminated in three coronary revascularization reports (Hay Group 2006; Hay Group 2007; Hay Group 2008) and included a recommendation and subsequent approval by the Ministry of Health to establish a new cardiac centre in IH at KGH. IH began providing, on a transition basis, PCI services in mid-november 2009 and will begin providing heart surgery in With the development of this new program, a co-ordinated provincial plan to realign CR services across the province was developed. The plan recommended that CSBC undertake a case costing and funding review of PCI and heart surgery services with funded rates reflecting patient acuity, academic mandates, product standardization and provincial procurement, and performance improvement. Case volumes for PCI and heart surgery were projected and are provided below. Significance: The projection models provided an accurate estimate of the demand in PCI and heart surgery service over the last two years. CSBC continues to update the projection models on an annual basis to ensure that new trends are incorporated into the model. The models suggest that overall growth is relatively flat for PCI and isolated CABG with some growth in other heart surgery procedures. With the commencement of a new PCI program in Kelowna in November 2009 and the development of a new surgical program in Kelowna scheduled for late 2012, there is sufficient physical capacity in the system to manage the expected volumes. Collaborative planning will be required to manage the shift in volumes out of existing sites to Kelowna to ensure that the system continues to operate efficiently. 54

56 Figure 6.2 Actual and Projected Demand for Heart Surgery (Volume of Cases ) 5,000 4,000 Actual = HS 0% growth Average = Planned Volumes AMI Trend = Expected Volumes Volume 3,000 2,000 = CABG 0% growth Average = Planned Volumes AMI Trend = Expected Volumes 1, Year = OTHER HS 0% growth HS = Heart Surgery Source: Cardiac Services BC Registry, 2001 to 2008 [PCI counts]; and Canadian Institute for Health Information, Discharge Abstract Database, 1995 to 2008 [AMI trends]. Figure 6.3 Provincial Summary of PCI and Heart Surgery Volumes and Capacity 12,000 10,000 PCI Capacity Plan PCI Planned Volumes PCI Expected Volumes PCI Unused capacity HS Capacity Plan HS Planned Volumes HS Expected Volumes HS Unused capacity Volume 8,000 6,000 4,000 2, / / / / / / /16 Year Findings: Figure Over the last two years, the funded (actual) volumes have closely aligned with expected volumes and as such the expected volumes are utilized for budgeting purposes. A comparison of planned volumes to capacity in Figure 6.3 indicates an increase of 8.9% of PCI volumes and 15.1% of heart surgery volumes over the period. If Definition: The figures show the projected volumes (both planned and expected) as well as total capacity available in the system. Projected volumes are based upon two projection models: Zero % Growth Model volumes are projected based upon growth in the population and aging only; and, Underlying Disease Trend Model volumes are projected based upon the trend of AMI hospitalizations and the procedure to AMI ratio. This model considers population growth, aging and disease burden. Planned volumes are based on the average of the two projection models and are utilized for planning overall physical capacity required in the system. Expected volumes are based upon the underlying disease trend model and are more closely linked to actual volumes. Figure 6.3 provides an overall indication of the available physical capacity in the system given current capacity plus the development of a new cardiac centre at KGH. planned volumes are achieved in 2015/16, 36% additional PCI physical capacity is available and 24% additional heart surgery physical capacity is available. Hence, overall system capacity is sufficient into the near future. Cardiac Services BC - Annual Report 2010 Chapter 6 55

57 Congestive Heart Failure (CHF) CHF is a significant health problem with over 90,000 BC residents reported to have CHF in 2008/09 with prevalence expected to nearly double by the year CHF care is the most expensive chronic disease in BC (at a cost of more than $500 million per year), the most common cause of hospitalization in people over 65 years of age, and has an average one-year mortality rate of 33%. 3 An accurate and timely diagnosis is critical to initiate treatment that will relieve symptoms, improve quality of life, reduce hospitalizations and prolong survival. 4 Improved management of these patients can avoid as much as 50% of inpatient care. Family practitioners provide the majority of care while multidisciplinary clinics are an important resource for patients and healthcare providers who manage CHF. An overall framework for CHF care is currently being developed that places the patient and primary care providers at the centre with a stepwise support system for access to CHF care. Regional health authorities have developed plans in line with this structure that include: Standards for infrastructure, education curricula, best practice guidelines, treatment protocols/algorithms; Seamless consultation, referral, and transfer of patients (from emergency, hospital, and primary care) to the regional centre, to the provincial program, and back to primary care; Telemedicine and remote monitoring strategies to facilitate self-management; and, Guidelines for the role of end-of-life decision making and palliation services (hospital or community based). CSBC in ACTION CSBC in collaboration with the health authorities have developed a three-year implementation plan. The plan focuses on the development, implementation, and expansion of evidence-based protocols across the province with specific focus on the development of telemedicine strategies and strategies that target specialized populations. Chapter 6 Cardiac Services BC - Annual Report Primary Health Care Congestive Heart Failure (CCHF) Registry 2008/09. 2 Cardiology Preeminence Roundtable. Beyond Four Walls: Cost-Effective Management of Chronic Congestive Heart Failure. Washington, D.C.: Advisory Board Company, Johansen H, Strauss B, Arnold JM, Moe G, Liu P. On the rise: The current and projected future burden of congestive heart failure hospitalization in Canada. Can J Cardiol 2003;19(4): Johnstone DE, Abdulla A, Arnold JMO, Bernstein V, et al. Diagnosis and management of heart failure. Can J Cardiol 1994;10:

58 Electrophysiology Services Cardiac electrophysiology is the cardiology subspecialty focused on the heart s electrical system and dealing primarily with heart rhythm disorders (arrhythmia). EP services span the continuum of care from initial consult, to diagnostic and therapeutic services, to follow up. Information from diagnostic EP studies informs the appropriate therapy for the patient (e.g., medications, surgical or catheter ablation procedure, or implantation of a pacemaker/icd). Over the past decade, catheter ablation procedures have expanded dramatically and most recently emerged as a promising approach for treating atrial fibrillation (AF). AF is the most prevalent of all arrhythmias and is responsible for over 580 hospital admissions per 100,000 population annually in Canada. In 2008, there were two EP centres in BC (RJH and SPH) performing approximately 1,250 ablations annually. Significantly long waits were noted with the total wait time for a complex ablation (i.e., from initial consult to procedure) estimated at 2.5 years. As a result of the long waiting times a provincial review of EP services was conducted in May Significance: In total 30 recommendations were put forward requiring: Development of a provincial EP database and wait list management system including a standardized patient triaging system; Increased EP lab capacity within the system to achieve a target volume of 2,500 EP procedures annually by 2011/12; Funding for additional procedure volumes and rates; Establishment of AF Clinics at each centre to provide better support to patients and healthcare providers, reduce wait times, allow more efficient and effective use of EP physician time, standardize wait-list management, and enhance the ability to recruit EP physicians; and Development of a regional network of EP services in the lower mainland organized around a single united group of electrophysiologists and linked to BC Children s Hospital and RJH through formal and collaborative efforts in registry development, transparent wait-list management, long-term outcomes research, standards development, and systematic approaches to treating patients presenting with arrhythmias may be possible. All recommendations were acted upon with new or expanded services in place or under development. Cardiac Services BC - Annual Report 2010 Chapter 6 57

59 Table 6.1 Device Implants Pacemaker Projections (2008/ /16) Patient Residence 2007/08 Extrapolated 2008/ / / / / / / /16 IH FH 1,019 1,053 1,086 1,121 1,156 1,197 1,238 1,280 1,323 VCH VIHA ,014 NH BC 3,383 3,479 3,570 3,662 3,759 3,870 3,983 4,094 4,209 Table 6.2 Device Implants ICD Projections (2008/ /16) Patient Residence 2007/08 Extrapolated 2008/ / / / / / / /16 IH FH VCH VIHA NH BC ,001 1,104 1,223 Table 6.3 EP Planning Parameters (2008/ /12) 2007/08 Actual 2008/ / / /12 EP Studies Ablations ,100 Complex Ablations ,000 1,150 Total 1,405 1,805 1,975 2,200 2,500 Electrophysiologists Chapter 6 Cardiac Services BC - Annual Report 2010 Procedures per electrophysiologist Laboratories Procedures per laboratory Definition: Tables indicate expected volumes for pacemakers, ICDs, and electrophysiology procedures, age 20, excluding out-of-province volumes. The projection models were defined separately for each of the procedure groups and adjusted for population growth and aging. Given data limitations in the reporting of EP procedures, a target volume of 2,500 EP procedures was estimated annually for British Columbia. Ideally this target would be achieved over a period of time that would allow for wait list verification and careful monitoring of wait list activity as well as a better understanding of appropriate utilization rates. 58

60 Findings: Growth in ICD volumes represented the largest budget pressure to CSBC in 2010/11. New clinical trials supported the benefit of expanding indications for ICD implants for primary prevention and enhanced education of physicians about appropriate management of heart failure for traditional indications has resulted in increased need for appropriate ICD implants. As such, the projection models have underestimated the expected volume of ICDs. As a result of the report, CSBC invested over $6.5 million in EP services resulting in significant service volume increases for EP from: 1,250 ablations annually (2007/08) to 1,750 (forecasted 2010/11); 620 ICDs annually (2007/08) to 845 (forecasted 2010/11); and, 45 laser lead extractions (2007/08) to 60 (forecasted 2010/11). CSBC has also developed a separate EP module to effectively manage wait times, track volumes, and monitor trends; we have also implemented a triage coordinator at each site to actively manage and prioritize wait listed patients, especially high-risk patients. In 2010/2011, CSBC developed four AF clinics with an additional clinic at KGH planned for 2011/12. The purpose of the clinics is to enhance patient and healthcare provider access to specialized EP knowledge using nurse educators and nurse practitioners to facilitate telephone intake, case conferencing, group education classes, intake consultation visits, facilitated referral for specialized services, anticoagulation management, follow-up clinics, and case management. CSBC in ACTION A Metro Vancouver Heart Rhythm Committee was established to plan EP services in the lower mainland including the expansion of the number of laboratory days, and recruitment of additional electrophysiologists. CSBC has also reviewed current projections, utilization patterns, and funding rates to assess requirements into the future. Cardiac Services BC - Annual Report 2010 Chapter 6 59

61 Chapter 7 Cardiac Services BC - Annual Report

62 Chapter 7 Financial Resources

63 Financial Resources The 2010/11 operating budget for CSBC is approximately $165 million to support cardiovascular disease-related treatment services and secondary prevention. The budget is managed through service level agreements as well as monthly monitoring of wait lists, wait times, and procedure volumes at the Cardiac Services Steering Committee (CSSC). Funding is allocated to health authorities based upon a rate-based funding model that incorporates supply cost changes, introduction of new technologies, devices and/ or drugs, changes in patient acuity, price savings from provincial tenders, and results of continuous case costing analysis. Procedure volume projections are reviewed annually against actual utilization, regional utilization variation corrections, changing indications for procedure use, acceptance of new technologies, and corresponding wait times. This section provides an overview of the budgeted volumes and allocation of funds for the 2010/11 fiscal year. Throughout the fiscal year, CSBC, in collaboration with the health authorities, manages cost pressures across the cardiac programs. As such, the budget provides an estimate of future spending at a point in time. Financial Resources: Cardiac Procedures Volumes and Budget by Major Program Significance: CSBC s operating budget is used to set and articulate provincial priorities as well as to compare actual operating results against planned strategies. The 2010/11 budget represents one year of a fouryear budget; i.e., 2010/11 to 2013/14 and therefore, represents progress toward the agency s overall goals. Ongoing management of throughput, wait lists, and wait times allow CSBC to evaluate performance against planned strategies. Chapter 7 Cardiac Services BC - Annual Report

64 Table 7.1 Cardiac Procedure Volumes by Major Program, 2009/ /11 Program 2009/10 Actual Budget 2010/11 Preliminary Budget Heart Surgery 3,412 3,414 Thoracic Endovascular Aortic Repair (TEVAR) Transcatheter Aortic Valve Implant (TAVI) Acute Heart Failure PCI/Other Interventional Procedures 7,217 7,182 Diagnostic Catheterization 11,523 12,146 Electrophysiology (EP) Studies EP Ablations EP Complex Ablations Lead Extractions Implantable Cardioverter Defibrillators (ICD) Table 7.2 Cardiac Services BC Budget by Major Program, 2009/ /11 Program 2009/10 Budget ($ 000) 2010/11 Budget ($ 000) Percentage of Total Budget Heart Surgery $ 61,438 $ 61, % Thoracic Endovascular Aortic Repair (TEVAR) $ 518 $ % Transcatheter Aortic Valve Implant (TAVI) $ 2,711 $ 3, % Acute Heart Failure $ 4,536 $ 5, % Cath Lab* $ 25,618 $ 42, % Electrophysiology $ 28,742 $ 28, % Heart Failure & Secondary Prevention $ 4,785 $ 4, % BC Children s Hospital $ 687 $ % Registry $ 1,240 $ 1, % Other Programs $ 35,172 $ 17, % Total $ 165,447 $ 165, % *Diagnostic catheterizations funded directly in 2010/11 within the cath lab. Funds were re-allocated from Other Programs (Medical/Cardiothoracic Services). Definition: Tables show the projected volumes and corresponding budget for 2010/11 by major program. To determine the budget for 2010/11, a funded rate per case is derived for each procedure and multiplied by the projected volume. Volumes are projected for several years based upon numerous factors including historical utilization patterns, the age-sex profile of the population and population forecasts. Market share assumptions are then applied to allocate program volumes to cardiac sites. Findings: Procedure volumes increased from 2009/10 while the total budget remained unchanged. Cost savings from provincial procurement have resulted in price savings which were redirected to address access-to-care issues. Cardiac Services BC - Annual Report 2010 Chapter 7 63

65 Appendix CSBC Staff Contributors The following CSBC staff directly contributed to the creation of this report: David Babiuk, Provincial Executive Director Karin Humphries, Provincial Director, Data Services, Evaluation and Research Min Gao, Director, Biostatistics and Data Manager Christopher Thompson, Medical Director Alexandra Flatt, Director of Planning, Operations and Finance Janis McGladrey, Clinical Services Planning and Operations Lead Lillian Ding, Senior Biostatistician May Lee, Senior Biostatistician Sharon Relova, Epidemiologist Aihua Pu, Biostatistician Ruth Zhang, Biostatistician Caroll Co, Statistical Analyst Fei Wang, Statistical Analyst Julia Zhu, Data Analyst Tricia Louis, Data Integrity Specialist Crystal Beers, Business Development Senior Systems Analyst Appendix Cardiac Services BC - Annual Report

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