Microsoft word - cardiovascularresourceallocationmay04.doc

Peter Satterthwaite
Senior Portfolio Manager
Capital & Coast District Health Board
Private Bag 7902
WELLINGTON
To:
C&C DHB BOARD
Through: Margot
Date: May
Subject:
Resource Allocation & Cardiovascular Resource Allocation
EXECUTIVE SUMMARY
In October 2002 the Board asked CPHAC (its Community and Public Health
Advisory Committee) to begin a programme of work to provide greater clarity
on how C&C DHB should determine resource allocation for the prevention and
treatment of cardiovascular disease (CVD).
CPHAC established a work programme, which included:

• A CPHAC paper in May 2003 which gave information on the spread of
CVD, options for intervention and some indications on how to compare
the relative benefits of those different intervention options,
• A community forum in June 2003 to discuss the above findings and
options,
• The current report (from a working group of CPHAC called the Resource
Allocation Working Group) which is being presented to the Board at this
meeting, following discussion at the April CPHAC meeting.

This report looks at the way in which resources have historically been
allocated for CVD, the different options for resource allocation and their
relative merits. Finally it makes recommendations on how resources should in
future be allocated for the prevention and treatment of CVD.
In making its recommendations the report seeks to find a model of resource
allocation which not only addresses current needs, but also reduces the
prevalence of CVD in 10 years time.
The working group’s assessment is that the current approach does not meet
both these aims, and that future resource allocation needs to invest more in
measures which will modify the risk factors (factors which cause CVD) for both
individuals and populations. This report recommends:
• Taking a strong advocacy role – and encouraging nationwide
programmes that target risk factors such as high fat or salt content in
foods, tobacco smoking and lack of exercise.
• Implementing the New Zealand Guidelines Group’s guidelines for
modifying CVD risk factors.
• Favouring innovative models of care which are community based for
funding – to reduce pressure/demand on hospitals, while building
capacity (and prevention) in the community.
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• That the reallocation of resources should be phased in over several
years (to avoid unnecessarily destabilising existing infrastructure for
combating CVD).
ORIGIN OF REQUEST
The CPHAC resource allocation working group (RAWG) has completed a work
programme proposed in the August 2003 CAPHAC meeting. A brief
chronology of the original request and subsequent workstream follows:

1. The Board asked CPHAC (October 2002 item 947) to examine rules and
principles of prioritisation that could reasonably be applied to
cardiovascular disease. Background papers appeared in the September
and October CPHAC agendas.
2. CPHAC report to Board (February 2003)
3. CPHAC information paper, May 2003, Decreasing the community Burden
of Cardiovascular Disease
4. CPHAC forum June 2003; Resource Allocation: A Case Study –
Cardiovascular Disease
5. RAWG Work Programme: October to November 2003
6. CPHAC informal meeting February 18th, 2004 to review RAWG Proposal
for Discussion
Other than to assert that Diabetes and Cardio Vascular Disease (CVD) are
priorities for the district, the Board has not developed a written strategy for
CVD. A specific Board decision has been made with respect to investing in a
new Cardiac Electrophysiology Service.
It is intended that this workstream will result in the development of a strategic
approach to service investment, disinvestment, and development to reduce the
burden of cardiovascular disease in the C&C District.

APPROACH: CARDIOVASCULAR DISEASE
The May 2003 CPHAC paper provided the epidemiological background to CVD,
options for intervention (DHB Toolkit) and identified some of the
methodological issues involved in comparing relative benefit of interventions.
The June 2003 CPHAC Community Forum shared some of the resource
allocation options available to the Board and discussed and obtained feedback
on some of the complex considerations that need to be taken into account by
the Board in making CVD resource allocation decisions.
The RAWG approach taken to addressing cardiovascular disease resource
allocation was to adopt the general approach developed and presented in
appendix one; and apply it to CVD. Some of the specific tasks undertaken by
the RAWG included:

1. Identify and acknowledge DHB resource allocation flexibility
2. Determine the scope of interventions
3. Examine the evidence on the cost effectiveness of interventions
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4. Determine and acknowledge political risks and vested interests in
changing the current mix of service funding
5. Acknowledge the historical drivers of current pattern of resource
allocation, including role of medical endeavour
6. Specifically address mechanisms for addressing inequalities
7. Weigh up balance of evidence to determine appropriateness of current
service funding for addressing future CVD incidence
8. Make recommendations on priorities for CVD funding

The results of the RAWG work programme are summarized in the “Proposal for
Discussion” in appendix one

VALUES AND CRITERIA
The values that guide resource allocation decisions can be summarised as:
1. Parity
2. Integration
3. Independence
4. Sustainability
5. Quality

These values were echoed in the themes that were discussed and presented at
the June 2003 CPHAC Community Forum. The process of resource allocation
for C&C DHB should therefore acknowledge and explicitly incorporate these
values into decision making processes.

The scope of interventions for CVD are summarised in the Proposal for
Discussion, and were covered in detail in the May 2003 CPHAC paper.

ASSESSMENT
The following trends were noted:
• The difficulty in evaluating very different service approaches such as health
promotion and surgical intervention, which have dramatically different
timeframes of effectiveness and collateral benefits;
• The successful development over the twentieth century of highly developed
medical specialisation and a concentration of resources in high technology
interventions in a hospital setting;
• The dramatic disparity in access to services and CVD health outcomes for
Maori and Pacific peoples; and
• The current trend for increasing prevalence of major population risk
factors, such as obesity.

The key question for DHBs could be summarised as:
“Is the current allocation of resources optimal to both address the needs of
today, and impact on the prevalence of disease in 10 years time?”
Given the historical pattern of resource allocation it is considered a safe
conclusion that the investment in population and individual risk factor
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modification is suboptimal. In summary, it is therefore considered that the
answer to the above question is almost certainly: “No”, and that investment in
population and individual risk factor modification should be preferred in future
resource allocation decisions.
initiatives.

RECOMMENDATIONS
It is recommended that the Board:

1. Ask CPHAC to examine rules and principles of prioritisation that could be
applied to cardiovascular disease.

2. Note that CPHAC was to assume constant real levels of funding for
cardiovascular services.

3. Note that some services are aspects of integrated public and primary health
systems and are not just specific to cardiovascular disease.

4. Agree that the following policy framework be used as a basis for
completing a proposal for resource allocation:
a) Constant real levels of funding for cardiovascular services will continue
b) The balance of funding between community and hospital services be
adjusted towards prevention and primary services.
c) The relative expenditure between community and hospital services
being adjusted gradually without sudden or large annual re-allocations.
d) Agree to the extent that resources are limited, movement towards parity
is best achieved on a population basis by prioritising (in order) Maori,
Pacific people, and peoples living in areas classified as NZ Dep Deciles
9-10.
e) Confirm developments of by Maori for Maori and by Pacific for Pacific
services as a significant strategy to achieve parity, respond to user
preferences and support Whanau and community development.
f) Promote equitable level of access to services recognising there are
significant disparities in access to services and health outcomes,
particularly for Maori and Pacific people.
g) The DAP and SOI priorities for contracting and resource allocation
include from 2004/2005:
• Implementing the NZGG National Guidelines for cardiovascular risk
modification.
• Reducing the use and funding of hospital services by developing
models of care that include frequent attend or case coordination,
hospital in the home services, and promoting the role of expert
patient.
• Assessing the introduction of new health technologies in terms of
contribution to the balance between community and hospital based
services.
h) Advocate strongly in encouraging national population based
approaches to prevention of cardiovascular disease such as reducing
salt levels in processed foods, promoting healthy fat use by commercial
food retailers and population approaches to smoking cessation and
exercise promotion.
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i) Priorities for 2004/2005 service development, contracting and resource
allocation will include advocacy and facilitation services to reduce
barriers to access.

5. Agree that the above policy framework be used as a basis for completing a
proposal for resource allocation inviting professional critique and for
drafting the statement of intent for 2004/2005.

6. Ask that the Chief Executive report peer responses to the proposal of the
July meetings of CPHAC and CPHAC to report to the Board in August.

7. Note that the recommendations in the policy and framework may imply a
higher financially sustainable threshold for surgery.

8. Ask the Chief Executive to estimate the impact of this approach on access
to surgery and consider the possibility of comparable demand management
for medical services.

9. Ask the Chief Executive to:
a) Identify equitable levels of access for Maori and Pacific peoples in order
to achieve the national guidelines.
b) Propose performance objectives for access and treatment based on
those levels.
c) Propose incentives for providers that implement current guidelines and
achieve performance objectives.
d) Consult with Maori and Pacific peoples on preferred options for
advocacy and facilitation services to reduce barriers to access.

10. Note that the Committee agreed that action points for implementation
should be prioritised that action points

11. Agree that a prioritisation process be put in place to implement this policy
framework in accordance with the District Strategic Plan and available
resources

12. Agree to review performance in 2006/2007 and consider the need to
specifically fund services for populations with high needs.

13. Refer the proposal to the strategic communications committee for advice
on communication and consultation with the relevant communities of
interest.

Approved for release:
WIN BENNETT
MARGOT MAINS
Director Planning & Funding
Chief Executive Officer
Capital & Coast District Health Board
Capital & Coast District Health Board
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APPENDIX ONE
PROPOSAL FOR DISCUSSION
Prepared by Peter Satterthwaite on behalf of the Resource Allocation Working
Group, a working group of the Community & Public Health Advisory Group of
Capital & Coast DHB
INTRODUCTION
The CPHAC resource allocation working group (RAWG) has completed a work
programme proposed in the August 2003 CAPHAC meeting. The first part of
this paper discusses specific aspects of a resource allocation process and
proposes a general approach that could be taken by a DHB to developing a
robust resource allocation process. The second part of the paper addresses
the specific Board request by applying the principles to cardiovascular
disease.

PART ONE: RESOURCE ALLOCATION - DECISION MAKING AND EVALUATION
1. RESOURCE ALLOCATION: DHB FLEXIBILITY
The DHB receives an allocation of funding which is directly related to the size
and characteristics of its population. The quantum of this funding is fixed
annually but is consistent with a government three year future funding track.
A DHB does not have total flexibility in the allocation of resources; there are a
number of constraints placed by the Minister and by a “clinical duty of care”.
Firstly, there are ringfences that restrict the movement of funding between the
so-called NDOCs, that is: Mental Health and Personal Health. There was
formerly a ringfence around Disability Support funding, but this has been
removed. Public Health funding has not been devolved to DHBs.
Secondly, whilst the Statement of Service Coverage states that there are not
entitlements for services, in reality there are some services to which all eligible
residents are entitled and which the DHB is obliged to fund whatever is
consumed. Examples of these include: immunisation benefits and
pharmaceutical reimbursements.
Thirdly, the DHB is required to fund and have provided a range of services, as
laid out in the Statement of Service Coverage, and has a ‘clinical duty of care’
to ensure that there is a sufficient level of service provided to fulfill this duty of
care. Examples of these include: Emergency Department access and acute
surgical services.
Fourthly, there is a current policy which prohibits reducing funding levels for
elective services.
The combined effect of the above four factors is to significantly curtail the
quantum of funding available for redistribution by any DHB.
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2. SCOPE OF INTERVENTIONS
In broad terms, the scope of interventions for addressing health problems can
in most cases be grouped into four categories of intervention. These are
shown below with some examples of characteristic interventions.
Population
Prevention by Targetting High
Acute Treatment of
Measures
Risk Individuals
Established
Treatment of
Established
Aim is to identify individuals at
high risk of developing disease.
Aim is to treat acute
This may lead to treatment of
episodes of disease
level of risk
modifiable risk factors such as
obesity, smoking, or blood
Examples:
impact of
population
pressure
Hospital treatment
disease or
for acute illness
reduce risk of
recurrence
developing
Examples:
Breast Screening Programme
GP treatment of
(secondary
acute respiratory
prevention)
Example:
Blood glucose screening for
diabetes in high risk populations
Example:
Promotion,
Effective
management
settings eg
health food
in school
levels in

For many health problems interventions will be available from all four
categories. In these instances, opportunities will exist for funders to fund a
comprehensive range of interventions to address the problems. However, the
essence of resource allocation for DHBs is to determine the relative mix of
interventions from the four categories, and the relative allocation within each
category. A discussion of approaches that can be taken to this task are
discussed in the next section.

3. COMPARISON OF BENEFITS OF DIFFERENT INTERVENTIONS
The task of resource allocation involves assessing comparative benefits and
making choices. There are numerous factors that make this an extraordinarily
difficult task. Perhaps the most fundamental difficulty is obtaining clarity and
agreement about what constitutes benefit. Whilst “health benefit” may seem
self evident, even a cursory exploration of the concept reveals that it can be
assessed in different ways. For example, benefit could be assessed as years
of life gained, quality of life gained or reduction in inequalities gained.
There have been varied approaches to addressing and simplifying this
problem. These include a focus on either:
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1. Maximising efficiency through such techniques as cost utility analysis
2. Maximising equity: a social justice approach
3. A values based approach

CUA, and in particular the use of the quality adjusted life years (QALYs), is a
health economic approach to assessing any health intervention in terms of it’s
cost in dollars for a standardised unit of benefit. A fuller discussion of this
relatively high profile approach is in section four.
The equity approach aims to specifically target services that help redress
disparities in health access and outcome.
Ham (1) states:
“The pursuit of equity may result in resources being allocated to services for
which the cost of achieving a certain quantum of benefit is greater than for
alternatives. Trade-offs of this kind are made all the time in health policy and
indicate the potential incompatibility of efficiency and equity objectives.”
An example of this trade-off would be the ‘equity choice’ of providing
outpatient services at three geographical locations with the volume of services
correlated to local need; versus the ‘efficiency choice’ of providing all services
from one central location to reduce infrastructural costs and lost productivity
due to health staff traveling between locations.
Ham (1) presented the contrasting views of proponents of efficiency and
equity:
“Williams maintained that effective priority setting required clarity about
objectives, information about costs and outcomes, and the ability to measure
performance. Klein responded the key task was less to refine the technical
basis of decision-making than to construct a process that enabled a proper
discussion to occur given that questions of rationing cannot be resolved by
appeal to science.”
The values approach is perhaps best demonstrated by the Swedish approach.
This has involved the attempt to rank values; the highest priority attached to
respect for human dignity, followed by solidarity or equity and then by
efficiency.

4. CONCERNS WITH COST UTILITY ANALYSIS
How does one compare the relative benefits of fluoridation of a water supply
with a coronary bypass operation. On the face of it, this would seem an
impossible task. Health economists have responded by developing, in the
QALY, a standard metric for comparing such vastly different interventions.
QALYs have a seductive appeal because they appear to simplify the very
complex. However, there have been many criticisms of the QALY, mainly to
the effect that in their simplicity they fail to account for important
considerations.
These issues are not just academic. QALYs are the most straightforward
means of assessing the relative value of services. The DHB owned Pharmac
organization uses QALYs as one of its eight inputs in benchmarking the value
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of all pharmaceutical agents it assesses. A high cost per QALY is a major
adverse factor in Pharmac’s assessment.
A selection of the questions raised about the validity of QALYs is presented
below:
Extrapolation from personal to allocative preferences
Although the techniques used in CUA, such as the “standard gamble” and the
“time tradeoff”, give an idea of what individuals would want for themselves,
they do not reveal what people would prefer as a principle for allocation. For
example, in assessing the quality of life gained from an intervention,
researchers ask individuals what percentage of their remaining life they would
forgo to obtain the benefit from the intervention. McGregor (2) quotes the
QALY evidence for Viagra, an erectile dysfunction remedy, where men
questioned were prepared to give up 26% of their remaining years for the
benefits of the drug (Their wives when asked would give up only 2%). The
resulting cost per QALY is less than renal dialysis. In this example, the men
were asked about the perceived value as an individual of a single intervention,
not the relative value to society of a range of interventions. It is clear that the
extrapolation from individual to allocative preferences may not be valid.
“Rule of Rescue”
Society does not consider a unit of health gained by a severely ill individual to
be of equal value to a unit of health gained by an individual who is less
severely ill. Concerns for fairness and equity are also important to the public
in distributional decisions. There is a generally held view that society has a
duty of care to those who are acutely and severely ill. This will not be reflected
in QALY calculations as shown in the Viagra example above. Several studies
have shown that the public is prepared to sacrifice overall health gain to some
extent in order to help the most severely ill.
Age and Disability Discrimination
It has been claimed that QALYs are ageist because the intrinsic calculation
(QALY = quality factor times number of years of benefit) would appear to
disadvantage those who have less years of life expectancy in which to benefit.
Several economic and ethical formulations have been developed to assess
whether and how to incorporate age as a criterion for resource allocation. One
of the main underlying rationales is the equalization of life health, the so called
‘fair innings’. The basic idea here is that all persons are entitled some equal
life-span and those having already lived these years of life should be given
less priority. Schwappach (3) notes that a moderate or even strong preference
for giving priority to the young has been observed. There is much less support
for negative discrimination against the elderly.
A similar argument has been made that QALYs discriminate against the
disabled or those with chronic conditions because in theory, these people
have less potential to benefit because they have a reduced quality of life as a
starting point. There is empirical evidence, however, that the public prefers to
give equal priority to those with and without disabilities in the allocation of life
saving technologies.
Two other observations from Schwappach (3) provide useful context:
“In general there seems to be reluctance to allocate resources on treatments
that leave patients in comparatively poor health.”

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“When explicit trade-offs between health gains achieved by curative or
preventive treatments are involved, there seems to be a slight trend to
prioritise preventive healthcare.”

5. MACRO / MESO / MICRO APPROACHES TO PRIORITISATION
Prioritisation can occur at a number of levels in the health system and can vary
in its explicitness. ‘Macro’ attempts at resource allocation have involved
attempts to define services which are and aren’t available under public
funding. They are therefore inherently explicit. Two of the most notable
examples worldwide are the Oregon prioritization process in the early 1990s
and the New Zealand attempt through the NZ Core Services Committee to
define a core of publicly funded services.
‘Meso’ level approaches have the prioritisation decisions being made by
funding organisations, where decisions are made about the type and mix of
services funded for a community. ‘Micro’ level approaches are decisions made
at the service or individual clinician level; for example using guidelines as a
tool to determine service access.
It is notable that the NZ Core Services Committee retreated from the macro
view to a meso/micro view that priority setting was best approached not by
limiting service coverage but by determining how services could be targeted
on those patients most likely to benefit. The major mechanism for
implementing this was ‘guidelines’. Rationing by guidelines rather than
exclusions leaves ultimate responsibility for deciding who should get access
to health care resources to agencies such health authorities at the meso level
and to physicians at the micro level.
Ham (1) is rather derogatory of “muddling through” approaches which avoid
explicit decision making in order to avoid political risk. However he notes that:
“The political cost of explicitness may outweigh the benefits and this could
result in a return to previous decision making processes”
Schwappach (3) notes too that the public is generally against allocative
decisions that are too extreme, there is an underlying preference for
moderation:
“There seems to be general reluctance against extreme final distributions. The
public wishes to maintain hope and the chance for treatment for all patients.”

6. CONSULTATION
The Health and Disability Act (2001) describes a legal obligation on DHBs to
consult on their District Strategic Plans. The minimum level of consultation
permitted is defined as the consultation process described in the Local
Government Act (1954).
Engaging the community in meaningful deliberation about health service
resourcing choices is difficult to do well. One of the concerns of the
community, in engaging with public agencies, is at which stage of the decision
making process they engage; and therefore what is the potential for the
consultation to influence decision making.
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Beierle, quoted in Abelson et al (4), described four factors that need to be
addressed in any consultation design or evaluation:
1. Representation
2. The structure of the process or procedures
3. The information used in the process
4. The outcome and decisions arising from the process

The question of representation concerns the extent to which those in the
community who are consulted with truly represent the views of the wider
community. There is often an inherent tension between the breadth of
consultation in terms of the range and representativeness of the consulted,
versus the depth of consultation. Many health resourcing issues require the
sharing of a significant amount of information to the consulted to put them in a
position to develop an opinion. For this reason, Abelson et al (4) assert that:
“Surveys are limited in their ability to communicate and obtain in-depth views
about complex issues.”
The choice of information shared with the consulted has the potential to
undermine the usefulness of the process, Abelson et al (4) state:
“A double edged sword built into the deliberative paradigm is the naïve
assumption about the role of information as a tool for informing dialogue
which ignores the reality of information as a source of power.”
Other consequences of the asymmetry of information and power between
public agencies and the consulted include (4):
“The vast majority of the public will defer to the experts when it comes to these
decisions because they may not have the expertise required to critically
appraise the information presented.”
”‘Once exposed to the complexities of the system, participants become
sympathetic to the challenges faced by decision makers who deal with these
types of issues on a daily basis.”
The numerous and potentially competing goals for public participation
processes and consequently the trade-offs inherent in designing public
participation processes may often result in a situation where, in emphasising a
particular goal they may sacrifice another.
Positive benefits can be gained from effective consultation in the formative
stages of planning. These would include a smoother implementation of policy.
It was suggested that broad and open consultation, that is open dialogue that
asks questions rather than provides options, was more likely to engage the
community and provide useful feedback on the real issues perceived by the
community. In this context the process of consultation and the models of
presentation were seen to be critical to the outcomes achieved from
consultation. Quite different engagement and outcomes could be expected
from pre-packaged versus open-ended consultation. This could represent the
difference between community tolerance or support.
Given that there are different levels of resource allocation occurring in the DHB
it was considered that it was appropriate to develop different levels of
consultation and have a gradient of methods based upon the importance, risk,
or community relevance of the decision.

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Abelson et al (4) concisely summarised the key challenges to effective
consultation:
• How to mitigate strong vested interests
• How to mitigate potential biases introduced by witness and information
selection
• How to achieve representativeness when citizens do not want to
participate
• How to ensure accountability of the participants for its outcome when
the deliberative process is only one input in the decision-making
process
• How to build an infrastructure of civic deliberation
7. ADDRESSING INEQUALITIES FOR MAORI
There is strong and consistent evidence that Maori and Pacific peoples have a
higher rate of hospitalization for acute cardiac events, and yet lower (40% and
64% respectively for Maori and Pacific men) rates of coronary bypass
[Tukuitonga (5) and Westbrook (6)]. This experience mirrors the situation of
black Americans in the United States.
There are a number of potential reasons for this phenomenon including:
patients’ health seeking behaviour, preferences for cardiac procedures or
medical treatment, physician practice styles and patient doctor interaction.
Discrimination against ethnic minorities has been suggested as a possible
reason for ethnic disparities in the use of these procedures in the USA.
There is a lack of information on the real causes for the reduced access to
interventions for Maori and Pacific People. RAWG discussion focused mainly
on Maori, but the issues were acknowledged to be similar for Pacific peoples.
It was considered likely that from community through to tertiary care there
could be inequalities in Maori:
• ability to access services
• assessment by mainstream services
• expectations of services
• ability and willingness to advocate on their own behalf

It was considered that ideally the “system” should be modified to be
responsive to the needs of Maori and provide equitable levels of service and
outcome. This is unlikely in the short term due to the immense effort required
to modify a system of such size and established patterns of practice. Four
potential mechanisms were discussed that could be used, in the shorter term,
to help overcome the inequitable service access and outcome experiences for
Maori.
Quotas or targets set for access levels for Maori to mainstream services
Analysis of the known pattern of morbidity for Maori could be used to develop
the expected level of mainstream services that would be expected to be
accessed. These service levels could be incorporated as service targets for
Maori. For example, if Maori were known to have twice the rate of cardiac
disease, the service expectation would be that Maori would access cardiology
assessments at twice the rate their proportion of the population would
indicate. That is 22% of consultations (11% of C&C population).

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The Ministry of Health in their Maori Health Advice to incoming Minister (2002)
suggested that the next ten years may see direct devolution of social service
funding to iwi and major urban groups. Options already being explored
include:
1. One government agency acting on behalf of other to streamline
contracting with iwi for a range of social services
2. A full devolution model where iwi would purchase services on their own

It follows from this that, if there was a failure to meet service targets, a
stronger approach could be to allocate a proportion of service funding for
Maori patients: quotas or ring-fencing of funding for Maori in selected services.
By Maori for Maori Service development
By Maori for Maori Service development is already a strategic priority. It
remains an important mechanism in developing a health system responsive to
Maori needs.
“Advocacy” for Maori of their needs and to ensure Maori access the system
effectively
Advocacy services could be developed to assist Maori in overcoming system
hurdles. These may be as simple as arranging transport to clinics or as
complex as assisting people to weigh up the pros and cons of major surgery.
There is some anecdotal local experience that advocacy services could be a
transitional step; for the services would help Maori develop confidence and
experience in advocating themselves for equitable access.
Provider incentives for clinical guidelines implementation for Maori
In clinical areas where there are clear guidelines and targets to Maori access
and treatment, incentives could be developed to reward providers who address
inequalities and meet clinical targets. Incentives should be tailored to each
provider to recognise the specific access difficulties of populations.

8. INCORPORATING INNOVATION
There is a progressive trend towards an increased burden of degenerative
diseases in an aging population, who are alive but are frailer and with greater
associated disability. This trend is likely to continue and intensify because of
the aging population and the development of life extending health
technologies.
In this context, the Health System needs to be able to adapt to the changing
demography, morbidity and consumerism. Around the western world
innovative approaches to care delivery are developing in response to these
trends. To a large extent these are driven by financial imperatives and
overburdened hospitals.
It is postulated that nearly one million unplanned hospitalisations in the US for
congestive heart failure each year may be prevented by improvements in
patient evaluation and management strategies.
Other studies, quoted by Davidson et al (7), have suggested that 50-75% of
readmissions may have been preventable by augmenting strategies to promote
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treatment compliance and development of mechanisms of outpatient support
and optimisation of medical therapy.
Some of the key concepts in these innovative approaches to care are:
1. Integrating services around the patient to avoid care fragmentation or
duplication
2. Stratification of patient groups: core patient group, hard to reach, and
hard to treat groups (recidivist populations), as opposed to “one size
fits all”
3. Development of specific services for these subpopulations of patients.
For example case management approaches to people with complex
conditions and high needs
4. Promotion of the expert patient concept where patients become the
experts in their own condition and health professionals become
consultants or advisors to them
5. Substitution of hospitalisation with community based alternatives such
as: hospital in the home, intermediate care, ‘GP hospitals’

Frequent Attenders: a small group of people with multiple health problems who
use large quantities of Capital and Coast District hospital services were
discussed as an example of current patterns of care. There is often a
fragmented approach to care management of complex patients. Integrated
care aims to coordinate the health providers’ responses around the patient.
The implication of these trends for the allocation of resources is that resource
allocation is not a static process that allocates existing resources into a
particular (possibly different) mix. Resource allocation must consider and
incorporate changing paradigms of practice. This may mean investment in
new types of services and consequent disinvestment in existing services.

9. INTERPRETATION
Resource allocation is a process that involves comparing and evaluating
different interventions in order to decide the nature and volume of services
that will be funded. As described in section two, the choices that can be made
are constrained by policy settings, and by a need to meet service coverage
expectations.
New funding is very limited. Over the next four years, for C&C there will be no
growth in funding to reflect population growth; as the Ministry of Health
reduces funding to the Population Based Funding Formula allocation. To
achieve a different mix of funding within the categories outlined in section two
will require a combination of investment and disinvestment in existing
services. This will involve difficult choices between investments in prevention,
and treatment of acute and chronic treatment services; and will require choices
about which services to fund less of.

Factors that
influence
Deciding the choice of interventions and quanta of funding needs to
choices of
incorporate a number of different considerations that need to be
Alternativ
weighed up
solutions
simultaneously
. The implications of resource allocation options needs to be
including:
evaluated. This train of logic is sh
scenarios
own below:
effectiveness
Populatio
Impact of
n at Risk:
Determine:
addressin
Utilise:
opportunity
Evaluate
decisions
costs, equity
problems
on health
benefits,
allocation
alignment
G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04
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with strategic
plan,
innovation,
and
G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04
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The diagram below attempts to summarise the process graphically.
Improved
Access to
New models
Consultation
Models of
Disabilit
Ad dressin
Services
Comparison
inequalitie
of Benefits
Capacity
Current &
Potential
Maori Health
Prioritising
Interventions
Allocation
Evaluation
of Impact

The scope of available interventions is wide and varied. The quanta exceed
available resources. Inherent in this is that for any funding opportunity there
are other alternative uses for resources and other benefits to be foregone.
A process is required that makes a comparison of the relative benefits,
considers the current and potential future capacity (and the impacts on this
capacity of changes in resources), determines the explicit benefit for Maori
Health, incorporates opportunities from changes to the model of care, and
incorporates an agreed process of consultation.
The cogs represent the need to mesh these factors into a composite process.
An important feature of this diagram is that the prioritisation process is not a
sequential series of steps addressing each of these factors, but a composite
process. Whilst this makes it inherently more complex, and thus difficult to
manage, it ensures that all aspects are considered alongside one another. A
sequential process is more likely to make decisions on single or few criteria
because of the ordering of the steps or failure to finish the sequence.
In addition, without making the whole problem insolubly complex, the relative
importance of the particular problem should also to be evaluated and
compared to other problems, for example cancer, child health, cardiovascular
disease etc.

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10. DRAFT RECOMMENDATIONS
Resource allocation is a complex and multi-factoral activity that is at the heart
of a DHB’s functions. It is inherently a developmental and iterative process.
The RAWG has considered a number of the aspects of resource allocation that
should be considered in developing a robust and transparent process.
Key principles that have emerged during the discussions include:
• DHB funding is limited which means that trade-offs and comparison of
relative benefit are essential
• There is no single, simple approach to resource allocation
• Cost effectiveness information is not a sufficient sole basis for allocative
decision making
• Consultation is difficult to do well, and must balance representation,
complexity (or depth), and timing
• Incorporating innovation needs to be considered at a system level and not
at a marginal level
• Specific weighting needs to be given to addressing inequalities and
specific mechanisms deployed

In further development of C&C’s resource allocation process, the key concepts
and ideas discussed above should be evaluated and incorporated into the
prioritisation and planning process. It is specifically recommended that:
1. C&C DHB adopt the principles described in this paper as a general
approach to resource allocation
2. C&C DHB apply these principles to the major components of the Board’s
work programme (And explicitly include the Statement of Intent)
3. The principles and approach to resource allocation be used to assist C&C
DHB’s high level decision making processes

With respect to addressing inequalities it is specifically recommended that:
1. The concept of negotiating targets for access levels for Maori to
mainstream services should be adopted where there are identified
inequities of access. If, after three years, targets fail to address inequities:
quotas or ring-fencing of funding for Maori could be considered.
2. By Maori for Maori Service development remains an important mechanism
in developing a health system responsive to Maori needs.
3. Advocacy services could be developed to assist Maori in overcoming
system hurdles
4. Introduction of provider incentives for implementing clinical guidelines for
5. Similar approaches should be used for Pacific peoples who have, in many
instances, similar epidemiology and service needs.
11. REFERENCES
1. Ham C, Coulter A
Explicit and implicit rationing: taking responsibility and avoiding blame for
health care choices J Health Serv Res Policy. 2001 Jul;6(3):163-9
2. McGregor M
Cost-utility analysis: use QALYs only with great caution
CMAJ. 2003 Feb 18;168(4):433-4

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3. Schwappach DL
Resource allocation, social values and the QALY: a review of the debate and
empirical evidence.
Health Expect. 2002 Sep;5(3):210-22
4. Abelson J, Forest PG, Eyles J, Smith P, Martin E, Gauvin FP
Deliberations about deliberative methods: issues in the design and evaluation
of public participation processes.
Soc Sci Med. 2003 Jul;57(2):239-51
5. Tukuitonga, C. and A. Bindman (2002). NZMJ 115(26 April): 179-82
Ethnic and gender differences in the use of coronary artery revascularisation
procedures in New Zealand
6. Westbrook, I., J. Baxter, et al. (2001)
Are Maori under-served for cardiac interventions?
NZMJ 114: 484-7
7. Davidson P et al
Addressing the burden of heart failure in Australia: the scope for home based
interventions
J Cardiovasc Nurs 2001: 16 (1) 56-68

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PART TWO: RESOURCE ALLOCATION - CARDIOVASCULAR DISEASE
1. INTRODUCTION
Cardiovascular disease (CVD) is the leading cause of death in New Zealand,
accounting for 41 percent of all deaths in 1997. An estimated $22.8m of
funding was allocated in the Capital & Coast District in 2002/03 for the
prevention or treatment of CVD.
This paper applies the generic approach discussed in Part One to the
prevention and treatment of CVD.
For:
Determine:
Utilise:
Evaluate
Alternativ
Factors that
Impact of
influence
allocation
decisions
scenarios
choices of
on health
Populatio
solutions
n at Risk:
addressin
including:
effectiveness
problems
, costs,
opportunity
costs, equity
benefits,
alignment
with strategic
plan,
innovation,
and

The wide range of approaches that can be used to prevent and treat CVD were
summarised in a May CPHAC paper, and are grouped into four categories in
this approach. The degree of funding flexibility the DHB has with respect to
CVD is assessed. RAWG has reviewed some of the scientific literature that
attempts to compare the relative effectiveness of these different interventions.

Page 20 of 1
2. THE SCOPE OF INTERVENTIONS
The range of interventions that are available for CVD were grouped into four
categories to simplify analysis. These categories are shown graphically below:

Population
Prevention by Targetting High
Acute Treatment of
Measures
Risk Individuals
Established
Treatment of
Established
Examples:
Examples:
Examples:

Examples:
Legislation
NZ Guidelines recommend
screening target groups, eg
Hospital treatment
Guidelines
Maori males over 35 years, for
for heart attack
Heart failure
absolute risk of a cardiac event
treatment
Salt or Fat
in the next 5 years.
Hospital treatment
for heart failure
Processed
Treatment of modifiable risk
factors for those at high risk eg
Secondary
cholesterol, weight, smoking,
Prevention
blood pressure reduces
Revascularisation
individual risk
Examples:

Examples:
Marketing
Coronary bypass
rehabilitation
Examples:
Angioplasty
smoking
TV

3. RESOURCE ALLOCATION: DHB FLEXIBILITY
The funding of CVD interventions was presented in the May 2003 CPHAC paper
and is summarised below:
Regional Public Health
Community laboratory
Primary care Providers:GMS etc
Community pharmaceuticals (cardiovascular and lipid lowering 2002)
$6,720k
Secondary Cardiology Inpatient Care (excluding interdistrict flows)
$6,414k
Secondary Cardiology Outpatient Care
Community Referred Cardiology Testing
Cardiac Education and Management
Page 21 of 1
Secondary Cardiothoracic Inpatient Care (excluding interdistrict flows)
$5,306k
Secondary Cardiothoracic Outpatient Care
Estimated District Expenditure on Cardiovascular Services
Secondary Cardiothoracic
Regional Public Health
Outpatient Care
Secondary Cardiothoracic
Community laboratory
Inpatient Care (excluding
interdistrict flows)
Primary Care GMS etc
Cardiac Education and
Management
Community Referred
Cardiology Testing
Community pharmaceutic
(cardiovascular and lipid
lowering 2002)
Secondary Cardiology
Outpatient Care
Secondary Cardiology
Inpatient Care (excluding
interdistrict flows)

The overall allocation is approximately $10m to Primary and Public Health
interventions and $12.8m to hospital based services. Unfortunately it is not
possible to accurately allocate the expenditure above across the four
categories described in section two because it is not known the relative
proportions of, for example laboratory tests, which are used for screening,
acute management or chronic management.
In terms of the DHB’s flexibility in altering funding levels for each category:
Regional Public Health
This funding for health promotion relating to CVD is from the Ministry of Health
to the Regional Public Health Service. C&C DHB do not influence this funding
level. The level of this funding cannot be reduced, but C&C DHB could allocate
its own funding for additional Public Health activity.
Community laboratory
Community laboratory funding is reimbursement for referred tests from public
and private sector medical practitioners and midwives. The level of funding
Page 22 of 1
cannot be directly influenced by C&C DHB, but can be indirectly influenced by
support for initiatives that promote clinical best practice and implementation of
clinical guidelines.
Primary care Providers
Primary care providers are paid by a combination of fee for service and
capitation formulae. Ultimately, it is expected that most funding will be
through PHO capitation. Because capitation formulae are nationally
determined, C&C DHB has no ability to decrease this level of funding but has
discretion to increase funding through additional funding initiatives outside of
capitation formulae.
Community pharmaceuticals
As with community laboratory, funding is reimbursement for prescribed
pharmaceuticals by public and private sector medical practitioners, dentists
and midwives. The level of funding cannot be directly influenced by C&C DHB,
but can be indirectly influenced by support for initiatives that promote clinical
best practice and implementation of clinical guidelines.
Secondary Cardiology Inpatient Care
Allocation of funding for Hospital and Health Services (HHS) is negotiated
between Planning and Funding (P&F) and the HHS annually. The service is a
combination of acute presentations and elective procedures (such as
angioplasty). Decreases in service access could be effected by new models of
care and by changes to access criteria for elective services. Increases in
funding could be effected by reallocating from other services into cardiology.
Secondary Cardiology Outpatient Care
Allocation of funding for the HHS is negotiated between P&F and the HHS
annually. The service is an elective service receiving referrals from medical
practitioners from the lower half of the North Island and Nelson Marlborough.
Decreases in service access could be effected by new models of care and by
changes to access criteria for elective services. Increases in funding could be
effected by reallocating from other services into cardiology.
Community Referred Cardiology Testing
Allocation of funding for the HHS is negotiated between P&F and the HHS
annually. The service provides a specialist diagnostic service upon referral
from a medical practitioner. Decreases in service access could be effected by
new models of care and by changes to access criteria for elective services.
Increases in funding could be effected by reallocating from other services into
cardiothoracic.
Cardiac Education and Management
Allocation of funding for the HHS is negotiated between P&F and the HHS
annually. The service contributes to patient education and cardiac
rehabilitation following a cardiac event. Decreases in service access could be
effected by new models of care and by changes to access criteria for elective
services. Increases in funding could be effected by reallocating from other
services into cardiothoracic.
Secondary Cardiothoracic Inpatient Care
Allocation of funding for the HHS is negotiated between P&F and the HHS
annually. The service is a combination of acute presentations and elective
procedures (such as coronary bypass surgery). Decreases in service access
Page 23 of 1
could be effected by new technologies and by changes to access criteria for
elective services. Increases in funding could be effected by reallocating from
other services into cardiothoracic.
Secondary Cardiothoracic Outpatient Care
Allocation of funding for the HHS is negotiated between P&F and the HHS
annually. The service is an elective service receiving referrals from medical
practitioners in the lower half of the North Island and Nelson Marlborough.
Decreases in service access could be effected by new models of care and by
changes to access criteria for elective services. Increases in funding could be
effected by reallocating from other services into cardiothoracic.

4. COMPARISON OF BENEFITS OF DIFFERENT INTERVENTIONS
Risk Factors and Thresholds
It is only in the last ten years that the contribution of risk factors to adverse
outcomes has become well understood. It is now clear that hypertension and
hypercholesterolemia, terms that imply that there is a level at which the level of
blood pressure or cholesterol becomes ‘high’ and below which is normal and
‘safe’, are false concepts.
In Western societies blood pressure, cholesterol and weight typically increase
as people age. This rise does not occur in hunter-gatherer communities, the
levels remain at low risk levels throughout life. The implication from this is
that it is aspects of the Western lifestyle, such as physical inactivity, high
animal fat diet, and smoking that directly contribute to the rise through life in
these risk factors.
There is a log linear relationship between risk factor levels and adverse CVD
outcomes. This means that there is a constant proportional increase in
adverse events with increasing levels of risk factors. The lower the risk factor,
the lower is the risk of disease, down to levels well below average Western
values. Some of the startling conclusions that can be drawn from this are:
1. Treat anyone at high risk! Blood pressure lowering drugs should not be
limited to people with high blood pressure, nor cholesterol lowering
agents to people with high cholesterol concentrations
2. The constant proportional relationship means that there is value in
modifying risk factors in people with high risk, whatever the reason for
the high risk and regardless of the level of risk factor
3. The conclusion is clear: anyone with existing disease (a previous
myocardial infarction or stroke for example) should be treated
irrespective of the level of the risk factors one seeks to modify
4. Because there is substantial benefit from lowering these physiological
variables from any starting value at persons at high risk, all the
reversible risk factors should be changed, not just those judged
“abnormal”

The practical implication of this information is that the development of
cardiovascular disease in people with a high susceptibility can be prevented or
delayed. To do this requires that people at high risk are identified and treated
with a range of interventions encompassing both lifestyle and pharmaceutical.
Page 24 of 1
Population Measures
Population measures are actions taken at a community or national level to
change the level of a risk factor in the whole population. Three examples of
how this might be achieved are through:
1. industry agreement, or legislation to progressively lower the added salt
in processed foods
2. industry agreement, or legislation to progressively move to healthier
cooking oils for commercially prepared foods
3. mass media smoking cessation and increasing exercise messages

Unfortunately limited information is available on the costs and benefits of
community wide intervention programs that have aimed to modify multiple risk
factors in the population. Whilst there have been a few large scale
programmes, their evaluation has not been particularly robust, and therefore
the cost effectiveness is hard to ascertain.
Those studies that have targeted specific risk factors, rather than multiple,
have shown that non personal health interventions to reduce blood pressure
and cholesterol are very cost effective (Murray et al [1]).

Prevention by Targeting High Risk Individuals
Most studies relating to CVD prevention have appraised interventions aimed at
modifying the three most important risk factors for CHD: smoking,
hypertension and hypercholesterolemia. Fewer studies have focused on the
costs and benefits of exercise and weight-loss programmes.
Crowley at al (2) summarise the evidence and state that hypertension treatment
does not pay for itself in healthcare savings from strokes or coronary heart
disease (CHD) prevented. It was estimated that only 22 per cent of the
treatment costs of moderate hypertension (DBP of 105 mmHg or higher) and 15
per cent of the costs of treating mild hypertension (DBP of 90 to 104 mm Hg)
were likely to be recovered. The epidemiological evidence for the
effectiveness of exercise, weight reduction and stress management on
hypertension is less conclusive.
Costs per QALY gained consistently place GP based smoking cessation
programs near the top of QALY league tables, thus supporting the evidence
that smoking cessation programs are clearly among the most cost-effective of
healthcare interventions.
The NZ Guidelines Group CVD Guidelines (December 2003) make
recommendations on which groups to target, how to assess risk, and how to
treat. The guideline recommends comprehensive cardiovascular screening of
men age 45 years or over and women aged 55 years or over without known
cardiovascular disease, known smokers and Maori people are to be screened
10 years earlier and diabetics are to be screened at diagnosis.
In New Zealand, absolute CVD risk is usually calculated from the Heart
Foundation risk assessment charts or electronic decision support tools based
on the Framingham Heart Study. The standard risks in the Heart Foundation
risk charts are:
1. A personal history of CVD
2. Age
Page 25 of 1
3. Sex
4. Smoking
5. Lipids
6. Blood
Pressure
7. Diabetes

It is notable that ethnicity, socioeconomic status, obesity and physical
inactivity do not contribute to the risk assessment.
A cost effectiveness analysis has been performed for the national
implementation of the guidelines for people with an absolute risk of 10% and
15%. Compared with no systematic screening and lipid-lowering programme,
the recommended ‘screen and treat’ strategy (at a treatment threshold of 15%
absolute risk) would prevent 6716 incident cardiovascular events and 1885
premature deaths. Over the lifetime of the cohort this provides 17,205 life years
and 21,317 QALYs. The net 5-year cost of the strategy is $70million including
pharmaceuticals, GP consultations, and laboratory tests. Hospital costs
avoided over 5 years (including incident and recurrent medical and surgical
cardiovascular admissions, AT&R and rural admissions) offset about two-
thirds of the net cost of pharmaceuticals.
The NZ Population (2001) = 3,737,277; the C&C Population (2001) = 245,560
(6.6%). The estimated net cost of fully implementing the Ministry strategy in
the C&C District would be approximately $4.62m. Net Five year implementation
costs for C&C Maori are estimated at $456k.
The cost effectiveness ratios of $4083 per life year gained and $3295 per QALY
gained are well within the range of those that have been accepted in
reimbursing novel drug therapies in New Zealand. Enlarging the pool of
individuals who are eligible for statin treatment by reducing the treatment
threshold from 15% to 10% absolute risk increases the QALY benefits by about
one-third but doubles the total cost of the strategy.
Murray et al summarise that overall Personal health service strategies have a
much greater potential to reduce the burden of disease – even though they are
less cost effective than the population-wide strategies.

Hospital Based Treatments for Established Disease
Health promotion and secondary prevention programs are not necessarily
more cost effective than high technology surgical or drug treatments.
Cost effectiveness analysis of cardiac interventions such as percutaneous
cardiac angioplasty (PTCA) and coronary bypass (CABG) has generally shown
these measures to be at least moderately cost effective. However, the
changing costs and rapidly changing technology make analyses of limited
application because they become out of date.
Crowley at al (2) in a 1995 literature review concluded that CABG was more
cost effective than treatment for either hypertension or high serum cholesterol
as single risk factors.

Page 26 of 1
Chronic Treatments of Established Disease
The scientific literature on the cost effectiveness of cardiac rehabilitation is
limited. There is a suggestion that it is moderately cost effective but the most
comprehensive review of the subject by Oldridge (3) ends with the following
conclusion:
We still do not have an answer to the following two critical questions:
…….what is the incremental value of exercise when added to other cost
effective secondary prevention interventions such as smoking cessation and
management of hyperlipidemia?
Does cardiac rehabilitation in fact reduce costs and save scarce healthcare
resources?

Key Points
There is no analysis comparing the cost effectiveness of the full range of CVD
interventions. Methodological issues have been raised as major criticisms of
QALY league tables and also make comparisons between studies difficult:
1. Wide variation in the specification and measurement of cost categories
2. Different epidemiological assumptions
3. Benefits mostly judged on disease specific effects
4. Average rather than marginal benefits
5. Different durations of study
6. Different discount rates

For reasons stated above relating to the difficulty in comparing different QALY
studies, there is unlikely to be in the near future. In such a situation the
balance of prevention versus intervention is probably the major strategic
decision for funders rather than the relative mix within interventions, or
prevention approaches.
Murray et al summarise:
“From the perspective of how best to achieve the best population health for the
available resources, the optimum overall strategy is a combination of the
population-wide and individual based interventions.”
Schulpher et al (4), reviewing cardiac interventions take a similar approach:
“For purchasers the evidence could imply that blanket decisions to provide
only one form of intervention to patients should not be made. The various
main forms of treatment for stable angina should be available and patients
should be informed of the therapeutic options rather than offered a single
therapy based upon provider preferences.”

5. MACRO / MESO / MICRO APPROACHES TO PRIORITISATION
In the context of CVD, macro approaches to prioritisation could include
national policies towards the funding of new technologies. A “macro” decision
could be made by the Ministry of Health, or DHBNZ, that certain new
technologies would, or would not be funded by all DHBs. There is a precedent
for the Ministry taking this position with oncology drugs.
Explicit funding by a DHB of clinical guidelines for CVD could be seen as a
meso approach, particularly if funding was specifically linked to the application
of the guideline or achievement of service targets.

Page 27 of 1
Micro level allocation decisions could be decisions by individual medical
practitioners on whether or not they agreed with clinical guidelines and
intended to incorporate them into their clinical practice.

6. ADDRESSING INEQUALITIES FOR MAORI
In a NZ study of heart failure outcomes for Maori and non-Maori over a ten year
period, mortality from heart failure was more than 8.8 times higher among
Maori men aged 45-64 years and 3.5 times higher among Maori aged 65 years
and over. Pacific peoples have the highest hospitalisation rate for rheumatic
fever, over nine times that of others (19 per 100,000, 45 cases, compared to 2
per 100,000). The Maori hospitalisation rate is just over five times that of non-
Maori (9 per 100,000, 54 cases) (Ministry of Health 2001).
And yet a study by Tukuitonga et al (5) showed that coronary bypass rates
were lower in Pacific and Maori men compared with other NZ men (ratios 0.64
and 0.40). Angioplasty rate ratios were 0.25 in Pacific and 0.29 in Maori men
compared with other men and 0.21 in Pacific and 0.43 in Maori women
compared with other NZ women.
The working group and guest participants were agreed that ideally the
mainstream system, that provides nearly all CVD services, should be modified
to be responsive to the needs of Maori and provide equitable levels of service
and outcome. This is unlikely in the short term due to the immense effort
required to modify a system of such size and established patterns of practice.
In the shorter term the generic options for addressing these inequalities, as
discussed and presented in the part one, could be applied to CVD. These
actions aim to compensate for the system rather than transform it. Specific
actions could include:
1. Determination of the expected level of mainstream services that would
be expected to be accessed to set service targets for Maori. Consider
funding quotas if performance does not move towards targets.
2. Continue by Maori for Maori Service development
3. Develop advocacy services to assist Maori in overcoming system
hurdles. Consult with Maori to identify preferred options
4. Implement performance incentives for meeting service targets for
guidelines implementation for Maori access and treatment. Incentives
should be tailored to each provider to recognise the specific access
difficulties of populations.

The Ministry of Health CVD Guidelines recommend that:
“Practitioners should be aware of the need to focus on population groups that
have a high burden of cardiovascular disease. These groups should be
specifically targeted to ensure they are able to benefit from risk screening and
subsequent management”

7. INCORPORATING INNOVATION
Innovative approaches to providing specialised services to people with
established disease were reviewed. Worldwide there have been many
initiatives to develop approaches to keeping people with CVD well, rather than
acute hospital management.

Page 28 of 1
Two of the key themes are case management by specialised nurses of high
needs patients and patient self management: the development of ‘expert
patients’ who actively participate in the management of their condition.
Evidence from overseas suggests that the improvements in patient care
provided by these approaches result in significant reductions in the need for
hospital based services.
A service providing case coordination for people with heart failure has
commenced in Porirua during 2003. This is an example of an integrated care
service targeting ‘hard to treat’ and ‘hard to reach’ people and improve the
management of their conditions.
There has been little explicit funding of specific self management initiatives, as
yet, in the C&C District.
Given the potential for different models of care to improve care and save on
hospitalisation costs, incorporating the funding of such service innovations
needs to be factored into resource allocation decisions.

8. INTERPRETATION
The review of resource allocation for service options for cardiovascular
disease by RAWG has confirmed that there is a substantial body of knowledge
about the causes, prevention and treatment of CVD. There is much less clarity
about the relative value of different options compared with one another.
A general assumption in this discussion is that the overall quantum of funding
for CVD will remain similar in real terms, and the key decisions to be made
concern the mix of services among the four service categories.
It is clear that services are required in all of the service categories presented in
section two. There is almost certainly unmet need in the C&C District in all of
the four service categories, for example: additional benefit could be obtained
from more population health, risk modification, cardiac surgery and cardiac
rehabilitation. Much of the information reviewed on the relative effectiveness
of interventions was from international sources. The working group has
assumed that the conclusions from this information can be generalised to the
New Zealand context.
C&C DHB has little new Ministry of Health revenue over the next few years as
adjustments in funding levels to meet Population Based Funding are
implemented. Within the current funding categories there is a variable degree
of ability to increase and decrease funding levels. Given the relatively static
total revenue, changes in funding for different categories of intervention will
need to be offset by changes in other categories.
In terms of the four categories of intervention:
Population measures:
Population measures can be very cost effective, and should be part of the
interventions supported. Some of these measures would require national
initiatives. A DHB could play an advocacy, catalyst or supportive role in the
development of such measures. Population measures could also be directed
at target groups such as social marketing approaches for Maori.

Page 29 of 1
Prevention by Targetting High Risk Individuals:
The NZ Guidelines Group recommendations strongly recommend systematic,
targeted risk reduction to reduce the incidence of CVD. There is almost
certainly significant current expenditure on investigation of CVD which would
not be recommended practice and offers a potential saving if resource were
directed as per the guidelines. For example, pharmaceutical treatment of
moderate hypertension in individuals with low absolute CVD risk is common
practice but no longer recommended.
Acute and Chronic Treatment of Established Disease:
There is mounting evidence that the investment in hospital based services
could be modified by implementation of innovative community based models
of care including case management and ‘the expert patient” self-management.
Specific strategies need to be employed to address low rates of access to
services for Maori and Pacific peoples.
The relative mix of resourcing is currently weighted towards treatment of
established disease. There have been strong historical drivers for the
accumulation of resource and expertise in high technology, medical, facility-
based, interventions. The key question for DHBs could be summarised as:
“Is the current allocation of resources optimal to both address the needs of
today, and impact on the prevalence of disease in 10 years time?”
Given the historical pattern of resource allocation it is considered a safe
conclusion that the investment in population and individual risk factor
modification is suboptimal. In summary, it is therefore considered that the
answer to the above question is almost certainly: “No”, and that investment in
population and individual risk factor modification should be preferred in future
resource allocation decisions.

9. DRAFT RECOMMENDATIONS
After reviewing the range of prevention and treatment options for CVD, the
RAWG makes the following recommendations:
1. Sudden, large funding reallocations should be avoided
2. C&C DHB should take a strong advocacy role in encouraging national
population-based approaches to prevention of CVD such as reducing salt
levels in processed foods, promoting ‘healthy’ fat use by commercial food
retailers, and social marketing approaches to smoking cessation and exercise
promotion. C&C should consider allocating Personal Health funding to
augment currently Public Health funded initiatives.
3. C&C DHB should treat as a resource allocation priority the implementation
of the NZGG guidelines for CVD risk factor modification. The priority
population groups for implementation should be Maori and Pacific Peoples if
limited funding is available.
4. Innovative models of care, such as frequent attender case coordination,
hospital in the home, and promotion of the “expert patient”, should be
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favoured for funding to reduce the utilisation of hospital based services and
alter the balance of community / hospital service funding more towards
prevention and community services
5. New health technology for CVD interventions should be considered
carefully within the context of the balance of community / hospital service
funding.
With respect to addressing inequalities, it is specifically recommended that
C&C DHB:
1. Determine an equitable level of access to mainstream services in order to
negotiate service targets for Maori. Consider funding quotas if performance
does not move towards targets after three years
2. Continue by Maori for Maori Service development
3. Develop advocacy services to assist Maori in overcoming system hurdles.
Consult with Maori to identify preferred options
4. Implement performance incentives for meeting service targets for guidelines
implementation for Maori access and treatment
5. Similar approaches should be used for Pacific peoples who have a similar
epidemiology and service needs
10. REFERENCES
1. Murray CJL et al
Effectiveness and costs of interventions to lower systolic blood pressure and
cholesterol: a global and regional analysis on reduction of cardiovascular-
disease risk
Lancet 2003: 361: 717-25

2. Crowley S, Dunt D, Day N Cost-effectiveness of alternative interventions for
the prevention of coronary heart disease,
Aust J Public Health, 1995, 19: 336-46
3. Oldridge NB
Comprehensive cardiac rehabilitation: is it cost-effective?
Eur Heart J (1998) 19 (Supplement O) O42-O49
4. Sculpher, MJ et al
Resource allocation for chronic stable angina: a systematic review of
effectiveness of alternative interventions
Health Technology Assessment 1998; Vol 2 No 10 (exec summary)
5. Tukuitonga, C. and A. Bindman (2002)
Ethnic and gender differences in the use of coronary artery revascularisation
procedures in New Zealand
NZMJ 115(26 April): 179-82

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Source: http://www.ccdhb.org.nz/meetings/CPHACpapers/2006_08_10/CardiovascularResourceAllocationMay04.pdf