Case:Health care to patients with

Coronary Heart Disease

Partly based on a Norwegian report (RHF South, 2002)

Nov 5th -2007Grete Botten

What is included in Health Needs Assessment?

• Defining the medical problem (need)

• Know the prevalence/incidence of the problem• Know the number that should be served

• Know the medical guidelines for examination and treatment - “state of the art”- evidence

• Know the patents’ situation and preferences

• Know the services available and their cost

• Argue for establishing services according to the need

Patients with coronary hearth disease • Illustrate several aspects of need assessment

• Changing epidemiology • Different patients groups

– screening for risk factors – preventive treatment – acute care – long-time care

• Cut-off problems• New (expensive) technology is being developed

– invasive – drugs

Defining the patients

• Population (screening)• Identified risk persons (high cholesterol, high blood

pressure, smokers…)• Sudden cardiac collapse• Patients with symptoms, chronically and acute - with

different EKG-pictures– Stabile angina– Unstable angina– Acute infarct with (most serious) or without ST-elevation

• Heart Failure (due to arteriosclerosis) --- both specific medical treatment and palliation

Prevalence/Incidence

• Prevalence relevant for chronically disease– preventive treatment – angina– cardiac failure

• Incidence relevant for– heart infarction (acute)

England

CHD absolute risk (%) Men (%) Women (%)

Blood Pressure >140/85 mmHg

>30 3.0 -

25-29 4.3 0.2

20-24 6.5 1.6

15-19 7.8 4.5

Total cholesterol >5.0 mmol/l

>30 3.2 -

25-29 4.7 0.2

20-24 7.8 1.7

15-19 10.9 5.1

Blood pressure >140/85 mmHg and Total cholesterol >5.0 mmol/l

>30 3.0 -

25-29 4.2 0.2

20-24 6.1 1.6

15-19 7.0 4.5

http://hcna.radcliffe-oxford.com/chdframe.htm

England, CHD-risk, Framington risk

Tables from

• http://hcna.radcliffe-oxford.com/chdframe.htm

• Tab 3 , 5,6,7,8,12

The population to be served

• Demography (the total number)– Age structure (increasing with age)– Sex (more common among men)– Ethnicity?

• Projection– The elderly population

Intervention possibilities• Screening of the healthy population (program/ wild)• Treatment of patients with identified risk factor

– High blood cholesterol/hypertension (by GP/specialists) • evidence for treatment • cut-off values for treatment • price for treatment, priority….

• Treatment of patients with symptoms (angina)– Drug therapy (aspirin, statins, ACE-inhibitor)– Revascularization

• Services for treating acute infarction– Ambulance with skilled personnel and equipment (emergency call)

• Distance to acute facilities, resuscitation – In patient

• Number of beds/intensive care units– Drugs (several, acute and prolonged therapy)– Revascularization (PCI, Bypass surgery)

• Rehabilitation• Heart failure

Mapping information together

• Make a plan to develop good services to all patient groups at all service level according to – Their need (medical and social)– Effective services (evidence based)

• Cost – benefit analyses

• Priority of resources

Health South Report in about services to Patients with

coronary health diseases. 2002

• Evaluate the capacity and quality of existing services to those patients in RHF South

• Develop future good and equal services for all the patients in RHF South

Focus

• Treatment of coronary arteriosclerosis

• Capacity according to need

• Localization – Qualified personnell– Distance for patients

Trends

• Declining mortality

• Declining incidence ?

• Increased prevalence

Defining the Patient group

• Care of patients with manifest coronary disease – Prevention not included

• Several symptoms, chronicle and acute - with different EKG-pictures– Stabile angina– Unstable angina– Acute infarct without ST-elevation– Acute infarct with ST-elevation

• Several new methods for examination and intervention/treatment

Examination/treatment

• Coronary angiography with contrast

• PCI- widening of the coronary vessel with a balloon

• Stent (drug diluting ?)

Kilde: SSB

239 793

216 456

165 710

102 945

157 851

0

50 000

100 000

150 000

200 000

250 000

300 000

Buskerud Vestfold Telemark Aust-Agder Vest-Agder

Fylkeskommuner

Antall innbyggere

Grafen gir en oversikt over antall innbyggere i fylkene i Helse Sør.

OSLO

Tonstad

Flekkefjord

Farsund

Mandal

Kristiansand

GrimstadArendal

EvjeTvedestrand

Risør

Valle

Kragerø

HaukeligrendRjukan

Seljord

Geilo

Gol

Hønefoss

Sande-fjord

Skien TønsbergHorten

DrammenKongsberg

Porsgrunn Larvik

Notodden

Rondeslottet2178

1881

Buskerud

Telemark

Aust-Agder

Vest-Agder

Vest-fold

X

Sykehus med akuttfunksjonSykehus uten akuttfunksjon

Rikshospitalet / Radiumhospitalet

X

X

X

X

X

500 100 150 km

239 793

165 710

157 851

102 945

216 456

Kilde: SSB

0

2000

4000

6000

8000

10000

12000

14000

I alt

4 år

9 år

14 år

19 år

24 år

29 år

34 år

39 år

44 år

49 år

54 år

59 år

64 år

69 år

74 år

79 år

84 år

89 år

94 år

99 år

104 år

109 år

114 år

Alder

Totalt Menn Kvinner

Antall innbyggere

Kilde: SSB

0

10 000

20 000

30 000

40 000

50 000

60 000

70 000

80 000

Alder

2002 55726 59899 60177 54201 53644 58065 64115 64254 62228 61929 60473 54912 39156 33467 32001 30851 23631 12624 4597 942

2005 56814 59987 62174 58015 53376 53814 63384 67271 63867 62991 60344 61272 45315 35787 30999 28098 24516 13374 5088 1084

2010 58941 60883 62519 63655 57560 52591 56702 66772 69522 64844 63105 59741 59925 43622 32874 26497 21359 15259 5812 1333

2015 61482 63020 63450 63989 62962 56621 55593 59883 68917 70528 65065 62593 58592 57691 40320 28457 20488 13587 6786 1551

2020 64291 65606 65634 64958 63245 61775 59669 58845 61956 69854 70768 64684 61575 56646 53506 35243 22429 13330 6202 1844

0 - 4 år

5 - 9 år

10 - 14 år

15 - 19 år

20 - 24 år

25 - 29 år

30 - 34 år

35 - 39 år

40 - 44 år

45 - 49 år

50 - 54 år

55 - 59 år

60 - 64 år

65 - 69 år

70 - 74 år

75 - 79 år

80 - 84 år

85 - 89 år

90 - 94 år 95+

Antall innbyggere

Kilde: SSB

-15 000

-10 000

-5 000

0

5 000

10 000

15 000

20 000

25 000

30 000

Alder

2002 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2005 1088 88 1997 3814 -268 -4251 -731 3017 1639 1062 -129 6360 6159 2320 -1002 -2753 885 750

2010 3215 984 2342 9454 3916 -5474 -7413 2518 7294 2915 2632 4829 20769 10155 873 -4354 -2272 2635 1288 391

2015 5756 3121 3273 9788 9318 -1444 -8522 -4371 6689 8599 4592 7681 19436 24224 8319 -2394 -3143 963 2262 609

2020 8565 5707 5457 10757 9601 3710 -4446 -5409 -272 7925 10295 9772 22419 23179 21505 4392 -1202 706 1678 902

0 - 4 år 5 - 9 år10 - 14

år15 - 19

år20 - 24

år25 - 29

år30 - 34

år35 - 39

år40 - 44

år45 - 49

år50 - 54

år55 - 59

år60 - 64

år65 - 69

år70 - 74

år75 - 79

år80 - 84

år85 - 89

år90 - 94

år95+

Antall innbyggere

1996 1997 1998 1999 2000 2001 20020

200

400

600

800

1000

Prognose basert på januar-november

Pasienter innlagt med ustabil angina og non-ST elevasjons hjerteinfarkt

213321

419 464

634711

966

1999 2000 2001 20020

50

100

150

200

250

300

Pasienter behandlet med PCI forST elevasjons hjerteinfarkt

Prognose basert på januar-november

275

170

80

25

In Norway

• 2000: 15 122 coronary angiography– 336/100 000– 5% annual increase

• 2001: 7 381 PCI, 162/100 000

• 2001: 3 299 coronary bypass, 73/100 000

• Each doctor need a certain volum

32303500

4026 4200

51705511

7381

2882 29453222 3207 3104 3021

3299

0

1000

2000

3000

4000

5000

6000

7000

8000

1995 1996 1997 1998 1999 2000 2001

PCI ACB

Antall pasienter

Figur 11: Antall PCI og ACB i Norge fra 1995 – 2001. (Kilde: Norsk Thoraxkirurgisk forening.)

-

100 000

200 000

300 000

400 000

500 000

600 000

700 000

800 000

900 000

- 20 40 60 80 100 120 140 160 180

Reisetid i minutter

Innbyggere

VAS ASA TSS SIV SB

Figuren viser hvor mange innbyggere i Helse Sør som når et behandlingstilbud når en kombinerer to sykehus, dvs Rikshospitalet med et annet sykehus i Helse Sør. (Rikshospitalet er her en konstant faktor.) Ambulansene holder en fart som ligger 20 % over fartsgrensen

Present fascilities

• Local hospitals– Stable angina, too long waiting time (3-6 months,

50%<3), should be max 6-8 weeks

• Invasive centers– Elective coronary examination/PCI; waiting time 5-6

weeks, Feiring (private non-profit) 8-10– Unstable angina: should be 2-3 days for PCI– Capacity: Ok

• Heart operation (centers) (bypass)– Capacity: Ok, some to Denmark (Agder)

Available/distance

• Too long waiting time for stable angina locally

• PCI mostly acceptable waiting time

• Surgery, too long waiting time for elective patients, mostly ok for unstable angina

• Quality good

•

Acute services

• Incidence: 100/100 000 inhab. annually– Does not specify age – PCI or trombolysis

• PCI acute– At RH 25 to 270 from 1999-2002

• Time critical– Ambulance personnel (prehospital trombolysis)– RH: within one hour– Decentralized service (Arendal)- transport

Summary in report

• Prevention should be improved as collaboration between GP and specialist

• Capacity for elective invasive examination ok, but need improved organization

• A decentralized center should be established for treating acute infarction

• Prehospital trombolysis should be improved

• Larger postoperative capacity at RH

Lessons• Use earlier number of patients to describe need

– Difficult as availability to new technology increases the use

– Must have age-specific data to make scenarios

• Important to know – efficiency of treatment– time for reaching the treatment facility– availability of health personnel– see the total chain of treatment (GP, prehospital

emergency, specialist emergency and elective care)

Questions to discuss

• Who should define need– Need and demand

• The validity of need assessment

• Value and use of need assessment in developing the supply of services

• Need and prioritizing

• Technology and future need

How should need be defined?

• Medical definition– Linked to diagnosis (CHD)– Linked to medical challenges– Linked to guidelines for examination and treatment/care– Often expressed as the optimal, no resource limitations

• Lay people/patient defined– Linked to suffering (Pallation)– Linked to human/patient’s right

• Management defined– Linked to resources and “the contract”

• Politically defined– Linked to patients’ rights– Linked to resources– Linked to priority