Māori Pathways to and Through Health Care for STEMIs in New Zealand. Summer Studentship Research by Ellie Tuzzolino- Smith

Transcription

1 Māori Pathways to and Through Health Care for STEMIs in New Zealand Summer Studentship Research by Ellie Tuzzolino- Smith

2 Terminology & Current Practice STEMI: S-T elevation Myocardial Infarction. Determined with ECG. More sever form of heart attack. Usually caused by blood clot, occluding coronary arteries, often these arteries are smaller than they should be due to arthrosclerosis. CODE STEMI: Protocol at Whangarei Hospital at time of study where patients presenting with STEMI flown by helicopter to Auckland for rescue PCI.

3 Terminology & Current Practice Rescue PCI: Percutaneous Coronary intervention, cardio angiography performed, clot (if found) is aspirated, vessel is dilated with a balloon and metal stent is placed in any arteries with significantly decreased lumen size. To reduce risk of permanent damage to myocardium needs to occur within mins from onset of pain (White, 2012). Thrombolysis/ TNK: Tenecteplase, current drug used for alternative intervention in case of STEMI. Dissolves clot that is causing the STEMI. To reduce risk of permanent damage to myocardium needs to occur within 30mins from onset of pain (White, 2012).

4 Background According to NDHB data, mortality rates from acute myocardial infarction (MI) in Māori in Northland are 3-6 times Non-Māori. In contrast, an initial study of management of STEMI patients in Northland referred for acute angiography and stenting at Auckland hospital showed 79% were Pākehā men (White, 2012).

5 Aims To determine any inequities in care pathways pre-, during and post-admission between Māori and Non-Māori presenting with STEMI in Northland in

6 Data retrieved from: Methods The PREDICT primary care database Patient files Concerto (Northland DHB s electronic clinical record system) STEMI audit data and cardiac rehabilitation data. It was collated into a standard format. Analysis of demographic, pre-admission, intra hospital and post-discharge variables was carried out.

7 Baseline demographics for Northland STEMI patients Total STEMI patents in : 106 Minus-Out of Northland residence: 99 Minus-Files not pulled before 21/01/2013: 96 Māori (%/n) Non-Māori (%/n) Total Males 83.3% (15) 73.1% (57) Females 16.7% (3) 26.9% (21) Median age Median Age: Males: 57 Females: 67 Males: 67 Females:68 NZdep Quintile:1&2 11.1% (2) 14.1% (11) 3&4 11.1% (2) 33.3% (26) 5&6 55.6% (10) 24.4% (19) 7&8 0% (0) 15.4% (12) 9& % (4) 12.8% (10)

8 Pre-Hospital Admission Factors Māori (%/n) Non-Māori (%/n) Entered in Predict: 77.8% (14) 44.9% (35) Predict risk >15%: 78.6% (11) 71.4% (11) Predict multiple risk factors 100% (14) 71.4% (11) Predict patients with: Diabetes 64.3% (9) 22.9% (25) Previous MI 21.4% (3) 34.3% (12) Current 57.1% (8) 14.3% (5) Smoker BMI> % (10) 75.9% (29) BP > 140/ % (4) 8.6% (3) Prescribed interventions 72.7% (8) 52% (13)

9 Annualised STEMI rates. Average of Māori (rate/100,000/year) Years Years Years Annualised Myocardial infarction deaths for Māori (rate/100,000/year) Non-Māori (rate/100,000/year) Non-Māori (rate/100,000/year) Years Years Years Female Male Female Male Years Years Years

10 Distances by car

11 Driving distance from home to hospital Live: Māori (%/n) Non-Māori (%/n) <30min of Hospital 83.3% (15) 64.1% (50) >30min of Hospital 16.7% (3) 35.9% (28) Initial admission factors Admitted to: Māori (%/n) Non-Māori (%/n) Bay of Islands ED 22.2% (4) 6.4% (5) Dargaville ED 5.6% (1) 9% (7) Kaitaia ED 11.1% (2) 9% (7) Rawene ED 0% (0) 1.3% (1) Whangarei ED 61.1% (11) 74.4% (58) Sent by GP/White cross 11.1% (2) 5.1% (4)

12 Clinical presentation

13 Treatment Decisions Māori (%/n) Non-Māori (%/n) Pre-ED Thrombolysis 5.6% (1) 11.5% (9) ED Thrombolysis 50% (9) 30.8% (24) CODE STEMI 38.9% (7) 47.4% (37) Non-Urgent 5.6% (1) 6.4% (5) Diagnostic angio 88.9% (16) 88.5% (69) PCI: 55.6% (10) 73.1%(57) Successful Stenting 80% (8) 84.2% (48) Unsuccessful Stent 20% (2) 15.8% (9) Diagnostic ECHO 83.3%(15) 83.3% (60) Pre-ED thrombolysis was more likely to occur if patients lived further than 30 minutes from a hospital, and overall, the CODE STEMI pathway was more likely to be offered to patients living within 30 minutes of Whangārei hosp (both stat sig). The travel time from onset of pain to time of call to GP/ambulance is of no difference between Maori and non-maori.

14 Total STEMI patients mortality Māori (%/n) Non-Māori (%/n) Deceased before discharge 0% (0) 7.7% (6) Deceased before outpatient appt. Deceased within 6months STEMI 5.6% (1) 11.5% (9) 11.1% (2) 11.5% (9) Mortality Thrombolysis patients vs PCI Of the 2 Māori who died, both had been sent for CODE STEMI and had succesful PCI. Of the 9 Non-Māori who died, 3 went for CODE STEMI but had unsuccessful PCI 3 had thrombolysis only 2 had thrombolysis followed by unsuccesful PCI 1 refused treatment

15 Post STEMI follow up Māori (%/n) Non-Māori (%/n) Have Outpatient records 76.5% (13) 87% (60) Reported follow up ECHO: 27.8% (5) 32.9% (24) Reported follow up ETT: 5.9% (1) 11.6% (7) Cardiac Monitoring Test: 0% (0) 5.8% (4) Offered cardiac rehab: 82.4% (14) 84.1% (58) Attended (of Offered): 35.7% (5) 55.2% (32) ECHO: Echocardiogram (Cardiac Ultrasound) ETT: Exercise tolerance test (done on treadmill hooked up to ECG)

16 Discussion 1) Only 18/96 were Māori of these most were entered in predict and most lived within 30minutes of the hospital, indicating that this group was not reflective of true Māori population. This group may face less barriers to health care and further investigation must be done into what barriers the unrepresented Māori are facing to health care.

17 2)There are inequities that need to be addressed, in terms of geographical access to CVD and STEMI management in Northland. Wider availability of treadmill testing and angiography, and systematic use of pre-ed thrombolysis may have a greater impact on patient outcomes than putting more effort into the CODE STEMI pathway. Further research is also needed to assess and address barriers for Māori to primary care, CVD risk assessment and management.

18 3)However there were no statistically significant inequities identified in the pathway of care between Māori and Non-Māori in this study, once STEMI was diagnosed, the mortality outcomes were similar. Geographical proximity to Whangārei hospital (<30mins by road) was the primary determinant of whether patients followed the CODE STEMI protocol rather than whether they were Māori or Non-Māori.

19 Strengths of this study Looking directly at patient files enabled a greater depth of knowledge to be gained. Opportunity for further analysis as medication data was also obtained. Weaknesses Information on modes of transport to the hospital would have been helpful in analysing timing and distance and should have been recorded during file data collection.

20 Opportunity for further research Gain ethics approval to look at if each STEMI patient was filling their medication scripts post STEMI. More qualitative research is needed to determine further, the barriers Māori are facing to CVD prevention and management and how they can be addressed, so that CVD inequities can be diminished. For example issues around health literacy, GP services and emergency transport in a more rural setting could be investigated further. Along with whether Māori want to go to hospital.

21 Acknowledgements Drs Clair Mills, Kyle Eggleton and Stephen Jennison: Supervisors Anil Shetty: Mapping, Technical support Ryan Howard & Sue Vallancey: STEMI Audit Data Stephen Jennison, Wendy Coleman & Lorraine Parker: Cardiac Rehabilitation Data Medical Records Staff: File Retrieval Pukawakawa Staff and Program: Facility Usage Northland DHB: Facility usage and creating the opportunity to carry out this study. University of Auckland: Funders of the Studentship programme.

22 Summer Studentship, How recruited. personal experience Māori students doing Māori research, will get funding. Jobs I did. What I enjoyed: Meeting people, seeing how DHBs work, Analysis, living at home. What I found challenging: Data collection, understanding statistics.