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Case: Health care to patients with Coronary Heart Disease

Case: Health care to patients with Coronary Heart Disease. Partly based on a Norwegian report (RHF South, 2002) Nov 5th -2007 Grete Botten. What is included in Health Needs Assessment?. Defining the medical problem (need) Know the prevalence/incidence of the problem

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Case: Health care to patients with Coronary Heart Disease

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  1. Case:Health care to patients with Coronary Heart Disease Partly based on a Norwegian report (RHF South, 2002) Nov 5th -2007 Grete Botten

  2. 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

  3. 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

  4. 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

  5. Prevalence/Incidence • Prevalence relevant for chronically disease • preventive treatment • angina • cardiac failure • Incidence relevant for • heart infarction (acute)

  6. England, CHD-risk, Framington risk http://hcna.radcliffe-oxford.com/chdframe.htm

  7. Tables from • http://hcna.radcliffe-oxford.com/chdframe.htm • Tab 3 , 5,6,7,8,12

  8. The population to be served • Demography (the total number) • Age structure (increasing with age) • Sex (more common among men) • Ethnicity? • Projection • The elderly population

  9. 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

  10. 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

  11. 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

  12. Focus • Treatment of coronary arteriosclerosis • Capacity according to need • Localization • Qualified personnell • Distance for patients

  13. Trends • Declining mortality • Declining incidence ? • Increased prevalence

  14. 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

  15. Examination/treatment • Coronary angiography with contrast • PCI- widening of the coronary vessel with a balloon • Stent (drug diluting ?)

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

  17. 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

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

  19. 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

  20. 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)

  21. 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

  22. 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

  23. 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

  24. 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)

  25. 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

  26. 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

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