REGIONAL DIFFERENCES IN HF SERVICE DEMAND AND DELIVERY

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1 REGIONAL DIFFERENCES IN HF SERVICE DEMAND AND DELIVERY Raewyn Fisher, Waikato Hospital On behalf of Midland Cardiac Network (With thanks to Population Health data analysts) Cardiac Network Plans (Midland) Patients with heart failure are optimally managed across the continuum, reducing the occurrence of acute admissions and disability. This care is to be delivered closer to home where practicable with a focus on: 1.Efficacy of management of heart failure 2.Timely access to investigations(as per expected standards) 3. Inequality across ethnicity or residential location must be addressed 1

2 Cardiac Network Plans (South Is) GOAL. Implement locally, regionally and nationally agreed protocols, guidance, processes and systems to ensure optimal management of patients with heart failure. ACTION. Determine current clinical situation of the management of patients with heart failure across South Island DHBs. ACTION. Identify resources required and barriers to the management of patients with heart failure in the South Island. ACTION. Utilise primary pathways for the management of patients with heart failure in all South Island DHBs. Suspected Heart Failure Patients with non-limiting symptoms and normal cardiac biomarkers (when not on treatment), normal ECG and normal chest X-ray Symptomatic patients with elevated cardiac biomarkers, abnormal Chest X-ray or ECG Timely assessment including early echocardiography A clinical governance structure that includes a multi-disciplinary heart failure service Optimisation of Heart Failure medication phase: at the end of (approx. 3 months) the titration phase, post revascularisation and or post MI when initial EF suspected to be <35% in order to determine future management including device implantation. Follow up: if change in clinical status or cardiac exam Baseline and serial re-evaluation in a patient undergoing therapy with cardiotoxic agents 2

3 The DEMAND : Burden of Disease HF admissions in Midland Admission numbers and rates (per population) Trends Demographics age, sex, ethnicity Geography area, rurality, deprivation Re-admissions Admission numbers vs patient numbers 3

4 HF admissions by DHB 42% Midland DHB hospitals (excl. WDHB) (BOP and Lakes DHBs into smaller units) 4

5 Regional variation DHB differences 42% of total HF admissions are in Waikato(rate 29 per 10,000) Highest rate in eastern BOP (rate 39 per 10,000) Within Waikato DHB High rate in Ruapehu, (rate 55 per 10,000) Male rate 62, female pts/year 5

6 Demographic variation Gender 53% patients male Male rates overall higher (1.3) Higher in eastern BOP (1.7) Age Number and rate increase with age 47% patients > 80 years (rate 164 per 10,000) Ethnic variation 67 % patients European Maori/Pacific rate = 2 x European No sig difference btw DHBs Average annual number and rate per 10,000 population (with 95% Total Māori/Pacific Non-Māori/Pacific M vs F DHB No. Rate 95% CI No. Rate 95% CI No. Rate 95% CI Rate ratio Waikato ( ) ( ) ( ) 2.0 Eastern Bay of Plenty ( ) ( ) ( ) 0.9 Western Bay of Plenty ( ) ( ) ( ) 2.8 Taranaki ( ) ( ) ( ) 1.3 Lakes (Rotorua) ( ) ( ) ( ) 2.2 Lakes (Taupo) ( ) ( ) ( ) 2.0 Tairawhiti ( ) ( ) ( ) 2.4 Midland DHBs ( ) ( ) ( ) 2.0 6

7 Ethnicity + age Age yrs : Numbers similar but M/P rate 5x Age 75+ : >5 x more Euro but M/P rate 3x Geographic variation 7

8 57% urban Urban rate > rural > semi-rural Deprivation Number and rate of HF admissions increase with Dep index 40% HF patients admitted live in

9 Readmissions 7% 18% 25% No sig. difference btw DHBs Re-Admissions Higher re-admission rate with : older, males (1.3), higher deprivation, Eastern BOP and Tairawhiti slighter higher Lower re-admission rate with : semi-rural (vs urban=rural) Early vs later re-admission rates : no diff btw DHB, sex, ethnicity, deprivation LOS doesn t correlate with re-admission NO ethnic difference in re-admission rates! Deprivation predicts re-admission 9

10 What does all this mean?? How should we focus HF services in NZ?? The DELIVERY : Service Stocktake Midland Region HF service stocktake questionnaire to HF nurse leaders in each of 5 DHBs Questions mostly Y/N/maybe Responses 4/5 have HF service Clinical leadership varies Case load uncertain in most ( at WDHB) 10

11 Responses 4/5 have ref criteria Discharge criteria variable OMT Education/self care Re-admission EF GP referrals 2/5 Audit 1/5 Registry participation 3/5 Home visits 4/5 GP liaison 5/5 Links with Maori providers 5/5 Midland Region stocktake 2016 FTE varies widely FTE 6 at WDHB, others HF RN FTE at 5 Midland DHBs Waikato BOP Taranaki Lakes Tairawhiti 11

12 HF Admissions per 10,000 popln HF Admissions per 10,000 popln HF RN FTE /07/ HF Admissions at 5 Midland DHBs 7.0 HF RN FTE at 5 Midland DHBs Waikato BOP Taranaki Lakes Tairawhiti 0.0 Waikato BOP Taranaki Lakes Tairawhiti 600 Ratio of HF Admissions to HF RN FTE at 5 Midland DHBs HF Admissions HF Nurse FTE Waikato BOP Taranaki Lakes Tairawhiti Ratio Admissions per 1 HF RN FTE Waikato BOP Taranaki Lakes Tairawhiti 12

13 Target our Resources?? Reduce HF risk factors Prevent HF development Improve diagnosis Early Rx Reduce first admission Reduce re-admission Reduce morbidity and mortality Target areas with most burden?? Target areas with most burden?? Target areas (most benefit?) Elderly? Age 55-74? 2/3 total HF admissions 1/2 of M/P 1/4 of non-m/p M/P > non-m/p Numbers similar but rates very different Half urban Deprived areas? Population approach Increase awareness RF identification and management Ensuring HF diagnosis and management appropriate in primary care 13

14 For discussion HF in Primary Care Midland Region 14

15 Midland Region PHO Data : 2016 Several PHOs Challenging to obtain?accuracy of diagnosis and coding > 100,000 patients Hauraki PHO Age > 40 years HF pts / 55,464 total pts 3% prevalence Midland PHO 15

16 HF prevalence in primary care by age and gender - Males have slightly higher rates than women (not statistically significant) HF prevalence by ethnicity - 35% (of HF patients) are M/P - Prevalence : 5% for Māori/Pacific 3% for non-māori/pacific - Māori/Pacific rate is 60% higher than for non-māori/pacific - (Rate ratio =1.6, statistically significant) - The largest equity gap is in the ages years. - In the age group years, the Māori/Pacific rate (3%) is almost 6 times higher than the non-māori/pacific rate 16

17 HF prevalence by ethnicity and age Primary Care Secondary Care - The Māori/Pacific rate is significantly higher than for non-māori/pacific across all age groups Deprivation Primary Care Secondary Care 17

18 HF prevalence in primary care by age and deprivation Heart failure prevalence among patients in Hauraki PHO (with 95% confidence interval) Equity gap Total NZ Dep 1-2 NZ Dep vs 9-10 Age group No. Rate 95% CI No. Rate 95% CI No. Rate 95% CI Rate ratio <40 yrs 24 0% (0-0) 1 0% (0-0) 14 0% (0-0.1) yrs 161 1% ( ) 8 0% (0-0.4) 97 1% (1-1.5) yrs 744 3% ( ) 38 1% ( ) 364 5% ( ) yrs and over % ( ) 80 10% ( ) % ( ) 1.5 Total % ( ) 127 1% ( ) 824 2% ( ) 2.3 Total >40 yrs % (3-3.3) 126 2% ( ) 810 5% (4.3-5) Among year olds, the prevalence in the most deprived areas is 5% (NZ Dep 9-10). The equivalent rate for the same age group in the least deprived area is 1% (NZ Dep 1-2). - Among 75 years and over, the prevalence in the most deprived areas is 14% (NZ Dep 9-10). The equivalent rate for the same age group in the least deprived area is 10% (NZ Dep 1-2). Midland Health Network (Pinnacle) 4,522 TOTAL HF PATIENTS DHB TOTAL HF >40YR M/PI % M/PI LAKES % TAIRAWHITI % TARANAKI % WAIKATO % TOTAL % 18