AWA: Academic Writing at Auckland

Quality in health care for cardiovascular disease (CVD) is an international concern.  It is the leading cause of death worldwide accounting for 29% of all deaths (1).  This is similar for New Zealand where CVD is the leading cause of amenable mortality in New Zealand.  Concerns have been raised about the equity of access to treatment services for some ethnic groups in New Zealand and therefore the quality of New Zealand’s cardiac care pathway.  This literature review will look at what are some of the factors that influence quality in cardiac care.  It will then discuss how one of those factors influences the quality of cardiac care in New Zealand.

Background:

Cardiovascular disease is the leading cause of morbidity and mortality in New Zealand(2).  However there are significant disparities in mortality rates between Maori and Non-Maori(3) that cannot be explained by socio-economic status and deprivation alone(4).  There are also concerns about the types of treatments received by Maori men, who are less likely to receive surgical interventions (4) given their significantly higher mortality rates.  Ethnic inequality in cardiac care is not an issue that is faced by New Zealand alone.  African American men are also significantly less likely to receive the same quality of cardiac care than white males, even after accounting for socio-economic status and hospital quality (5). Concerns have been raised about the adequacy and implementation of diagnostic tools for risk management (2) and the role of the clinician (4) as gate keeper to services. 

Quality in health care refers to the extent to which health services meet desired health outcomes in a way that is consistent with evidenced best practice (6).  It is made up several indicators or domains: Effectiveness, Patient-centeredness, Timeliness, Efficiency, Equity, Appropriateness and Safety(7) (8, 9).  Each are interdependent so problems in one or more of these domains can impact negatively on the others (9).  The process health service providers used to achieve and maintain quality is Quality Improvement (QI).  It is an ongoing, dynamic process that is reliant on several factors in order to be successful(6).  The following section will discuss current literature on the influences on quality and QI.  To provide focus, the literature reviewed will look at the relationship between clinical/health services staff and some of the quality indicators.

Why focus on the Clinician: Access, Appropriateness and Equity

Nash & Goldfarb (6) view the role of the clinician and other health services staff as vital to quality and QI of healthcare services.  Not only are they responsible for conducting the treatment so their level of expertise is paramount, but the way they deliver the service and to whom is also key. Access, Appropriateness and Equity means ensuring that those who require care can obtain the right care that is delivered in a way that does not unfairly exclude others(9). Part of providing the right care requires an ongoing commitment to ensuring that the treatment is best practice and/or evidence based (6). 

The rate at which new treatments are developed makes it difficult for the clinician to stay abreast, let alone incorporate it into their clinical practice. “20 % of medicine has a scientific basis, but it takes a decade to integrate it into clinical practice”(6). Even where clinicians endeavour to stay current with latest developments, they were found to be suffering under “ extreme data overload” which was thought to negatively affect their ability to work (10).    

A QI method that can help with data overload is the use of computer based diagnostic tools (CBDT), which standardises diagnosis and treatment (11). Yet if these tools are not used appropriately there will still be differences in the treatment received by patients which will impact on equity. A review of QI performance factors in Utah identified that some hospitals with CBDT, it was either underutilised or inconsistently used and was highlighted as an area to be addressed (10). In New Zealand the use of a CBDT called CPAC is used to assign clinical priority for coronary bypass graft surgery. However evidence suggests is not being used in the way it was intended by the Ministry of Health.  Whilst it is being used appropriately to restrict access to coronary bypass graft surgery, once people are on the list, clinicians do not use it to assign priority, rather they are assigning urgency themselves (12). More relevantly for the equity of Maori access to CVD care, even though Maori males had higher scores, clinicians did not prioritise them as being more urgent (12). The qualitative methodology of this study was appropriate for determining how often, and on whom CPAC is used, however it was dependant on clinical staff using CPAC for each surgery performed and entering data accurately.  A qualitative study into why clinicians do not use CPAC to assign urgency of surgery should be undertaken, in order to improve utilisation of a useful tool.  Potentially the study may not have captured every patient who received treatment.  The authors also point out that there are often issues with ethnicity data not being recorded appropriately in the hospital, so Maori patients may have been undercounted.    

Patient-centeredness and the clinician:

Patient-centric care is vital for quality health care services (13).  It involves putting the patients need’s first and taking into account their needs and preferences (6).  However the way the clinician interacts with the patient can impact on the quality of care that the patient receives. Crengle et al. (14) found that some General Practitioners in New Zealand had difficulty building relationships with Maori patients, and on average had shorter consultation times with them. Maori also were under prescribed and referred for fewer tests than non Maori.  In situations where the relationship between clinician and patient is strained, there is potential for “clinician uncertainty” where clear communication between the parties difficult. This can result in under-diagnosis, as the clinician is less able to understand or interpret what their patient is telling them (4). The figures presented in Crengle et al.(14) were ethnic sample averages. Without in-depth comparison of patient status at the time of consultation it is unclear if the disparity is due to Non Maori patients presenting with worse symptoms.  However given the relatively poorer health status of Maori compared to non Maori (3), it would be logical to expect this not to be the case.

Clearly the role of the clinician cannot be underestimated in terms of their influence on the quality of health care a patient receives. As the gatekeeper and provider of services their clinical expertise and interaction with the patient can be a barrier to access and quality of care. To improve access to CVD treatment for Maori the role of the clinician should be investigated. Special attention should be paid to enabling non Maori clinicians to build good working relationships with their Maori patients.       

Access for equity: The role of diagnostic tools

Equity of access to cardiac care for Maori was highlighted as in issue for Maori in 2001 after it was found that even after accounting for demographics, socio-economic status and severity of condition at presentation, Maori were still less likely to receive surgical intervention than non Maori (15). Often the focus is on lifestyle factors like healthy eating, reducing smoking or increasing awareness of heart health issues (4) which is useful for minimising harms. However for equity in health outcomes and access to services, steps should be taken to increase the number of Maori treated. 

Society cannot be discounted as both a determinant of heart health, and an influence on a patient’s ability to navigate the cardiac care pathway (4). Curtis et al. (4) also stresses the role of the clinician as gatekeeper and advocate for their patient as vital for improving access to cardiac care. This is particularly so when clinicians are under pressure from time constraints, have difficulty connecting with Maori patients or has preconceptions (stereotypes) about Maori, whether recognised or unrecognised. These factors can have negative impacts on Maori patients accessing appropriate care. Based on this their recommendation is for best practice guidelines to be implemented in New Zealand(4). However as noted earlier, there are already existing issues with the underutilisation of diagnostic tools. 

In Utah where they also had less use of CBDT’s a QI initiative looked at the human factors involved in the gaps in care. This involved putting the onus on nursing and pharmacy staff to prompt doctors to use CBDT’s when they thought a patient might benefit from a particular strategy but had yet to receive it. This system proved successful in improving the hospitals performance in meeting their QI indicator targets (10). This approach could be useful for Maori, by engaging nursing staff to intervene if they thought that a patient’s care could be maximised through use of diagnostic tools. However the concern is that this kind of approach would require a level of trust between clinical staff, the organisation providing ongoing education for nursing staff so they can recognise the signs, and could increase workloads.

In New Zealand the use of CBDT to support risk management decisions is used to prepare post discharge care plans for patients. One of the limitations to implementation was encouraging busy nursing staff to use the system. Yet it was found to provide equitable access to post discharge care plans when it was used. Although they were unable to ascertain how many patients did not receive an assessment due to staff unavailability or early discharge (2). The findings do suggest that with consistent utilisation of CBDT’s there can be positive impacts for equity of access. The author suggests that the system may actually be transferable to other countries to improve quality there but it was dependant on nursing staff being interested in QI. However of the 1813 patients admitted to the Coronary Care Unit, 46.3 % did not receive an assessment. This may have been because the system was not appropriate for use in those patients. But it is still a significant number of people that may benefit from should the system should it be adjusted to suit them. This could be an area worth investigating, in particular what were the characteristics of the patients not assessed, and how the CBDT could be improved to suit their needs.

Conclusions:  

Maori inequalities in CVD treatment are a concern for the quality of the healthcare system in New Zealand. Particularly concerning is the role of the clinician, the way they interact with their Maori patients, and how that has the potential to influence a patients progression down the clinical pathway. The use of computer based diagnostic tools is common place in quality improvement initiatives, as they encourage treatment consistency between patients. However there are concerns about their sporadic use, and their capacity to accurately capture every patient that presents to the service. For Maori health outcomes, implementing strategies to ensure consistent use of CBDT’s could be beneficial for improving their access to treatments.

References

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