cardiac_framework by jizhen1947

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									Cardiac Services Framework
for Victoria
A report prepared for the Department of
Human Services
April 2008
This report has been prepared solely for internal use by the Department of Human Services (Victoria)
and is not to be used for any other purpose. We do not accept any responsibility for losses occasioned
to any other party, or to Department of Human Services (Victoria) for use for any other purpose, for any
consequences that may arise from the circulation, reproduction or use of this report.

The report is based on information supplied by Department of Human Services (Victoria), submissions
received by PricewaterhouseCoopers as part of the review, data collected during the public
consultations, information supplied by Department of Human Services (Victoria) staff, and interviews
conducted with a range of stakeholders. We have not verified the completeness or accuracy of that
information and are not liable for any loss or damage sustained by Department of Human Services
(Victoria) or any other person in connection with our reliance on it.
Contents
1               Executive summary                                                         1
2               Recommendations                                                           4
3               Introduction                                                             11
                Background to the review                                                 11
                Scope of this report                                                     12
4               Method                                                                   13
                Quantitative data                                                        13
                Qualitative data                                                         13
5               The current cardiac service system                                       15
                Key features of the service system                                       15
                Research                                                                 16
                Range and volume of major services                                       17
6               The future cardiac service system                                        27
                Planning principles                                                      27
                A system of care                                                         27
                Monitoring of and accountability for quality of care                    84
                Variation and appropriateness                                            85
7               Conclusion and Implementation Plan                                      88
Appendix A      Cardiac services review and service planning framework development       99
Appendix B      Glossary                                                                101
Appendix C      Admitted patient activity – all cardiology                              103
Appendix D      Admitted patient activity – Other cardiology                            111
Appendix E      Admitted patient activity – Cardiothoracic surgery                      116
Appendix F      Admitted patient activity – Interventional cardiology                   120
Appendix G      Utilisation                                                             127
Appendix H      Sameday/non sameday and average length of stay trends                   134
Appendix I      Self sufficiency and catchment areas                                    140
Appendix J      ICU and CCU, MAPU and SOU usage                                         156
Appendix K      Emergency department presentations                                      160
Appendix L      List of attendees at focus groups                                       167
Appendix M      Survey results                                                          170
Appendix N      Average length of stay by hospital                                      173
Appendix O      Public hospital admissions by CRG, hospital region and patient region   176
Appendix P      Data survey                                                             178
Appendix Q      References                                                              181




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                              i
1         Executive summary
1.1       Cardiac disease is expensive, debilitating and challenging to manage. Coronary heart disease
          is the single largest single cause of death and the highest cost individual disease in Australia.
          The incidence of cardiovascular disease is increasing and developments in treatments and
          care are evolving constantly. In response, health planners must be proactive in managing
          future service development. To this end, Victoria’s Department of Human Services sought
          proposals from consultants to review cardiac services and develop a planning framework to
          ensure services are fit for the future. PricewaterhouseCoopers (‘We’) were appointed to
          conduct this review and report on our findings.

1.2       This project has been undertaken under the guidance of the Department of Human Services via
          a project steering committee; the Cardiac Services Advisory Committee which was comprised
          of clinical and managerial staff from across the State (Appendix A) and which provided direction
          and information and gave expert specialist opinion to the Review.

1.3       PricewaterhouseCoopers developed and documented a full understanding of current service
          provision through data gathering and analysis from standard secondary data sets; structured
          primary data gathering of quantitative and qualitative measures from healthcare providers; a
          review and consideration of alternative models of care; and a comprehensive program of
          stakeholder engagement.

1.4       This document sets out firstly to outline current services and then addresses planning future
          services. It is structured to review and recommend initiatives at system planning levels, then at
          the level of clinical operational and delivery systems, and finally at the level of ensuring
          continuity of flow and co-ordination across the system. The following sections and
          recommendations therefore pertain to:
         •       System Planning (Recommendations 1-6)
         •       Clinical Delivery and Standards ( Recommendations 7-27)
         •       Resource Planning and Support ( Recommendations 28-31)
         •       Effective Co-ordination and Patient Flow ( Recommendations 32-48)

1.5       Unless otherwise noted, this report addresses public sector services.

1.6       In the Victorian public sector, cardiac surgery is provided by six tertiary hospitals and
          Percutaneous Coronary Intervention is provided by a further four metropolitan hospitals.
          Approximately 120 public hospitals provide cardiac services of varying levels of complexity to
          their communities.

1.7       This report recommends the adoption of planning principles to form the basis for the future
          development of Victoria's cardiac services system. The principles highlight quality and safety as
          the overriding considerations.

1.8       Acute Coronary Syndrome is a life threatening emergency, the management of which has
          changed markedly over the past two decades. With appropriate intervention it is possible in
          many patients to prevent or limit permanent damage to the myocardium and reduce short-term
          and long-term complications of the disease. In addition, there is an increasing burden of




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                           1
Executive summary




          disease associated with chronic cardiac conditions which need to be managed actively in
          accordance with good practice to optimise quality of life and minimise disease complications
          and progression.

1.9       Victorian hospitals have adapted well to the increasing demands for and opportunities relating
          to quality cardiac care, but the international literature suggests that further significant gains in
          the management of Acute Coronary Syndrome will only be achieved through developing more
          formal systems of care incorporating role definition of providers, agreed clinical standards and
          guidelines, defined networks for patient flows between hospitals, formal protocols for patient
          referral and transfer and greater provision and uptake of effective rehabilitation programs.

1.10      The report recommends that the Victorian public sector adopts agreed clinical standards and a
          defined system of cardiac care. Timely access to services is the key to good outcomes,
          particularly for patients with Acute Coronary Syndrome. A role delineation framework is
          proposed. It also is proposed that detailed regionalised plans will be developed, under the
          guidance of a cardiac clinical network, that define evidence-based local responses to the care
          of patients with Acute Coronary Syndrome in the context of the patient's presenting symptoms
          and the infrastructure that is accessible within defined timeframes. Protocols for pre-hospital
          thrombolysis where appropriate; linkage of ambulance vehicles to emergency departments
          and/or cardiac catheter laboratories enabling rapid transfer of appropriate patients straight to
          the laboratory; transfer of appropriate patients direct to a hospital capable of providing cardiac
          intervention; rapid interhospital transfer of appropriate patients; and formalisation of referral
          pathways so that all patients, particularly rural patients, can access timely care will be features
          of the cardiac care system in Victoria.

1.11      The cardiac clinical network also will play a key role in informing ongoing planning of services;
          advising on policy; defining meaningful infrastructure, clinical care and performance standards;
          developing clinical guidelines and protocols; monitoring and reporting on the accessibility and
          quality of care; investing in people and influencing resource allocation priorities.

1.12      The Review recommends that all public hospitals are required as a condition of funding, to
          contribute a minimum dataset relating to all interventional procedures to a centralised registry.
          This will provide a rich source of data for the cardiac clinical network to oversee system-wide
          access and quality.

1.13      The report assesses in detail the arguments for and against decentralising critical cardiac
          interventional infrastructure. Although this infrastructure is needed on a time critical basis by
          only a small proportion of patients with cardiac disease, it acts as a catalyst for the
          development of specialist cardiac services and therefore has the potential to bring considerable
          benefits to communities. A desire for local access needs to be balanced, however, with the
          clear evidence that concentrating services is necessary to promote service quality. Decisions
          also need to be taken in the context that an effective medical alternative treatment is available
          for most patients with Acute Coronary Syndrome.

1.14      The report concludes that it is reasonable to continue the development of facilities for
          Percutaneous Coronary Intervention (PCI) in the four general metropolitan health services
          which do not currently provide cardiac surgery. It also recommends the development of new
          PCI facilities in Bendigo and new diagnostic angiography facilities in Ballarat under the
          supervision of a highly experienced operator and with appropriate monitoring of performance.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                 2
Executive summary




          Over the planning period, additional investment will be required in laboratories in some existing
          services. Further development of PCI facilities is not recommended during the planning period,
          but it is noted that cardiac CT is evolving rapidly as a diagnostic technology and it may become
          a viable alternative to diagnostic angiography infrastructure in large regional centres during the
          planning period.

1.15      The Review recommends that there be no change in the number or distribution of cardiac
          surgical services. It is recommended, however, that waiting list data be collated centrally and
          that patients are advised of waiting times in other hospitals, to facilitate their choice of a
          provider who can provide earlier access.

1.16      The Review noted the evolving applicability of highly specialised testing such as Cardiac CT
          and MRI. The development of these diagnostic tools should be supported in tertiary hospital
          settings but it is recommended that these services are not introduced into new non-tertiary
          settings until their clinical application and cost effectiveness are better understood.

1.17      There is a growing need for specialist services for people suffering congestive heart failure.
          This is a common and debilitating disease requiring a multidisciplinary approach and the
          application of evidence-based treatment. Heart failure management programs in the
          metropolitan area have been successful but generally are not available in rural areas. In
          addition, various therapies such as biventricular pacing and Implantable Cardiac Defibrillators
          are effective in some patients and should be available to them.

1.18      There is inadequate uptake of cardiac rehabilitation services in Victoria. It is likely that this
          relates to a combination of factors including lack of funded programs, inflexible programs and
          sub-optimal referral practices. The report recommends a significant investment in cardiac
          rehabilitation which has been demonstrated to improve clinical outcomes significantly.

1.19      There was significant representation to the Review that the Department should mandate the
          structure and/or number of specialist cardiac resources to be provided by health services,
          including intensive care beds for cardiac surgery and cardiac care units. The report
          recommends that these issues remain the responsibility of individual hospitals and health
          services but that the proposed cardiac clinical network and the Department's Intensive Care
          Advisory Committee take an oversight role to ensure that adequate resources are applied to
          the service system as a whole.

1.20      There are substantial workforce challenges affecting the delivery of cardiac services in Victoria.
          The role of cardiac nurses is changing and there are barriers to recruitment and retention.
          There is a significant shortage of technologists. The report proposes that the Department of
          Human Services Service and Workforce Planning Branch works with the proposed cardiac
          clinical network and other bodies to develop a strategy to ensure a sustainable workforce for
          the future.

1.21      The recommendations of this Review balance a desire for local access to services with the
          need to centralise services for quality purposes; the duty of care to individual patients versus
          responsibility to the overall population; and the diversity of demographics. They need to be
          interpreted in the context of different settings of care.

1.22      The final section of the report describes a high level implementation plan to assist in taking
          forward the recommendations.




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2         Recommendations
Recommendation 1

That the following planning principles form the basis for future development of the Victorian cardiac
services system:

•     Quality and safety of care are the overriding considerations in planning and delivering cardiac
      services in Victoria.
•     Cardiac services are time critical – better outcomes are achieved with quicker treatment: thus
      access to cardiac services must be timely and equitable for the residents of Victoria
•     The system should be developed to meet volume requirements necessary to maintain quality
      standards.
•     Service delivery will define the system structure – teaching and research will follow services.

Recommendation 2

That Victoria's cardiac care services are planned and developed to form an integrated system of care,
with the objective of ensuring equity of access to safe, high quality services for all Victorians, regardless
of their place of residence or place of presentation to the health care system.

Recommendation 3

That the Department of Human Services establishes a clinical network for cardiac services in Victoria to
provide clinical leadership, define standards for infrastructure and leadership, promote quality care,
improve the coordination and efficient use of clinical resources and monitor and report on the quality of
cardiac care in Victoria.

Recommendation 4

That the proposed cardiac clinical network works with stakeholders across the State to develop region-
specific plans for the optimal use and coordination of cardiac care resources in accordance with
evidence-based practice in all metropolitan and rural regions.

Recommendation 5

That the Department of Human Services supports the appointment of specialist cardiac care
coordinators in each metropolitan health service that provides acute cardiac services and in each rural
region.

Recommendation 6

That the publications of the Cardiac Society of Australia and New Zealand and the National Heart
Foundation of Australia: Guidelines for the Management of Acute Coronary Syndromes 2006 and
Guidelines for the Prevention, Detection and Management of Chronic Heart Failure in Australia 2006 as
updated from time to time are adopted by the Victorian public health care system as the appropriate
standard of care for patients suffering from relevant cardiac conditions.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                            4
Recommendations




Recommendation 7

That the proposed cardiac clinical network develops guidelines for angiography and PCI services without
on-site surgical back-up in Victoria, for endorsement by the Department of Human Services and
incorporation into conditions of funding if necessary, and that the guidelines are consistent with the
Cardiac Society of Australia and New Zealand's 2008 Guidelines on Support Facilities for Coronary
Angiography and Percutaneous Coronary Intervention (PCI) including Guidelines on the Performance of
Procedures in Rural Sites.

Recommendation 8

That PCI is not offered in centres in Victoria unless the predicted volumes of procedures (individual and
centre) reach levels at least equivalent to those recommended in the Guidelines for the Management of
Acute Coronary Syndromes 2006 and Guidelines in Competency in Coronary Angioplasty, which
currently are:

•     75 cases per year for each cardiologist
•     200 cases per year for each centre (the centre volume can be less when operators are
      concurrently practising at other centres)
•     Greater than 36 cases of primary PCI per unit per year.

Recommendation 9

That all public hospitals in which PCI infrastructure is available work towards providing 24 hour access to
primary PCI for patients suffering ST Elevated Myocardial Infarction (STEMI).

Recommendation 10

That the Department of Human Services supports the development of 24-hour PCI services at Northern,
Frankston and Bendigo Hospitals.

Recommendation 11

That the Department of Human Services supports the development of diagnostic angiography services
at Ballarat Base Hospital.

Recommendation 12

That the Department of Human Services ensures that new angiography and PCI services are developed
under the supervision of a highly experienced operator and in compliance with recommended patient
selection criteria and that outcomes are monitored by the supervising operator to ensure appropriate
quality standards are achieved.

Recommendation 13

That the Department of Human Services reviews the cost weights for PCI to take account of the cost
differentials between elective, in-hours emergency and out-of-hours emergency PCI.

Recommendation 14

That the current service system configuration for cardiac surgery is maintained and that no additional
surgical units are developed in Victoria during the planning period.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                            5
Recommendations




Recommendation 15

That the proposed cardiac clinical network monitors indicators of demand for and supply of cardiac
services as well as appropriateness of service provision to ensure that an appropriate balance between
community need and service provision is maintained.

Recommendation 16

That the Department of Human Services requests its Intensive Care Advisory Committee to consider the
issue of access to intensive care beds for cardiac surgical patients in the context of the overall supply of
intensive care beds in the State.

Recommendation 17

Both cardiac magnetic resonance imaging and cardiac computerised tomography are developing as
effective technologies with distinct and defined clinical applications; it is recommended that their
development and evaluation within centres of excellence are supported; but that they are not
introduced into new non-tertiary settings in Victoria until their clinical application including cost-
effectiveness is fully evaluated and there is a sustainable arrangement for funding that incorporates
an appropriate contribution from the Australian Government.

Recommendation 18

That the current service system configuration for complex electrophysiology continues and that no
additional complex electrophysiology units are developed in Victoria in the foreseeable future, unless
indications for its application change substantially leading to a significant increase in demand.

Recommendation 19

That the Department of Human Services investigates the feasibility of reforming funding for
electrophysiology so that the case payment for these services reflects their true cost including the cost of
single use devices.

Recommendation 20

That the Department of Human Services:

•     seeks advice from all relevant health services about the number of patients predicted to meet
      eligibility criteria as established by the Medical Services Advisory Committee for Implantable
      Cardioverter Defibrillators and combined implantable cardiac resynchronisation and cardioverter
      defibrillator therapy; and
•     with the advice of the proposed cardiac clinical network negotiates and includes within health
      service funding agreements a target level of provision by each health service that is predicted to
      meet reasonable demand.

Recommendation 21

That each proposed region-specific plan for the optimal use and coordination of cardiac care resources
incorporates a detailed plan, developed in conjunction with the Hospital Admission Risk Program -
Chronic Disease Management (HARP-CDM) Program, for the management of congestive heart failure in
accordance with the relevant clinical guidelines.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                           6
Recommendations




Recommendation 22

That the Department of Human Services works with the proposed cardiac clinical network and with
relevant stakeholders to develop structural and service coordination models for a designated state-wide
service for adults with congenital heart disease, with services to be provided from two sites (Monash
Medical Centre and the Royal Melbourne Hospital).

Recommendation 23

That the National Heart Foundation of Australia and the Australian Cardiac Rehabilitation Association
Recommended Framework for Cardiac Rehabilitation is adopted by the Victorian public health care
system as the appropriate standard for the provision of cardiac rehabilitation services.

Recommendation 24

That the proposed cardiac clinical network reviews and advises the Department of Human Services on
necessary updates to the publication Best Practice Guidelines for Cardiac Rehabilitation and Secondary
Prevention, ensuring its consistency with the Recommended Framework for Cardiac Rehabilitation.

Recommendation 25

That the proposed cardiac clinical network leads a project incorporating:

•     the development of specific standards for provision of Phase 1 and provision of or referral to
      Phase II cardiac rehabilitation programs;
•     provision of incentives to all acute hospitals that offer cardiac services for the development and
      implementation of referral improvement plans consistent with the endorsed standards;
•     an audit program of hospital records to monitor and evaluate compliance with the endorsed
      protocols;
•     performance bonuses to acute hospitals based on assessed performance; and
•     performance indicator development and ongoing monitoring.

Recommendation 26

That the Department of Human Services reviews funding of cardiac rehabilitation services across
Victoria and ensures that:

•     there is sufficient funding which is appropriately distributed to ensure equitable access to quality
      services by all eligible patients;
•     funding streams are consolidated so as not to create an undue administrative burden on providers;
      and
•     funding enables the development and provision of a mix of services tailored to patient needs.

Recommendation 27

That the Department of Human Services' Palliative Care Advisory Committee is asked to advise the
Department on strategies to strengthen palliative care services for cardiac patients across the state.

Recommendation 28

That the Department of Human Services continues to support all hospitals which offer emergency
cardiac services to develop the infrastructure necessary to monitor and evaluate patients with chest pain
in accordance with the Guidelines for the Management of Acute Coronary Syndromes 2006.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                           7
Recommendations




Recommendation 29

That the proposed cardiac clinical network:

•     assists hospitals and health services to undertake a cardiac equipment stocktake and develop
      equipment replacement plans; and
•     advises the Department of Human Services on system-wide priorities for the funding of cardiac
      equipment.

Recommendation 30

That the Department of Human Services Service and Workforce Planning Branch works with the
proposed cardiac clinical network and relevant professional bodies to develop a strategy to ensure a
sustainable cardiac workforce in Victoria with particular emphasis on the nursing and technology
workforce.

Recommendation 31

That the cardiac clinical network works with the designated level 5 and 4 cardiac hospitals and relevant
tertiary education institutions to design and implement appropriate education modules for the cardiac
nursing and allied health workforces.

Recommendation 32

That the Department of Human Services supports the Metropolitan Ambulance Service and Rural
Ambulance Victoria to complete the installation of equipment to support12-lead electrocardiogram
capability in all Victorian ambulances that are used to transport patients suffering from Acute Coronary
Syndrome, and to implement associated protocols, training and technologies.

Recommendation 33

That the region-specific plans proposed in recommendation 4 incorporate plans for the maintenance
and/or enhancement of pre-hospital cardiac care resources and models of care in accordance with best
practice standards, including pre-hospital thrombolysis for appropriate patients.

Recommendation 34

That the region-specific plans proposed in recommendation 4 incorporate region-specific protocols for
the ambulance transport of patients suffering STEMI direct from home to PCI-capable facilities if access
can be achieved reliably within timeframes recommended in the Guidelines for the Management of
Acute Coronary Syndromes 2006.

Recommendation 35

That the proposed cardiac clinical network oversees the development of a state-wide inter-hospital
transfer protocol for the emergency management of patients with STEMI who present to a hospital that
does not offer primary PCI.

The protocol should:

•     be consistent with the Guidelines for the Management of Acute Coronary Syndromes 2006;
•     identify the hospitals which are located sufficiently proximate to a provider of primary PCI to enable
      primary PCI to be offered routinely to appropriate patients;
•     provide for the acute inter-hospital transfer of appropriate patients if the time since onset of the
      patient's symptoms, local conditions including the hospital's location and infrastructure and




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                           8
Recommendations




      ambulance transport infrastructure are such that primary PCI can be accessed within a time that is
      consistent with the Guidelines for the Management of Acute Coronary Syndromes 2006; and
•     require hospitals that offer primary PCI to guarantee access without delay on a 24 hour basis to
      patients referred in accordance with the protocol.

Recommendation 36

That the Department of Human Services sponsors the development and evaluation of 'intention to treat'
trials for the safe referral of and inter-hospital transfer for the provision of primary PCI to appropriate
patients suffering STEMI who present to Ballarat Base and Latrobe Regional Hospitals.

Recommendation 37

That the Department of Human Services considers reimbursing private hospitals for the marginal costs
of care of uninsured patients who present with a cardiac emergency and are provided with emergency
cardiac interventional services in accordance with Guidelines for the Management of Acute Coronary
Syndromes 2006.

Recommendation 38

That the Department of Human Services raises with the Australian Government stakeholder concerns
about the sale of private health insurance products that exclude services necessary in a life-threatening
emergency.

Recommendation 39

That the proposed cardiac clinical network supports all hospitals which provide primary PCI services to
develop, in conjunction with ambulance services and local Divisions of General Practice, a protocol for
direct access to the catheterisation laboratory for patients who are diagnosed with STEMI in the pre-
hospital phase; and for rapid diagnosis and transit through the Emergency Department for patients who
present with undiagnosed STEMI.

Recommendation 40

That the proposed cardiac clinical network oversees the development of a template agreement between
referring and receiving hospitals, specifying the types of obligations that will apply to referring and
receiving hospitals when a referral of a cardiac patient is made for diagnosis or medical or surgical
treatment.

Recommendation 41

That the proposed cardiac clinical network supports hospitals that do not provide a comprehensive range
of specialist cardiology services to negotiate agreements with appropriate receiving hospitals, consistent
with the template agreement, providing for equitable access by their referred patients to an appropriate
range of services.

Recommendation 42

That clinicians in referring hospitals retain the right to refer patients to the clinician/hospital of choice as
agreed with the patient and/or their representative (other than in acute cardiac emergencies requiring
PCI as provided for in recommendation 35) but in the event that a timely service cannot be arranged the
agreement provides a 'default' referral option and the receiving hospital that is a party to the agreement
is obliged to accept the patient in accordance with the terms of the agreement.




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Recommendations




Recommendation 43

That the Department of Human Services evaluates the feasibility of implementing a 'rural referral WIES
bonus' so that hospitals that accept urgent or semi-urgent referrals from rural and regional centres do not
incur a net financial penalty if, as a result, the allocation of a bed to a patient waiting in their emergency
department is delayed.

Recommendation 44

That metropolitan hospitals are funded via the proposed ‘rural referral WIES bonus’, and required
through the relevant inter-hospital agreements, to provide clinically-necessary metropolitan
accommodation and to explore mechanisms for supporting the reasonable costs of transport home
where necessary for rural cardiac patients who have been admitted on an urgent or semi-urgent basis.

Recommendation 45

That the proposed cardiac clinical network establishes a reliable system for collecting information about
waiting times for various cardiac services so that cardiac patients who are placed on waiting lists for
consulting, diagnostic, interventional or surgical services can be provided with clear advice about their
expected waiting times and the average waiting times in other hospitals and can be offered access to
alternative services.

Recommendation 46

That the Department of Human Services endorses the role delineation model proposed in this report
including the definition of levels 5-1 and the associated hospital designations.

Recommendation 47

That the proposed cardiac clinical network oversees the establishment and ongoing analysis of a
comprehensive cardiac services registry covering interventional and surgical services provided to all
patients in all public hospitals in Victoria, for the purposes of monitoring and advising on the quality of
cardiac care including accessibility, effectiveness and appropriateness. Provision of data to the Victorian
cardiac services registry is a condition of funding of all hospitals providing interventional and surgical
cardiac procedures

Recommendation 48

That DHS take action to ensure the provision of timely and accurate data to the Victorian Cardiac
Services Registry.

.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                           10
3         Introduction
3.1       This report has been developed for the Department of Human Services (DHS). It consolidates
          the findings of a review conducted by PricewaterhouseCoopers (PwC) into the current state of
          acute and subacute cardiac services in Victoria and outlines a service planning framework for
          the future development of cardiac services.

3.2       In the course of this document a number of recommendations have been made, some of which
          have considerable funding implications. The DHS will have to consider these within the
          confines of usual funding processes and priorities.


Background to the review
3.3       The DHS commissioned PwC to review cardiac services and develop a service planning
          framework for Victoria (the Review).

3.4       The objectives of the Review were to:
         •       review current and projected adult cardiac services in Victoria;
         •       develop a planning framework to co-ordinate delivery of acute (diagnostic assessment
                 and treatment) and sub-acute (rehabilitation) adult cardiac services in Victoria; and
         •       develop an integrated state-wide approach to the care of adults with cardiac disease.

3.5       The scope of the Review included cardiology, cardiac surgery and rehabilitation services. While
          its primary focus was public sector services, it incorporated consideration of the private sector
          service system and, in particular, public/private service interfaces.

3.6       The planning framework developed as part of this Review recognises that some health system
          components (for example primary prevention, ambulance services and general practice) are
          essential to a well-functioning cardiac services system although they were not included in the
          scope of the Review.

3.7       The Review process commenced in June 2007 and concluded in February 2008. Governance
          was provided by the Cardiac Services Advisory Committee (CSAC), the composition of which
          included members with the following expertise and/or links:
         •       cardiology, cardiac surgery, cardiac nursing, rehabilitation, emergency physician, rural
                 and remote medicine, ambulance;
         •       metropolitan & rural health service managers;
         •       peak body (National Heart Foundation Australia); and
         •       consumer/consumer advocate

3.8       Various members were endorsed by their respective professional organisations (Cardiac
          Society of Australia and New Zealand (CSANZ), Royal Australasian College of Surgeons,
          Australasian College for Emergency Medicine, Australasian College of Rural and Remote
          Medicine, Victorian Association of Cardiac Rehabilitation, Victorian Cardiac Nurses’
          Association, Metropolitan Ambulance Service and Rural Ambulance Victoria).




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                         11
Introduction




3.9        A list of members of CSAC is attached at Appendix A.

3.10       The methodology for the Review consisted of:
           •     an analysis of data held by the DHS in its routine datasets (primarily the Victorian
                 Admitted Episodes Dataset (VAED) and the Victorian Emergency Minimum Dataset
                 (VEMD);
           •     collection and analysis of qualitative and quantitative data held at health service level;
           •     demographic analysis;
           •     a literature review;
           •     a comprehensive program of stakeholder consultation;
           •     development of 'current state' and 'future state' reports; and
           •     development of a service planning framework for the next 10 years.


Scope of this report
3.11       This report provides an overview of cardiac services in Victoria and proposes a framework for
           planning for the next 10 years.

3.12       It has been written with the guidance of CSAC and DHS.

3.13       Unless explicitly identified by reference to the private sector, the report addresses public
           cardiac services. Nevertheless, standards and principles recommended for public sector
           services are equally relevant to the private sector and the document addresses some issues of
           relevance to the private sector.

3.14       Out of scope for this report were:
      •   A review of paediatric cardiac services
      •   A review of funding models associated with cardiac care
      •   A cost analysis of acute and sub-acute cardiac services
      •   A comprehensive analysis of acute and sub-acute cardiac care in the private sector,
          although the interface between the private and public sectors will be explored
      •   A comprehensive analysis of the ambulance services, primary care, aged care
          services and non-Government organisations in the delivery of cardiac care.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                              12
4               Method
Data for this review were collected and collated in order to provide an understanding of both current
service provision in Victoria and best practice elsewhere. Qualitative and quantitative data were
collected in the course of the review as described below.


Quantitative data
4.1             Data were gathered from the following sources for the purpose of describing current activity
                and capacity of cardiac services within the public health system:
                •        VAED for 2001/02 – 2005/06;
                •        VEMD for 2001/02 – 2005/06;
                •        Australian Institute of Health and Welfare (AIHW) for 2001/02 – 2004/05; and
                •        Australian Bureau of Statistics (ABS).

4.2             A data collection form was developed by PwC (Appendix P). The data collection strategy was
                reviewed and endorsed by CSAC and approved by DHS. The data collection form was sent to
                more than 100 public hospitals in Victoria. All metropolitan health services and 23 regional and
                rural hospitals responded. Responses covering 8 private hospitals from 5 provider groups also
                were received.


Qualitative data

Literature review

4.3             The review of literature for this report examined the published information regarding cardiac
                services within Victoria. The literature review used online databases such as PubMed and Ovid
                Medline and journal publications such as Journal of American Cardiac Intervention, American
                Heart Journal, Annals of Thoracic Surgery, The New England Journal of Medicine and
                Circulation. Websites visited included the National Heart Foundation, the Baker Heart Research
                Institute, the Cochrane Library, The Society of Thoracic Surgery and CSANZ.

4.4             Key words searched included but were not limited to: cardiac services, cardiac models of care,
                heart failure, heart care, history of cardiology, cardiology progress, volume versus quality of
                cardiac services, guideline recommendations, treatment of coronary syndromes, thrombolysis,
                electrophysiology, rural cardiac services, transport systems for cardiac services, public versus
                private interaction, out of hospital diagnosis and out of hospital thrombolysis.

4.5             In addition websites of relevant government and cardiac organisations were searched for grey
                literature.i


    i
        Grey literature is defined by the National Library of Australia as "information that is not searchable or accessible through conventional
        search engines or subject directories and is not generally produced by commercial publishing organisations. It can include
        publications issued by government, industry, business and academia occurring in databases and intranets - see
        http://www.nla.gov.au/padi/topics/372.html.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                              13
Method




Stakeholder consultation

4.6       The stakeholder consultation was led by Dr Heather Wellington (DLA Phillips Fox Lawyers) on
          behalf of PwC. The objectives of the stakeholder consultation were to:
         •       provide an overview of the scope and objectives of the Review and opportunities for
                 participation;
         •       achieve key stakeholder commitment to the Review through early participation; and
         •       gain an understanding of stakeholder views about the configuration of the current service
                 system, models of care, the main issues affecting quality service delivery and
                 opportunities/plans for improvement and development.

4.7       The consultation process consisted of:
         •       interviews with multidisciplinary groups nominated by individual service provider
                 organisations, with a focus on understanding agency service delivery arrangements,
                 barriers to quality service delivery and plans for service development. These interviews
                 were conducted with:
                 –     the six major health services that provide cardiac surgery, cardiology and
                       rehabilitation services (Austin, Barwon, Bayside, Melbourne, Southern and St
                       Vincent's Health);
                 –     the four major acute metropolitan health services that provide specialist cardiology
                       and rehabilitation but not cardiac surgical services (Eastern, Northern, Peninsula
                       and Western Health);
                 –     major regional health services (Ballarat, Bendigo, Goulburn Valley, West Gippsland
                       and Latrobe);
         •       focus groups with multidisciplinary groups from a cross-section of service providers,
                 community services and consumer groups. Three focus groups were conducted in
                 Melbourne and three in rural areas (Hamilton, Warragul and Shepparton);
         •       a focus group with consumers;
         •       a focus group with private sector providers; and
         •       interviews with peak bodies whose member organisations have a significant interest in
                 cardiac services, including the General Practice Division Victoria and the Victorian
                 Cardiac Nursing Association.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                         14
5         The current cardiac service system
5.1       In order to establish a baseline state for future service planning a review of the current service
          system was undertaken. This review examined current activity, role delineation, referral
          patterns and reported areas for improvement. This chapter provides an overview of the
          findings. An overview of the full data analysis is provided in the appendices of this document.


Key features of the service system
5.2       Adult acute cardiac services (including emergency, inpatient, outpatient and rehabilitation
          services) are provided by approximately 120 public hospitals (approximately 28 metropolitan
          and 90 regional and rural) as well as a number of private hospitals.

5.3       Cardiac surgery including Coronary Artery Bypass Graft (CABG) surgery is provided by six
          tertiary hospitals (The Alfred Hospital, the Austin Hospital, Monash Medical Centre – Clayton
          Campus (MMC), the Royal Melbourne Hospital (RMH), St Vincent’s Hospital (SVH), and The
          Geelong Hospital).

5.4       Other highly specialised services including electrophysiology, Cardiac Computed Tomography
          (Cardiac CT) and Cardiac Magnetic Resonance Imaging (Cardiac MRI) also are provided by
          one or more of those six tertiary hospitals.

5.5       Percutaneous Coronary Intervention (PCI) is provided by each of the tertiary hospitals listed
          above and a further four metropolitan hospitals –
         •       Box Hill, Northern and Western Hospitals on a 24-hour-a-day basis (Northern expanded
                 its service to a 24-hour-a-day service during the course of this review); and
         •       Frankston Hospital on an “in hours” basis.

5.6       A range of associated treatments and diagnostic services including coronary angiography,
          Automated Implantable Cardiac Defibrillator (AICD) insertion, pacemaker insertion (including
          biventricular pacing), echocardiography and specialist cardiology consulting services are
          provided by the tertiary and other metropolitan hospitals listed above. Some larger regional
          public hospitals also provide some or all of these services.

5.7       Smaller metropolitan, sub-regional and rural services generally provide emergency
          assessment, basic diagnostic services, general inpatient care and rehabilitation services to
          patients with cardiac conditions. In rural centres, consulting services usually are provided by
          general physicians rather than specialist cardiologists.

5.8       The private sector provides a full range of inpatient services, representing between 25% and
          30% of total inpatient activity for the state.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                            15
The current cardiac service system




5.9           Most but not all patients who present with Acute Coronary Syndrome ii (ACS) to a hospital in
              the metropolitan area or Geelong have the opportunity of timely access to a full suite of
              diagnostic and interventional technologies either directly within the hospital to which they
              present or through referral to another hospital within the same health service (with the
              exception that patients who require cardiac surgery may require inter-hospital transfer to one of
              the six surgical provider hospitals).

5.10          In regional and rural Victoria, however, access to specialist consulting, diagnostic and
              interventional services differs significantly from region to region. With the exception of patients
              referred to The Geelong Hospital, rural patients with ACS who require emergency reperfusion
              do not have access to interventional services and almost invariably receive fibrinolytic therapy
              followed by urgent or semi-urgent transfer to a tertiary or other metropolitan hospital for further
              investigation and treatment.

5.11          There is no formalised system of care incorporating role delineation, defined networks for
              patient flows between hospitals and formal protocols for patient referral and transfer in Victoria.
              Access to cardiac care is based around the services provided by individual hospital and/or
              health services, complemented by a network of informal referral arrangements between
              individual professionals and units. Referral patterns currently are driven by a range of factors
              including:
              •        professional relationships between clinicians;
              •        organisational relationships;
              •        a history of good service by a receiving clinician;
              •        patient preference;
              •        geographic proximity; and
              •        bed availability.

5.12          Although referral patterns are not formalised, many providers of specialist cardiac services
              assume responsibility for service provision to people who present to other hospitals within their
              own health services and to residents of particular rural areas and attempt to respond to
              referrals from those areas where possible.


Research
5.13          Research is conducted by all of the major tertiary centres and increasingly by other centres,
              particularly those with interventional cardiology services. The Baker Institute in Victoria is a
              leading Australian research institute which undertakes research into the prevention and cure of
              cardiac disease. It has strong links with the Alfred Hospital, the University of Melbourne,
              Monash University and a number of other organisations.




  ii
        Acute coronary syndromes include "a broad spectrum of clinical presentations, spanning ST-segment-elevation myocardial infarction
       through to an accelerated pattern of angina without evidence of myonecrosis" - see Acute Coronary Syndrome Guidelines Working
       Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184 (8 Suppl): S1-S32




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                      16
The current cardiac service system




Range and volume of major services

Overview

5.14      In 2005/06 there were 112,945 adult inpatient cardiac separations in Victoria (including both
          public and private hospitals). This represented approximately 5.7% of all inpatient separations
          in Victoria. Cardiac separations have reduced slightly as a proportion of total separations, from
          6.0% in 2001/02.

5.15      Approximately 72% of cardiac inpatient services are provided in public hospitals (Table 1). This
          rate varies depending on the type of service provided - for example approximately 39% of
          CABG surgery, 42% of all cardiothoracic surgery and 48% of PCI were provided by private
          hospitals in 2005/06, but the public sector provided the vast majority of services in the very
          large category of 'other cardiology'. The proportion of PCI’s performed in the private sector is
          noteworthy given that 42.9% of Victorians had private health insurance in the quarter ended 30
                             1
          September 2007 and that a high proportion of emergency PCIs are likely to be provided in the
          public sector. These figures support stakeholder assertions that access to PCI for insured
          patients is significantly better than for uninsured patients. Assessments about relative
          disadvantage of uninsured patients, however require an analysis of issues such as intervention
          rates and the availability of alternative therapies, which are discussed later in this report.

Table 1: Cardiac separations - Private and public hospitals

  Financial Year       Public Hospitals      Private Hospitals %Public Grand Total
 2001/02                          70,644                29,167    71%       99,811
 2002/03                          74,033                31,255    70%      105,288
 2003/04                          75,690                32,009    70%      107,699
 2004/05                          77,726                32,184    71%      109,910
 2005/06                          81,093                31,852    72%      112,945
Increase                          10,449                 2,685              13,134
% increase p.a.                     3.5%                  2.2%                3.1%

5.16      Table 2 summarises cardiac activity in Victoria, showing the total volume of activity in public
          metropolitan, public rural and private hospitals.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                            17
The current cardiac service system




Table 2: Number of activities performed as per VAED, VEMD and survey

                                                                             Volume (per year)

                     Activity                  Total Volume Public - Metro Public - Rural        Private
Inpatient
   Coronary Artery Bypass (CABG)                       2,907         1,505             280            1,122
   Other Cardiothoracic Surgery                        3,424         1,613             246            1,565
   Electrophysiology                                   1,374           523              31              820
   Percutaeous Coronary Angioplasty                    9,106         4,423             268            4,415
   Coronary Angiography                               16,702         5,887           2,022            8,793
   Other Interventional - AICD                           785           313              50              422
   Other Interventional - Pacemaker                    3,958         1,561             364            2,033
   Other Cardiology                                   74,689        41,342          20,665           12,682
Total Inpatient                                      112,945        57,167          23,926           31,852

High Dependency Care
   ICU                                                 7,838         3,052           1,869            2,917
   CCU                                                12,387        11,103             927              357
   Medical Assessment and Planning Unit                2,602         2,295             307
   Short Stay Observation Unit                         8,129         7,002           1,127

Emergency Presentations                               85,133        60,750          24,383
Diagnostics
   Echocardiography                                   44,637        31,996          10,637 a          2,004 b
   Coronary Angiography                               10,458         8,323           1,685 a            450 b
   Cardiac MR and CT                                     664           664               0                0b

Cardiac Rehab                                         29,092        21,764           5,266 a          2,062 b

Outpatient Appointments
   Cardiology                                           69,519      50,990          18,529 a               0
   Cardiac Surgery                                       6,737       5,960             777 a               0
Notes:
a Based on replies to survey received from 18 rural hospitals
b Based on replies to survey received from 8 private hospitals
   Inpatient Activity 2005/06 from VAED
   Emergency Department Activity 2005/06 from VEMD
   Diagnostic, Rehab and Outpatient Activity 2006/07 from Survey




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                18
The current cardiac service system




Cardiothoracic surgery

5.17         Virtually all cardiothoracic surgery is provided in major metropolitan hospitals, as shown in
             Table 3:

Table 3: Public hospital cardiothoracic surgery separations by hospital

                                                                                                                 % of total
                   Hospital                  2001-02 2002-03 2003-04 2004-05 2005-06    Diff     %Change p.a.    (2005-06)
Royal Melbourne Hospital - City Campus            831     858     785     777     771      -60           -1.9%          21%
Monash Medical Centre [Clayton]                   446     557     540     458     532       86            4.5%          15%
St Vincents Hospital                              598     599     602     518     509      -89           -3.9%          14%
Alfred, The [Prahran]                             651     558     588     516     501     -150           -6.3%          14%
Geelong Hospital                                  354     398     451     447     452       98            6.3%          12%
Austin Hospital                                   537     434     519     443     443      -94           -4.7%          12%
Box Hill Hospital                                  70      59     109      93     113       43          12.7%            3%
Western Hospital [Footscray]                       78      69      78      99      95       17            5.1%           3%
Peter MacCallum Cancer Institute [East Melbo        9      19      13      24      60       51          60.7%            2%
Frankston Hospital                                 44      44      42      47      50        6            3.2%           1%
Bendigo Hospital, The                              29      55      55      42      36        7            5.6%           1%
Northern Hospital, The [Epping]                    50      18      24      32      26      -24         -15.1%            1%
Ballarat Health Services [Base Campus]             16      21      15      25      25        9          11.8%            1%
Other                                              81      38      51      55      31      -50         -21.3%            1%
Total                                           3,794   3,727   3,872   3,576   3,644     -150           -1.0%        100%


Source VAED


5.18         Coronary Artery Bypass Graft (CABG) surgery is performed at the following hospitals:

Table 4: Coronary artery bypass grafts by hospital

                                                                                                                 % of total
                   Hospital              2001-02 2002-03 2003-04 2004-05 2005-06        Diff     %Change p.a.    (2005-06)
Royal Melbourne Hospital - City Campus        530     540     464     418     446          -84           -4.2%          25%
Monash Medical Centre [Clayton]               283     367     341     269     303           20            1.7%          17%
Geelong Hospital                              246     256     275     283     280           34            3.3%          16%
St Vincents Hospital                          348     389     368     265     278          -70           -5.5%          16%
Alfred, The [Prahran]                         401     331     342     293     275         -126           -9.0%          15%
Austin Hospital                               226     203     208     195     203          -23           -2.6%          11%
Total                                       2,035   2,086   1,998   1,723   1,785         -250           -3.2%          49%



5.19         The following map shows the geographic areas from which patients are referred to major
             hospitals for Cardiothoracic Surgery. St Vincent's and the Royal Melbourne Hospitals are the
             main referral destinations for patients from a large number of rural Statistical Local Areas
             (SLA):




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                              19
The current cardiac service system




                                                                                    Cardiothoracic catchments
                                                                                                 2005-06

                                                                                               RMH            (45)
                                                                                               St Vincent's   (31)
                                                                                               Alfred         (26)
                                                                                               Geelong        (24)
                                                                                               Austin         (23)
                                                                                               MMC Clayton    (23)
                                                                                               Bendigo         (6)
                                                                                               Box Hill        (6)
                                                                                               Ballarat        (3)
                                                                                               Frankston       (1)




                                                                                0         50        100

                                                                                       kilometers




Source VAED


5.20      While it was not the intention of this Review to comment on the safety and quality of cardiac
          care in Victoria, it is noted that safety and quality data for cardiac surgery are monitored on a
          statewide basis. The Australasian Society of Cardiac and Thoracic Surgeons (ASCTS)
                                                                                                            2
          database records data from the six specialist cardiac units in Victoria. The fifth annual report
          states that “five of the Victorian cardiac surgery units had a mortality rate below the rate of the
          United States and either at or below the rate for the United Kingdom”. The report also states
          that “all units had very low rates of both complications (deep sternal infection and post
          operative infection) and there were no significant differences between the cardiac units”.


Coronary angiography and percutaneous coronary intervention

5.21      Coronary angiography is performed by 13 public hospitals across the state - the 6 tertiary
          hospitals plus Box Hill, Northern, Peninsula, Western, Ballarat Base, Bendigo and Dandenong
          Hospitals. PCIs are performed by 10 of these public hospitals (9 metropolitan excluding
          Dandenong, plus Geelong). Small numbers of AICD and pacemaker insertion are performed by
          a further 4 regional hospitals.

5.22      Survey respondents reported a total of 15 cardiac catheterisaton laboratories across the state,
          with 1 or 2 laboratories per hospital. The laboratories are between 1 and 7 years old with an
          average age of 3 years.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                     20
The current cardiac service system




Table 5: Public hospital interventional cardiology separations by hospital
                                                                                               % Change     % of total
                   Hospital              2001-02 2002-03 2003-04 2004-05 2005-06    Diff          p.a.      (2005-06)
Royal Melbourne Hospital - City Campus      2,298   2,296   2,186   2,269   2,129     -169          -1.9%          14%
Western Hospital [Footscray]                  682     803   1,041   1,364   1,810    1,128          27.6%          12%
St Vincents Hospital                        1,492   1,590   1,584   1,595   1,662      170           2.7%          11%
Austin Hospital                             1,324   1,464   1,476   1,563   1,427      103           1.9%           9%
Geelong Hospital                              871   1,099   1,374   1,411   1,410      539          12.8%           9%
Monash Medical Centre [Clayton]             1,000   1,150   1,219   1,346   1,388      388           8.5%           9%
Alfred, The [Prahran]                       1,560   1,631   1,466   1,351   1,331     -229          -3.9%           9%
Box Hill Hospital                             502     799   1,029   1,182   1,185      683          24.0%           8%
Northern Hospital, The [Epping]                 1       1       1     176     873      872         443.6%           6%
Bendigo Hospital, The                         289     239     300     535     817      528          29.7%           5%
Frankston Hospital                            458     605     683     771     760      302          13.5%           5%
Ballarat Health Services [Base Campus]         42     160     344     400     416      374          77.4%           3%
Dandenong Campus                              178     130     128     176     134        -44        -6.9%           1%
Other                                         179     170     163     140     100        -79       -13.5%           1%
Total                                      10,876  12,137  12,994  14,279  15,442    4,566           9.2%         100%


5.23        Only 47% of rural patients have their interventional cardiology procedure in the region in which
            they live compared to 75% of metropolitan-based patients. 28% of public hospital PCIs are
            provided for rural patients. This figure is consistent with the distribution of the Victorian
            population – in 2003 approximately 72% of the population lived in metropolitan areas and 28%
                                              3
            lived in rural and regional areas . A total of 2,354 PCIs were provided to rural patients in public
            and private hospitals in 2005/06.

5.24        The proportion of PCIs which result from emergency admissions where the patient has
            transferred from another hospital is higher for rural patients than for metropolitan patients as
            shown in Table 6:

Table 6: Total PCI admissions by separation type (public and private)

                                                                                                                    %     % of 2005-
                                                                                                                  Change   06 sub
                    Admission type               2001-02 2002-03 2003-04 2004-05 2005-06               Diff        p.a.     total
Metro      Emergency - Same Hospital                    0       0   1,395   1,544   1,662               1,662                  26%
           Other admission                          3,442   3,848   2,782   2,738   2,953                -489       -3.8%      46%
           Other emergency admission                1,396   1,848     828     697     682                -714      -16.4%      11%
           Planned Admission from Waiting List          0       0   1,099   1,241   1,141               1,141                  18%
Metro sub total                                     4,838   5,696   6,104   6,220   6,438               1,600        7.4%     100%
Rural      Emergency - Same Hospital                    0       0     173     183     242                 242                  10%
           Other admission                          1,370   1,486   1,189   1,299   1,302                   -68     -1.3%      55%
           Other emergency admission                  326     490     457     455     489                 163       10.7%      21%
           Planned Admission from Waiting List          0       0     378     364     321                 321                  14%
Rural sub total                                     1,696   1,976   2,197   2,301   2,354                 658        8.5%     100%
Total                                               6,534   7,672   8,301   8,521   8,792               2,258        7.7%


5.25        26% of PCIs for metropolitan patients in 2005/06 were provided to patients admitted on an
            emergency basis within the same hospital, while the equivalent figure for rural patients was
            10%.

5.26        The majority of public hospital PCIs for rural patients are performed by the Royal Melbourne
            Hospital and St Vincent’s Hospital, as shown in Table 7.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                21
The current cardiac service system




Table 7: Public hospital PCI separations by hospital
 Region of patient residence   Alfred     Austin     Box Hill    Frankston       Geelong MMC Clayton     RMH         St Vincent’s   Western Grand Tota
Barwon-SW                             2          4           2                         225         1             2             39           1     276
Eastern Metro                        49         56         391                           1      132             14             22           2     667
Gippsland                            42          3          19           13              1      102              2             66           4     252
Grampians                            31          8           5                          17         1            18             77          21     178
Hume                                  7         24           7               1                     2           104             85           6     236
Loddon Mallee                        23         52           6                           2         1            40           215            9     348
North-West Metro                     42        483          31           3              13         4           228           195          575   1,574
Southern Metro                      213          6          29         279               1      449             13             20           2   1,012
Grand Total                         409        636         490         296             260      692            421           719          620   4,543



5.27         The following map shows the geographic areas of patient referral for major hospitals for
             interventional cardiology. The map shows that the majority of patients from rural SLAs are
             referred to St Vincent's, Royal Melbourne and The Geelong Hospitals. Bendigo and Ballarat
             Base Hospitals also provide non-PCI interventional services (eg angiography, AICD and
             pacemaker insertion) for patients who reside in SLAs in their regions:

                                                                                                         Interventional cardiology catchments
                                                                                                                               2005-06
                                                                                                                           St Vincent's     (26)
                                                                                                                           RMH              (29)
                                                                                                                           Geelong          (23)
                                                                                                                           MMC Clyton       (21)
                                                                                                                           Ballarat         (16)
                                                                                                                           Bendigo          (17)
                                                                                                                           Alfred           (14)
                                                                                                                           Box Hill         (15)
                                                                                                                           Western          (12)
                                                                                                                           Frankston         (8)
                                                                                                                           Austin            (6)
                                                                                                                           Northern          (6)
                                                                                                                           SW Healthcare     (1)




                                                                                                 0        50         100

                                                                                                       kilometers




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                                    22
The current cardiac service system




5.28         The following maps show the PCI separations for Royal Melbourne and St Vincent’s Hospitals
             by SLA:


   RMH PC Angioplasty seps
                   2005-06                                                         Moira (S) West
                                                                                   Moira (S) -- West


                   21 to 26 (5)                                                                                  Moira (S) East
                                                                                                                 Moira (S) -- East

                   16 to 21 (2)
                                                       Campaspe (S) Kyabram
                                                       Campaspe (S) -- Kyabram
                   11 to 16 (3)
                    6 to 11 (13)                                                                                            Wangaratta (RC) Central
                                                                                                                            Wangaratta (RC) -- Central
                                                                              Gr. Shepparton (C) -- Pt A
                                                                              Gr. Shepparton (C) Pt A
                    1 to 6 (67)


                                                                                                                                                  Alpine (S) West
                                                                                                                                                  Alpine (S) -- West

                                                                                      Strathbogie (S)
                                                                                      Strathbogie (S)




                                           Macedon Ranges (S) -- Romsey
                                           Macedon Ranges (S) Romsey




                                                                                                                              0         20        40

                                                                      Royal Melbourne Hospital
                                                                      Royal Melbourne Hospital                                       kilometers




                       Gannawarra (S)
                       Gannawarra (S)



                                                          Moira (S) West
                                                          Moira (S) -- West
                                                                                              Wodonga (RC)
                                                                                              Wodonga (RC)


                                                      Gr. Shepparton (C) Pt A
                                                      Gr. Shepparton (C) -- Pt A

                     Loddon (S) South
                     Loddon (S) -- South



                                     Gr. Bendigo (C) Pt B
                                     Gr. Bendigo (C) -- Pt B




                                                                                      Wellington (S) Maffra
                                                                                      Wellington (S) -- Maffra
                      Ballarat (C) South
                      Ballarat (C) -- South
                                                        St Vincents Hospital
                                                        St Vincents Hospital
                                       Wyndham (C) North
                                       Wyndham (C) -- North

                                                                 Baw Baw (S) -- Pt B West
                                                                                                                      St Vincent's Hospital PC Angioplasty seps
                                                                 Baw Baw (S) Pt B West
                                                                                                                                                   2005-06
 Warrnambool (C)
 Warrnambool (C)                                                                         Wellington (S) Rosedale
                                                                                         Wellington (S) -- Rosedale

                                                                                                                                              0   25 to 33
                                                                                                                                                       50     (4)
                                                                                                                                                              100

                                                                                                                                                   kilometers (4)
                                                                                                                                                  19 to 25
                                                                                                                                                  13 to 19    (4)
                                                                                                                                                   7 to 13 (21)
                                                                                                                                                   1 to 7 (114)




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                                                       23
The current cardiac service system




5.29      It is worth noting that while a centralised database to measure outcomes in interventional
          cardiology does not exist, the Melbourne Interventional Group has established a database to
          monitor the outcomes and variation in practice of those performing interventional cardiology
          procedures. Not all public hospitals contribute to this database. This database includes
          indicators such as door to balloon time, time from onset of symptoms and 30 and 60 day follow
          up. Later in this report it is recommended that all public hospitals contribute to this database as
          a condition of funding.


Diagnostic services

5.30      Data for non-interventional diagnostics are limited as this information is not collected and
          reported routinely. To this end a survey was conducted to gather information. Table 8 below
          demonstrates the activity reported.

Table 8: Reported diagnostic activity

               Survey Data              The Alfred      Austin       Geelong    Monash    Royal Melb. St Vincents
                                         2005/06       2005/06       2005/06    2005/06    2005/06      2005/06
ECG - inpatients (survey data)            4,502          717          1,381      1,139      2,256          0
ECG - outpatients (survey data)           7,585         4,320          703        721         0         11,898
Exercise ECG (survey data)                  0              0            0          76        273          187
MRI - inpatients (survey data)             250            36            0          4         75            0
MRI - outpatients (survey data)             5              0            0          17         0            0
CT Scan - inpatients (survey data)          0             44            0           1        100           0
CT Scan - outpatients (survey data)         0              0            0          2          0            0
Echo - inpatients (survey data)            118             0            0         660       4717         1036
Echo - outpatients (survey data)          3205          3863          5205       4309         0          1955


Intensive cardiac care units
                                                                                                             4
5.31      Victoria currently has 25 approved Cardiac / Coronary Care Units (CCUs) in public hospitals .
          These units consist of monitored beds either in a stand alone unit or incorporated into another
          ward. The use of these units is changing. Table 9 shows the trend in the proportion of total
          separations which included some time in CCU, as well as the trend in the time spent in CCU. A
          reducing proportion of admissions have included some time in CCU while the average length of
          stay in CCU has remained steady.

Table 9: Trend in CCU as % of separations and CCU ALOS


                  CCU     Non-CCU       Total                    CCU       CCU
    Year          Seps      Seps        Seps         % CCU       Days      ALOS
  2001/02          12,697    57,947      70,644         18%       32,306      2.5
  2002/03          12,874    61,159      74,033         17%       32,253      2.5
  2003/04          12,273    63,417      75,690         16%       30,488      2.5
  2004/05          12,171    65,555      77,726         16%       30,057      2.5
  2005/06          12,030    69,063      81,093         15%       28,711      2.4
- Total            62,045 317,141       379,186         16%      153,814      2.5




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The current cardiac service system




5.32      CCU is utilised for a range of cardiac conditions which fit into the three major cardiac specialty
          areas as described below in Table 10. The majority of utilisation is related to interventional
          cardiology. Cardiac nurses report that the nature of CCU nursing has changed considerably as
          the clinical emphasis on interventional cardiology has increased. The nature of modern CCU
          nursing needs to be taken into account when planning for a sustainable cardiac nursing
          workforce.

Table 10: CCU specialty and admission type


         Speciality                  Emergency     Elective        Other   % of Total
Cardiology                                 9,031         251           998       36%
Cardiothoracic Surgery                     1,707         175           179        7%
Interventional Cardiology                 13,577      1,763          1,029       57%
Total                                     24,315      2,189          2,207     100%


Outpatient services

5.33      Adult cardiac services (including emergency, inpatient, outpatient and rehabilitation services)
          are primarily provided by approximately 120 public hospitals (approximately 28 metropolitan
          and 90 rural) as well as a number of private hospitals.

5.34      Five metropolitan health services provide cardiac surgery outpatient services, with between 500
          and 1,600 appointments being provided in 2006/07. Some Hospital Admission Risk Program -
          Chronic Disease Management (HARP-CDM) services provide cardiac services in community
          settings. Of the 7 rural health services that reported providing cardiology outpatient services, 4
          provided less than 500 appointments in 2006/07 and the remainder provided over 2,000
          services in 2006/07.


Rehabilitation services

5.35      Results of the survey suggest that while cardiac rehabilitation programs generally are available,
          eligible patients often do not access them.

5.36      The National Heart Foundation of Australia and the Australian Cardiac Rehabilitation
          Association Recommended Framework for Cardiac Rehabilitation is accepted by stakeholders
          as the basis for designing and delivering cardiac rehabilitation services.

5.37      Cardiac rehabilitation programs generally include three-phases: inpatient; outpatient and
          maintenance. The aims of rehabilitation are recovery, education and secondary prevention.

5.38      There is very strong support for ensuring that all patients access appropriate rehabilitation
          services. The current rate of uptake of rehabilitation programs by eligible patients varies but
          some providers estimate it is as low as 30%. Stakeholders suggested that the capacity of
          rehabilitation services would be inadequate if all eligible patients accessed them.




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5.39      In the Metropolitan areas hospital-based cardiac rehabilitation is provided by the Alfred
          Hospital, the Austin Hospital, The Geelong Hospital, Monash Medical Centre and the Royal
          Melbourne, St. Vincent’s, Box Hill, Western, Frankston Hospital and Northern Hospitals. HARP
          - CDM services currently deliver outpatient cardiac rehabilitation in community health settings
          and also provide multidisciplinary services, including cardiac outreach, home and site nursing.

5.40      Of the responding rural hospitals, 83% reported providing outpatient cardiac rehabilitation.




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6             The future cardiac service system
Planning principles
6.1           CSAC supported the adoption of a number of planning principles to support the development of
              cardiac services in Victoria. These are detailed in Recommendation 1 below and underpin the
              further recommendations made in this report about the configuration of, and model of care to
              be provided by, the future Victorian cardiac services system.

Recommendation 1

That the following planning principles form the basis for future development of the Victorian cardiac
services system:

•         Quality and safety of care are the overriding considerations in planning and delivering cardiac
          services in Victoria.

•         Cardiac services are time critical – better outcomes are achieved with quicker treatment: thus
          access to cardiac services must be timely and equitable for the residents of Victoria.

•         The system should be developed to meet volume requirements necessary to maintain quality
          standards.

•         Service delivery will define the system structure – teaching and research will follow services.


6.2           Nationally and internationally, rather than relying on individual providers working together
              informally, there is an increasing emphasis on the development of systems of careiii for complex
              conditions.


A system of care
6.3           Hollenberg (1996) and the Cardiac Care Network of Ontario note several characteristics that, in
              combination, make a disease particularly suited to a systems approach to care:
             •        The disease has a great impact on the population.
             •        There is high public awareness and strong concern, leading to public insistence on
                      consistent quality and equitable access to services across the province.
             •        Government considers the disease a priority.
             •        There is potential for improving outcomes and cost through better management of the
                      disease.




    iii
       A system has been defined as an “integrated group of separate entities within a region providing specific services for the system that
      could include emergency medical services (EMS) providers, a community hospital(S), a tertiary centre(S) and others (Jacobs AK,
      Antman EM, Faxon DP, Gregory T, Solis P. Development of systems of care for ST elevation myocardial infarction patients
      :executive summary. Circulation. 2007; 116:217-230)




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          •       The disease requires a range of interventions, necessitating multiple approaches, both
                  regional and province-wide service planning, and human resource planning in several
                  disciplines.
          •       Treatments and technologies are rapidly developing and expensive, with a requirement
                  for high expertise, making it difficult to offer all treatments at all centres.
          •       Costs of the disease are high.
          •       Cardiac care lends itself well to a system approach.

6.4       Cardiac disease is common, debilitating and expensive to manage:
          •       each year in Australia there are more than 48,000 major coronary events, half of which
                  are fatal;
          •       coronary heart disease is the largest single cause of death in Australia, claiming 26,063
                  lives in 2002;
          •       an estimated 356,800 Australians have manifestations of coronary heart disease; and
          •       coronary heart disease is the highest cost individual disease in Australia, consuming 3%
                  of total allocated health system expenditure, the largest proportion (72%) of which is
                                      5
                  spent on hospitals.

6.5       Cardiovascular disease is one of the biggest burdens on our economy, accounting for an
          estimated $14.2 billion in both direct health system costs and indirect financial costs in 2004.
          •       Direct health system costs of cardiovascular disease were estimated at $7.6 billion in
                  2004.
                                                                                 6
          •       Indirect financial costs were estimated at $6.6 billion in 2004 .

6.6       The number of people affected by cardiac disease, the time-criticality of some services, the
          complexity of services required and the expense of providing quality care justify investment in a
          'best practice' service system configuration and models of care.

6.7       In the context of cardiac services, although the 'systems' debate tends to focus on access to
          primary PCI, systems of care are relevant to acute and chronic conditions, both time-critical and
          non-time-critical and requiring medical or surgical interventions.

6.8       Experience internationally suggests that well-coordinated systems may improve quality,
          particularly timeliness, of acute cardiac care. Relevant findings from the USA include:
          •       the establishment of integrated systems that reduce barriers to collaborative care
                  between different hospitals and different groups of healthcare professionals is feasible;
                  and
          •       standardized protocols that increase timely access to reperfusion as well as adherence
                  to all evidence-based therapies, establishment of coordinated transport (and backup)
                  plans, and comprehensive real-time data feedback and quality assurance to all system
                                             7
                  participants are critical.




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6.9       In 2007 the American Heart Association launched Mission: Lifeline which is described as "A
          community-based initiative aimed at quickly activating the appropriate chain of events critical to
          opening a blocked artery to the heart that is causing a heart attack." The goal of Mission:
          Lifeline is to develop community-based systems across the country so patients can access
          appropriate care more quickly. It comprises:
          •       patient education;
          •       improved pre-hospital diagnosis of STEMI;
          •       early activation of catheterisation laboratories;
          •       treatment according to standard protocols;
          •       working with payors and policy makers to ensure appropriate reimbursement and
                  accountability; and
          •       development of a STEMI centre certification program with criteria for both STEMI referral
                  and receiving hospitals.

6.10      The Guidelines for the Management of Acute Coronary Syndromes 2006 published by CSANZ
          and the National Heart Foundation state that:

          "Effective systems of care are required to deliver optimal care for patients with acute coronary
          syndromes, particularly in rural and remote areas. Systems of care should be regionally based,
          and have formal links with specialist centres for consultation and acute inter-hospital transfer.
          Systems should include appropriate monitoring, feedback and quality improvement
          components. Clinical decisions about care and transfer should take into account patients'
                                                     8
          cultural and personal beliefs and wishes."

6.11      An effective cardiac care system for Victoria should include:
          •       strong and effective clinical leadership;
          •       a system-wide commitment to providing quality care;
          •       a planned and rational distribution of services;
          •       coordination of resources to improve access to appropriate care through:
                  –     community education about preventing and responding to cardiac symptoms;
                  –     pre-hospital diagnosis of STEMI and pre-hospital thrombolysis where appropriate;
                  –     ambulance transport directly to a PCI capable facility (if necessary by-passing
                        other facilities) if patients are assessed early as likely to benefit from PCI;
                  –     expedited inter-hospital transfers when clinically appropriate;
                  –     agreed referral destinations and formal protocols for referrals between primary care
                        providers and hospitals, and between hospitals; and
                  –     strong clinical governance, with a focus on engagement of and leadership by
                        clinicians and accountability through institutional and system-wide data collection
                        and monitoring of service quality.

6.12      Systematisation of care also implies that providers become accountable to a broader rather
          than a local community for ensuring equitable patient access to high quality care.




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Recommendation 2

That Victoria's cardiac care services are planned and developed to form an integrated system of care,
with the objective of ensuring equity of access to safe, high quality services for all Victorians, regardless
of their place of residence or place of presentation to the health care system.


6.13      The various elements of a strong cardiac care system for Victoria are discussed below, and
          recommendations to achieve them are outlined.


Clinical leadership

6.14      There is evolving evidence that managed clinical networks provide an effective mechanism for
                                                  9 10 11
          improvement of clinical service delivery , , .

6.15      Clinical networks have been described as “..linked groups of health professionals and
          organisations from primary, secondary and tertiary care working in a co-ordinated manner
          unconstrained by existing professional and Health Board boundaries to ensure the equitable
                                                                  12
          provision of high quality clinically effective services… ”

6.16      The Greater Metropolitan Clinical Taskforce in New South Wales has established a Cardiac
          Services Specialty Services Network. The recent Northern Territory (NT) Cardiac Services Plan
          recommended the establishment of a reference group, with the Chair having a defined senior
          role in the coordination of cardiac services across the NT. It was envisioned that this role would
          include: making detailed recommendations on priorities for service development in accordance
          with the Cardiac Services Plan; establishing standards for the care of cardiac patients in the
          various clinical settings across the NT; ensuring the integration of different types of services
          and their integration with interstate referral services; and negotiating with peak professional
                                                                             13
          bodies for the accreditation of specialist training posts in the NT .

6.17       In Western Australia clinical networking has been defined as “a new focus across all clinical
                                                                                            14
          disciplines toward prevention of illness and injury and maintenance of health ”. The Report of
          the Health Reform Committee (Reid Review) recommended the establishment of a
          Cardiovascular Clinical Network. The aim of the Cardiovascular Clinical Network is documented
          as “to facilitate a collaborative and partnerships approach to service provision across the
          continuum of care, in order to improve access to consistent and high quality services across the
          state, maximise the efficiency of resource use and minimise health costs through prevention
          and early intervention. It is envisioned that four clinical and service related groups (Cardiology,
          Interventional Cardiology, Cardiothoracic Surgery and General Medicine) would focus on:
          •       engaging clinical leaders and key stakeholders in state-wide planning, policy and clinical
                  reforms;
          •       focusing on the patient and the community by increasing participation, partnerships,
                  communication and responsibility;
          •       improving patient care in terms of quality, access, appropriateness and integration;
          •       providing a focus on improving and promoting links between country and metropolitan
                  health services;
          •       driving an increased focus on the provision of co-ordinated population health strategies;




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             •        facilitating the alignment of strategic and operational functions of the health system;
             •        promoting continuous improvement in all services and clinical practices by developing
                      and advising on the implementation of evidence based practice standards and protocols
                      and referral and support structures between and within health services with an emphasis
                      on clinical management and partnerships; and
             •        ensuring accountability and reporting arrangements for the network are clearly defined
                      and the networks’ operation and dealings with all stakeholders are transparent.

6.18         The DHS has indicated an intention to develop networks in a number of clinical specialty areas.
             An emergency care improvement and innovation emergency network and a stroke clinical
             network have been established and the establishment of a maternity clinical network is in
             progress. The draft framework for clinical networksiv proposed by the DHS suggests the
             following roles for these networks:
             •        provide advice on the development and utilisation of KPI’s;
             •        develop models of care that better integrate systems;
             •        timely review and dissemination new evidence and early adoption into practice;
             •        be involved in the development, review, dissemination and adoption of evidence based
                      clinical guidelines and protocols;
             •        develop guidance for the appropriate uptake diffusion and disinvestment of clinical
                      practices and techniques;
             •        create a collaborative forum;
             •        develop systems and processes to support consumer engagement in networks;
             •        provide clinical leadership; and
             •        inform strategic policy and facilitate change at the clinical interface.

6.19         It is also recommended that a cardiac clinical network is established for Victoria. The core
             functions of the clinical network would include informing ongoing planning of services; advising
             on policy; defining meaningful infrastructure, clinical care and performance standards;
             developing clinical guidelines and protocols; monitoring and reporting on the accessibility and
             quality of care; investing in people and influencing resource allocation priorities.

6.20         The clinical networks structure will need to be further defined, but we consider that it may
             establish sub-groups on a specialty basis (eg cardiac surgery and cardiology) and on a regional
             basis. In particular, regional differences in patient need, geography and available services
             strongly suggest that there is a need to develop region-specific plans for the distribution and
             coordination of cardiac services. Such plans should be developed by local stakeholders
             including community representatives, ambulance services, general practitioners and hospitals,
             with assistance from the cardiac clinical network.

6.21         A well defined governance structure with defined terms of reference will be required for
             successful implementation of the network.




  iv
       Information is taken from an as yet unpublished document provided by DHS.




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6.22      Successful clinical networks in other jurisdictions advise that a key to their success is the
          appointment of specialist health care professionals as coordinators who have regional
          accountability and work collaboratively with stakeholders to develop regional protocols, provide
          specialty-specific education, collect and report data and generally assist with service system
          coordination and responsiveness. Coordinators may come from a range of professional
          backgrounds. At least one metropolitan hospital has appointed a cardiac liaison nurse, a
          position which is highly valued by referring health care professionals. This model also is in
          place as a component of the Victorian trauma system and is highly effective.

6.23      The size, complexity and clinical importance of the cardiac care system supports investment in
          similar coordinators across the state.

Recommendation 3

That the Department of Human Services establishes a clinical network for cardiac services in Victoria to
provide clinical leadership, define standards for infrastructure and services, promote quality care,
improve the coordination and efficient use of clinical resources and monitor and report on the quality of
cardiac care in Victoria.

Recommendation 4

That the proposed cardiac clinical network works with stakeholders across the State to develop region-
specific plans for the optimal use and coordination of cardiac care resources in accordance with
evidence-based practice in all metropolitan and rural regions.

Recommendation 5

That the Department of Human Services supports the appointment of specialist cardiac care
coordinators in each metropolitan health service that provides acute cardiac services and in each rural
region.


6.24      These recommendations are consistent with current policy within the Department of Human
          Services on the future direction of clinical networks as collaborative groups of interested people
          and organisations including health professionals, patients, carers, consumers and others.


Clinical quality standards

6.25      CSANZ and the National Heart Foundation have published two important consensus
          documents:
          •       Guidelines for the Management of Acute Coronary Syndromes 2006 (the Australian ACS
                  Guidelines);
          •       Guidelines for the prevention, detection and management of chronic heart failure in
                  Australia, 2006 (the Australian Heart Failure Guidelines).

6.26      These consensus documents represent best practice as defined following an exhaustive search
          and analysis of the literature.




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Recommendation 6

That the publications of the Cardiac Society of Australia and New Zealand and the National Heart
Foundation of Australia: Guidelines for the Management of Acute Coronary Syndromes 2006 and
Guidelines for the Prevention, Detection and Management of Chronic Heart Failure in Australia 2006 as
updated from time to time are adopted by the Victorian public health care system as the appropriate
standard of care for patients suffering from relevant cardiac conditions.



A planned and rational distribution of services

Balancing access and quality

6.27      The challenge for any system with a commitment to service quality is to strike an appropriate
          balance between distributing the infrastructure necessary to support the provision of high
          quality services in local areas and concentrating the specialist expertise necessary to provide
          these services in a manner that accords with current understanding of the relationship between
          health care outcomes and volume of services provided. This was the major challenge for the
          Review.

6.28      In addition, the service system configuration for cardiac services needs to take into account:
          •       the requirement to utilise expensive infrastructure efficiently;
          •       the scarcity of some professionals who are critical to the effective and efficient
                  functioning of cardiac services; and
          •       critical interrelationships with other clinical services, such that each cardiac service has
                  the non-cardiac service support and each non-cardiac service has the cardiac service
                  support necessary to provide a quality service.

6.29      Local access to services is of particular benefit where treatment and outcome are time-
          dependent as is the case for patients with ACS including those with unstable angina; non–ST-
          elevation acute coronary syndrome (NSTEACS); and ST-elevation myocardial infarction
          (STEMI). It is also important, however, to make all reasonable efforts to facilitate access to
          specialist cardiac consulting, diagnostic, interventional and surgical services for the many
          cardiac patients who have less time-critical conditions.

6.30      Below, we discuss the various issues that impact on the rational distribution of services and
          make relevant recommendations.

Angiography in rural Victoria

6.31      The 2005 CSANZ “Policy on performance of coronary angiography and percutaneous coronary
          intervention in rural sites” recommends a number of standards for application to angiography in
          rural settings. These include the training and experience of staff and selection of patients and
          laboratories as follows:
          •       “laboratories performing diagnostic angiography should have access to coronary care or
                  intensive care facilities and they should be capable of inserting intra-aortic balloon
                  pumps and transvenous pacemakers;




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          •       physicians performing diagnostic angiography at rural hospitals should have completed
                  training as outlined in CSANZ “Guidelines for competency in diagnostic cardiac
                  catheterisation and coronary angiography”; and
          •       patients selected for elective angiography should have a stable clinical profile: Special
                  care should be taken in cases with left main stenosis, critical valvular disease and in
                  patients with significant associated co-morbidities including uncontrolled hypertension,
                  unstable diabetes, significant renal impairment or significant left ventricular impairment.”

6.32      The 2005 CSANZ “Guidelines for competency in diagnostic cardiac catheterisation and
          coronary angiography” suggest that angiographers should undertake a minimum of 100
          procedures per year; participate in regular case and coronary angiogram image review; and
          participate in auditing of angiogram quality and complications.

6.33      Diagnostic angiography services currently are provided in Bendigo and Ballarat.

PCI without on-site surgical backup

6.34      Some PCI services are already operating without on-site surgical backup in Victoria, and a
          number of new PCI services were proposed during this Review. The question of whether it is
          appropriate to develop new services without on-site surgical backup has been the subject of
          debate internationally 15,16,17, and was considered in detail by CSAC.

6.35      The Society for Cardiovascular Angiography and Interventions (SCAI) published an expert
                                                   18
          consensus document on this issue in 2007 , which included recommendations (reproduced
          below):
          •       PCI without on-site surgical backup is being performed with acceptable outcomes and
                  risks in the United States and many other countries. The recommendations outlined in
                  this document are made to ensure patient safety and quality outcomes in such a work
                  environment. This is not an open endorsement of PCI without on-site surgery and we do
                  not support the widespread use of PCI without on-site surgery, especially in the United
                  States, but acknowledge that this practice may be appropriate in some circumstances.
          •       The decision to begin or operate a PCI program without on-site surgical backup should
                  be based on the health needs of a local area, not on desires for personal or institutional
                  gain, prestige, market share, or other similar motives. Rural communities may have
                  different health care delivery needs than urban centres and this should be considered.
          •       It is to the goal of SCAI to promote the highest possible program quality. Accordingly,
                  PCI programs both with and without on-site surgical backup must evaluate their
                  outcomes against their countries' benchmark for program performance or other
                  acceptable standard.
          •       Operators performing PCI without on-site surgery should perform at least 100 total PCIs
                  per year, including at least 18 primary PCIs per year. The initial operators at a facility
                  without on-site backup should not begin performing PCI in such facilities until they have
                  a lifetime experience of more than 500 PCIs as primary operators after completing
                  fellowship. Only operators with complication rates and outcomes equivalent or superior
                  to national benchmarks should perform PCI procedures.
          •       Independent program oversight should occur either within the context of a local facility's
                  quality assurance program or through an independent government or external agency.
                  Any program failing to perform adequately should close.




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          •       Further data collection and analysis should be undertaken to more completely
                  understand the role of PCI without on-site surgical back up as a strategy for the delivery
                  of care.

6.36      CSANZ has endorsed these recommendations as stated in the 2008 Guidelines on Support
          Facilities for Coronary Angiography and Percutaneous Coronary Intervention (PCI) including
                                                                        19
          Guidelines on the Performance of Procedures in Rural Sites . The 2008 guidelines note that
          “under certain conditions the cardiac society believes that appropriately trained individuals can
          perform coronary interventional procedures safely in hospitals without on site surgical backup”.
          The 2008 Guidelines on Support Facilities for Coronary Angiography and Percutaneous
          Coronary Intervention (PCI) including Guidelines on the Performance of Procedures in Rural
          Sites suggest a number of additional conditions should apply to the development of and
          supervision of PCI services without onsite surgical backup, including the establishment of a
          formal liaison with a high volume PCI centre with on site cardiac surgery. CSANZ notes that
          careful selection of cases is important and that patients with a stable clinical condition but high
          risk anatomy may be better served if the procedure is performed in a facility with on-site
          surgical back up. On the other hand CSANZ notes the potential benefits of early reperfusion
          with potential myocardial salvage in individuals with large ST elevation myocardial infarction or
          in individuals with cardiogenic shock.

Recommendation 7

That the proposed cardiac clinical network develops guidelines for angiography and PCI services without
on-site surgical back-up in Victoria, for endorsement by the Department of Human Services and
incorporation into conditions of funding if necessary, and that the guidelines are consistent with the
Cardiac Society of Australia and New Zealand's 2008 Guidelines on Support Facilities for Coronary
Angiography and Percutaneous Coronary Intervention (PCI) including Guidelines on the Performance of
Procedures in Rural Sites.


Other factors influencing patient access to PCI

6.37      The overwhelming concern for many stakeholders consulted during this Review was that a
          significant proportion of Victorian patients (particularly but not exclusively those from rural
          areas) who experience a STEMI are greatly disadvantaged because they are unable to access
          primary PCI within the time frames necessary to optimise the clinical benefit of that service.
          They are, therefore, treated with thrombolysis, following which it is necessary for access to a
          bed in a tertiary or other metropolitan hospital to be arranged for further investigation and, for
          some, PCI or surgery. Secondary access to such services is also very difficult to arrange on
          some occasions.

6.38      Below, we detail the status of PCI service availability in regional and rural Victoria:
          •       Barwon Health provides a full in-hours elective and urgent and a partial out-of-hours
                  urgent PCI service, depending on the availability of interventional cardiologists;
          •       a number of interventional cardiologists reside in or visit Ballarat and there is one private
                  sector laboratory located in St John of God Hospital, to which the public sector has
                  negotiated limited access for diagnostic services. There is no urgent PCI service
                  available in Ballarat at present, although there are plans to commence one in the private
                  sector in 2008;




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          •       one interventional cardiologist resides in Bendigo and another visits. There is one
                  cardiac laboratory in the public sector and one in the private sector, both of which
                  provide diagnostic services only at present. The Bendigo Health Care Group aims to
                  develop an in-hours interventional service (urgent and elective) in the foreseeable future
                  but the lack of availability of activity funding (WIES) is a major concern; and
          •       there are no cardiac angiography or PCI services available in either Shepparton or the
                  Latrobe Valley at present, but both Goulburn Valley Health and the Latrobe Regional
                  Hospital aspire to progressively develop diagnostic and then interventional services.

6.39      Patients requiring access to primary PCI are only a small proportion of the cohort of patients
          requiring cardiac services and many stakeholders observed that it would not be sensible to
          design an entire service system around them. The infrastructure necessary to support the safe
          delivery of a primary PCI service, however, includes a comprehensive range of specialist
          diagnostic and consulting services. Investment in PCI services stimulates service development,
          enabling local access to specialist cardiac services for the larger group of patients who would
          benefit from such services but who do not require time-critical access to PCI. In a sense, PCI
          infrastructure forms a critical core that attracts a comprehensive range of specialist cardiology
          diagnostic and treatment services.

6.40      It is sensible, therefore, to plan for appropriate access to PCI provided services can be
          provided sustainably and to an acceptable level of quality. The necessary associated
          infrastructure then provides a much broader benefit to a wider range of cardiac patients who
          require urgent and elective services.

6.41      There are well-accepted volume and practice standards for the provision of PCI procedures
          that should be undertaken in Australian centres to support the maintenance of competence.
          CSANZ recommends the following standards for maintenance of competence in PCI:
          •       Individual – 75 cases per year is the recommended minimum.
          •       Centre – 200 cases per year is the recommended minimum. The centre volume can be
                  less when operators are concurrently practising at another centre.
          •       Ongoing audit of centre/operators procedural outcome and complications.
          •       Regular case and angiogram image review by the cardiologists and others as
                  appropriate.
                                                                                                     20
          •       Regular mortality / morbidity review by the cardiologists and others as appropriate .

6.42      The CSANZ guidelines for competency in coronary angioplasty state that the desirable
          characteristics of angioplasty training centres include:
          •       Two experienced interventional cardiologist trainers
          •       Individual – trainers 200 + cases per year
          •       Centre - 250 + cases per year
          •       Ongoing audit of centre/operators procedural outcome and complications.
                                                                                                     21
          •       Regular mortality / morbidity review by the cardiologists and others as appropriate .

6.43      The Guidelines for the Management of Acute Coronary Syndromes 2006 also recommend that
          if primary PCI is to be offered, the unit should perform a sufficient volume of primary PCIs, with
          international experience suggesting that this might be more than 36 per year.




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Recommendation 8

That PCI is not offered in centres in Victoria unless the predicted volumes of procedures (individual and
centre) reach levels at least equivalent to those recommended in the Guidelines for the Management of
Acute Coronary Syndromes 2006 and Guidelines in Competency in Coronary Angioplasty, which
currently are:

•      75 cases per year for each cardiologist

•      200 cases per year for each centre (the centre volume can be less when operators are
       concurrently practising at other centres)

•      Greater than 36 cases of primary PCI per unit per year.


6.44      There was considerable discussion during the Review about whether these volume standards
          should apply to the private sector as well as to the public sector. There was support for this
          proposition from within CSAC and also at a forum held with the private sector during the course
          of the Review. DHS's licensing authority may provide the opportunity to consider the
          volume/quality implications of private sector services. A recommendation that similar standards
          should apply to the private sector is considered to be outside the terms of reference of this
          Review but is supportable on quality grounds and should be referred to the DHS private
          hospital licensing unit for consideration.

6.45      The expense of developing appropriate infrastructure, the distribution of the Victorian
          population and the outcome benefit enjoyed by patients who undergo primary PCI for STEMI
          suggests that when such infrastructure is developed it should be available 24 hours per day for
          primary PCI.

Recommendation 9

That all public hospitals in which PCI infrastructure is available work towards providing 24 hour access to
primary PCI for patients suffering STEMI.


Implications for the development of diagnostic angiography and PCI services in Victoria

6.46      A number of hospitals indicated their desire to develop or enhance existing cardiac
          catheterisation facilities in order to provide an improved service for their patients:
          •       Frankston Hospital (enhancing an existing service to provide a 24 hour PCI service);
          •       Northern Hospital (enhancing an existing service to provide a 24 hour PCI service - this
                  service was instituted during the course of the Review);
          •       Bendigo Hospital (enhancing an existing service to provide a 24 hour PCI service);
          •       Ballarat Base Hospital (developing infrastructure to commence a diagnostic service
                  followed by a PCI service);
          •       Latrobe Regional Hospital (developing infrastructure to commence a diagnostic service
                  followed by a PCI service); and




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          •       Goulburn Valley Hospital (developing infrastructure to commence a diagnostic service
                  followed by a PCI service).

6.47      There was considerable debate at CSAC about whether the development of such facilities
          would align with the Guidelines for the Management of Acute Coronary Syndromes 2006 and
          the principles and general recommendations for service delivery endorsed by CSAC and
          described above.

6.48      Stakeholders also reported some current and emerging issues relevant to primary PCI
          services:
          •       the reliable availability of PCI services 24 hours a day is important;
          •       24-hour PCI is a resource-intensive service. A minimum critical mass of three
                  interventional cardiologists (and preferably more) together with a cohort of specialist
                  nursing and technical staff is required for a sustainable service. We believe that four
                  interventional cardiologists are required for sustainability – a team of four requires each
                  consultant to be on-call two nights each week, allowing for usual periods of leave. We
                  note that Barwon Health has struggled to maintain a reliable 24-hour roster with three
                  interventional cardiologists;
          •       the proportion of patients who require PCI who present as an emergency is increasing;
          •       technical efficiency is improved if services are concentrated in larger units
          •       not all laboratories have state-of-the-art equipment;
          •       at least two laboratories are necessary if both electrophysiology (EP) and primary PCI
                  are to be provided. EP procedures are time-consuming and the laboratory in which they
                  are performed cannot be relied on for primary PCI purposes;
          •       even with two laboratories, some hospitals are experiencing 'bottlenecks' as the
                  throughput of patients with STEMIs requiring primary PCI increases. It is reported that in
                  some hospitals this high level of throughput is resulting in fatigue and turnover of
                  laboratory staff; and
          •       there is no funding distinction between elective, in-hours PCI and 24-hour emergency
                  PCI, but the provision of emergency services is more costly than elective services
                  because of the need for some system redundancy to allow a rapid response in
                  emergency situations and the on-call and recall costs of providing out-of-hours primary
                  PCI.

6.49      Table 11 demonstrates current PCI separations, and those projected on three scenarios:
          •       no change to the hospitals performing PCIs;
          •       PCIs performed at Bendigo Hospital in addition to the current hospitals; and
          •       PCIs performed at Bendigo Hospital, Ballarat Base Hospital, Latrobe Regional Hospital
                  and Goulburn Valley Hospital (Shepparton) in addition to the current hospitals.

6.50      Projected numbers for each regional hospital are based on the following assumptions:
          •       the regional hospital will perform 75% of projected public hospital PCI separations for the
                  region in which the hospital is located (ie Bendigo will perform 75% of the projected
                  public hospital PCI separations for the Loddon Mallee region, Ballarat Base will perform
                  75% of the projected public hospital PCI separations for the Grampians region); and
          •       the regional hospital will perform 25% of projected private hospital PCI separations for
                  the region in which the hospital is located.




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Table 11: Projected PCI separations

                                                                   Projected PCI separations (2015/16)
                       Actual PCI separations
       Hospital                                                         PCIs at Bendigo, Ballarat,
                              (2005/06)           DHS Projection                                       PCIs at Bendigo only
                                                                          Shepparton & Latrobe
      The Alfred                          417                    603                            486                     574
        Austin                            645                    639                            542                     580
        Box Hill                          496                    753                            714                     746
       Ballarat                             0                      0                            275                         0
       Bendigo                              0                      0                            551                     551
      Frankston                           299                    480                            466                     480
       Geelong                            263                    422                            400                     421
       LaTrobe                              0                      0                            340                         0
       Monash                             700                  1,100                            980                   1,098
     Other Public                           7                     11                               5                        7
        Private                         4,415                  6,720                          6,365                   6,573
     Royal Melb.                          427                    563                            378                     516
     Shepparton                             0                      0                            356                         0
     St Vincents                          814                  1,161                            647                     916
       Western                            623                  1,021                            968                   1,010
       Northern *                           0                    600                            600                     600
         Total                          9,106                 14,072                         14,072                  14,072


*Note: Northern projections are based on numbers provided by Northern Hospital directly in February 2008

6.51       Table 11 shows that, on the assumptions above, there would be expected to be approximately
           550 PCI separations at Bendigo Hospital in 2015/16, which is well above the minimum as set
           out in the guidelines. However, if services were developed at the same time at Ballarat Base
           Hospital, Latrobe Regional Hospital and Goulburn Valley Hospital, each of these services
           would provide less than 360 PCIs per year.

6.52       On the basis of predicted activity and the broad benefits to be gained as a consequence of the
           development of comprehensive cardiology services, we consider that it is appropriate to
           enhance the existing service at Frankston Hospital to provide 24-hour primary PCI capability
           (which may require additional investment including WIES funding) and to develop a fully-
           resourced service at Bendigo Hospital. In addition the continued development of a 24-hour
           service at Northern should be supported.

6.53       Representatives of CSANZ provided the project team with a draft policy on support facilities for
           coronary angiography and PCI, which includes the following principles relating to the
           development of new services and in particular to services in rural and regional areas:
           •        Diagnostic angiography service should be operational for 12 months and demonstrate
                    acceptable morbidity and mortality for performance of these procedures before
                    commencing a coronary interventional program.
           •        Once coronary interventional procedures are performed at a facility, there should be an
                    on call team available 24 hours per day, to deal with post-procedural complications.
           •        There should be access to coronary care facilities for routine post procedure
                    management including sheath removal.
           •        New PCI services, especially those in rural and regional centres more than 1 hour travel
                    time from cardiac surgery, should be initially supervised by a highly experienced
                    operator (an operator with a life time experience of more than 1000 PCI cases), who
                    should be present during cases and mentor less experienced operators. This supervision
                    should continue until the mentor and all operators are satisfied that local policies,




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                  facilities, case selection, outcomes and experience are sufficient to allow the service to
                  operate safely without the presence of the mentor.
          •       Rural and regional centres more than 1 hour travel time from cardiac surgery should not
                  perform elective, high risk PCI as defined as:

                  Patients with:
                  –     Left ventricular ejection fraction < 25%.
                  –     Left main stenosis.
                  –     Single or multiple target lesions that in aggregate jeopardise over 50% of the
                        remaining viable myocardium.
                  –     Co-morbidities significantly increasing the risk of complications.
                  Target lesion with:
                  –     Excessive proximal tortuosity or lesion angulation.
                  –     Moderate or greater calcification of the target lesion or proximal segment.
                  –     Bifurcation lesions (side branch > 2.25mm) where iatrogenic occlusion of a side
                        branch would be an indication for emergency CABG.
                  –     Degenerative vein grafts.
                  –     Chronic total occlusion.

6.54      Current data projections indicate that service volumes would be relatively low at Ballarat Base
          Hospital, Goulburn Valley Base Hospital and Latrobe Regional Hospital if PCI services were
          commenced during the planning period. Even allowing for a substantial increase in absolute
          demand for PCI for patients residing in the referral areas of these hospitals if these services
          were instituted, it is considered that these relatively low procedural volumes combined with
          difficulties attracting and retaining a specialist workforce would preclude the provision of quality
          services.

6.55      It is recommended, however, that a diagnostic angiography service is developed at Ballarat
          Base Hospital. There already is significant specialist cardiac infrastructure established in
          Ballarat and the purchase of a combined modality cardiac/peripheral vascular angiography
          suite would support the appropriate development of cardiac diagnostic services. As with new
          PCI services, this service should be developed under the guidance of experienced operators
          working in an established unit, who should monitor service quality to ensure it meets
          acceptable standards.

6.56      It should be noted that there was a diversity of views amongst CSAC members about the
          appropriateness of this recommendation. Whilst many cardiologists did not support the
          development of stand-alone angiography services or PCI services in rural areas, other
          members were supportive on the basis of the improved access to diagnostic services and the
          support for the general development of specialist cardiac infrastructure such a service would
          provide.




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6.57      There was a strong view amongst some CSAC members that coronary CT is likely to become a
          useful diagnostic tool for coronary artery disease over the next 5-10 years, eliminating the need
          for many patients to undergo more invasive procedures. The role of percutaneous angiography
          at La Trobe and Goulburn Valley Base hospital should be re-considered in the future with
          reference to emerging evidence regarding the role of coronary CT.

6.58      It should be noted that a number of stakeholders believe that rural and regional residents are
          seriously disadvantaged because they do not have local access to PCI. It is important to note,
          however, that although early PCI is the treatment of choice for STEMI provided the procedure
          is performed by experienced operators in high volume centres, the benefit conferred even
          under ideal circumstances is small to moderate and medical reperfusion is an effective
          alternative therapy for most patients. If PCI is offered in low volume centres and/or by
          inexperienced operators, the relative benefit of early PCI for patients suffering STEMI almost
          certainly will be lost and the much larger proportion of cardiac patients with less urgent
          conditions are very likely to suffer a quality disadvantage compared with travelling to higher
          volume centres.

6.59      It also should be noted that rural patients appear, in aggregate, to be accessing the proportion
          of PCI resources that would be expected in relation to the proportion of the population that lives
          in rural areas - 28% of public hospital PCIs are performed for rural patients and 28% of the
          community lives in rural Victoria.

6.60      We do not consider, therefore, that "any PCI service is better than no PCI service at all". PCI
          should only be developed in regional Victoria where safety and effectiveness can reasonably
          be assured. We believe that if the recommendations of this report are implemented, rural and
          regional patients will be well-served by the cardiac service system.

6.61      Table 12 below describes the projected number of catheterisation laboratories which will be
          required at each site at which PCI is provided during the planning period. These projections are
          based on previous public inpatient activity, VACS and Medicare funded outpatient angiography
          and the following assumptions:
          •       DHS projected activity at 2016;
          •       current (2006/07) outpatient angiography procedures based on either the survey
                  response or estimated as being equal to an additional 60% of in-patient angiography;
          •       outpatient angiography procedures growing by 40% between 2006 & 2016;
          •       catheterisation laboratories operating 8.0 hours per day x 5.5 days per week x 45 weeks
                  per year;
          •       time allocated to procedures:
                  –     angiography 0.7 hours;
                  –     EP 4.0 hours;
                  –     PCIs with or without stent 90 mins on average;
                  –     AICD 1hour; and
                  –     pacemaker 1hour.




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6.62      It should be noted that these projections only take account of predicted demand for public and
          private patients in public hospitals. Some public hospitals have agreements with collocated
          private hospitals which enable the private hospital to use catheter laboratory infrastructure for
          its patients. We consider that such arrangements are appropriate because they enable efficient
          use of expensive capital and human infrastructure, but they must be commercially viable and
          should not involve public sector subsidisation of private operators. Investment in additional
          laboratories to cover such arrangements can only be justified if there is no net capital or
          operating cost imposition on the public sector.

6.63      CSAC members noted that it may be difficult to operate a catheter laboratory routinely on a
          Saturday morning, because staff prefer to work regular working hours. We believe, however,
          that whilst this may pose a challenge to health services it is reasonable to plan for more
          intensive use of very high cost infrastructure in the health care system and that with appropriate
          planning, recruitment and retention strategies it should be possible to develop a more flexible
          workforce.




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Table 12: Projected catheterisation laboratory requirements

                                              The Alfred                     Austin                Geelong                  Monash               Royal Melb.            St Vincents
                                        2005/06       2015/16      2005/06         2015/16   2005/06     2015/16     2005/06     2015/16    2005/06      2015/16   2005/06      2015/16
Average operating hours per day           8.0            8.0         8.0             8.0       8.0         8.0         8.0         8.0        8.0          8.0       8.0          8.0
Average operating days per week           5.5            5.5         5.5             5.5       5.5         5.5         5.5         5.5        5.5          5.5       5.5          5.5
Average operating weeks per year          45             45          45              45        45          45          45          45         45            45       45            45
Total Labs (calculated)                   0.9            1.3         1.2             1.7       0.7         1.2         1.1         1.7        1.7          2.3       1.1          1.7
Total Labs                                 2              2           2               2         2           2           2           2          2             3        2             2


                                                 Box Hill                     Frankston                   Northern                  Western                  Bendigo
                                           2005/06      2015/16         2005/06       2015/16       2005/06      2015/16      2005/06     2015/16      2005/06     2015/16
Average operating hours per day              8.0          8.0             8.0           8.0           8.0          8.0          8.0         8.0          8.0         8.0
Average operating days per week              5.5          5.5             5.5           5.5           5.5          5.5          5.5         5.5          5.5         5.5
Average operating weeks per year             45           45              45            45            45           45           45          45           45          45
Total Labs (calculated)                      0.9          1.3             0.5           0.8           0.5          0.8          1.1         1.9          0.5         0.7
Total Labs                                    1            2               1             1             1            1            1           2            1           1




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Recommendation 10

That the Department of Human Services supports the development of 24-hour PCI services at Northern,
Frankston and Bendigo Hospitals.

Recommendation 11

That the Department of Human Services supports the development of diagnostic angiography services
at Ballarat Base Hospital.

Recommendation 12

That the Department of Human Services ensures that new angiography and PCI services are developed
under the supervision of a highly experienced operator and in compliance with recommended patient
selection criteria and that outcomes are monitored by the supervising operator to ensure appropriate
quality standards are achieved.

Recommendation 13

That the Department of Human Services reviews the cost weights for PCI to take account of the cost
differentials between elective, in-hours emergency and out-of-hours emergency PCI.


Cardiac surgical services

6.64      As noted earlier in this report, there are six cardiac surgical services in Victoria, each providing
          at least 400 separations annually. Cardiac surgical volumes are predicted to remain relatively
          stable and each unit is expected to maintain an annual patient volume of at least 400
          separations over the planning period.

6.65      There has been considerable analysis of the relationship between surgeon and centre volume
          and cardiac surgical outcome. Chassin et. al. identified 16 relevant articles and selected 9 high
          quality articles which met specific inclusion criteria, for further analysis. 7 of the 9 studies
          demonstrated a statistically significant association between mortality and surgeon or hospital
                                         22
          volume of procedures, or both .

6.66      A 2005 study in the USA concluded that for CABG surgery hospital procedural volume was
          modestly associated with risk-adjusted mortality rates; however, there were many low-volume
          centres with low mortality rates and some high-volume centres with mortality rates higher than
          expected.

6.67      The importance of maintaining surgical volume for each cardiac surgery centre in Victoria was
          accepted by CSAC. Although some stakeholders would prefer a more distributed service
          system there was consensus from CSAC that:
          •       no additional cardiac surgical services should be developed;
          •       the predicted activity in each existing service is sufficient to meet volume-quality criteria;
                  and
          •       the critical interrelationships between cardiac surgical services and other tertiary hospital
                  services means that a surgical service could not be relocated from any existing host
                  hospital without significant redefinition of the role of the host hospital as a whole.




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6.68               Relocation of a cardiac surgical unit from a tertiary hospital to an outer metropolitan area would
                   have implications well beyond the terms of reference for this review. Equity of access for all
                   patients to surgical services is the most important objective, and this can be achieved without
                   relocation of an existing cardiac surgical unit.

6.69               A significant complaint from some stakeholders was that there are insufficient theatre sessions
                   and ICU beds available within their hospitals to meet reasonable demand for cardiac surgery
                   and that these factors are the primary limitation on throughput.

6.70               At the same time, cardiac surgeons advise that the threshold for intervening in complex
                   patients, many of whom have multi-system disease, is lowering steadily and they are now
                   operating on patients who previously would not have been considered to be suitable candidates
                   for surgery. Analysis of mortality and cardiac function in older patients suggests that such
                                                                      23
                   procedures on the whole produce good outcomes , although many nursing stakeholders
                   suggested to the Review team that outcome analysis should look at broader factors such as
                   quality of life.

6.71               Achieving a balance between patient needs and clinical infrastructure to provide cardiac
                   surgical services is a priority for the service system. Throughput and waiting list data provide
                   some insight into whether the system is meeting community need, but the efficiency of resource
                   utilisation and the appropriateness of patient selection are critical factors that also need to be
                   considered.

6.72               The ESIS database demonstrates that both the number of patients waiting and the waiting time
                   for CABG vary between services.

Figure 1: CABG waiting list numbers


                                                 Coronary Bypass Waiting List Numbers
             100

             90

             80

             70

             60
  Patients




             50

             40

             30

             20

             10

               0
                Jun-02   Dec-02         Jun-03         Dec-03       Jun-04   Dec-04      Jun-05        Dec-05      Jun-06


                                  Alfred, The [Prahran]                          Austin Hospital
                                  Geelong Hospital                               Monash Medical Centre [Clayton]
                                  Royal Melbourne Hospital - City                St Vincents Hospital




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Figure 2 CABGs average waiting times


                                                  Average Coronary Bypass Waiting Times
             250



             200



             150
  Days




             100



             50



               0
                Jun-02    Dec-02         Jun-03         Dec-03       Jun-04       Dec-04        Jun-05        Dec-05      Jun-06


                                   Alfred, The [Prahran]                                Austin Hospital
                                   Geelong Hospital                                     Monash Medical Centre [Clayton]
                                   Royal Melbourne Hospital - City                      St Vincents Hospital



6.73               Figure 3 shows a slight increase in waiting time with a substantial increase in the number of
                   patients waiting for their procedures from September 2001 to June 2006.

Figure 3 Waiting list data for cardiac procedures for Victorian hospitals, 2001 to 2006


                                                   Waiting List Data

    250                                                                                                        700

                                                                                                               600
    200
                                                                                                               500
    150                                                                                                        400

    100                                                                                                        300

                                                                                                               200
         50
                                                                                                               100

         -                                                                                                     0
         Se 0 2




         Se 0 3




         Se 0 4




         Se 0 5




               06
         Ju 02




         Ju 03




         Ju 4




         Ju 5




         Ju 6
         De 01

         M 1




         De 02
         M 2




         De 03
         M 03




         De 04
         M 4




         De 05

         M 5
             -0




             -0




             -0
              0




              0




              0




              0
            n-




            n-




            n-




            n-




            n-
             -




             -
           p-
            c-




           p-
            c-




           p-
            c-




           p-
            c-




           p-
            c-
          ar




          ar




          ar




          ar




          ar
         Se




                                             Average Waiting Time             Numbers


Source: ESIS




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6.74      Prioritisation of resource allocation within hospitals should occur on the basis of clinical need
          and is the responsibility of each health service. The current Victorian system of governance
          ensures that resource allocation decisions occur at the local level, closest to service delivery
          and in conjunction with clinicians. It does not provide for the DHS to advise or require hospitals
          to manage their internal resources in specific ways and we are reluctant to recommend that
          resources are 'quarantined' for cardiac surgery, despite significant advocacy by stakeholders
          for us to do so. The proposed cardiac clinical network will be responsible for monitoring
          community need and indicators of the adequacy of supply on an ongoing basis; advising the
          DHS of the implications of trends; and establishing a factual basis on which the DHS can make
          decisions about funding/purchasing policy if it appears that supply of services is not keeping
          pace with community need over time. In addition, the issue of cardiac surgical access to
          intensive care beds should be referred to the Department's Intensive Care Advisory Committee
          for consideration in the context of the overall supply of intensive care beds in the State.

Recommendation 14

That the current service system configuration for cardiac surgery is maintained and that no additional
surgical units are developed in Victoria during the planning period.

Recommendation 15

That the proposed cardiac clinical network monitors indicators of demand for and supply of cardiac
services as well as appropriateness of service provision to ensure that an appropriate balance between
community need and service provision is maintained.

Recommendation 16

That the Department of Human Services requests its Intensive Care Advisory Committee to consider the
issue of access to intensive care beds for cardiac surgical patients in the context of the overall supply of
intensive care beds in the State.


Cardiac MRI and cardiac CT

6.75      Highly specialised testing such as Cardiac CT and MRI are only available at a small number of
          major metropolitan services. Cardiac CT currently is performed at the Austin, Royal Melbourne
          and Western Hospitals and Cardiac MRI is performed at the Austin, Alfred, Monash and Royal
          Melbourne Hospitals.

6.76      These technologies each are applicable to a range of distinct clinical situations. While their
          applicability is well-documented the indications for their use are still evolving. It is likely that the
          utilisation of both technologies will increase over the planning period.
                                                                                                              24
6.77      According to the British Cardiovascular Society Working Group, with respect to cardiac MRI :
          •       it is the investigation that is most likely to see the largest expansion in the next decade;
          •       it is currently the gold standard for determining ventricular function and its quantification,
                  and increasingly is becoming so for myocardial viability;
          •       perfusion imaging has attained an acceptable level to allow widespread clinical use but
                  long-term data is still lacking for predicting clinical outcome;




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          •       it allows excellent assessment of patients with cardiomyopathy and heart failure;
          •       it is valuable for assessment of coronary anomalies and it is of some value in
                  assessment of coronary anatomy but at lower resolution than CT with more segments
                  that are non-analysable; and
          •       plaque imaging is a potentially important development but currently a long way from
                  having clinical relevance.

6.78      With respect to Cardiac CT, the British Cardiovascular Society Working Group suggests:
          •       it is the best non-invasive test for demonstrating coronary anatomy with real potential to
                  improve as the number of detector rows increase and other technological advances
                  occur;
          •       important current applications include imaging of grafts and aorta;
          •       it is fairly simple to use with rapid acquisitions making it a relatively inexpensive test;
          •       the negative predictive value of a normal scan for CAD is high;
          •       it provides limited functional data - for example, LV wall thinning and systolic function -
                  although developments are ongoing; and
          •       its drawbacks include its poor performance when calcification is present, the high
                  radiation dose for anatomy, potential nephrotoxic effects of contrast and the need for low
                  heart rates when assessing coronary artery anatomy. Perfusion imaging is less likely to
                  develop and there is no chance currently of proceeding on to PCI.

6.79      CSANZ's guidelines for the use of Cardiac CT and Cardiac MRI for coronary artery imaging are
          contained in its publication: Noninvasive Coronary Artery Imaging: Current Clinical Applications
          which includes the following summary statements:
          •       Multi-detector computed tomography and magnetic resonance imaging are the only two
                  non-invasive techniques that reliably image coronary arteries.
          •       The current literature supports the use of coronary MRA or CTA in expert centres for
                  defining the course of anomalous coronary arteries and assessing the patency of
                  coronary bypass grafts.
          •       Coronary MRA of the native coronary arteries remains investigational for the purpose of
                  coronary stenosis evaluation at this stage, awaiting further technical improvements.
          •       Coronary CTA is technically more feasible in patients with slower heart rates (or able to
                  tolerate beta-blockers) and with no or low levels of coronary calcification.
          •       The clinical place of coronary CTA potentially includes;
                  –     exclusion of significant CAD in lower risk cohorts of patients with acute chest pain
                        syndromes;
                  –     investigation of equivocal stress tests/stress imaging tests;
          •       Expertise in performance and interpretation of such scans is very important.

6.80      CSAC's strong consensus advice was that at present, cardiac MR is most relevant to tertiary
          hospital centres providing complex cardiology and cardiac surgery assessment and treatment
          services and that its development in such settings should be supported but its evolution and
          applicability should be monitored before it is introduced into routine use across the State.




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6.81      CSAC expressed some particular concern about the potential early dissemination of Cardiac
          CT for routine imaging of coronary arteries, but advised that in the longer term some CSAC
          members believed that it may become an effective alternative to invasive angiography in some
          settings.

6.82      Investigations using these technologies do not attract a Medicare benefit but the DHS provides
          some specific funding for the use and development of cardiac MR in a limited number of sites
          via new technology grants.

6.83      Under usual circumstances, responsibility for funding the wider introduction of new ambulatory
          technologies would be shared between the Commonwealth and the State, with the
          Commonwealth evaluating the safety, effectiveness and cost-effectiveness of the technology
          via its Medical Services Advisory Committee prior to introducing a Medicare Benefit or other
          form of public funding. The State would be expected to assume responsibility for funding
          investigations on public hospital patients only. We consider that this is an appropriate pathway
          for the evaluation and funding of new technologies which are used primarily for ambulatory
          patients. While State investment in such technologies in specialist centres with a complex
          patient mix and a focus on evaluation and research is appropriate, we do not recommend that
          the State funds further dissemination of these technologies beyond the State's tertiary hospital
          network until their appropriate clinical application has been fully evaluated and there is an
          appropriate arrangement for shared Commonwealth/State funding.

Recommendation 17

Both cardiac magnetic resonance imaging and cardiac computerised tomography are developing as
effective technologies with distinct and defined clinical applications; it is recommended that their
development and evaluation within centres of excellence are supported; but that they are not
introduced into new non-tertiary settings in Victoria until their clinical application including cost-
effectiveness is fully evaluated and there is a sustainable arrangement for funding that incorporates
an appropriate contribution from the Australian Government.


Cardiac electrophysiology

6.84      EP encompasses a number of diagnostic and treatment procedures. Members of CSAC have
          described two groups of services, simple electrophysiology including pacing, biventricular
          pacing and ICD insertion and complex EP including diagnostic EP and ablation. All of the
          tertiary cardiac service providers with the exception of St Vincent's currently provide complex
          EP services.

6.85      Most EP services are considered elective and stakeholders report that there are substantial
          waiting times for many services which are increasing as the scope of services increases.
          Reported limitations to services appear to relate to hospital activity budgets and workforce
          limitations rather than limitations in the availability of major infrastructure including laboratories
          and equipment.

6.86      Catheter ablation for atrial fibrillation currently has limited application. It is a time-consuming
          procedure which carries a 3-6% risk of major complications and at present is recommended for
          patients younger than 70 years with refractory paroxysmal AF, a left atrial diameter of <5cm
                                           25
          and an ejection fraction >40% .




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6.87      Future demand for EP services is likely to increase markedly as indications for its use broaden.
          At present it is offered to a limited number of patients and there is a significant waiting list in
          some services. Stakeholders believe that in the future, however, ablation may be more
          applicable to a large number of elderly patients, requiring a substantial increase in resources
          for existing services and possibly necessitating expansion of infrastructure to meet growing
          demand.

6.88      Some stakeholders are concerned about the impact on sustainability of EP services of the
          recent prohibition on reuse of single use devices. At present, the increased costs related with
          cessation of reuse are being supported by the DHS through 'top up' grants but providers
          believe that these additional costs need to be recognised, ultimately, in the DHS cost weights
          for these services. This issue is complex because there is no discrete Diagnosis Related Group
          DRG) for EP services and rolling up the cost of catheters into a generic DRG would
          disadvantage the providers of EP services compared with those hospitals that provide the
          same DRG but not EP services.

Recommendation 18

That the current service system configuration for complex electrophysiology continues and that no
additional complex electrophysiology units are developed in Victoria in the foreseeable future, unless
indications for its application change substantially leading to a significant increase in demand.

Recommendation 19

That the Department of Human Services investigates the feasibility of reforming funding for
electrophysiology so that the case payment for these services reflects their true cost including the cost of
single use devices.


Congestive heart failure services

6.89      It is estimated that 4% of the population aged 45 years of more has congestive heart failure
                  26
          (CHF) . The system will likely need to cope with increasing demand as prevalence increases
          with age, the continued impact of lower mortality from AMI and improved diagnosis. Heart
          failure has a particularly high hospitalisation rate, as approximately 25% of patients are
                                                                    27
          readmitted within one year of their first hospitalisation . American data suggest that the
          incidence of heart failure is not declining; 5 year age-adjusted survival is approximately 50%;
          and men and younger persons are experiencing survival gains but women and elderly persons
                   28
          are not . It has been reported that less than one in five eligible patients receives specialist
          heart failure management after hospitalisation for acute heart failure29.

6.90      Heart failure management requires a multidisciplinary approach and involves pharmacological
          interventions and other interventions that may include lifestyle modification, device therapies
          and surgical procedures. As noted earlier in this report, the National Heart Foundation and
          CSANZ have published a comprehensive document: Guidelines for the prevention, detection
          and management of chronic heart failure in Australia, 2006. These guidelines comprehensively
          address the continuum of issues from prevention to rehabilitation and palliation and we have
          recommended that they are adopted as the appropriate standard of care in Victorian public
          hospitals (Recommendation 23).




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6.91      In metropolitan areas, heart failure management programs have been developed, targeting
          recently hospitalised patients in an effort to optimise care after discharge. The HARP-CDM
          Program has established a chronic heart failure disease management working party, the key
          focus of which is to establish a systematic framework for managing the CHF patient population
          that:
          •       promotes evidence-based practice;
          •       spans the continuum of care;
          •       promotes service coordination and efficiency in service delivery;
          •       is patient centric;
          •       demonstrates improvement in patient outcome and quality of life; and
          •       minimises exacerbations of the condition and reduces Emergency Department
                  presentations.

6.92      It is clear that such programs minimise readmissions, improve quality of life, reduce costs and
          prolong survival. It also is clear, however that services are concentrated in metropolitan areas
          and rural patients are relatively disadvantaged. In 2004/05, there were 62 chronic heart failure
          management programs in Australia, of which 58 were located in capital cities or metropolitan
                                                               30
          areas. Only 1 service was located in rural Victoria .

6.93      A major concern for cardiologists is accessibility by patients with heart failure to biventricular
          pacing (also called cardiac resynchronisation therapy) and/or Impalantable Cardioverter
          Defibrillators (ICD). Studies have shown a 20-30% decrease in mortality over the span of one
                                 31 32
          to five years with ICD , . The use of these therapies is constrained by their high cost despite
                                                                                33
          a considerable number of patients who could benefit from their use .

6.94      In some regional centres, the limitation on access to these therapies relates to the availability of
          cardiologists. More commonly, however, cardiologists report that hospitals have placed limits
          on the number of devices that can be provided, because of their very high cost. There is a clear
          view that access to these therapies by patients in the private sector is substantially better than
          access by patients in the public sector.

6.95      The Medical Services Advisory Committee (MSAC) which advises the Australian Government
          on the evidence regarding the safety, effectiveness and cost-effectiveness of new and existing
          medical technologies and procedures, made the following recommendation in 2006:
          •       On the strength of evidence relating to safety, effectiveness and cost effectiveness,
                  MSAC concludes that the use of implantable cardioverter defibrillators for the primary
                  prevention of sudden cardiac death is beneficial and appropriate for:
                  –     patients with a left-ventricular ejection fraction of less than or equal to 30 per cent
                        at least one month after a myocardial infarct when the patient has received optimal
                        medical therapy; and
                  –     patients with chronic heart failure associated with mild to moderate symptoms
                        (NYHA II and III) and a left-ventricular ejection fraction less than or equal to 35 per
                        cent when the patient has received optimal medical therapy.




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          •       On the strength of evidence relating to safety, effectiveness and cost effectiveness,
                  MSAC concludes that the use of combined implantable cardiac resynchronisation and
                  cardioverter defibrillator therapy is beneficial and appropriate for patients with chronic
                  heart failure associated with moderate to severe symptoms (NYHA III and IV), sinus
                  rhythm, a left-ventricular ejection fraction of less than or equal to 35 per cent and a QRS
                  duration greater than or equal to 120ms, when the patient has received optimal medical
                  therapy.
                                                                                                            34
6.96       The Federal Minister for Health and Ageing accepted this recommendation on 6 June 2006.

6.97       We support this MSAC recommendation and believe that these devices should be available to
           eligible patients in the public health care system.

6.98       Ventricular Assist Devices (VADs) also are being used more commonly, and some are being
           used on a longer term basis. VADs are extremely expensive and although an increase in
           demand is expected, overall patient numbers are likely to remain small. VADs are
           predominantly used in patients awaiting transport and should be restricted to centres with
           cardiac transplant back-up.

Recommendation 20

That the Department of Human Services:

•       seeks advice from all relevant health services about the number of patients predicted to meet
        eligibility criteria as established by the Medical Services Advisory Committee for Implantable
        Cardioverter Defibrillators and combined implantable cardiac resynchronisation and cardioverter
        defibrillator therapy; and

•       with the advice of the proposed cardiac clinical network negotiates and includes within health
        service funding agreements a target level of provision by each health service that is predicted to
        meet reasonable demand.

Recommendation 21

That each proposed region-specific plan for the optimal use and coordination of cardiac care resources
incorporates a detailed plan, developed in conjunction with the Hospital Admission Risk Program -
Chronic Disease Management (HARP-CDM) Program, for the management of congestive heart failure in
accordance with the relevant clinical guidelines.


Congenital heart disease services

6.99       It has been estimated that in 2000 there were 15,000 people with congenital heart disease in
                                                           35
           Victoria, with 1400 people with complex disease . Despite this, no designated specialist
           centre exists within Victoria.

6.100      Transitioning patients from paediatric to adult services is a complex process which requires
           significant planning and service coordination. The Royal Children's Hospital has a relationship
           with the Royal Melbourne Hospital for the provision of many services for children with chronic
           disease who are transitioning to adult services. Monash Medical Centre is the second major
           provider of specialist paediatric services in Victoria and is able to offer integrated paediatric and
           adult services under the same governance and management structure. Paediatric service




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          planning in Victoria has resulted in the proposal that the Royal Melbourne Hospital and Monash
          Medical Centre are designated as centres for adults with congenital heart disease.

6.101     International standards specify that one specialist centre is required for populations from 3 to
                    36 37 38
          10 million , , and it is estimated that this centre would have approximately 100 annual
                   39
          referrals .

6.102     Requirements for geographic accessibility across the state and existing organisational
          relationships suggest, however, that designation of a single service with dual clinical sites at
          both Monash Medical Centre and the Royal Melbourne Hospital should be considered and
          would represent a practical outcome in the Victorian context.

Recommendation 22

That the Department of Human Services works with the proposed cardiac clinical network and with
relevant stakeholders to develop structural and service coordination models for a designated state-wide
service for adults with congenital heart disease, with services to be provided from two sites (Monash
Medical Centre and the Royal Melbourne Hospital).


Rehabilitation services

6.103     The World Health Organisation defines cardiac rehabilitation as “the sum of activities required
          to influence favourably the underlying causes of the disease, as well as the best possible
          physical, mental and social conditions, so that they may, by their own efforts preserve or
          resume when lost, as normal a place as possible in the community. Rehabilitation cannot be
          regarded as an isolated form of therapy, but must be integrated with the whole treatment, of
                                        40
          which it forms only one facet” .

6.104     Cardiac rehabilitation comprises:

     •    Phase I inpatient rehabilitation;

     •   Phase II outpatient rehabilitation from two to twelve weeks after discharge; and

     •   Phase III long term maintenance.

     The most frequently seen conditions for which patients are referred to cardiac rehabilitative
     programs are related to ACS. Cardiac rehabilitative programs also treat clients who have had
     surgical repair/replacement of heart valves. Unless a specific heart failure program is available,
     many cardiac rehabilitation programs also treat clients with CHF. Many cardiac rehabilitation
     programs also treat clients with other cardiac conditions such as arrhythmias (in some cases, where
     a pacemaker or implantable defibrillator has been inserted), or those clients who are at risk of
     developing coronary artery disease due to risk factors such as hypercholesteremia, diabetes or
     obesity.
                                                                    41
6.105     Cardiac rehabilitation is a “proven effective intervention” . There is firm evidence that three-
          phase rehabilitation programs (inpatient, outpatient and maintenance) provide a range of
          benefits to health and wellbeing of patients who have suffered a cardiac event. The National
                                          42                                   43
          Heart Foundation of Australia and the World Health Organization recommend that all
          patients with cardiovascular disease are referred routinely to an appropriate cardiac




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          rehabilitation program. The National Heart Foundation of Australia and the Australian Cardiac
          Rehabilitation Association Recommended Framework for Cardiac Rehabilitation is accepted by
          stakeholders as the basis for designing and delivering cardiac rehabilitation services.

Recommendation 23

That the National Heart Foundation of Australia and the Australian Cardiac Rehabilitation Association
Recommended Framework for Cardiac Rehabilitation is adopted by the Victorian public health care
system as the appropriate standard for the provision of cardiac rehabilitation services.


6.106     In April 1999 the Victorian Department of Human Services published a document produced by
          the Heart Research Centre: Best Practice Guidelines for Cardiac Rehabilitation and Secondary
          Prevention. The document is now almost a decade old and should be reviewed in light of the
          more recent publication of the National Heart Foundation/Australian Cardiac Rehabilitation
          Association Recommended Framework for Cardiac Rehabilitation.

Recommendation 24

That the proposed cardiac clinical network reviews and advises the Department of Human Services on
necessary updates to the publication Best Practice Guidelines for Cardiac Rehabilitation and Secondary
Prevention, ensuring its consistency with the Recommended Framework for Cardiac Rehabilitation.


6.107     There is very strong support for ensuring that all patients access appropriate rehabilitation
          services. The current rate of uptake of rehabilitation programs by eligible patients varies but
          some providers estimate it is as low as 30%. It is likely that the capacity of rehabilitation
          services would be inadequate if all eligible patients accessed them.

6.108     Providers attribute the reported low rate of access to cardiac rehabilitation services to the
          following factors:
                                                                         44
          •       non-referral of eligible patients. A study in Queensland demonstrated that of all
                  patients discharged from participating hospitals 59% were eligible for cardiac
                  rehabilitation but only 29% were referred. Proportionally more patients were referred
                  from secondary and private hospitals than from tertiary and public hospitals;
          •       improved treatments including PCI and thrombolysis mean that patients who previously
                  would have experienced prolonged hospitals stays and required extended periods of
                  recovery are now often experiencing short hospital stays and few ongoing symptoms.
                  This can lead to a lack of patient recognition of the underlying seriousness of their
                  condition and the need for lifestyle change;
          •       many patients who have been treated effectively for ACS are able to return to work
                  almost immediately. Cardiac rehabilitation programs that are offered in traditional day-
                  time sessions are not accessible to these patients;
          •       cardiac rehabilitation programs are not always accessible to minority groups including
                  those who do not speak English;
          •       there are insufficient places available in some centres to meet demand, but there is no
                  additional funding available to expand programs; and
          •       economic pressures in rural areas have impacted on the ability of patients to travel long
                  distances to access health care services.




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6.109     Some providers have developed complementary programs which focus on secondary
          prevention of cardiac disease - for example, the COACH Program (Coaching patients on
          Achieving Cardiovascular Health) developed by St Vincent's Hospital Melbourne is a telephone
          support and education program for patients with coronary heart disease. A health professional
          (Coach) aims to empower patients to drive the process of achieving and monitoring target
          levels of their identified risk factors. COACH involves recruiting patients in hospital, measuring
          their vital statistics such as cholesterol and weight, discussing with the patients what they need
          to do to achieve key health targets to help prevent or reduce future heart problems and
          following up with regular telephone calls home to check on progress and maintain motivation in
                                                                                               45
          the patient. The program has been adopted by a number of Melbourne hospitals . It is now
          funded by the Department of Human Services and is a HARP-CDM service.

6.110     The Victorian cardiac service system should ensure that every eligible patient is referred to
          cardiac rehabilitation and that patients are encouraged and supported to access programs
          which meet their needs. Rehabilitation providers repeatedly advised the Review team that there
          are insufficient places and insufficiently flexible cardiac rehabilitation programs in Victoria
          because funding for these programs is inflexible and, overall, inadequate.

6.111     We propose the following principles to support quality improvement in rehabilitation services:
          •       it is the responsibility of the hospital which provides acute cardiac care to ensure that
                  patients have access to Phase I rehabilitation and are referred appropriately to Phase II
                  cardiac rehabilitation in appropriate settings.
          •       it is the responsibility of Phase II rehabilitation providers to ensure that patients are
                  referred appropriately to Phase III services.
          •       hospitals should be rewarded for adopting effective referral practices.
          •       a mix of centre-based community and outreach services should be available.
          •       where possible, Phases II and III cardiac rehabilitation should be provided in non-
                  hospital settings.
          •       partnerships between hospitals and community-based providers to deliver cardiac
                  rehabilitation services should be encouraged.
          •       the Department of Human Services should provide adequate funding, equitably
                  distributed, to enable the provision of an appropriate range of Phase I to III cardiac
                  rehabilitation services which are culturally-appropriate, flexible and responsive to patient
                  needs.
          •       funded providers must be accountable to the DHS for quality service delivery..There are
                  currently seven different funding streams by which rehabilitation programs can attain
                  funding, however none of these is dedicated specifically to cardiac rehabilitation. This
                  reportedly places a considerable administrative burden on providers.




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Recommendation 25

That the proposed cardiac clinical network leads a project incorporating:

•       the development of specific standards for provision of Phase I and provision of or referral to Phase
        II cardiac rehabilitation programs;

•       provision of incentives to all acute hospitals that offer cardiac services for the development and
        implementation of referral improvement plans consistent with the endorsed standards;

•       an audit program of hospital records to monitor and evaluate compliance with the endorsed
        protocols;

•       performance bonuses to acute hospitals based on assessed performance; and

•       performance indicator development and ongoing monitoring.

Recommendation 26

That the Department of Human Services reviews funding of cardiac rehabilitation services across
Victoria and ensures that:

•       there is sufficient funding which is appropriately distributed to ensure equitable access to quality
        services by all eligible patients;

•       funding streams are consolidated so as not to create an undue administrative burden on providers;
        and

•       funding enables the development and provision of a mix of services tailored to patient needs.


Palliative care services

6.112      An increasing number of patients with chronic heart failure require specialist palliative care
           services but do not have comparable access to palliative care when compared to patients
                                  46
           suffering from cancer . A comparison of death from lung cancer and death from congestive
           heart failure found that patients with congestive heart failure generally had less information
           about their illness; a poorer understanding of their illness and progression; less involvement in
           important decision making; frustration with progressive losses; fewer health and social services
                                                                                                           47
           and financial benefits; less access to palliative care services and poorly coordinated services .

6.113      This has been further supported in a recent study that identified the need for funding and policy
           support for palliative care provision in heart failure, as well as the need for education of
           cardiology clinicians in palliative care and of palliative care clinicians in heart failure
                           48
           management . There is a difference between palliative care for cancer patients, where
           palliation is focused solely on the alleviation of symptoms without being able to control the
           underlying disease, and patients with chronic heart failure where even in the very end stages
           there is a requirement for active management of cardiac function.




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6.114     The CSANZ guidelines recommend an individualised program of palliative care be considered
          for patients facing the strong possibility of death within 12 months, who have advanced
          symptoms (NYHA Class IV) and poor quality of life, resistant to optimal pharmacological and
          non-pharmacological therapies (National Heart Foundation of Australia and CSANZ 2006).

Recommendation 27

That the Department of Human Services' Palliative Care Advisory Committee is asked to advise the
Department on strategies to strengthen palliative care services for cardiac patients across the state.


Hospital facilities to support quality cardiac care

6.115     The provision of a quality cardiac service requires facilities for the rapid and accurate
          evaluation of chest pain, diagnostic equipment and intensive cardiac care. For cardiac surgery,
          access to general Intensive Care Unit beds and operating theatres is required. A skilled
          workforce is essential to support the provision of quality care.

6.116     Under current governance arrangements in Victorian hospitals, health services are responsible
          for determining the amount and direction of investment in such human and physical resources.
          The DHS supports hospitals and health services in this process by providing funding for minor
          equipment replacement in accordance with hospital-determined priorities. In addition, the DHS
          invests in innovative models of service delivery, particularly if they create the potential to enable
          system-wide improvements in the quality or efficiency of care.

6.117     Stakeholders raised a number of issues with the Review team during the course of the review,
          including:
          •       there is strong support for the continuing development of capability to monitor and
                  evaluate patients who present to hospital with chest pain;
          •       there is a need for system-wide investment in minor equipment upgrading and
                  replacement; and
          •       hospitals need to invest appropriately in intensive cardiac care facilities.

6.118     At a system-wide level, the DHS has stimulated, though targeted investment, the development
          of Chest Pain Evaluation Units (CPEUs) for the rapid and reliable evaluation and monitoring of
          low or moderate risk patients. CPEUs have designated staff and provide short stay observation,
          electrocardiogram (ECG) monitoring, cardiac marker testing and (usually) exercise stress
          testing.

6.119     Patients generally are admitted to such units for 6 to 12 hours in an attempt to improve
                                                                       49
          diagnostic accuracy, shorten length of stay and save money . Their development was
          stimulated by two concerns:
          •       that patients with chest pain are admitted to hospital, consuming scarce and expensive
                  resources, to rule out ACS when the cause is non-cardiac; and
          •       that a small number of patients with atypical signs and symptoms are inadvertently
                  discharged from the Emergency Department when they are suffering from ACS.




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6.120     The Guidelines for the Management of Acute Coronary Syndromes 2006 recommend that
          patients with suspected ACS without ST elevation on ECG should be further evaluated, the
          initial objective being to define the likelihood of ACS as the cause of presentation and the
          second objective being to determine the risk of short-term adverse outcomes, which will direct
          the management strategy. High risk patients should be treated aggressively; intermediate risk
          patients should be observed by trained staff and undergo an accelerated diagnostic evaluation
          and further risk stratification, during which they should have frequent ECG (with or without
          continuous ST-segment monitoring), repeat troponin testing and provocative testing if a repeat
          troponin assay is negative; and low risk patients should undergo an appropriate period of
          observation and assessment.

6.121     The Guidelines for the Management of Acute Coronary Syndromes 2006 also state that
          patients whose ECG and cardiac marker levels are normal after a suitable period of
          observation should, where practical, undergo provocative testing (eg stress testing) before
          discharge. Stakeholders advised that waiting times for such testing are prolonged and patients
          often have to return for testing at a later date. It appears that the main limiting factor is the
          availability of an appropriate workforce to provide this service to the CPEU or Emergency
          Department.

6.122     Ensuring compliance with evidence-based protocols is a clinical governance responsibility for
          Boards, managers and clinicians. However it is proposed that to improve the clinical
          governance of cardiac services there should be network wide adoption of the Guidelines for the
          Management of Acute Coronary Syndromes 2006.

6.123     In Victoria 13 hospitals reported using a CPEU model. CSAC strongly endorsed the model
          because it is perceived to support efficient and effective care.

6.124     An evaluation of CPEAs conducted for the Department of Human Services by KPMG
          Consulting in 2000 supported the continuation and future development of the CEPA model of
          care in the Victorian hospital system. More recent international studies have found this model to
                                 50         51
          be both cost effective and safe . Arnold, Goodacre and Morris (2007) also suggest that “it
          might be more appropriate to consider the [CPU] as a process of care rather than a physical
          entity because the key elements relate to process rather than structures.”

Recommendation 28

That the Department of Human Services continues to support all hospitals which offer emergency
cardiac services to develop the infrastructure necessary to monitor and evaluate patients with chest pain
in accordance with the Guidelines for the Management of Acute Coronary Syndromes 2006.


6.125     Lack of availability of CCU and ICU beds was cited by clinicians involved in this review as a
          frequent barrier to access to quality cardiac care. The issue of ICU bed availability is discussed
          elsewhere in this report (see discussion commencing at paragraph 6.69).

6.126     CCUs are resource intensive and the increasing practice of interventional cardiology is altering
          demand for these services. Currently 57% of CCU admissions in Victoria are for interventional
          cardiology DRG’s and the majority of these are emergency admissions (see discussion
          commencing at paragraph 5.31).




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6.127     Recognising changing practice and in an attempt to unify and improve the function of Intensive
          Cardiac Care Units (ICCU) the European Society of Cardiology (ESC) published
                                                                                                     52
          Recommendations for the structure, function and operation of intensive cardiac care units
          which, while recognising the independence of the clinician, offer the following admission criteria
          for consideration:
          •       STEMI up to 24 hours from onset of symptoms;
          •       AMI > 24 hours from onset of symptoms +/- complications;
          •       cardiogenic shock;
          •       high risk unstable ACS;
          •       unstable post complicated PCI;
          •       life threatening Cardiac arrhythmias;
          •       acute Pulmonary Oedema (APO);
          •       massive pulmonary embolus;
          •       patients in need of haemodynamic monitoring; and/or
          •       post heart transplant/ cardiac surgery for haemodynamic evaluation.

6.128     Hassin et al53 further describe requirements for equipment within ICCUs.

6.129     It is estimated that, based on international recommendations, 223 intensive and high
          dependency cardiac care beds will be required within the Victorian system by 2016 (four beds
          per 100,000 population for a population of 5,574,756) 54. Appropriate planning for and staffing
          and use of these facilities will be essential to ensuring access and patient flow and will be a key
          consideration for hospitals and health services that establish or expand interventional
          cardiology services.

6.130     There was significant advocacy by some stakeholders for the Review to mandate the structure
          of CCUs and/or bed numbers in specific health services.

6.131     Some senior cardiac nurses are committed to the traditional physical separation of the CCU
          from other inpatient facilities, whereas others believe there are benefits in integrating CCU
          services within broader cardiac units, allowing greater flexibility of bed and staff utilisation and
          more opportunities for patient access, improved workflow, bed management efficiency and the
          development of junior nursing staff. This latter model is viewed by some nurses, however, as
          increasing the likelihood of specialist cardiac nurses being required to nurse non-cardiac
          patients, impacting on their skills maintenance, job satisfaction and retention.

6.132     As noted in paragraph 6.74, the DHS delegates a considerable level of governance and
          management control to health services and usually does not mandate either bed numbers or
          configuration. It is important, nevertheless, that the cardiac care system is configured in a way
          which supports system-wide objectives including retention of an expert workforce. On balance,
          we do not consider that there is sufficient evidence of superiority of one CCU model over
          another to justify a recommendation about configuration of services and we consider it remains
          appropriate for each health service to configure its internal resources according to local
          conditions. It will be a key role of the proposed cardiac clinical network to maintain an ongoing




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          overview of the performance of each health service and hospital in this regard and the
          adequacy of resources across the system.

6.133     Most metropolitan and large regional health services are providing, or aspire to provide, a full
          range of diagnostic services to admitted and non-admitted patients including:
          •       diagnostic angiography;
          •       electrocardiography;
          •       trans-thoracic echocardiography;
          •       trans-oesophageal echocardiography;
          •       exercise stress testing;
          •       stress echocardiography;
          •       tilt table testing;
          •       Holter monitoring;
          •       ambulatory blood pressure monitoring; and
          •       nuclear medicine testing including perfusion scanning and gating.

6.134     Some of the major regional and outer metropolitan hospitals do not have nuclear cardiology
          services but most plan to develop them over time.

6.135     Many health services provide most diagnostic services on a Medicare-funded basis and are
          marketing their services actively to private patients, creating some concern in the private sector
          about competition by public providers with private services. Of nine metropolitan health
          services who reported providing diagnostic services in 2006/07:
          •       two reported services being funded entirely by VACS;
          •       five reported services being funded entirely by Medicare; and
          •       two reported services being funded by both VACS and Medicare.

6.136     The utility of echocardiography is increasing and service volumes are increasing rapidly. This
          increase is viewed as appropriate and will continue as the availability of 3-dimensional
          echocardiography increases. Stakeholders reported that waiting times for tests such as stress
          echo (which is largely centralised in most hospitals) may be weeks or months. It should be
          noted that in the United Kingdom the National Health Service has set a target that no patient
          should wait more than 13 weeks for diagnostic tests including echocardiography.

6.137     The main limitation to providing and/or increasing the provision of diagnostic services is the
          shortage of trained technologists, particularly for echocardiography. Some services have
          excessive waiting times, extending to months. Public providers report that the majority of
          training is conducted in the public sector but there are significant opportunities in the private
          sector for qualified sonographers, resulting in their rapid exodus from the public sector at the
          completion of their training.

6.138     Lack of information regarding these tests make it difficult to either project service demand or
          plan service capacity. Undoubtedly with an increasing incidence of cardiovascular disease,
          technological advances and an ageing population, demand for such tests will increase and
          planning for this is required.




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6.139     Governance arrangements in the Victorian public health care system mean that the
          responsibility for planning and managing these services in accordance with expected clinical
          standards rests with hospitals and health services. Monitoring and reporting on the quality of
          cardiac care, including timely provision of appropriate investigations, and encouraging
          compliance with accepted clinical standards will be a key role for the proposed cardiac clinical
          network which we believe will lead to improvements in standards of care.

6.140     There is, however, a potential role for the DHS and/or the proposed cardiac clinical network in
          addressing system-wide issues that are impairing the capability of health services and hospitals
          to provide these services or their willingness to invest in them. We believe that the major
          impediment to the provision of an adequate range of services in all hospitals at present is
          workforce-related. Later in this report we make recommendations about workforce issues.

6.141     We also note stakeholder claims that there has been poor planning for equipment replacement.
          We suggest that the proposed cardiac clinical network works with hospitals to undertake a
          stocktake of existing cardiac care equipment and to advise the DHS on priorities for equipment
          replacement across the system.

Recommendation 29

That the proposed cardiac clinical network:

•       assists hospitals and health services to undertake a cardiac equipment stocktake and develop
        equipment replacement plans; and

•       advises the Department of Human Services on system-wide priorities for the funding of cardiac
        equipment.


Workforce

6.142     In the course of this review difficulty attracting a specialist workforce was identified by many
          health services as a major constraint on quality service provision and service development.

Nursing

6.143     In the 2006 Nurse Labour Force census, 219 nurses reported their specialty field to be
                                                                                          55
          cardiology nursing and 129 reported their specialty to be cardiothoracic nursing .

6.144     There are particular concerns about the specialist cardiac nursing workforce. Nurses report that
          there are few incentives to train as a specialist cardiac nurse. Many courses are costly to
          complete and specialist nursing staff receive very little financial reward in recognition of their
          increased qualifications. Nurses also report that the experience of being a cardiac nurse is
          changing, as models of care change. The proportion of specialist staff in some CCUs is low and
          the patient mix has changed. For some nurses, these factors are making cardiac nursing less
          attractive as a profession. Nurses are calling for new models of training, financial support for
          training and more financial recognition of their qualifications.




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6.145     Although the European Society of Cardiology recommends a ratio of 1 nurse to 2 patients there
          is no evidence to support this ratio and further work needs to be done to determine appropriate
          matching of specialist resources, patient acuity and workflow to support best patient outcomes.
          Nurse staffing profiles in CCUs also are untested - it is recommended that a minimum of 60% -
          75% of nurses have postgraduate qualifications, which poses a large problem for the future of
          the cardiac nursing workforce.

6.146     The concept of a 'generic' critical care nurse is not attractive to specialist cardiac nurses, who
          favour a highly specialised cardiac nursing model. Similarly, many specialist cardiac nurses
          dislike working in environments where the patient mix is broad, but are finding that a focus only
          on cardiac nursing is increasingly difficult to achieve.

6.147     Some health services have developed new models of cardiac nursing which involve rotation of
          specialist nurses through cardiac laboratories and emergency chest pain assessment services,
          to ensure that their skills are maintained and developed through ongoing exposure to patients
          with a full range of cardiac conditions. In some health services, nurses have been trained to
          assume the role of the cardiac technologist in the catheter laboratory. There is strong
          multidisciplinary support for continuing expansion of the role of the cardiac nurse, but some
          health services point out that there are costs associated with developing new models of training
          and practice which need to be funded if such development is to progress.

6.148     Support for the development of the cardiac nursing workforce through innovative course
          development, flexible delivery models and subsidised fees are likely to be necessary in order to
          develop a sustainable future workforce. Consideration also could be given to new professional
          models including greater use of RN Division 2 nurses with medication endorsement, who would
          need support to develop skills and core competencies but could be effective members of the
          nursing team, as has been the experience in Australian Intensive Care Units.

Technologists

6.149     British standards suggest the need for 25 trained technologists for every tertiary centre (serving
                                                                                                 56
          1.5 million people), with an increase to 39 technologists per tertiary program by 2010 .

6.150     Cardiac technologists, particularly sonographers, are in short supply in Victoria. There is a
          widespread view that the public sector is investing in the training of large numbers of
          technologists, many of whom move to the private sector once qualified. Some services rotate
          technologists through diagnostic and laboratory services which increases professional
          satisfaction and service flexibility.

Doctors
                                                57
6.151     The British Cardiac Society (2005) recommended 52.7 to 84.2 cardiologists per million
          population. Recent planning in New Zealand has recommended three medical cardiologists, 0.5
                                                                                             58
          interventional cardiologists and 0.2 electrophysiologists per 100,000 population . The Royal
          Australasian College reports 160 fellow members, of which 143 were metropolitan based and
          17 were in rural locations. Most cardiologists consulted were confident that there were sufficient
          cardiologists being trained, although the question of whether cardiologists with diagnostic
          angiography skills but no interventional skills should be trained was raised, in the context of the
          requirement for a critical mass of interventional cardiologists to run an increased number of




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             effective and sustainable continuously-accessible PCI services. British standards recommend
             six to eight consultant cardiac surgeons for each training centre, with approximately 200
             operations per year.

6.152        Anaesthetic trainees need to access a defined number of cardiac surgical cases during their
             training. This may become an issue with the plateauing of cardiac surgical patient numbers.
             Providers are also keen to pursue private sector opportunities for training.

6.153        Many of the recommendations of this report are heavily dependent on the availability of
             appropriately skilled staff. CSAC report that attracting and retaining staff is already presenting a
             considerable challenge. The challenges facing the cardiac workforce are reflective of workforce
             issues throughout health services and will require a multifactorial solution. In ensuring the
             continuing availability of high quality staff in the public sector the DHS will need to consider
             strategies to provide:
             •       training and career progression for nurses and support staff; and
             •       incentives to work in regional and rural areas of the state.

6.154        Workforce shortages are problematic internationally. In countries such as the United Kingdom
             workforce redesign has been instigated in many areas of health in order to develop a more
             flexible, fit for purpose workforce.

Recommendation 30

That the Department of Human Services Service and Workforce Planning Branch works with the
proposed cardiac clinical network and relevant professional bodies to develop a strategy to ensure a
sustainable cardiac workforce in Victoria with particular emphasis on the nursing and technology
workforce.

Recommendation 31

That the cardiac clinical network works with the designated level 5 and 4 cardiac hospitalsv and relevant
tertiary education institutions to design and implement appropriate education modules for the cardiac
nursing and allied health workforces.



Coordinating the service system

6.155        Coordination of cardiac services generally is important but it is critical in relation to access to
             reperfusion therapy for patients with STEMI.

6.156        A 2003 review demonstrated that almost 40% of eligible patients with STEMI in Victoria were
                                                                                                   59
             not being treated within a 90-minute 'call to needle' time benchmark for thrombolysis.




  v
      As discussed in table 16 page 83




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6.157        Increasingly, health care systems nationally and internationally are taking strategic approaches
             to the provision of optimal cardiac care. For patients with ACS, optimal therapy will depend on
             specific patient characteristics, time of presentation and local expertise and resources.

6.158        A care pathway for ACS is suggested in Figure 4. This pathway draws on published
             international models to maximise rapid access to appropriate treatment and minimise delays
             and variation in management. It proposes a state wide chest pain assessment protocol within a
             framework that allows for designated PCI hospitals, pre-hospital ECG, pre-hospital
             thrombolysis in appropriate cases, pre-hospital or ED-physician activated laboratories, defined
             (fall back) referral routes, priority diagnostics and automatic rehabilitation referral. The pathway
             also recognises that not all patients will be able to access PCI within time guidelines and that
             these patients should be treated with fibrinolytic therapy.

Figure 4: Recommended pathways for the management of acute coronary syndrome in Victoria

                                                                STEMI – PCI onsite                          Primary PCI1                Referral to cardiac rehab
                  Emergency Department
     Chest pain assessment protocol2. ECG within 5 mins
        Stat pathology biomarkers PCI lab activation
                                                                                                  If primary PCI accessible within 2
                                                                STEMI – PCI offsite                hours, transfer. Otherwise early     Referral to cardiac rehab
                                                                                                              fibrinolysis1



                        Own transport                                                                                                   Transfer to cardiac centre1
                                                                                                  High-risk NSTEACS Angioplasty




                                                                     NSTEACS                        Intermediate-risk NSTEACS
                                                            Other diagnostics stress test                Further diagnostics



                                                                                                        Low risk NSTEACS                 Outpatient clinic
                 Individual with chest pain

                                                                    If 1hr from symptoms 60 minutes door to balloon time1
                                                                    If > 1hr from symptoms 90 minutes door to balloon time1


                          Ambulance                             STEMI – PCI onsite                          Primary PCI1                Referral to cardiac rehab
     To designated cardiac centre where appropriate, with
      protocol for immediate response for STEMI1 12 lead
                     ECG PCI lab activation                                                       If primary PCI accessible within 2
                                                                                                   hours, transfer. Otherwise early
                                                                STEMI – PCI offsite                                                     Referral to cardiac rehab
                                                                                                   fibrinolysis including prehospital
                                                                                                             with protocols1


                                                                                                                                        Transfer to cardiac centre1
                                                                                                  High-risk NSTEACS Angioplasty


References
1.   National Heart Foundation and CSANZ (2006)                      NSTEACS                        Intermediate-risk NSTEACS
                                                            Other diagnostics stress test                Further diagnostics
2.   Goodacre et al. 2007; Arnold et al 2007

                                                                                                        Low risk NSTEACS                 Outpatient clinic




Early symptom recognition

6.159        Many health care professionals reported to the Review their perception that patients delay their
             presentation with symptoms of ACS. There was strong representation by health professionals
             from rural areas in particular that delays in presentation are contributed to by:
             •           a lack of community awareness about the seriousness of relevant symptoms and the
                         need to respond rapidly;
             •           socio-economic barriers to ambulance service membership; and
             •           the cost for non-members of emergency transport.




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6.160     Studies confirm that only about 20% of patients present to hospital within an hour of the onset
                                               60
          of symptoms of myocardial infarction . A cross-sectional telephone survey of people from
          metropolitan and rural areas of Victoria conducted in 2000/01 demonstrated that the Victorian
          public appears to lack the knowledge of the varied range of heart attack symptoms and
          recommended that methods of disseminating information regarding symptoms and ways to
                                   61
          reduce prehospital delay .

6.161     Delay in accessing definitive treatment has been shown repeatedly to have a major impact on
                                       62 63 64
          outcome, including mortality , , . Patient with acute ischaemic chest pain who call their
          general practice instead of the ambulance service are likely to have delayed thrombolysis
                                               65
          which is likely to increase mortality . Public awareness campaigns and community-based
          interventions can be effective in reducing the time from symptom onset to first medical
                        66
          presentation .

6.162     The National Heart Foundation specifically recommends that people with known or at high risk
          of coronary heart disease, people in rural and remote locations and Aboriginal and Torres Strait
          Islander people have tailored efforts to overcome psychosocial barriers to early action,
          communicate the urgency and importance of early action and how to recognise a heart attack,
          and a specific action pathway. The National Heart Foundation recognises that the success of
          such efforts will require the engagement of health professionals and institutions involved in
                                                              67
          emergency management of suspected heart attack .

6.163     This issue is outside the terms of reference of this Review and we have not developed specific
          recommendations to address it, but we note its critical impact on the outcomes of cardiac care,
          particularly for patients suffering ACS. We encourage the DHS to pursue the development of an
          appropriate community-based strategy with relevant stakeholders including the Australian
          Government Department of Health and Ageing and the National Heart Foundation.

Pre-hospital diagnosis of STEMI

6.164     While STEMI can be diagnosed in some cases without the assistance of 12-lead ECG, the
          availability of this technology is necessary for reliable diagnosis in all patients.

6.165     Pre-hospital ECGs have been shown to be associated with both significantly shorter door-to-
          reperfusion times and a higher proportion of patients receiving reperfusion therapy within
                                             68
          guideline-recommended timeframes .

6.166     Twelve-lead ECGs have been installed in some ambulances that are used to transport patients
          suffering ACS in Victoria. Major equipment purchase and installation as well as significant
          training for staff, which is critical if the pre-hospital ECG is to play its potential role in expediting
          patient access to appropriate reperfusion therapy, will be necessary if 12 lead ECGs are to be
          applied successfully to improve the management of ACS in Victoria.

6.167     Continuation of a program of installation of 12 lead ECGs is strongly recommended, within
          financial and technological constraints. Ultimately, all ambulance vehicles that are used to
          transport patients with ACS should be equipped with 12-lead ECGs, with associated
          standardised protocols on how and by whom pre-hospital ECGs should be performed and
          interpreted, and reliable technological capability to transmit data to receiving hospitals.




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Recommendation 32

That the Department of Human Services supports the Metropolitan Ambulance Service and Rural
Ambulance Victoria to complete the installation of equipment to support 12-lead electrocardiogram
capability in all Victorian ambulances that are used to transport patients suffering from Acute Coronary
Syndrome, and to implement associated protocols, training and technologies.


Pre-hospital cardiac care

6.168     Enhancement of pre-hospital cardiac care has been advocated as a strategy to improve
          outcomes in a broad range of cardiovascular diseases including STEMI, NSTEACS, other high
                                       69
          risk ACS and cardiac arrest . A meta-analysis of randomised controlled trials of pre-hospital
          versus in-hospital thrombolysis for acute myocardial infarction has demonstrated that pre-
          hospital thrombolysis significantly decreases the time to thrombolysis and all-cause hospital
                   70                                                                                  71
          mortality . Paramedic-based pre-hospitals thrombolysis has been demonstrated to be safe .
          A 2003 Victorian study demonstrated that a significant proportion of patients were not receiving
          thrombolysis within guideline times and recommended that strategies to reduce call-to-needle
          time should be region-specific and should include attempts to reduce door-to-needle time and
          to enhance ambulance-hospital communication, and that pre-hospital thrombolysis may be
          appropriate for some regions.

6.169     A trial of paramedic-administered pre-hospital thrombolysis has been conducted in a rural
          Victorian region since 2002 but the number of eligible patients has been surprisingly low.

6.170     The Guidelines for the Management of Acute Coronary Syndromes 2006 note that in the
          Australian context, pre-hospital fibrinolysis (by general practitioners, ambulance paramedics,
          nurses or other qualified staff in a variety of pre-hospital settings) needs to be considered:
          •       when the delay in PCI is outside acceptable limits; and
          •       when transport delay to a hospital for fibrinolysis exceeds 30 minutes.

6.171     The Guidelines for the Management of Acute Coronary Syndromes 2006 propose the following
          decision framework for pre-hospital management of patients with STEMI.




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Figure 5: The guidelines for the management of acute coronary syndromes 2006 decision
framework for pre-hospital management of patients with STEMI

            STEMI confirmed by 12-lead ECG with expert interpretation


                      No contraindications to fibrinolytic therapy*


                       Time delay to PCI acceptable (see below)




                  Yes                                                 No



                                                   Time delay to hospital for fibrinolysis
                                                              < 30 minutes



                                                      Yes                            No



                                                                                Pre-hospital
                                                                                 fibrinolysis

   Direct to PCI-capable hospital
                                             Direct to hospital for               Hospital
                                              fibrinolytic therapy

                   Time since onset of symptoms

                   < 1 hour            1-3 hours          3-12 hours          > 12 hours
Acceptable         60 minutes          90 minutes         120 minutes         Not routinely
delay to PCI                                                                  recommended
(from first
medical contact
to balloon
inflation)
*If fibrinolysis is contraindicated, it is important that an attempt to reperfuse is made, even
if there is a long delay (up to 12 hours)




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6.172     It has been suggested that the optimal future elements of pre-hospital care will include the four
          key areas of personnel, information technology, pharmacological treatment and medical
          technology as outlined in table 13:
                                           72
Table 13: Pre-hospital care elements

                                                    Resource
Personnel                              At least 2 ACLS trained paramedics available within 7 minutes of
                                       call
Information Technology                 Reliable communication with remote physician. Seamless electronic
                                       health record
                                       Online capacity to interrogate available resources (ED beds, CCU
                                       beds, cath lab capacity)
Pharmacological treatment              Current evidence-based treatments: aspirin, anticoagulation, bolus
                                       fibrinolysis,IIb/IIIa receptor blockers, clopidogrel, inotropes,
                                       antiarrhythmics
                                       Expansion of armamentarium to include future evidence-based
                                       treatments
Medical technology                     Automated external defibrillators
                                       12 lead ECG, defibrillator, and external pacemaker
                                       Intravenous pumps for accurate administration of pharmacological
                                       treatment
                                       "Cooling therapies" post cardiac arrest
                                       Mobile IABP
ACLS = Advanced Cardiac Life Support; CCU = Cardiac Care Unit; ED = Emergency Department; IABP
= Intra-aortic balloon pump

Recommendation 33

That the region-specific plans proposed in Recommendation 4 incorporate plans for the maintenance
and/or enhancement of pre-hospital cardiac care resources and models of care in accordance with best
practice standards, including pre-hospital thrombolysis for appropriate patients.


6.173     These plans for maintaining and enhancing pre-hospital care are likely to differ from region to
          region depending on the location of services. Their implementation may require ongoing
          investment in training and other support.

Direct transport of STEMI patients to a PCI capable facility

6.174     Primary PCI when performed in a timely fashion by experienced operators in experienced
          centres improves outcomes (reduced deaths, myocardial infarctions and strokes) in patients
          with STEMI presenting within 12 hours compared with fibrinolytic therapy. Whilst it is important
          not to overstate the relative clinical benefit of PCI - the short-term benefit has been described
                                 73
          as 'small-to-moderate - meta analysis suggests that results for primary PCI remain better than
                                                                               74
          those seen with thrombolytic therapy during long-term follow-up . The Guidelines for the
          Management of Acute Coronary Syndromes 2006 conclude that the benefit may only occur,




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          however, if the additional time delay associated with PCI - over and above that associated with
                                            75
          fibrinolysis - is less than 1 hour .

6.175     On the basis that primary PCI is the preferred intervention for patients suffering STEMI, many
          stakeholders consulted during this review supported role delineation and direct ambulance
          transport of appropriate patients to a PCI-capable facility. This may involve travelling past
          hospitals that are more accessible but do not have the required infrastructure. The Victorian
          trauma system was identified by some stakeholders as an appropriate model.

6.176     Canadian researchers who evaluated the impact of an expedited pre-hospital diagnosis and
          transfer pathway developed by a multidisciplinary team on the door-to-balloon time in a large
          urban community concluded that:

             "In a community with multiple regional hospitals and a single facility for percutaneous
             coronary intervention, the implementation of a multidisciplinary pre-hospital diagnosis and
             transfer pathway was feasible and resulted in most patients in the study cohort receiving
             primary percutaneous coronary intervention within the recommended door-to-balloon time of
                          76
             90 minutes."

6.177     Internationally, transporting appropriate patients to the nearest PCI-capable facility, in
          accordance with protocols that take into account local circumstances is supported:

             "In the ideal system for EMS [Emergency Medical Services] and EDs [Emergency
             Departments], standardized point-of-entry protocols (created by state-based coalitions of
             EMS personnel, emergency physicians, and cardiologists and supported by payers and
             administrators) would dictate which patients are transported to the nearest facility and which
             patients are transported to the nearest PCI-capable facility, in part based on the acquisition,
             interpretation, and transmission of prehospital 12-lead ECGs. The catheterisation laboratory
             would be activated by EMS personnel in the field or by emergency physicians after receiving
                                  77
             transmitted ECGs" .

6.178     The Guidelines for the Management of Acute Coronary Syndromes 2006 support ambulance
          transport of patients suffering a STEMI direct to a PCI-capable hospital if the time delay to PCI
          is acceptable, as follows:

Table 14: Guidelines for the management of acute coronary syndromes 2006 regarding time
delay to PCI

                                                    Time since onset of symptoms


                        <1 hour                1-3 hour             3-12 hours            >12 hours


Acceptable delay        60 minutes             90 minutes           120 minutes           Not routinely
to PCI (from first                                                                        recommended
medical contact to
balloon inflation)




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6.179     With respect to the management of presentations of the broader group of patients with ACS,
          the GRACE study investigated the relationship between access to a cardiac catheterisation
          laboratory and clinical outcomes in patients admitted to hospital with suspected ACS, using a
                                               78
          multinational observational registry . The authors noted that the availability of a catheterisation
          laboratory is associated with more use of PCI and CABG surgery in patients presenting with
          ACS, but despite this, following adjustment for baseline variables, medical history and
          geographic region, patients admitted first to hospitals with catheterisation facilities did not have
          a survival benefit but seemed to have higher rates of major bleeding and stroke in hospital than
          those first admitted to hospitals without such facilities. Noting the limitations of a registry-type
          study, they suggested that:
          •       their results were supported by other registry data but were at variance with those of
                  recent randomised trials, and that discrepancies between randomised trials and
                  registries are well known but not fully understood. One of the most important reasons for
                  discrepancies is the reluctance of investigators to include high risk patients in
                  randomised studies
          •       a more selective use of invasive procedures in high risk patients of the registry may be
                  partly responsible for the favourable outcomes observed in those first admitted to
                  community hospitals without catheterisation facilities
          •       a more restrictive selective use of invasive procedures, as usually applied to patients
                  admitted to a community hospital, is at least as effective as a more liberal routine use
          •       the analysis supports the 'current strategy' of admitting patients with ACS as rapidly as
                  possible to the nearest hospital, irrespective of the availability of a catheterisation
                  laboratory, and argues against the early routine transport of these patients to a
                  specialised regional tertiary care hospital with interventional facilities.

6.180     A recent Australian study suggests, however, that there are deficits in the implementation and
          adherence to evidence-based guidelines for managing chest pain in hospitals across Australia,
          and significant differences between hospitals with and without interventional facilities. Patients
          treated at centres without interventional facilities were less likely to receive guidelines-based
          medical therapy and referral for coronary angiography than patients treated at centres with
                                   79
          interventional facilities .

6.181     The current policy of Rural Ambulance Victoria and the Metropolitan Ambulance Service
          regarding hospital by-pass is that patients with STEMI should preferably be transported to a
                                                               80
          hospital offering PCI in accordance with local policy .

6.182     The recommendations of this Review will, if implemented, improve the accessibility of PCI
          services in the metropolitan and Loddon Mallee regions. With appropriate pre-hospital transport
          protocols, we envisage that most patients who are located in metropolitan, metropolitan-fringe
          and rural areas proximate to both Geelong and Bendigo will have the opportunity to access
          primary PCI facilities in appropriate circumstances. Implementation of appropriate protocols for
          direct patient transfer to a PCI-capable facility in these regions has the potential to significantly
          improve access by most metropolitan and many rural patients to primary PCI.




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Recommendation 34

That the region-specific plans proposed in Recommendation 4 incorporate region-specific protocols for
the ambulance transport of patients suffering STEMI direct from home to PCI-capable facilities if access
can be achieved reliably within timeframes recommended in the Guidelines for the Management of
Acute Coronary Syndromes 2006.


Inter-hospital transfer for primary PCI and/or other services in appropriate cases

6.183     Consistent with a 'systems' approach to the management of cardiac conditions, a further issue
          to be considered is whether acute inter-hospital transfer for primary PCI is preferable to
          thrombolysis for the relatively large proportion of patients suffering STEMI who present directly
          to non-PCI-capable hospitals in Victoria.

6.184     At present when patients undergo inter-hospital transfer for primary PCI the time-critical need
          for access tends to overcome concerns about the availability of a bed in the receiving hospital.
          Stakeholder consultation suggests, however, that at least some patients with STEMI who
          present to metropolitan hospitals without PCI capability may be thrombolysed because there
          are few established protocols for rapid inter-hospital transfer for primary PCI, even though in
          ideal circumstances such transfers should be able to be effected within clinically-appropriate
          timeframes.

6.185     The transfer of STEMI patients to another facility during the acute phase of care is considered
                    81 82 83
          to be safe , , although it remains challenging to achieve benchmark door-to-balloon times
                                         84
          when patients are transferred . Data from hospitals participating in the National Registry of
          Myocardial Infarction between 1999 and 2002 showed that patients who were transferred from
                                                                                                         85
          other acute-care facilities appeared to be at high risk of long delays in door-to-balloon time: .

6.186     It should be noted that many of the relevant studies showing a benefit from inter-hospital
          transfer have been conducted in Europe, where the health service system may be better
          coordinated than it is in Australia.

6.187     A consensus statement from the American Heart Association's 2006 conference proceedings
          states:

             "Patients transported to a non-PCI-capable hospital by EMS would remain on the stretcher
             with EMS personnel in attendance until the decision about whether to transport to a PCI-
             capable hospital has been rendered. For patients who transport themselves to a non-PCI-
             capable hospital and require primary PCI, activation of EMS via a 9-1-1 system would occur.
             An ideal system would also foster a coordinated curriculum to teach EMS providers and ED
             staff to care for STEMI patients and provide feedback on performance or compliance with
             guidelines."

6.188     The Guidelines for the Management of Acute Coronary Syndromes 2006 state that if PCI can
          be performed in an appropriate time frame the patient should be transferred to a PCI centre,
          with it being essential that the PCI centre is warned that the patient is being transferred.
          Otherwise, fibrinolysis should be given. Time frames recommended by the Guidelines are 90
          minutes (including transport times) from presentation at the referral hospital to PCI if the
          patient's onset of symptoms has occurred 1-3 hours prior to initial presentation; and 2 hours




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          (including transport times) from presentation at the referral hospital to PCI if the patient's onset
          of symptoms has occurred 3-12 hours prior to initial presentation.

6.189     CSAC considered whether interhospital transfers of patients suffering ACS to hospitals that
          offer primary PCI but not surgery were appropriate, given that a small number of patients will
          require surgery and, therefore, a further transfer. CSAC supported such arrangements
          providing the receiving hospital had an appropriate on-referral arrangement in place.

6.190     If the recommendations of this Review to develop 24-hour PCI services at a number of
          metropolitan hospitals are implemented, we anticipate that patients who present with STEMI to
          the emergency service of any acute general hospital in the metropolitan area should have
          access within the host health service to a full suite of specialist cardiology services including
          primary PCI in accordance with the following service system configuration, which reflects
          governance and management arrangements of public health services in the metropolitan area.
          The bolded hospitals are those that will offer primary PCI

Table 15: PCI service configuration

                   Austin Health                       Austin Hospital
                   Bayside Health                      The Alfred Hospital
                                                       Sandringham Hospital
                   Eastern Health                      Box Hill Hospital
                                                       The Angliss Hospital
                                                       Maroondah Hospital
                   Melbourne Health                    The Royal Melbourne Hospital
                   Northern Health                     The Northern Hospital
                   Peninsula Health                    Frankston Hospital
                                                       Rosebud Hospital
                   Southern Health                     Casey Hospital
                                                       Dandenong Hospital
                                                       Monash Medical Centre
                   Western Health                      Western Hospital
                                                       Sunshine Hospital
                                                       The Williamstown Hospital
                   St Vincent's Hospital               Werribee Mercy

6.191     Werribee Mercy Hospital is not part of a metropolitan health service but has strong links with St
          Vincent's Hospital. It should develop formal referral and receiving protocols for primary PCI with
          an appropriate partner hospital, with the guidance of the proposed cardiac clinical network,
          taking into account geography and the critical need for timely access to a PCI laboratory.




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6.192      Arrangements for time-critical referral, inter-hospital transfer and access to primary PCI in the
           receiving hospital for appropriate patients should be formalised through protocols developed by
           the relevant hospitals and ambulance service, consistent with the Guidelines for the
           Management of Acute Coronary Syndromes 2006.

6.193      There are a number of hospitals on the metropolitan fringe which we consider are located
           within sufficient proximity to primary PCI services to make such protocols feasible in those
           areas also.

6.194      In rural and regional areas, patients who present to an emergency service which is located
           within acceptable travel times to a metropolitan or regional PCI centre should have access to
           primary PCI through the implementation of similar protocols.

Recommendation 35

That the proposed cardiac clinical network oversees the development of a state-wide inter-hospital
transfer protocol for the emergency management of patients with STEMI who present to a hospital that
does not offer primary PCI.

The protocol should:

•       be consistent with the Guidelines for the Management of Acute Coronary Syndromes 2006;

•       identify the hospitals which are located sufficiently proximate to a provider of primary PCI to enable
        primary PCI to be offered routinely to appropriate patients;

•       provide for the acute inter-hospital transfer of appropriate patients if the time since onset of the
        patient's symptoms, local conditions including the hospital's location and infrastructure and
        ambulance transport infrastructure are such that primary PCI can be accessed within a time that is
        consistent with the Guidelines for the Management of Acute Coronary Syndromes 2006; and

•       require hospitals that offer primary PCI to guarantee access without delay on a 24 hour basis to
        patients referred in accordance with the protocol.


6.195      Both Ballarat Base and Latrobe Regional Hospitals expressed an interest in developing primary
           PCI services. As discussed earlier in this report, for volume/quality reasons, we do not consider
           that this is appropriate at this stage. In optimal circumstances we consider, however, that both
           of these hospitals are within travel distances which may enable a proportion of appropriately-
           selected patients to access primary PCI (eg Ballarat - Western Hospital (distance
           approximately 100 km); Ballarat - The Geelong Hospital (distance approximately 90 km);
           Ballarat - Bendigo Hospital (distance approximately 120 km); Latrobe Regional Hospital -
           Monash Medical Centre (distance approximately 130 km).

6.196      As both Ballarat Base and Latrobe Regional Hospitals receive patients from a wide regional
           catchment area, however, which may result in significant delays from symptom onset to initial
           presentation to the regional hospital, we consider that substantial planning, facilitation and
           coordination of different elements of the cardiac care system will be required if appropriate
           patients who present to these facilities are to access primary PCI. Significant infrastructure
           investment may be required to develop and test an appropriate system and the safety of such a
           system needs to be assessed and assured. It may be necessary, for example, to develop a




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          study protocol involving immediate thrombolysis followed by rapid transfer to a PCI-capable
          centre, to test the feasibility of primary transfer within accepted timeframes. The size of and
          potential benefit to these regional communities, however, makes such an investment
          worthwhile.

Recommendation 36

That the Department of Human Services sponsors the development and evaluation of 'intention to treat'
trials for the safe referral of and inter-hospital transfer for the provision of primary PCI to appropriate
patients suffering STEMI who present to Ballarat Base and Latrobe Regional Hospitals.


6.197     A further issue of concern to ambulance personnel, patients and private hospitals is the number
          of patients who believe they are insured but in fact do not have sufficient health insurance to
          cover the management of ACS in the private sector. It clearly is difficult for ambulance
          personnel to assist patients to determine the adequacy of their insurance coverage in such
          circumstances. Where there is significant doubt patients are taken to a public hospital but a
          proportion of under- or un-insured patients are taken to private hospitals.

6.198     Private hospital stakeholders report that in such cases they provide urgent care including
          primary PCI and then attempt to arrange transfer of the patient to a public provider.

6.199     There is a strong stakeholder view that it is unethical to market heath insurance products that
          exclude emergency care for a condition which is as common as ACS.

6.200     Whilst the public sector needs to avoid establishing a system that encourages uninsured or
          inadequately-insured patients to present to private hospitals, or that makes it attractive for
          private hospitals to promote the provision of services to this group of patients, we consider that
          in the circumstances it is most unlikely that such decisions are being made intentionally.

6.201     If such patients presented to a public hospital they almost certainly would be admitted as public
          patients and their costs would be borne by the public sector. Funding to private hospitals
          equivalent to that provided to public hospitals at marginal casemix rates for private patients
          would reimburse the majority of the non-fixed costs associated with the care, which we
          consider would be a reasonable approach to resolve the current difficulties. Service provision
          would need to be subject to audit if this system were introduced.

Recommendation 37

That the Department of Human Services considers reimbursing private hospitals for the marginal costs
of care of uninsured patients who present with a cardiac emergency and are provided with emergency
cardiac interventional services in accordance with the Guidelines for the Management of Acute Coronary
Syndromes 2006.

Recommendation 38

That the Department of Human Services raises with the Australian Government stakeholder concerns
about the sale of private health insurance products that exclude services necessary in a life-threatening
emergency.




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Rapid activation of the PCI laboratory for STEMI patients

6.202     Most hospitals report a considerable increase in demand for emergency services, a significant
          component of which relates to chest pain and/or other cardiac conditions. This is supported by
          the VEMD data which shows that over the two years to 30 June 2006 there was an increase of
          11% in the number of cardiac presentations to emergency departments (from 76,878 in
          2003/04 to 85,133 in 2005/06).

6.203     Where hospitals provide continuously-accessible PCI services there are established
          arrangements for recalling nursing, medical and technical staff after-hours and some hospitals
          have implemented systems to deliver patients with confirmed STEMIs directly to the
          catheterisation laboratory. It is more common, however, for patients to be admitted initially via
          the Emergency Department. Stakeholders acknowledge that this practice incurs significant
          delays for some patients and most hospitals are aiming to develop a direct-to-laboratory patient
          delivery system.

6.204     In a 2006 review of strategies for reducing door to balloon time in acute myocardial infarction,
          Bradley et al surveyed 365 acute hospitals to identify which of 28 strategies were being used
          and the association between the strategies and door to balloon time. This study found that 6
          strategies were significantly related to door to balloon time. These included:
          •       emergency physicians activating the catheterisation lab;
          •       a single call to a central page operator to activate the lab;
          •       Emergency Department activation of the laboratory while the patient is on route;
          •       expecting staff to arrive within 20 minutes of being paged;
          •       having an attending cardiologist always on site; and
                                                                                                       86
          •       Emergency Department and catheterisation lab staff using real-time data feedback.
                                                                        87
6.205     The ideal systems of care published by Jacobs et al 2007 include many of these initiatives
          and make a number of further suggestions that may be useful in the Victorian context,
          including:
          •       development of standardised treatment protocols and clinical pathways in ED and
                  STEMI referral and receiving hospitals according to (ACC/AHA) guidelines; and
          •       development of standardised protocols and toolkits for assessment.

Recommendation 39

That the proposed cardiac clinical network supports all hospitals which provide primary PCI services to
develop, in conjunction with ambulance services and local Divisions of General Practice, a protocol for
direct access to the catheterisation laboratory for patients who are diagnosed with STEMI in the pre-
hospital phase; and for rapid diagnosis and transit through the Emergency Department for patients who
present with undiagnosed STEMI.




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Formalisation of referral pathways for rural and regional patients

6.206     Each metropolitan health service accepts its responsibility to provide services equitably to
          patients who present to each of the hospitals/campuses it governs and manages, although the
          extent of documentation of formal protocols for patient transfer within health services varies
          considerably.

6.207     There are no formal relationships between Victoria's regional and rural hospitals and other
          hospitals which provide specialist cardiology services.

6.208     The availability of cardiac surgery is limited to the six tertiary hospitals listed earlier in this
          report. Most of these surgical services are located in health services which do not have major
          acute general hospitals as part of their organisational structure - the corollary is that most
          Victorian hospitals do not have any formal organisational link with a cardiac surgery provider.

6.209     Consultation during this Review highlighted a high degree of frustration by referring clinicians
          and hospitals about difficulties accessing specialist cardiac services, particularly semi-urgent
          angiography, PCI and surgery. Rural and regional stakeholders advise that transfer of public
          patients post-thrombolysis for STEMI, and patients with NSTEACS to specialist services for
          further management including semi-urgent angiography, angioplasty and/or cardiac surgery
          can be delayed significantly because of bed shortages in metropolitan hospitals, creating
          considerable inefficiency in bed management and prolonged lengths of stay in rural and
          regional hospitals.

6.210     Inability to transfer these patients promptly is a concern for both the referring and receiving
          hospitals and appears to be causing a significant administrative burden in referring hospitals.
          Hospitals that offer specialist services also complain of difficulty discharging admitted patients
          back to the rural and regional hospitals which referred them initially, because of bed pressures
          in those hospitals.

6.211     Most hospitals that offer specialist services feel obliged to give priority to patients from their
          own Emergency Departments before they accept external referrals. Part of their motivation for
          prioritising local patients is that their organisations may suffer a financial penalty if Emergency
          Department patients awaiting care are not admitted to ward beds within defined timeframes.

6.212     The expense of transport is also a problem for both the referring hospital and the patient. From
          a patient perspective this can be a particularly difficult issue. Some patients are discharged
          directly from metropolitan hospitals post-PCI and many rural patients are asked to remain in
          Melbourne for at least one night post-discharge, following which they are responsible for
          making their own way home. This is reported to create a significant financial and practical
          burden for many rural Victorians.

6.213     As noted earlier in this report, the cardiac care system in Victoria is based largely on the
          provision of services by individual hospitals and professionals, with significant informal links
          between various providers but no formalised referral or patient acceptance pathways and no
          system-wide policies or procedures for patient referral or transfer.




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6.214     Various strategies to improve access for rural and regional Victorians have been suggested,
          including formalising referral networks. There are diverse views about the merits of such an
          approach. Below, we describe three referral models that were considered during this Review.

Option 1 - maintain the status quo

6.215     Some clinicians have expressed a preference for maintaining the status quo. They consider
          that the choice and flexibility offered by the current system outweigh the disadvantages of
          difficulty accessing services. Some clinicians consider that the current system stimulates
          competition by specialist providers for outer metropolitan, rural and regional patients which in
          turn drives better quality of care. They were concerned that their patients may receive poorer
          quality services if they are obliged to access them from specified providers. Some believe that
          there are alternative means of improving access for their patients, for example quarantining
          beds in metropolitan centres for referred patients.

Option 2 - defined fixed geographic regions for the provision of cardiac care

6.216     An alternative model to the status quo would be to define geographic regions centred around
          the health services which provide primary PCI services. These health services would be
          obliged to accept all referrals from their defined geographic area. Similarly, referring clinicians
          would be obliged to refer all public patients to their designated health service. Access
          performance indicators could be developed and monitored.

6.217     Some clinicians believe that such a system would improve access for outer metropolitan, rural
          and regional patients by increasing the accountability of metropolitan specialist service
          providers to patients from outside their immediate catchment areas. On the other hand, some
          metropolitan specialist service providers are concerned that they may be unable to respond
          adequately to mandated referrals from within their designated areas because of resource
          constraints. Others are concerned that such a system would result in preferential access to
          cardiac patients over non-cardiac patients with conditions of equivalent severity.

Option 3 - a hybrid model

6.218     A further model for consideration is a hybrid model. Under this model, current flexibility of
          referral destination would be maintained, but if a clinician experienced difficulty accessing a
          specialist service, a defined specialist provider would be obliged to accept the referral. This
          model would enable existing referral patterns to be maintained but also would provide a default
          mechanism whereby all outer metropolitan, rural and regional hospitals would have a
          designated specialist provider who was obliged to ensure access to appropriate care for their
          patients.

The preferred model

6.219     CSAC supported option 3, with the proviso that the default designated specialist provider
          should be negotiated for each referring and receiving hospital before being endorsed by the
          Department. Agreed referral pathways may not follow geographic boundaries and there may
          not be an equal distribution of regional and rural patients between specialist providers. The
          formal agreements between hospitals, based on a statewide template, would clarify the
          obligations of referring and receiving hospitals.




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6.220     It should be noted that two metropolitan hospitals (St Vincent's and the Royal Melbourne
          Hospitals) provide a particularly high level of service to rural and regional patients at present
          and have invested significantly in systems of care to meet the needs of these patients. It would
          be anticipated that negotiated referral pathways would follow existing referral pathways in the
          main and that the investment in rural services made over a significant period of time by these
          hospitals would be validated through this negotiated process.

Recommendation 40

That the proposed cardiac clinical network oversees the development of a template agreement between
referring and receiving hospitals, specifying the types of obligations that will apply to referring and
receiving hospitals when a referral of a cardiac patient is made for diagnosis or medical or surgical
treatment.

Recommendation 41

That the proposed cardiac clinical network supports hospitals that do not provide a comprehensive range
of specialist cardiology services to negotiate agreements with appropriate receiving hospitals, consistent
with the template agreement, providing for equitable access by their referred patients to an appropriate
range of services.

Recommendation 42

That clinicians in referring hospitals retain the right to refer patients to the clinician/hospital of choice as
agreed with the patient and/or their representative (other than in acute cardiac emergencies requiring
PCI as provided for in Recommendation 35) but in the event that a timely service cannot be arranged the
agreement provides a 'default' referral option and the receiving hospital that is a party to the agreement
is obliged to accept the patient in accordance with the terms of the agreement.

Recommendation 43

That the Department of Human Services evaluates the feasibility of implementing a 'rural referral WIES
bonus' so that hospitals that accept urgent or semi-urgent referrals from rural and regional centres do not
incur a net financial penalty if, as a result, the allocation of a bed to a patient waiting in their emergency
department is delayed.

Recommendation 44

That metropolitan hospitals are funded via the proposed rural referral WIES bonus, and required through
the relevant inter-hospital agreements, to provide clinically-necessary metropolitan accommodation and
to explore mechanisms for supporting the reasonable costs of transport home where necessary for rural
cardiac patients who have been admitted on an urgent or semi-urgent basis.


6.221     It should be noted that recommendation 44 assumes that any rural WIES bonus will be in
          addition to current payments to hospitals, acknowledging the additional level of service to be
          provided.

Enhancing patient choice of provider for elective services

6.222     There is a clinical, economic and emotional burden associated with waiting for a major cardiac
          procedure, which increases as patients wait beyond their recommended maximum waiting time
                                     88
          for the required procedure .




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6.223     As previously demonstrated (Figure 3) average waiting times for CABG vary significantly in
          Victorian public hospitals - in June 2006 some hospitals had negligible average waiting times
          whilst in one hospital average waiting time exceeded 100 days. Waiting times for non-surgical
          procedures, diagnostic investigations and consultations are not collected centrally and
          therefore are not available.

6.224     Whilst hospitals need the autonomy to make internal decisions about the allocation of
          resources to particular services, patients who are recommended to undergo a specific
          procedure or consultation should be:
          •       clearly advised of the way in which the waiting list is managed and of their predicted
                  waiting time; and
          •       offered choice of provider if the hospital to which they have been referred has a
                  particularly long waiting time for the relevant procedure or clinic.

6.225     If patients were informed of their expected waiting time and provided with average waiting time
          information relating to all hospitals that provide similar services, they could make a choice of
          whether they remain on the waiting list of the hospital to which they were referred initially, or
          seek advice from another hospital with shorter average waiting times about the potential for
          their service to be provided earlier.

6.226     CSAC members were divided in their response to this proposal. Some expressed concern that
          patients who are advised that a specific intervention is necessary may not receive the same
          advice if they undergo a second consultation with another provider - surgeons believe that this
          is particularly likely to happen with patients who have complex problems and may be offered a
          relatively high risk intervention by one surgeon but not by another. Other CSAC members
          supported the proposal on the basis that it empowers patients and promotes equity of access.

6.227     Whilst it is recognised that clinical judgement may vary, we do not consider that this justifies not
          providing patients with basic information about their options. We consider that patients are
          entitled to and may benefit from a second opinion about the accessibility and appropriateness
          of a particular service. Experience in other clinical areas (orthopaedic surgery and radiation
          therapy) suggests that some patients will elect to remain with the clinician with whom they have
          formed an initial relationship whilst others will seek earlier access elsewhere. We believe that
          patients should have this choice.

6.228     Successful implementation of such a system will depend on clear and accurate information
          being collected and disseminated to patients, via providers, including current waiting times for
          various cardiac services. The proposed cardiac clinical network, including the network of
          cardiac care coordinators, may be the appropriate vehicle to implement this system.

Recommendation 45

That the proposed cardiac clinical network establishes a reliable system for collecting information about
waiting times for various cardiac services so that cardiac patients who are placed on waiting lists for
consulting, diagnostic, interventional or surgical services can be provided with clear advice about their
expected waiting times and the average waiting times in other hospitals and can be offered access to
alternative services.




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A role delineation framework for the Victorian cardiac service system

6.229     Based on the principles and patient journey endorsed by CSAC and the recommendations in
          the preceding sections, Table 16 outlines a role delineation model for provider hospitals within
          the cardiac care system. The framework identifies 5 service levels, outlines degrees of
          specialisation and suggests the appropriate levels for each of the existing services. The model
          has been endorsed by CSAC. With respect to appropriateness, we do not consider that a
          formulaic approach would be helpful in determining which specific interventions are appropriate
          for which groups of patients - certainly any formula based on age would be inappropriate. We
          do support, however, a focus on multidisciplinary decision-making about the appropriateness of
          offering certain interventions and systematic monitoring of patient outcomes including quality of
          life following major cardiac interventions. This should occur at a local level (with
          multidisciplinary pre-intervention decision-making and post-intervention monitoring of
          outcomes) and at a system-wide level (with ongoing monitoring of patterns of intervention and
          outcomes).




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Table 16: Service delineation framework
                   Hospital                                                                                                                                        Teaching and
Location           Designation           Assessment          Diagnosis            Management             Treatment              Rehabilitation   Palliative care   Research
Metropolitan       Level 5 Cardiac       Emergency           Specialist           Inpatient              Full range of          Inpatient                          Specialist training
                   Centre                                    Lower volume high    Specialist             surgery, including                                        Leading research
                   Alfred, Austin,                           complexity           Interventional         lower volume high                                         centre
                   Geelong, Monash,                          (Cardiac CT, MRI)    Cardiology             complexity
                   RMH, St Vincent’s                                              Specialist             Interventional
                                                                                  outpatient clinics     cardiology (PCI,
                                                                                                         EP)
                                                                                  Secondary
                                                                                  consultation           Cardiology
                                                                                  (including
                                                                                  outreach)
                                                                                  Telemedicine hub
                   Level 4               Emergency           Specialist           Inpatient              Interventional         Inpatient        Inpatient         Specialist training
                   Metropolitan                                                   specialist             cardiology (PCI        Outpatient       Outpatient        Research
                   Cardiac Centre                                                 Interventional         and simple EP) –
                   Western/Sunshine                                               Cardiology             by 2015/16 all sites
                   Northern,                                                                             should have 24
                                                                                  Specialist             hour access for
                   Frankston, Box Hill                                            outpatient clinics     PCI
                   Level 3 Cardiac       Emergency chest     Specialist           Inpatient Specialist                          Inpatient        Inpatient
                   Program Other         pain protocol       (? No angiography)   Cardiology/                                   Outpatient       Outpatient
                   metropolitan          (patient                                 Specialist
                   hospitals             presentation – no                        Physician
                   (Dandenong,           ambulance
                   Casey                 presentation)
                   Sandringham,
                   Angliss,
                   Maroondah,
                   Werribee Mercy
                   etc)




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                    Hospital                                                                                                                                                   Teaching and
Location            Designation            Assessment             Diagnosis            Management             Treatment           Rehabilitation       Palliative care         Research
Regional            Level 4 Regional       Emergency              Specialist           Inpatient Specialist   Moving towards in   Inpatient            Inpatient               Research
                    Cardiac Centre                                                     Cardiology             hours               Outpatient           Outpatient
                    Initially Bendigo,                                                 Specialist             interventional      Community            Community
                    then consideration                                                 outpatient/outreach    cardiology (PCI)
                    of Ballarat, and                                                   clinics                when standards
                    Latrobe Regional                                                                          are met.
                    based on STEMI
                    transfer trial
                    Level 2 Cardiac        Emergency chest                             Specialist                                 Inpatient            Inpatient               Research
                    Programs Sub-          pain protocol                               Physician                                  Outpatient           Outpatient
                    regional hospitals                                                                                            Community            Community
Rural               Level 1 Cardiac        Emergency chest                             GP                                         Inpatient            Inpatient               Research
                    Response All rural     pain protocol                                                                          Outpatient           Outpatient
                    hospitals                                                                                                     Community            Community
Specialist diagnostics refer to stress testing, echocardiography, angiography

Detailed Requirements

Assessment                        Diagnosis                        Management                       Treatment                     Rehabilitation                    Palliative care
Chest pain unit/ protocol:        Emergency priority access to:    Early protocol-based decision    Volume quality guidelines     Workforce availability            Inclusion of cardiac
Increased diagnostic capacity     12 lead ECG (if not              on transfer or admission         Workforce availability        Quality control data and          conditions in palliative care
for STEMI                         completed prior to               applied consistently across      Quality control data and      review                            capacity/service provision
Priority access to diagnostics    presentation), ECHO, stress      State                            review
Cath Lab activation               testing, pathology               Quality control data and         Infrastructure
                                  Skills capacity and protocols    review
Agreed thrombolysis protocol
                                  Infrastructure




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Level 5

6.230     The suggested level 5 hospitals are the existing acute tertiary hospitals who would maintain
          their current responsibilities and have sole responsibility for cardiac surgery, highly specialised
          diagnostics and where appropriate complex electrophysiology (including ablation).

6.231     The specialist capacity at these hospitals should have formalised secondary consultation links
          to other hospitals. This may be further enhanced by the development of level 5 cardiac
          hospitals as telemedicine hubs, capable of providing emergency and planned consultations and
          receiving diagnostic information for interpretation. The evidence regarding volume and quality
          has been a recurring theme in this review and the opportunity to provide centralised expertise
          more broadly through technology should be further explored.

6.232     This future state suggests that inpatient rehabilitation is provided by all hospitals that treat
          cardiac conditions either on-site or by referral to another site and outpatient and community
          rehabilitation should be available more broadly, close to where patients reside, enhancing
          access. Research should also be supported at all cardiac care facilities.

Level 4

6.233     All level 4 hospitals should maintain and/or develop 24hr PCI services. Projections show that
          the suggested hospitals would still have sufficient demand to meet volume requirements. 24
          hour access would improve access to primary PCI when combined with chest pain protocols
          and established referral routes. Level 4 hospitals would not perform cardiac surgery.

6.234     Level 4 hospitals would only perform simple electrophysiology including pacing, biventricular
          pacing and ICD insertion. However diagnostic EP would be strictly limited to level 5 hospitals.

6.235     Level 4 hospitals, like level 5 hospitals would have inpatient and outreach capability to provide
          palliative care consistent with the palliative care service plan for the state.

6.236     Regional and metropolitan areas would have level 4 hospitals that provide defined specialist
          services and capacity for training and education in cardiac specialties. Five hospitals are
          suggested to fit the level 4 delineation.

Level 3-1

6.237     The suggested level 3 hospitals are based in regional and rural areas with catchment
          populations that do not generate sufficient demand for locally-based specialist services. These
          hospitals do not have the infrastructure or volumes to provide specialist interventional and
          surgical services but should have established links to level 4 and 5 hospitals. The key cardiac
          care roles of these hospitals would include:
          •       Emergency diagnosis and initiation of chest pain protocol
          •       General medical support (inpatient and outpatient) for patients with cardiac conditions
          •       Provision of outpatient and community based rehabilitation
          •       Health promotion




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Recommendation 46

That the Department of Human Services endorses the role delineation framework proposed in this report
including the definition of levels 5 -1 and the associated hospital designations.



Monitoring of and accountability for quality of care
6.238     The Victorian Quality Council's Better Quality, Better Health Care: A Safety and Quality
          Improvement Framework for Victorian Health Services (the Framework) provides an effective
          framework for monitoring and reporting on the quality of care of cardiac services. The
          Framework defines the following dimensions of quality:
          •       safety;
          •       effectiveness;
          •       appropriateness;
          •       acceptability;
          •       access; and
          •       efficiency.

6.239     Responsibility for monitoring and responding to activity, performance and outcomes rests at
          various levels in the system. Individual hospitals are responsible for:
          •       ensuring that their resources are allocated to support the provision of the appropriate
                  range of services to their community; and
          •       establishing systems for monitoring quality and responding to concerns about quality at a
                  unit, department and institutional level.

6.240     The proposed cardiac clinical network would play two major roles:
          •       promoting and supporting local, multidisciplinary approaches to ensuring appropriate
                  patient selection and monitoring performance across all dimensions of quality including
                  appropriateness; and
          •       assuming a system-wide responsibility for monitoring patterns of intervention and
                  outcomes across all dimensions of quality.

6.241     Access can be monitored using information about service system configuration, utilisation data
          and waiting list data. Patient-level data is necessary to support monitoring of other dimensions
          of quality such as safety, effectiveness and appropriateness. The establishment of a minimum
          dataset which incorporates patient-level data will be necessary if these dimensions are to be
          monitored and evaluated at a system-wide level. We consider that this will be a key
          responsibility for the cardiac clinical network.




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6.242     Establishment of a registry which enables medium to long term follow up of cardiac patients will
          be an essential tool to ensure ongoing service quality and that supply of resources keeps pace
          with reasonable patient demand over the planning period. Managing such registries is a
          specialist function which requires epidemiological, biostatistical and public health expertise. We
          recommend that the proposed cardiac clinical network oversees this work but that an academic
          department of epidemiology and biostatistics (or similar) is contracted to manage the registry.

Recommendation 47

That the proposed cardiac clinical network oversees the establishment and ongoing analysis of a
comprehensive cardiac services register covering interventional and surgical services provided to all
patients in all public hospitals in Victoria, for the purposes of monitoring and advising on the quality of
cardiac care including accessibility, effectiveness and appropriateness. Provision of data to such a
register would be mandatory for all hospitals providing interventional and surgical cardiac procedures.

Recommendation 48

That DHS take action to ensure the provision of timely an accurate data to the Victorian Cardiac
Services Registry.



Variation and appropriateness
6.243     Decreasing variation in practice and controlling processes within agreed parameters is a
          consistent aim of quality and safety programs throughout the world. To this end consistent
          guidance and minimum standards for: care pathways, components of care pathways and
          chronic disease management regimes have been developed. The consequent reduction in
          variation promotes optimal resource allocation and consumption; consistent and safe quality of
          care; and equity of access and provision.

6.244     In all developed and developing economies, cardiovascular disease is not only an existing
          major cause of mortality and morbidity, but its incidence and prevalence are growing at an
          alarming rate. The impact of this goes beyond the health of the nation and impinges on public
          spending and on the operational and economic effectiveness of business. Thus, the Federal
          Government has identified cardiovascular health as a health priority to be addressed in
          Australia. To achieve this successfully, resources such as funding, facilities, workforce and
          equipment must be appropriately matched to the needs of various populations as opposed to
          being distributed on the basis of historical consumption patterns. To address this the National
          Service Improvement Framework aims to reduce variations in care that appear across different
          clinicians and health care services, across people from metropolitan, regional, rural and remote
          areas and in the care provided to disadvantaged groups.

6.245     Studies have suggested rates of inappropriate PCI of 14% and 29% and 10% and 4% for
                              89 90                                    91
          inappropriate CABG , . The Canadian Cardiovascular Atlas identified substantial variation
          in practice across Ontario which led to the Cardiac Care Network of Ontario working with
          member hospitals to develop and implement best practice guidelines for:
          •       referral triage and case management;
          •       informing patients on access options;




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             •            standardised reports for referring physicians;
             •            optimising care for patients that travel; and
             •            patient repatriation from referring centres.

6.246        In Victoria to date, patient pathways for accessing cardiac services have not been applied
             consistently and there is limited monitoring of variation in practice. Our analysis of the data
             suggests that there may be indicators of variation in practice within the current data collection
             including:
             •            Intervention rates - Table 17 demonstrates the crude rate of intervention by state using
                          both CABG and PCI. Since the late 1990s there have been many studies that have
                          demonstrated significant variations in the type of revascularisation, as well as in the
                          rates of revascularisation. While many of the studies have explored American utilisation
                          where there is a substantially different system, there may be lessons for Victoria. For
                          example in a 2006 study, the rates of revascularisation in American states ranged from
                          186 to 340 PCIs per 100,000 population over 20 years and 118 to 182 CABGs per
                                                              92
                          100,000 population over 20 years . These authors found that the rate of cardiac
                          catheterisation was a predictor of revascularisation rate, and the rate of catheterisation
                          was related to the number of cardiologists. As far as we could determine, a standard
                          outlining the appropriate CABG rate has not been established, and may be changing as
                          primary PCI becomes more accessible.
             •            Within Australia, Victoria has the 4th highest rate of CABG and 3rd highest rate of PCI -
                          this may be worthy of further analysis.

Table 17: Intervention rates within Australia
        State       Estimated Population       Coronary Bypass               PCI                Both Procedures
                          '000's (a)        Number Crude Rate (b) Number      Crude Rate (b)   Number Crude Rate
Victoria                             4,963     2,966           0.60    8,784           1.77     11,750        2.37
NSW                                  6,721     3,947           0.59   10,822           1.61      14769        2.20
Queensland                           3,888     2,745           0.71    5,281           1.36       8026        2.06
Western Australia                    1,979       437           0.22    2,787           1.41       3224        1.63
South Australia                      1,533     1,079           0.70    2,776           1.81       3855        2.51
Tasmania                               482       207           0.43      498           1.03        705        1.46
ACT                                    324       205           0.63      629           1.94        834        2.57
Northern Territory                     200         0           0.00        0           0.00           0       0.00
Australia                          20,091     11,586           0.58   31,577           1.57     43,163        2.15
Sources: Australian Hospital Statistics, 2004-05 (AIHW) and Australian Demographic Statistics (ABS)

Notes:
(a) Observed population at 30 June 2004 - 3222.0 Population Projections, Australia (Reissue).
(b) Per 1000 of population.

             •            Average Length of Stay - CABG procedures average length of stay (ALOS) is relatively
                          consistent across the state while for those undergoing PCI there is a large variation in
                          average LOS. While there may be multiple influences on this basic measure, ALOS may
                          be one indicator of variation in the patient’s clinical pathway.

Table 18: ALOS for multiday separations - 2005/06

                 The Alfred     Austin   Geelong   Monash   Royal Melb. St Vincents   Box Hill   Frankston   Northern   Western
 Procedure
PCI                 3.7          2.5       4.5       3.7        3.3         2.0         2.9        3.2                    3.0
CABG                9.8          9.9      11.8      11.4       10.5        11.5




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6.247     Similarly standards of care discussed in this document are not currently monitored within the
          private sector and outcomes across the whole of the system are not compared.

6.248     Many recommendations in this report pertain to decreasing variability in service delivery
          particularly in regards to patient access. In the future, services should be monitored for
          variations in practice that may be impacting upon service equity and where possible such
          analysis should include private sector providers.




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7         Conclusion and Implementation Plan
7.1       Over the next 10 years the burden of cardiovascular disease in Victoria will increase. Providing
          high quality services and ensuring that patients have access to appropriate care will be
          imperative. The recommendations in this report provide a framework by which to plan and
          deliver resources in an effective and efficient manner. In order to instigate the
          recommendations of this report the prompt development of the suggested clinical network and
          formulation of a work plan will be required. To aid this development we have provided an
          implementation plan tasks regarding each recommendation and a suggested timeframe for
          action.
 Recommendations                                             Action                              Timeframe
 Recommendation 1
 That the following planning principles form the basis for   That future business cases for      Ongoing until end of
 future development of the Victorian cardiac services        service development are             planning period
 system:                                                     assessed against these criteria.
 • Quality and safety of care are the overriding
     considerations in planning and delivering cardiac
     services in Victoria.
 • Cardiac services are time critical – better outcomes
     are achieved with quicker treatment this access to
     cardiac services must be timely and equitable for
     the residents of Victoria.
 • The system should be developed to meet volume
     requirements necessary to maintain quality
     standards
 • Service delivery will define the system structure –
     teaching and research will follow services.
 Recommendation 2
 That Victoria's cardiac care services are planned and       Develop a common cardiac            3-6 months
 developed to form an integrated system of care, with        register to monitor activity,
 the objective of ensuring equity of access to safe, high    interventions and outcomes
 quality services for all Victorians, regardless of their
 place of residence or place of presentation to the          Develop mechanisms for
 health care system.                                         hospitals to contribute to this
                                                             register and receive data.

                                                             Begin benchmarking between
                                                             services and best practice
                                                             standards where available.

                                                             Clinical Network to regularly
                                                             review outcomes data across
                                                             Victoria.
 Recommendation 3
 That the Department of Human Services establishes a         Formalise Clinical Network for      3- 6 months
 clinical network for cardiac services in Victoria to        Victoria, invite cardiac services
 provide clinical leadership, define standards for           across state to be involved as
 infrastructure and leadership, promote quality care,        appropriate.
 improve the coordination and efficient use of clinical
 resources and monitor and report on the quality of          Establish Clinical Network and
 cardiac care in Victoria.                                   develop comprehensive terms of
                                                             reference and governance
                                                             arrangements that ensure the
                                                             Network is able to undertake the




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 Recommendations                                          Action                                 Timeframe
                                                          identified roles.

                                                          Develop a communications plan
                                                          to inform broader stakeholders of
                                                          the role of the clinical network.

                                                          Develop formal communication
                                                          lines between network members

                                                          Design and implement evaluation
                                                          criteria for the success of the
                                                          Clinical Network.
 Recommendation 4
 That the proposed cardiac clinical network works with    Develop, host and lead regional        6-12 months
 stakeholders across the State to develop region          working groups to discuss the
 specific plans for the optimal use and coordination of   practical operation of services,
 cardiac care resources in accordance with evidence-      linkages and disconnects.
 based practice in all metropolitan and rural regions.
                                                          Based on current data formalise
                                                          these arrangements and develop
                                                          standard processes for cardiac
                                                          services across the state.

                                                          Design evaluation tools to monitor
                                                          implementation and outcomes.

                                                          Ensure activity is monitored and
                                                          evaluated to allow continuous
                                                          improvement.
 Recommendation 5
 That the Department of Human Services supports the       Clinical Network representatives       6-12 months
 appointment of specialist cardiac care coordinators in   to work with stakeholders to
 each metropolitan health service that provides acute     develop position description for
 cardiac services and in each rural region.               the specialist cardiac care
                                                          coordinators.

                                                          Advertise and appoint to the role
                                                          on a trial basis in three locations.

                                                          Review the role at 6 months with
                                                          the incumbents and other
                                                          stakeholders.

                                                          Make any adjustments to the role
                                                          and as appropriate role out
                                                          across the state.
 Recommendation 6
 That the publications of the Cardiac Society of          Review current data collection         6-12 months
 Australia and New Zealand and the National Heart         methods and undertake gap
 Foundation of Australia: Guidelines for the              analysis to see what/if any
 Management of Acute Coronary Syndromes 2006 and          additional data needs to be
 Guidelines for the Prevention, Detection and             collected to ensure audit against
 Management of Chronic Heart Failure in Australia         guidelines is possible.
 2006 as updated from time to time are adopted by the
 Victorian public health care system as the appropriate   Ensure that additional data
 standard of care for patients suffering from relevant    requirements are captured by




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Conclusion and Implementation Plan




 Recommendations                                             Action                                Timeframe
 cardiac conditions.                                         new cardiology register.

                                                             Provide benchmarking and
                                                             feedback to services.
 Clinical Delivery and Standards
 Recommendation 7
 That the proposed cardiac clinical network develops         Review current guidelines             6-12 months
 guidelines for angiography and PCI services without         referring to angiography and PCI
 on-site surgical back-up in Victoria, for endorsement by    services without onsite backup in
 the Department of Human Services and incorporation          Australia and overseas.
 into conditions of funding if necessary, and that the
 guidelines are consistent with the Cardiac Society of       Develop and formalise clinical
 Australia and New Zealand's 2008 Guidelines on              support networks for both medical
 Support Facilities for Coronary Angiography and             and nursing staff at new centres.
 Percutaneous Coronary Intervention (PCI) including
 Guidelines on the Performance of Procedures in Rural
 Sites.                                                      Build into policy and funding
                                                             guidelines as appropriate.            Ongoing

                                                             Review and disseminate
                                                             information regarding best
                                                             practice.

                                                             Clinical network to review these
                                                             guidelines and develop specific
                                                             guidelines for Victoria.
 Recommendation 8
 That PCI is not offered in centres in Victoria unless the   Develop cardiac register to           3-6 months
 predicted volumes of procedures (individual and             capture activity across the state.
 centre) reach levels at least equivalent to those
 recommended in the Guidelines for the Management            Cardiac Network to monitor
 of Acute Coronary Syndromes 2006 and Guidelines in                                                Ongoing every 6 months
                                                             register regularly to ensure
 Competency in Coronary Angioplasty, which currently         standard activity levels are
 are:                                                        maintained.
 • 75 cases per year for each cardiologist
 • 200 cases per year for each centre (the centre            Develop formal processes to           3-6months
     volume can be less when operators are                   communicate issues to services
     concurrently practising at other centres)               who may breach standard levels.
 • Greater than 36 cases of primary PCI per unit per
     year.
 Recommendation 9
 That all public hospitals in which PCI infrastructure is    Undertake cost, resource and          6-12 months
 available work towards providing 24 hour access to          utilisation analysis of proposed 24
 primary PCI for patients suffering STEMI.                   hr service.

                                                             Assess benefit to patients and
                                                             service.

                                                             Develop business case for
                                                             service.

                                                             Ensure MAS and RAV are
                                                             involved as key partners in the
                                                             development of these services.




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Conclusion and Implementation Plan




 Recommendations                                           Action                                Timeframe
 Recommendation 10
 That the Department of Human Services supports the        Review resource requirements          6-12 months
 development of 24-hour PCI services at Northern,          and cost of expanding service to
 Frankston and Bendigo Hospitals.                          24 hours.

                                                           Develop Business Cases for            ongoing
                                                           services.

                                                           Ensure activity of services are
                                                           monitored and captured on
                                                           register.
 Recommendation 11
 That the Department of Human Services supports the        Cost benefit analysis of              3 – 6 months
 development of diagnostic angiography services at         developing new diagnostic
 Ballarat Base Hospital.                                   services

                                                           Develop business case for new         6 – 12 months
                                                           service.
 Recommendation 12
 That the Department of Human Services ensures that        Clinical Network to formalise links   6-12 months
 new angiography and PCI services are developed            with new services.
 under the supervision of a highly experienced operator
 and in compliance with recommended patient selection      Develop selection criteria for
 criteria and that outcomes are monitored by the           patients who could be safely
 supervising operator to ensure appropriate quality        treated at these services.
 standards are achieved.

                                                           Register patients and procedures
                                                           for audit.

                                                           Clinical Network monitor and
                                                           review activity against
                                                           projections.
 Recommendation 13
 That the Department of Human Services reviews the         Undertake cost weight review of       12 months
 cost weights for PCI to take account of the cost          PCI.
 differentials between elective, in-hours emergency and
 out-of-hours emergency PCI.
 Recommendation 14
 That the current service system configuration for         Monitor activity across the state     12 months
 cardiac surgery is maintained and that no additional      via Cardiac register.
 surgical units are developed in Victoria during the
 planning period.                                          Monitor population and practice
                                                           changes and review location of
                                                           services as required.
 Recommendation 15
 That the proposed cardiac clinical network monitors       Measure activity, waiting times       12 months
 indicators of demand for and supply of cardiac services   and referral patterns of cardiac
 as well as appropriateness of service provision to        services using the cardiology
 ensure that an appropriate balance between                register.
 community need and service provision is maintained.
                                                           Benchmark intervention rates
                                                           across the state. Clinical Network
                                                           to monitor cardiac service levels.




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Conclusion and Implementation Plan




 Recommendations                                              Action                                Timeframe
 Recommendation 16
 That the Department of Human Services requests its           Ensure coordination across            Ongoing
 Intensive Care Advisory Committee to consider the            planning programs.
 issue of access to intensive care beds for cardiac
 surgical patients in the context of the overall supply of
 intensive care beds in the State.
 Recommendation 17
 Both cardiac magnetic resonance imaging and cardiac          Monitor utilisation, outcomes and     12 months
 computerised tomography are developing as effective          current centres.
 technologies with distinct and defined clinical
 applications; it is recommended that their development       Continue to evaluate the use of
 and evaluation within centres of excellence are              cardiac MR and Cardiac CT as
 supported; but that they are not introduced into new         effective treatments based on
 non-tertiary settings in Victoria until their clinical       literature and current practice.
 application including cost-effectiveness is fully
 evaluated and there is a sustainable arrangement for
 funding that incorporates an appropriate contribution        Undertake cost analysis of
 from the Australian Government.                              introducing these new
                                                              technologies at specified sites.

                                                              Clinical Network to assess results
                                                              and submit business case for
                                                              new technologies as appropriate.
 Recommendation 18
 That the current service system configuration for            Monitor use of complex EP using       ongoing
 complex electrophysiology continues and that no              cardiac register.
 additional complex electrophysiology units are
 developed in Victoria in the foreseeable future, unless      Monitor outcomes and clinical
 indications for its application change substantially         applications of complex EP.
 leading to a significant increase in demand.

 Recommendation 19
 That the Department of Human Services investigates           Independent cost analysis of EP       12 months
 the feasibility of reforming funding for electrophysiology   service
 so that the case payment for these services reflects
 their true cost including the cost of single use devices.
 Recommendation 20
 That the Department of Human Services:                       Monitor indications for utilisation   12 months
 • seeks advice from all relevant health services             over time.
    about the number of patients predicted to meet
    eligibility criteria as established by the Medical        Independent cost analysis of
    Services Adviosry Committee for Implantable               providing these services.
    Cardioverter Defibrillators and combined
    implantable cardiac resynchronisation and
                                                              Develop protocol
    cardioverter defibrillator therapy; and
 • with the advice of the proposed cardiac clinical
    network negotiates and includes within health             Clinical Network to review
    service funding agreements a target level of              projections and costs and present
    provision by each health service that is predicted to     findings to DHS for funding
    meet reasonable demand.                                   requirements.
 Recommendation 21
 That each proposed region-specific plan for the optimal      Development of region-specific        6-12 months
 use and coordination of cardiac care resources               plans incorporates CHF
 incorporates a detailed plan, developed in conjunction       requirements for their population.
 with the Hospital Admission Risk Program – Chronic
 Disease Management (HARP-CDM) Program, for the               Review CHF patient data -
 management of congestive heart failure in accordance         location of treatment and services
 with the relevant clinical guidelines.                       utilised.




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Conclusion and Implementation Plan




 Recommendations                                            Action                               Timeframe

                                                            Map future demand

                                                            Clinical Network to develop
                                                            formalised process to be agreed
                                                            by service providers.
 Recommendation 22
 That the Department of Human Services works with           Review services provided for         18 months
 the proposed clinical cardiac network and with relevant    congenital heart patients.
 stakeholders to develop structural and service
 coordination models for a designated statewide service     Host and lead working groups to
 for adults with congenital heart disease, with services    discuss design of congenital
 to be provided from two sites (Monash Medical Centre       heart disease services.
 and the Royal Melbourne Hospital).

                                                            Review best practice.

                                                            Establish services according to
                                                            best practice guidelines and
                                                            monitor outcomes.

                                                            Monitor demand for services.
 Recommendation 23
 That the National Heart Foundation of Australia and        Undertake a gap analysis of          12 months
 the Australian Cardiac Rehabilitation Association          current services as compared to
 Recommended Framework for Cardiac Rehabilitation           the National Heart Foundation of
 is adopted by the Victorian public health care system      Australia and the Australian
 as the appropriate standard for the provision of cardiac   Cardiac Rehabilitation
 rehabilitation services.                                   Association Recommended
                                                            Framework for Cardiac
                                                            Rehabilitation.

                                                            Document required
                                                            improvements / changes in
                                                            service provision for ratification
                                                            by Clinical Network and feedback
                                                            to DHS.
 Recommendation 24
 That the proposed cardiac clinical network reviews and     Review guidelines as they are        Ongoing
 advises the Department of Human Services on                published
 necessary updates to the publication Best Practice
 Guidelines for Cardiac Rehabilitation and Secondary
 Prevention, ensuring its consistency with the
 Recommended Framework for Cardiac Rehabilitation.
 Recommendation 25
 That the proposed cardiac clinical network leads a         Working team established to          6-12 months
 project incorporating:                                     develop the standards, the
 • the development of specific standards for the            appropriate incentives and audit
     provision of Phase I and provision of or referral to   program and performance
     Phase II cardiac rehabilitation programs;              indicators.
 • provision of incentives to all acute hospitals that
     offer cardiac services for the development and
     implementation of referral improvement plans
     consistent with the endorsed standards;
 • an audit program of hospital records to monitor and
     evaluate compliance with the endorsed protocols;
 • performance bonuses to acute hospitals based on




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Conclusion and Implementation Plan




 Recommendations                                          Action                                 Timeframe
    assessed performance; and
 • performance indicator development and ongoing
    monitoring.
 Recommendation 26
 That the Department of Human Services reviews            Independent cost review of             6-12 months
 funding of cardiac rehabilitation services across        rehabilitation services in Victoria.
 Victoria and ensures that:
 • there is sufficient funding which is appropriately     Review current service utilisation
     distributed to ensure equitable access to quality    across providers.
     services by all eligible patients;
 • funding streams are consolidated so as not to          Develop new consolidated
     create an undue administrative burden on             funding model for cardiac
     providers; and                                       rehabilitation services.
 • funding enables the development and provision of
     a mix of services tailored to patient needs.
                                                          Monitor activity and adjust
                                                          services if/when required based
                                                          on changes in care or best
                                                          practice.
 Recommendation 27
 That the Department of Human Services' Palliative        Utilise the newly developed            12 months
 Care Advisory Committee is asked to advise the           palliative care data set to monitor
 Department on strategies to strengthen palliative care   services across the state.
 services for cardiac patients across the state.
                                                          Consult with stakeholders to
                                                          evaluate current service and
                                                          areas for improvement or change.

                                                          Provide report on the future
                                                          direction of Palliative care
                                                          services for cardiac patients
                                                          across Victoria.
 Resource Planning and Support
 Recommendation 28
 That the Department of Human Services continues to                                              ongoing
 support all hospitals which offer emergency cardiac
 services to develop the infrastructure necessary to
 monitor and evaluate patients with chest pain in
 accordance with the Guidelines for the Management of
 Acute Coronary Syndromes 2006.
 Recommendation 29
 That the proposed cardiac clinical network:              Develop standard inventory             12 months
 • assists hospitals and health services to undertake a   checklist for hospitals/providers to
    cardiac equipment stocktake and develop               monitor cardiac equipment levels
    equipment replacement plans; and                      in their service and maintain on
 • advises the Department of Human Services on            central database.
    system-wide priorities for the funding of cardiac     Monitor cardiac activity against
    equipment.                                            resource requirements
                                                          Review current and standardise
                                                          purchase policy
                                                          Review and standardise lifecycle
                                                          of all cardiac equipment currently
                                                          used in Victoria
                                                          Monitor best practice against
                                                          equipment requirements to
                                                          accurately project future stock
                                                          and funding requirements.




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Conclusion and Implementation Plan




 Recommendations                                           Action                              Timeframe
 Recommendation 30
 That the Department of Human Services Service and         DHS workforce planning              Ongoing
 Workforce Planning Branch works with the proposed         representation regularly attend
 cardiac clinical network and relevant professional        network meetings
 bodies to develop a strategy to ensure a sustainable
 cardiac workforce in Victoria with particular emphasis
 on the nursing and technology workforce.
 Recommendation 31
 That the cardiac clinical network works with the          Review current training programs    12 months
 designated level 5 and 4 cardiac hospitals and relevant   being conducted across the
 tertiary education institutions to design and implement   service.
 appropriate education modules for the cardiac nursing
 and allied health workforces.                             Define objectives of training
                                                           modules

                                                           Clinical Network to work with
                                                           education provider to develop
                                                           appropriate modules which aligns
                                                           with objectives.
 Effective Co-ordination and Patient Flow
 Recommendation 32
 That the Department of Human Services supports the        Cost the installation of required   3-6 months
 Metropolitan Ambulance Service and Rural Ambulance        12 lead ECG's. Develop business
 Victoria to complete the installation of equipment to     case for installation.
 support 12-lead electrocardiogram capability in all
 Victorian ambulances that are used to transport           Research best practice for 12-
 patients suffering from Acute Coronary Syndrome, and      lead ECG use and develop
 to implement associated protocols, training and           training module and care
 technologies.                                             protocols in partnership with MAS
                                                           and RAV.

                                                           Engage with MAS and RAV who
                                                           will be receiving ECG and
                                                           schedule training.

                                                           Conduct ongoing training

                                                           Monitor use of 12-lead ECG over
                                                           time in Ambulance.
 Recommendation 33
 That the region-specific plans proposed in                Implement a regular review          Ongoing
 recommendation 4 incorporate plans for the                process to profile resources
 maintenance and/or enhancement of pre-hospital            against model of care
 cardiac care resources and models of care in              developments.
 accordance with best practice standards, including pre-
 hospital thrombolysis for appropriate patients.
 Recommendation 34
 That the region-specific plans proposed in                Conduct regional workshops with     3 – 6 months
 recommendation 4 incorporate region-specific              ambulance and hospital staff to
 protocols for the ambulance transport of patients         evaluate current protocols and
 suffering STEMI direct from home to PCI-capable           any requirements to update them.
 facilities if access can be achieved reliably within
 timeframes recommended in the Guidelines for the          Monitor literature and best
 Management of Acute Coronary Syndromes 2006.              practice reports on commute time
                                                           for STEMI patients and update
                                                           protocols based on best practice.




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Conclusion and Implementation Plan




 Recommendations                                                Action                                Timeframe
 Recommendation 35
 That the proposed cardiac clinical network oversees            Review current process of inter-      6-12 months
 the development of a state-wide inter-hospital transfer        hospital transfer and 'accepted'
 protocol for the emergency management of patients              protocols.
 with STEMI who present to a hospital that does not
 offer primary PCI.                                             Review current transport levels
 The protocol should:                                           and travel times.
 • be consistent with the Guidelines for the
     Management of Acute Coronary Syndromes 2006;               Identify hospitals with primary PCI
 • identify the hospitals which are located sufficiently        in Victoria and areas within
     proximate to a provider of primary PCI to enable           acceptable referral times of these
     primary PCI to be offered routinely to appropriate         hospitals.
     patients;
 • provide for the acute inter-hospital transfer of
                                                                Identify areas not within required
     appropriate patients if the time since onset of the
                                                                time frame of primary PCI facility
     patient's symptoms, local conditions including the
                                                                for STEMI patients and develop
     hospital's location and infrastructure and
                                                                alternate options.
     ambulance transport infrastructure are such that
     primary PCI can be accessed within a time that is
     consistent with the Guidelines for the Management          Work with stakeholders to
     of Acute Coronary Syndromes 2006; and                      produce a standard referral plan
 • require hospitals that offer primary PCI to                  for hospitals and ambulance
     guarantee access without delay on a 24 hour basis          services.
     to patients referred in accordance with the protocol.
                                                                Monitor transport activity of
                                                                patients including time to
                                                                treatment.

                                                                Monitor best practice for
                                                                treatment of STEMI and update
                                                                protocol as required.
 Recommendation 36
 That the Department of Human Services sponsors the             Clinical Network to develop           3 – 6 months
 development and evaluation of 'intention to treat' trials      working group to design ‘intention
 for the safe referral of and inter-hospital transfer for the   to treat’ trials protocols and
 provision of primary PCI to appropriate patients               evaluation measures.
 suffering STEMI who present to Ballarat Base and
 Latrobe Regional Hospitals.                                    Identify funding for ‘intention to
                                                                treat’ trials.
 Recommendation 37
 That the Department of Human Services considers                Review current numbers of             6-12 months
 reimbursing private hospitals for the marginal costs of        patients who present to private
 care of uninsured patients who present with a cardiac          hospitals for emergency
 emergency and are provided with emergency cardiac              treatment.
 interventional services in accordance with the
 Guidelines for the Management of Acute Coronary                Establish working group with
 Syndromes 2006.                                                private sector to explore
                                                                reimbursement options.
 Recommendation 38
 That the Department of Human Services raises with              Review data on number of people       6-12 months
 the Australian Government stakeholder concerns                 presenting in a life-threatening
 about the sale of private health insurance products that       emergency with inadequate
 exclude services necessary in a life-threatening               health insurance.
 emergency.
                                                                Liaise with the Australian
                                                                Government and express
                                                                Victorian Government concerns




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Conclusion and Implementation Plan




 Recommendations                                              Action                              Timeframe
                                                              regarding exclusion criteria on
                                                              some health insurance products.
 Recommendation 39
 That the proposed cardiac clinical network supports all      Review data on current              3 – 6 months
 hospitals which provide primary PCI services to              catheterisation lab utilisation
 develop, in conjunction with ambulance services and          across those providing primary
 local Divisions of General Practice, a protocol for direct   PCI.
 access to the catheterisation laboratory for patients
 who are diagnosed with STEMI in the pre-hospital             Develop protocol for direct
 phase; and for rapid diagnosis and transit through the       access to cath labs for STEMI
 Emergency Department for patients who present with           patients in pre hospital phase.
 undiagnosed STEMI.
 Recommendation 40
 That the proposed cardiac clinical network oversees          Review current referral practices   Initiate 3 – 6 months
 the development of a template agreement between              and collected data.                 Ongoing periodic review
 referring and receiving hospitals, specifying the types
 of obligations that will apply to referring and receiving    Work with regional working
 hospitals when a referral of a cardiac patient is made       groups to develop specific
 for diagnosis or medical or surgical treatment.              agreement including obligations
                                                              for referrals.

                                                              Standardise template agreement
                                                              for all service providers.

                                                              Review agreement against
                                                              guidelines to ensure appropriate
                                                              care for patients.
 Recommendation 41
 That the proposed cardiac clinical network supports          Use Recommendation 32 and 38        3 – 6 months
 hospitals that do not provide a comprehensive range of       to develop a transport protocol
 specialist cardiology services to negotiate agreements       and agreement between
 with appropriate receiving hospitals, consistent with the    hospitals.
 template agreement, providing for equitable access by
 their referred patients to an appropriate range of
 services.
 Recommendation 42
 That clinicians in referring hospitals retain the right to   Ensure template referral            3 – 6 months
 refer patients to the clinician/hospital of choice as        agreement includes a ‘default’
 agreed with the patient and/or their representative          option.
 (other than in acute cardiac emergencies requiring PCI
 as provided for in recommendation 35) but in the event
 that a timely service cannot be arranged the
 agreement provides a 'default' referral option and the
 receiving hospital that is a party to the agreement is
 obliged to accept the patient in accordance with the
 terms of the agreement.
 Recommendation 43
 That the Department of Human Services evaluates the          Review numbers of patients from     6 – 12 months
 feasibility of implementing a 'rural referral WIES bonus'    rural centres presenting at metro
 so that hospitals that accept urgent or semi-urgent          hospitals for urgent/semi-urgent
 referrals from rural and regional centres do not incur a     procedures.
 net financial penalty if, as a result, the allocation of a
 bed to a patient waiting in their emergency department       Undertake independent cost
 is delayed.                                                  analysis of proposed WIES
                                                              bonus




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Conclusion and Implementation Plan




 Recommendations                                            Action                               Timeframe
 Recommendation 44
 That metropolitan hospitals are funded via the             As above                             6 – 12 months
 proposed rural referral WIES bonus, and required
 through the relevant inter-hospital agreements, to
 provide clinically-necessary metropolitan
 accommodation and to explore mechanisms for
 supporting reasonable costs of transport home where
 necessary for rural cardiac patients who have been
 admitted on an urgent or semi-urgent basis.
 Recommendation 45
 That the proposed cardiac clinical network establishes     Review best practice for             6 – 12 months
 a reliable system for collecting information about         recording and monitoring waiting
 waiting times for various cardiac services so that         times.
 cardiac patients who are placed on waiting lists for
 consulting, diagnostic, interventional or surgical         Establish standard definitions and
 services can be provided with clear advice about their     data collection protocols.
 expected waiting times and the average waiting times
 in other hospitals and can be offered access to
 alternative services.                                      Establish comprehensive
                                                            monitoring processes for use
                                                            across the service.
 Recommendation 46
 That the Department of Human Services endorses the         Adoption of role delineation         ongoing
 role delineation model proposed in this report including   model by clinical network and
 the definition of levels 5-1 and the associated hospital   service providers.
 designations.
 Recommendation 47
 That the proposed cardiac clinical network oversees        Establish an expert clinical group   3-6 months
 the establishment and ongoing analysis of a                to design the data set based on
 comprehensive cardiac services register covering           the existing cardiac surgical and
 interventional and surgical services provided to all       MIG data collections.
 patients in all public hospitals in Victoria, for the
 purposes of monitoring and advising on the quality of      Establish a central recording unit
 cardiac care including accessibility, effectiveness and    and mechanism for data transfer
 appropriateness. Provision of data to such a register      that does not increase the burden
 would be mandatory for all hospitals providing             of existing data collection.
 interventional and surgical cardiac procedures.

                                                            Consider partnering with an
                                                            academic institution in
                                                            establishing the register.
 Recommendation 48
 That DHS take action to ensure the provision of timely     Link public funding to data          12 months
 and accurate data to the Victorian Cardiac Services        provision
 Registry.




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Appendix A                Cardiac services review and service planning
                          framework development
Cardiac services advisory committee – Membership

Expertise              Member                  Position                               Endorsing Organisation
CHAIR - Health         Dr Jennifer King /      Director, Programs Branch,             Department of Human
policy                 Mr Geoff Lavender       Metropolitan Health and Aged           Services
                                               Care Services, DHS
Cardiology –           Prof Ian Meredith       Director, Monash Heart, Monash         Cardiac Society of
interventional                                 Medical Centre                         Australia and New
                                                                                      Zealand (CSANZ)
Cardiology –           Assoc Prof              Director, Cardiac Investigation        CSANZ
interventional         Andrew MacIsaac         Unit, St Vincent’s
Cardiology –           Assoc Prof Gishel       Director, Cardiology, Eastern          CSANZ
interventional         New                     Health
Cardiology –           Prof Jon Kalman         Royal Melbourne Hospital               CSANZ
electrophysiology
Cardiology –           Dr Jennifer Johns       Director, Cardiology, Austin           CSANZ
Echocardiography                               Hospital
Cardiology –           Dr Andrew Taylor        Alfred                                 CSANZ
Imaging
Cardiac surgery        Assoc Prof James        Divisional Director Cardiac            Royal Australasian
                       Tatoulis                Services Royal Melbourne               College of Surgeons
                                               Hospital
Emergency              Dr Peter Ritchie        Clinical Services Director, Division   Australasian College for
physician                                      of Access & Emergency Care             Emergency Medicine
                                               Western Health Director ED,
                                               Sunshine Hospital
Rural & remote         Assoc Prof David        President, Australian College of       Australian College of
medicine               Campbell                Rural & Remote Medicine Director,      Rural and Remote
                                               East Gippsland Regional Clinical       Medicine
                                               School Monash University
Cardiac nursing        Ms Carolyn              Austin Hospital (Cath Lab NUM)         Victorian Cardiac
                       Naismith                                                       Nurses’ Association
Cardiac nursing        Ms Hella Parker         Box Hill Hospital, NUM, CCU            Victorian Cardiac
                                                                                      Nurses’ Association
Cardiac                Assoc Prof Helen        Faculty of Health Sciences, La         Victorian Association of
rehabilitation         McBurney                Trobe University                       Cardiac Rehabilitation
Ambulance              Mr Kevin Masci          Manager, Paramedic Education &         Metropolitan Ambulance
                                               Training, Metropolitan Ambulance       Service
                                               Service




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Cardiac services review and service planning framework development




Expertise              Member                  Position                          Endorsing Organisation
Ambulance              Assoc Prof Tony         General Manager, Clinical         Rural Ambulance
                       Walker                  Governance                        Victoria
Metropolitan           Ms Jennifer             CEO, Alfred                       DHS
health service –       Williams
CEO
Regional/rural         Mr Greg Pullin          CEO, Goulburn Valley Hospital     DHS
health service –
CEO
Peak body              Mr Marcus Daddo         Manager, Cardiovascular Care      DHS
                                               Programs National Heart
                                               Foundation – Victorian Division
Consumer group         Mr Alistair Kerr        Consumer Nominated by Health      DHS
                                               Issues Centre



Departmental attendees
•     Lea Pope, Manager, Continuing Care & Clinical Service Development
•     Louise Devereux, Manager, Clinical Service Development
•     Vijaya Sundararajan, Senior Medical Advisor, Programs
•     Usha Mudaliar, Project Manager, Clinical Service Development
•     Helen D’Offay, Manager, Private Hospitals Unit
•     Maureen Robinson, Manager, Service Development Manager, RRHACS
•     Martin Lum, Senior Medical Advisor, AMP




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Appendix B                Glossary
ABS                Australian Bureau of Statistics
ACC                American College of Cardiologists
ACHPR              Agency for Health Care Policy & Research guidelines
ACLS               Advanced Cardiac Life Support
ACS                Acute Coronary Syndrome
AF                 Atrial Fibrillation
AHA                American Heart Association
AICD               Automated Implantable Cardiac Defibrillator
AIHW               Australian Institute of Health and Welfare
ALOS               Average Length of Stay
AMI                Acute Myocardial Infarction
APO                Acute Pulmonary Oedema
ASCTS              Australasian Society of Cardiac and Thoracic Surgeons
CABG               Coronary Artery Bypass Graft
CAD                Coronary Artery Disease
CCU                Cardiac Care Unit
CHF                Congestive Heart Failure
CMRI               Cardiac Magnetic Resonance Imaging
CPEA               Chest Pain Evaluation & Assessment
CPEU               Chest Pain Evaluation Units
CSAC               Cardiac Services Advisory Committee
CSANZ               Cardiac Society of Australia and New Zealand
CT                 Computed Tomography
CTA                Computed Tomography Angioplasty
CVD                Cardiovascular Disease
DHS                Department of Health Services
DRG                Diagnosis Related Group
ECG                Electrocardiogram
ECHO               Echocardiogram
ED                 Emergency Department
EMS                Emergency Medical Services
EP                 Electrophysiology
ESIS               Elective Surgery Information System
GP                 General Practitioner




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Glossary




GRACE              Global Registry of Acute Coronary Events
HARP - CDM         Hospital Admission Risk - Chronic Disease Management
HARP               Hospital Admission Risk Program
IABP               Intra-Aortic Balloon Pump
ICCU               Intensive Coronary Care Units
ICD                Implantable Cardioverter Defibrillators
ICES               Institute for Clinical Evaluative Sciences
ICU                Intensive Care Unit
LV                 Left Ventricle
MMC                Monash Medical Centre - Clayton Campus
MR                 Magnetic Resonance
MRA                Magnetic Resonance Angioplasty
MRI                Magnetic Resonance Imaging
MSAC               Medical Services Advisory Committee
NSTEACS            Non-ST-Elevation Acute Coronary Syndrome
NT                 Northern Territory
NYHA               New York Heart Association
PCI                Percutaneous Coronary Intervention
PCTA               Percutaneous Transluminal Coronary Angioplasty
PWC                PricewaterhouseCoopers
RFT                Response for Tender
RMH                Royal Melbourne Hospital
SLA                Statistical Local Areas
STEMI              ST Elevation Myocardial Infarction
USA                United States of America
VACS               Victorian Ambulatory Classification System
VADs               Ventricular Assisted Devices
COACH              Coaching patients on Achieving Cardiovascular Health
VAED               Victorian Admitted Episodes Dataset
VEMD               Victorian Emergency Minimum Dataset
WIES               Weighted Inlier Equivalent Separations




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Appendix C                             Admitted patient activity – all cardiology
Overall activity
The following section provides an overview of admitted patient activity in cardiac services in Victoria. In
this context “cardiac services” includes all admissions falling into the “Other Cardiology”, “Cardiothoracic
Surgery” and “Interventional Cardiology” major clinical related groups (MCRGs). A hierarchy of the
MCRGs, clinical related groups (CRGs) and diagnostic related groups (DRGs) within cardiac services is
shown below. Sections Appendix D, Appendix E and Appendix F show more detail regarding the activity
within each MCRG.

Table 19: Cardiac services MCRGs CRGs and DRGs


          MCRG                                        CRG                    DRG    DRG name
Other Cardiology            Chest Pain                                       F74Z   Chest Pain
                            Unstable Angina                                  F72A   Unstable Angina W Cat/Sev CC
                                                                             F72B   Unstable Angina W/O Cat/Sev CC
                            Heart Failure and Shock                          F62A   Heart Failure and Shock W Cat CC
                                                                             F62B   Heart Failure and Shock W/O Cat CC
                            Non-Major Arrhythmia and Conduction Disorders    F71A   Non-Major Arrhythmia and Conduction Disorders W Cat/Sev CC
                                                                             F71B   Non-Major Arrhythmia and Conduction Disorders W/O Cat/Sev CC
                            AMI W/O Invasive Cardiac Inves Pro               F60A   Circ Disorders W AMI W/O Inv Cardiac Invest Proc W Cat/Sev CC
                                                                             F60B   Circ Disorders W AMI W/O Inv Cardiac Invest Proc W/O Cat/Sev CC
                                                                             F60C   Circ Disorders W AMI W/O Inv Cardiac Invest Proc Died
                            Other Cardiology                                 F40Z   Circ System Diagnosis W Ventilator Support
                                                                             F61Z   Infective Endocarditis
                                                                             F63A   Venous Thrombosis W Cat/Sev CC
                                                                             F63B   Venous Thrombosis W/O Cat/Sev CC
                                                                             F66A   Coronary Atherosclerosis W CC
                                                                             F66B   Coronary Atherosclerosis W/O CC
                                                                             F67A   Hypertension W CC
                                                                             F67B   Hypertension W/O CC
                                                                             F68Z   Congenital Heart Disease
                                                                             F69A   Valvular Disorders W Cat/Sev CC
                                                                             F69B   Valvular Disorders W/O Cat/Sev CC
                                                                             F70A   Major Arrhythmia and Cardiac Arrest W Cat/Sev CC
                                                                             F70B   Major Arrhythmia and Cardiac Arrest W/O Cat/Sev CC
                                                                             F75A   Other Circ System Diagnoses W Cat CC
                                                                             F75B   Other Circ System Diagnoses W Severe CC
                                                                             F75C   Other Circ System Diagnoses W/O Cat/Sev CC
Cardiothoracic Surgery      Coronary Bypass                                  F05A   Coronary Bypass W Inv Cardiac Inves W Cat CC
                                                                             F05B   Coronary Bypass W Inv Cardiac Inves W/O Cat CC
                                                                             F06A   Coronary Bypass W/O Inv Cardiac Inves W Cat or Severe CC
                                                                             F06B   Coronary Bypass W/O Inv Cardiac Inves W/O Cat or Severe CC
                            Other Cardiothoracic Surgery                     E01A   Major Chest Proc W Cat CC
                                                                             E01B   Major Chest Proc W/O Cat CC
                                                                             F03Z   Cardiac Valve Proc W CPB Pump W Inv Cardiac Invest
                                                                             F04A   Cardiac Valve Proc W CPB Pump W/O Inv Cardiac Invest W Cat CC
                                                                             F04B   Cardiac Valve Proc W CPB Pump W/O Inv Cardiac Invest W/O Cat CC
                                                                             F07A   Other Cardiothoracic/Vascular Proc W CPB Pump W Cat CC
                                                                             F07B   Other Cardiothoracic/Vascular Proc W CPB Pump W/O Cat CC
                                                                             F09A   Other Cardiothoracic Proc W/O CPB Pump W Cat CC
                                                                             F09B   Other Cardiothoracic Proc W/O CPB Pump W/O Cat CC
Interventional Cardiology   Invasive Cardiac Inves Pro                       F41A   Circ Disorders W AMI W Inv Cardiac Invest Proc W Cat/Sev CC
                                                                             F41B   Circ Disorders W AMI W Inv Cardiac Invest Proc W/O Cat/Sev CC
                                                                             F42A   Circ Disorders W/O AMI W Inv Cardiac Invest Proc W Complex DX/Pr
                                                                             F42B   Circ Disorders W/O AMI W Inv Cardiac Invest Proc W/O Complex DX/Pr
                            Perc Coronary Angioplasty                        F10Z   Percutaneous Coronary Intervention W AMI
                                                                             F16Z   Percutaneous Coronary Intervention W/O AMI W/O Stent Impl
                            Perc Coronary Angioplasty W/O AMI W Stent Impl   F15Z   Percutaneous Coronary Intervention W/O AMI W Stent Impl
                            Other Interventional Cardiology                  F01A   Impl or Replacement of AICD Total System W Cat/Sev CC
                                                                             F01B   Impl or Replacement of AICD Total System W/O Cat/Sev CC
                                                                             F02Z   AICD Component Impl/Replacement
                                                                             F12Z   Cardiac Pacemaker Impl
                                                                             F17Z   Cardiac Pacemaker Replacement
                                                                             F18Z   Cardiac Pacemaker Revision Except Device Replacement
                                                                             F19Z   Other Trans-Vascular Percutaneous Cardiac Intervention




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Admitted patient activity – all cardiology




By gender and age group
In 2005/06 there were a total of 115,097 inpatient cardiac admissions in Victoria (including both public
and private hospitals). This represented approximately 5.7% of all inpatient admissions in Victoria.
Cardiac admissions have slightly reduced as a proportion of total admissions, from 6.0% in 2001/02. The
distribution of these by age and gender is shown in Table 20. This table and the remaining tables in
Sections Appendix C to Appendix J are based on the Victorian Admitted Episodes Dataset (VAED).

Table 20: Cardiac admissions by age and gender



   Age          Males   Females              Total
00-04               445      439                 884
05-09               158      137                 295
10-14               174      166                 340
15-19               368      265                 633
20-24               429      380                 809
25-29               608      494               1,102
30-34             1,018      731               1,749
35-39             1,691    1,064               2,755
40-44             2,754    1,444               4,198
45-49             3,927    2,196               6,123
50-54             5,210    2,938               8,148
55-59             6,593    3,746              10,339
60-64             7,011    3,959              10,970
65-69             7,531    4,537              12,068
70-74             7,974    5,590              13,564
75-79             8,407    6,959              15,366
80-84             6,822    6,967              13,789
85+               4,624    7,341              11,965
Total            65,744   49,353             115,097


The remainder of the analysis shown includes only admissions for patients age 20 and over, a total of
112,945 admissions in 2005/06.


Public/private split
Public hospital cardiac admissions have grown fairly consistently over the last 5 years. Private hospital
cardiac admissions have levelled off over the last three years at approximately 32,000 admissions
(Table 21).




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Table 21: Cardiac admissions split between private and public hospitals

  Financial Year         Public Hospitals         Private Hospitals %Public Grand Total
 2001/02                            70,644                   29,167    71%       99,811
 2002/03                            74,033                   31,255    70%      105,288
 2003/04                            75,690                   32,009    70%      107,699
 2004/05                            77,726                   32,184    71%      109,910
 2005/06                            81,093                   31,852    72%      112,945
Increase                            10,449                    2,685              13,134
% increase p.a.                       3.5%                     2.2%                3.1%



Regional split
Table 22 shows that 75,133 admissions in 2005/06 related to patients residing in Melbourne, with 35,361
admissions related to patients residing in rural Victoria and 2,551 relating to patients residing outside
Victoria. Private hospital usage was greatest among patients in the Southern and Eastern Metropolitan
regions, with these regions having 34% and 40% (respectively) of admissions being in private hospitals.

Table 22: Cardiac admissions by region for 2005/06

                                             Separations

        Region                      Public                 Private        %Public Grand Total
North-West Metro                             22,773               6,416      78%       29,189
Southern Metro                               17,359               9,127      66%       26,486
Eastern Metro                                11,716               7,742      60%       19,458
Barwon-SW                                     7,275               1,857      80%        9,132
Loddon Mallee                                 6,113               1,885      76%        7,998
Hume                                          5,627               1,741      76%        7,368
Gippsland                                     4,833                 792      86%        5,625
Grampians                                     3,687               1,451      72%        5,138
Interstate                                    1,710                 841      67%        2,551
Total                                        81,093              31,852      72%      112,945
Metro Total                                  51,848              23,285      69%       75,133
Rural Total                                  27,535               7,726      78%       35,261
Victorian Total                              79,383              31,011      72%      110,394

Table 23 shows that growth in the use of total cardiology services has been similar for patients resident
in metropolitan and rural Victoria, while Table 24 shows that growth in private hospital use has been
greater for metropolitan patients. There was a noticeable drop in private hospital usage by rural
Victorians in 2005/06.




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Table 23: Public hospital cardiac admissions split between metro and rural

  Financial Year                Metro                 Rural            Grand Total
 2001/02                                44,876                24,220        69,096
 2002/03                                46,590                26,001        72,591
 2003/04                                47,136                26,982        74,118
 2004/05                                48,759                27,315        76,074
 2005/06                                51,848                27,535        79,383
Increase                                 6,972                 3,315        10,287
% increase p.a.                          3.7%                  3.3%           3.5%



Table 24: Private hospital cardiac admissions split between metro and rural

  Financial Year                Metro                 Rural            Grand Total
 2001/02                                21,081                7,428         28,509
 2002/03                                22,976                7,588         30,564
 2003/04                                23,279                7,978         31,257
 2004/05                                23,107                8,315         31,422
 2005/06                                23,285                7,726         31,011
Increase                                 2,204                  298          2,502
% increase p.a.                          2.5%                 1.0%            2.1%



Public hospital activity – By local government area
The Local Government Areas (LGA) of Greater Geelong, Brimbank, Casey and Mornington Peninsula
accounted for over 16% of cardiac admissions at Victorian public hospitals (Table 25):

Table 25: Public hospital cardiac admissions by top 20 LGAs (2003-04 to 2005-06)

           LGA             2003-04 2004-05 2005-06    Difference     % Change p.a.    % of total
Greater Geelong (C)           3,555   3,705   3,863            308             4.2%           5%
Brimbank (C)                  3,022   3,175   3,446            424             6.8%           4%
Casey (C)                     2,164   2,342   2,905            741           15.9%            4%
Mornington Peninsula (S)      2,767   2,783   2,852             85             1.5%           4%
Darebin (C)                   2,310   2,347   2,405             95             2.0%           3%
Moreland (C)                  2,401   2,414   2,345            -56            -1.2%           3%
Whitehorse (C)                2,047   2,045   2,248            201             4.8%           3%
Frankston (C)                 2,213   2,121   2,224             11             0.2%           3%
Hume (C)                      1,746   2,041   2,187            441           11.9%            3%
Greater Dandenong (C)         1,932   2,053   2,111            179             4.5%           3%
Whittlesea (C)                1,780   1,989   2,076            296             8.0%           3%
Kingston (C)                  1,857   1,995   2,048            191             5.0%           3%
Monash (C)                    1,924   1,802   1,916             -8            -0.2%           2%
Greater Bendigo (C)           1,547   1,535   1,866            319             9.8%           2%
Yarra Ranges (S)              1,746   1,702   1,862            116             3.3%           2%
Banyule (C)                   1,471   1,520   1,839            368           11.8%            2%
Knox (C)                      1,542   1,520   1,717            175             5.5%           2%
Interstate                    1,572   1,652   1,710            138             4.3%           2%
Wyndham (C)                   1,027   1,339   1,632            605           26.1%            2%
Hobsons Bay (C)               1,452   1,470   1,630            178             6.0%           2%
Other                        35,615  36,176  36,211            596             0.8%          45%
Total                        75,690  77,726  81,093          5,403             3.5%        100%




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Admissions from the LGAs of Wyndham (C), Surf Coast (S), Cardinia (S), Melton (S) and Casey (C)
have grown the most over the period in terms of percentage increase (Table 30) with Casey and
Wyndham LGAs growing the most in terms of total admissions (Table 33):

Table 26: Top 10 LGAs by percentage growth (2003-04 to 2005-06)

           LGA                     2003-04 2004-05 2005-06         Difference     % Change p.a.
Wyndham (C)                           1,027   1,339   1,632                 605           26.1%
Surf Coast (S)                          244     245     364                 120           22.1%
Cardinia (S)                            512     492     702                 190           17.1%
Melton (S)                              779     899   1,059                 280           16.6%
Casey (C)                             2,164   2,342   2,905                 741           15.9%
Hume (C)                              1,746   2,041   2,187                 441           11.9%
Banyule (C)                           1,471   1,520   1,839                 368           11.8%
Greater Bendigo (C)                   1,547   1,535   1,866                 319             9.8%
Gannawarra (S)                          329     344     386                  57             8.3%
Whittlesea (C)                        1,780   1,989   2,076                 296             8.0%
Other                                64,091  64,980  66,077               1,986             1.5%
Total                                75,690  77,726  81,093               5,403             3.5%


Table 27: Top 10 LGAs by absolute growth (2003-04 to 2005-06)

           LGA                     2003-04 2004-05 2005-06         Difference     % Change p.a.
Casey (C)                             2,164   2,342   2,905                 741           15.9%
Wyndham (C)                           1,027   1,339   1,632                 605           26.1%
Hume (C)                              1,746   2,041   2,187                 441           11.9%
Brimbank (C)                          3,022   3,175   3,446                 424             6.8%
Banyule (C)                           1,471   1,520   1,839                 368           11.8%
Greater Bendigo (C)                   1,547   1,535   1,866                 319             9.8%
Greater Geelong (C)                   3,555   3,705   3,863                 308             4.2%
Whittlesea (C)                        1,780   1,989   2,076                 296             8.0%
Melton (S)                              779     899   1,059                 280           16.6%
Whitehorse (C)                        2,047   2,045   2,248                 201             4.8%
Other                                56,552  57,136  57,972               1,420             1.2%
Total                                75,690  77,726  81,093               5,403             3.5%




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By region
Growth has been greatest in the North-Western Metro and Southern Metro regions (Table 30):

Table 28: Growth by region (2003-04 to 2005-06)

           Region                  2003-04 2004-05 2005-06         Difference     % Change p.a.
North-West Metro                     20,196  21,466  22,773               2,577             6.2%
Southern Metro                       15,724  16,198  17,359               1,635             5.1%
Eastern Metro                        11,216  11,095  11,716                 500             2.2%
Barwon-SW                             6,869   7,111   7,275                 406             2.9%
Loddon Mallee                         5,614   6,085   6,113                 499             4.3%
Hume                                  5,512   5,750   5,627                 115             1.0%
Gippsland                             5,176   4,659   4,833                -343            -3.4%
Grampians                             3,811   3,710   3,687                -124            -1.6%
Interstate                            1,572   1,652   1,710                 138             4.3%
Total                                75,690  77,726  81,093               5,403             3.5%



By hospital
Over the past three years, admissions across Victorian hospitals have increased by 7%. This reflects
growth at 40% of the 122 public hospitals that provided cardiac care and a decrease in the remaining
60%. The top 10 hospitals represent over 60% of the cardiac admissions in 2005-06 while the top 30
hospitals represent over 90% of the cardiac admissions in 2005-06 (Table 29).




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Table 29: Public hospital cardiac admissions by top 30 hospitals (2003-04 to 2005-06)

                   Hospital                  2003-04 2004-05 2005-06    Difference     % Change p.a.    % of total
Royal Melbourne Hospital - City Campus          6,537   6,643   6,257           -280            -2.2%           8%
Monash Medical Centre [Clayton]                 5,382   5,482   5,696            314             2.9%           7%
Austin Hospital                                 5,050   5,173   5,231            181             1.8%           6%
Western Hospital [Footscray]                    4,198   4,623   5,071            873             9.9%           6%
Geelong Hospital                                4,553   4,672   4,886            333             3.6%           6%
Alfred, The [Prahran]                           4,703   4,505   4,621            -82            -0.9%           6%
St Vincents Hospital                            4,512   4,139   4,559             47             0.5%           6%
Frankston Hospital                              4,331   4,421   4,439            108             1.2%           5%
Box Hill Hospital                               4,161   4,175   4,427            266             3.1%           5%
Northern Hospital, The [Epping]                 2,532   3,139   3,692          1,160           20.8%            5%
Dandenong Campus                                3,124   3,098   3,298            174             2.7%           4%
Maroondah Hospital [East Ringwood]              2,195   2,275   2,360            165             3.7%           3%
Bendigo Hospital, The                           1,680   1,814   2,238            558           15.4%            3%
Sunshine Hospital                               1,430   1,721   1,863            433           14.1%            2%
Goulburn Valley Health [Shepparton]             1,433   1,726   1,668            235             7.9%           2%
Ballarat Health Services [Base Campus]          1,521   1,573   1,595             74             2.4%           2%
Angliss Hospital                                1,292   1,184   1,334             42             1.6%           2%
Latrobe Regional Hospital [Traralgon]           1,255   1,241   1,225            -30            -1.2%           2%
Mildura Base Hospital                             891   1,147   1,062            171             9.2%           1%
Rosebud Hospital                                  817     890   1,020            203           11.7%            1%
Northeast Health Wangaratta                       976     956     962            -14            -0.7%           1%
South West Healthcare [Warrnambool]               865     960     931             66             3.7%           1%
Mercy Public Hospitals Inc [Werribee]             555     672     874            319           25.5%            1%
Sandringham & District Memorial Hospital          807     869     860             53             3.2%           1%
Casey Hospital                                      0     139     809            809             0.0%           1%
Wodonga Regional Health Service                   754     739     781             27             1.8%           1%
Bairnsdale Regional Health Service                570     563     568             -2            -0.2%           1%
Wimmera Base Hospital [Horsham]                   562     508     536            -26            -2.3%           1%
Central Gippsland Health Service [Sale]           700     492     530           -170          -13.0%            1%
West Gippsland Healthcare Group [Warragul]        517     463     448            -69            -6.9%           1%
Other                                           7,787   7,724   7,252           -535            -3.5%           9%
Total                                          75,690  77,726  81,093          5,403             3.5%        100%


The most significant growth has been observed in Northern Hospital, Western Hospital and Casey
Hospital (which only opened within the past two years - Table 30):

Table 30: Top 10 hospitals by percentage growth (2003-04 to 2005-06)

                   Hospital                      2003-04 2004-05 2005-06         Difference     % Change p.a.
Northern Hospital, The [Epping]                     2,532   3,139   3,692               1,160           20.8%
Western Hospital [Footscray]                        4,198   4,623   5,071                 873             9.9%
Casey Hospital                                          0     139     809                 809             0.0%
Bendigo Hospital, The                               1,680   1,814   2,238                 558           15.4%
Sunshine Hospital                                   1,430   1,721   1,863                 433           14.1%
Geelong Hospital                                    4,553   4,672   4,886                 333             3.6%
Mercy Public Hospitals Inc [Werribee]                 555     672     874                 319           25.5%
Monash Medical Centre [Clayton]                     5,382   5,482   5,696                 314             2.9%
Box Hill Hospital                                   4,161   4,175   4,427                 266             3.1%
Goulburn Valley Health [Shepparton]                 1,433   1,726   1,668                 235             7.9%
Other                                              49,766  49,563  49,869                 103             0.1%
Total                                              75,690  77,726  81,093               5,403            3.5%




By admission type
Approximately 80% of admissions in 2005/06 were from the Emergency Department of which
approximately 88% were from the Emergency Department at the same hospital with the remaining 12%
being “other emergency admissions”.




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The other 20% of total admissions were split roughly evenly between Planned Admission from Waiting
List and Other admissions (Table 31).

Table 31: Cardiac admissions by type (2003-04 to 2005-06)

           Admission Type               2003-04 2004-05 2005-06     Difference     % Change p.a.    % of total
Emergency - Same Hospital                 49,998  54,350  57,572           7,574             7.3%          71%
Planned Admission from Waiting List        8,318   8,474   8,417              99             0.6%          10%
Other emergency admission                 11,463   8,984   7,658          -3,805          -18.3%            9%
Other admission                            5,911   5,918   7,446           1,582           12.2%            9%
Total                                     75,690  77,726  81,093           5,450             3.5%         100%




Victorian activity relative to Australian activity
The following chart shows the number of admissions (for each of Interventional Cardiology,
Cardiothoracic Surgery and Other Cardiology) as a proportion of admissions for Australia (based on
AIHW data):


                    Ratio of Victorian Activity/ Australian Activity

   27.0%

   26.0%

   25.0%

   24.0%

   23.0%
                  2001-02              2002-03            2003-04          2004-05

                    Other cardio         Cardiothoracic      Interventional Cardiology



Victorian activity has represented a relatively stable proportion of Australian activity, between 24% and
26% over the period 2001/02 to 2004/05.




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Appendix D                           Admitted patient activity – Other cardiology
Background
The “Other Cardiology” Major Clinical Related Group (MCRG) consists of the following Clinical Related
Groups (CRGs) and Diagnosis Related Groups (DRGs):

Table 32: “Other cardiology” CRGs and DRGs


                          CRG                   DRG    DRG name
Chest Pain                                      F74Z   Chest Pain
Unstable Angina                                 F72A   Unstable Angina W Cat/Sev CC
                                                F72B   Unstable Angina W/O Cat/Sev CC
Heart Failure and Shock                         F62A   Heart Failure and Shock W Cat CC
                                                F62B   Heart Failure and Shock W/O Cat CC
Non-Major Arrhythmia and Conduction Disorders   F71A   Non-Major Arrhythmia and Conduction Disorders W Cat/Sev CC
                                                F71B   Non-Major Arrhythmia and Conduction Disorders W/O Cat/Sev CC
AMI W/O Invasive Cardiac Inves Pro              F60A   Circ Disorders W AMI W/O Inv Cardiac Invest Proc W Cat/Sev CC
                                                F60B   Circ Disorders W AMI W/O Inv Cardiac Invest Proc W/O Cat/Sev CC
                                                F60C   Circ Disorders W AMI W/O Inv Cardiac Invest Proc Died
Other Cardiology                                F40Z   Circ System Diagnosis W Ventilator Support
                                                F61Z   Infective Endocarditis
                                                F63A   Venous Thrombosis W Cat/Sev CC
                                                F63B   Venous Thrombosis W/O Cat/Sev CC
                                                F66A   Coronary Atherosclerosis W CC
                                                F66B   Coronary Atherosclerosis W/O CC
                                                F67A   Hypertension W CC
                                                F67B   Hypertension W/O CC
                                                F68Z   Congenital Heart Disease
                                                F69A   Valvular Disorders W Cat/Sev CC
                                                F69B   Valvular Disorders W/O Cat/Sev CC
                                                F70A   Major Arrhythmia and Cardiac Arrest W Cat/Sev CC
                                                F70B   Major Arrhythmia and Cardiac Arrest W/O Cat/Sev CC
                                                F75A   Other Circ System Diagnoses W Cat CC
                                                F75B   Other Circ System Diagnoses W Severe CC
                                                F75C   Other Circ System Diagnoses W/O Cat/Sev CC




Overall activity – Public/private split
Other Cardiology admissions have grown by 8% over the past five years, with this growth occurring
entirely in public hospitals, as shown in Table 33.

Table 33: Public and private hospital other cardiology admissions



   Financial Year                Public Hospitals       Private Hospitals %Public Grand Total
 2001/02                                    55,974                 13,097    81%       69,071
 2002/03                                    58,169                 13,240    81%       71,409
 2003/04                                    58,824                 13,165    82%       71,989
 2004/05                                    59,871                 13,115    82%       72,986
 2005/06                                    62,007                 12,682    83%       74,689
Increase                                     6,033                    -415              5,618
% increase p.a.                               2.6%                  -0.8%                2.0%




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Admitted patient activity – Other cardiology




By CRG and DRG
Both public and private hospitals have similar patterns in terms of CRGs with chest pain admissions
growing more in the public hospitals and unstable angina declining more in the private hospitals.

Table 34: Public hospital other cardiology admissions by CRG

                                                                                                                           %Change
                                     CRG                              2001-02 2002-03 2003-04 2004-05 2005-06 Difference     p.a.
Chest Pain                                                              14,801  16,214  17,355  18,837  19,424     4,623        7.0%
Unstable Angina                                                          7,596   7,724   7,110   6,469   6,137    -1,459       -5.2%
Heart Failure and Shock                                                  8,476   8,096   8,278   8,187   8,271      -205       -0.6%
Non-Major Arrhythmia and Conduction Disorders                            7,700   7,932   7,985   8,441   8,982     1,282        3.9%
AMI W/O Invasive Cardiac Inves Pro                                       5,423   5,490   5,561   5,561   6,034       611        2.7%
Other Cardiology                                                        11,978  12,713  12,535  12,376  13,159     1,181        2.4%
Total                                                                   55,974  58,169  58,824  59,871  62,007     6,033        2.6%




Table 35: Private hospital other cardiology admissions
                                                                                                                           %Change
                                      CRG                             2001-02 2002-03 2003-04 2004-05 2005-06 Difference     p.a.
 Chest Pain                                                              2,599   2,945   3,136   3,452   3,076       477        4.3%
 Unstable Angina                                                         1,182   1,005     842     703     615      -567      -15.1%
 Heart Failure and Shock                                                 2,438   2,463   2,607   2,431   2,412       -26       -0.3%
 Non-Major Arrhythmia and Conduction Disorders                           2,638   2,576   2,575   2,780   2,813       175        1.6%
 AMI W/O Invasive Cardiac Inves Pro                                        865     881     705     613     699      -166       -5.2%
 Other Cardiology                                                        3,375   3,370   3,300   3,136   3,067      -308       -2.4%
 Total                                                                  13,097  13,240  13,165  13,115  12,682      -415       -0.8%


Activity in each CRG for public hospitals is shown in the following charts. The first shows that the
number of admissions for chest pain has increased steadily over the past five years:

                                  Chest Pain - Public Hospital
               25,000


               20,000
 Separations




               15,000


               10,000


                5,000


                   0
                        2001-02      2002-03     2003-04    2004-05      2005-06
                                                  Year




Admissions for unstable angina continue to decline:




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                       112
Admitted patient activity – Other cardiology




                                               Unstable Angina - Public Hospital
               9,000
               8,000
               7,000
               6,000
 Separations




               5,000
               4,000
               3,000
               2,000
               1,000
                             0
                                         2001-02      2002-03     2003-04    2004-05     2005-06
                                                                   Year



Admissions for heart failure and shock remain stable:

                                           Heart Failure and Shock - Public Hospital
                        9,000
                        8,000
                        7,000
                        6,000
       Separations




                        5,000
                        4,000
                        3,000
                        2,000
                        1,000
                                 0
                                          2001-02     2002-03     2003-04    2004-05    2005-06
                                                                   Year




Admissions for “Non-Major Arrhythmia and Conduction Disorders” have increased the most after chest
pain:

                                 Non Major Arrhythmia Conduction Disorders - Public
                                                      Hospital


                             10,000

                              8,000
               Separations




                              6,000

                              4,000

                              2,000

                                     0
                                            2001-02     2002-03    2003-04   2004-05    2005-06
                                                                    Year




Admissions for “AMI W/O Invasive Cardiac Inves Proc” increased by 473 in 2005-06:

                                         AMI W/O Invasive Cardiac Inves Proc - Public
                                                           Hospital
                        7,000
                        6,000
                        5,000
       Separations




                        4,000
                        3,000
                        2,000
                        1,000
                                 0
                                          2001-02     2002-03     2003-04    2004-05    2005-06
                                                                   Year




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                   113
Admitted patient activity – Other cardiology




Admissions for “Other Cardiology” have increased by 10% in public hospitals but declined by 9% in
private hospitals over the same time period:

                           Other Cardiology - Public Hospital
               14,000
               12,000
               10,000
 Separations




                8,000
                6,000
                4,000
                2,000
                   0
                        2001-02    2002-03     2003-04     2004-05     2005-06
                                                Year




Public hospital admissions by DRG are shown in Table 36. This shows the greatest increase in
admissions over the period to be in Chest Pain, with the most significant declines in Angina. It is quite
likely that these trends are caused by admissions previously defined as Angina increasingly being
defined as Chest Pain, rather than any actual change in incidence.

Table 36: Public hospital other cardiology admissions by DRG
                                                                                                                                             %Change
  DRG               DRG name                                                          2001-02 2002-03   2003-04 2004-05 2005-06 Difference     p.a.
F74Z                Chest Pain                                                           14,801  16,214   17,355  18,837  19,424     4,623        7.0%
F71B                Non-Major Arrhythmia and Conduction Disorders W/O Cat/Sev CC          6,373   6,510    6,573   6,814   7,149       776        2.9%
F62B                Heart Failure and Shock W/O Cat CC                                    6,543   6,167    6,172   5,857   5,901      -642       -2.5%
F72B                Unstable Angina W/O Cat/Sev CC                                        6,486   6,606    6,104   5,507   5,264    -1,222       -5.1%
F60B                Circ Disorders W AMI W/O Inv Cardiac Invest Proc W/O Cat/Sev CC       3,219   3,298    3,343   3,152   3,411       192        1.5%
F66B                Coronary Atherosclerosis W/O CC                                       2,762   2,996    2,878   2,497   2,624      -138       -1.3%
F62A                Heart Failure and Shock W Cat CC                                      1,933   1,929    2,106   2,330   2,370       437        5.2%
F60A                Circ Disorders W AMI W/O Inv Cardiac Invest Proc W Cat/Sev CC         1,629   1,682    1,713   1,918   2,125       496        6.9%
F63B                Venous Thrombosis W/O Cat/Sev CC                                      1,798   1,857    1,906   1,843   1,958       160        2.2%
F75C                Other Circ System Diagnoses W/O Cat/Sev CC                            1,600   1,776    1,750   1,845   1,879       279        4.1%
F71A                Non-Major Arrhythmia and Conduction Disorders W Cat/Sev CC            1,327   1,422    1,412   1,627   1,833       506        8.4%
F69B                Valvular Disorders W/O Cat/Sev CC                                     1,101   1,201    1,146   1,235   1,217       116        2.5%
F66A                Coronary Atherosclerosis W CC                                           969     899      903   1,150   1,192       223        5.3%
F72A                Unstable Angina W Cat/Sev CC                                          1,110   1,118    1,006     962     873      -237       -5.8%
F70B                Major Arrhythmia and Cardiac Arrest W/O Cat/Sev CC                      841     851      868     881     865        24        0.7%
F67B                Hypertension W/O CC                                                     776     846      737     696     720       -56       -1.9%
F75B                Other Circ System Diagnoses W Severe CC                                 412     516      563     513     697       285       14.0%
F60C                Circ Disorders W AMI W/O Inv Cardiac Invest Proc Died                   575     510      505     491     498       -77       -3.5%
F75A                Other Circ System Diagnoses W Cat CC                                    266     287      275     302     441       175       13.5%
F63A                Venous Thrombosis W Cat/Sev CC                                          348     362      359     321     336       -12       -0.9%
F70A                Major Arrhythmia and Cardiac Arrest W Cat/Sev CC                        282     317      297     294     304        22        1.9%
F67A                Hypertension W CC                                                       276     280      270     284     267        -9       -0.8%
F40Z                Circ System Diagnosis W Ventilator Support                              207     202      213     189     212         5        0.6%
F69A                Valvular Disorders W Cat/Sev CC                                         118     119      142     155     184        66       11.7%
F61Z                Infective Endocarditis                                                  155     127      154     115     174        19        2.9%
F68Z                Congenital Heart Disease                                                 67      77       74      56      89        22        7.4%
Total               Total                                                                55,974  58,169   58,824  59,871  62,007     6,033        2.6%




By hospital
E.11 The top 10 public hospitals represent 52% of Other Cardiology activity, while the top 30 public
hospitals represent 88% of Other Cardiology activity as shown in Table 37:




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                                   114
Admitted patient activity – Other cardiology




Table 37: Public hospital other cardiology admissions by hospital
                                                                                                                                %Change       % of total
                   Hospital                2001-02 2002-03 2003-04 2004-05 2005-06                                 Diff           p.a.        (2005-06)
Monash Medical Centre [Clayton]               3,620   3,642   3,623   3,678   3,776                                   156            1.1%             6%
Frankston Hospital                            3,364   3,433   3,606   3,603   3,629                                   265            1.9%             6%
Austin Hospital                               3,082   3,150   3,055   3,167   3,361                                   279            2.2%             5%
Royal Melbourne Hospital - City Campus        3,634   3,447   3,566   3,597   3,357                                  -277           -2.0%             5%
Western Hospital [Footscray]                  2,713   3,417   3,079   3,160   3,166                                   453            3.9%             5%
Dandenong Campus                              2,910   3,160   2,973   2,898   3,159                                   249            2.1%             5%
Box Hill Hospital                             2,513   2,474   3,023   2,900   3,129                                   616            5.6%             5%
Geelong Hospital                              2,500   2,584   2,728   2,814   3,024                                   524            4.9%             5%
Northern Hospital, The [Epping]               2,196   2,480   2,507   2,931   2,793                                   597            6.2%             5%
Alfred, The [Prahran]                         3,099   3,212   2,649   2,638   2,789                                  -310           -2.6%             4%
St Vincents Hospital                          2,150   2,263   2,326   2,026   2,388                                   238            2.7%             4%
Maroondah Hospital [East Ringwood]            1,903   1,971   2,166   2,249   2,353                                   450            5.4%             4%
Sunshine Hospital                             1,731   1,198   1,430   1,720   1,862                                   131            1.8%             3%
Goulburn Valley Health [Shepparton]           1,266   1,316   1,431   1,723   1,664                                   398            7.1%             3%
Bendigo Hospital, The                         1,051   1,461   1,325   1,237   1,385                                   334            7.1%             2%
Angliss Hospital                              1,158   1,209   1,292   1,182   1,334                                   176            3.6%             2%
Latrobe Regional Hospital [Traralgon]         1,188   1,410   1,248   1,239   1,220                                      32          0.7%             2%
Ballarat Health Services [Base Campus]        1,242   1,219   1,162   1,148   1,154                                     -88         -1.8%             2%
Mildura Base Hospital                           681     796     861   1,108   1,031                                   350           10.9%             2%
Rosebud Hospital                                477     576     817     890   1,020                                   543           20.9%             2%
Northeast Health Wangaratta                     818     869     975     955     962                                   144            4.1%             2%
South West Healthcare [Warrnambool]             802     819     830     938     902                                   100            3.0%             1%
Mercy Public Hospitals Inc [Werribee]           514     558     555     672     873                                   359           14.2%             1%
Sandringham & District Memorial Hospital        677     813     807     869     860                                   183            6.2%             1%
Casey Hospital                                    0       0       0     138     808                                   808                             1%
Wodonga Regional Health Service                 667     688     754     735     780                                   113             4.0%            1%
Bairnsdale Regional Health Service              531     660     569     563     567                                      36           1.7%            1%
Central Gippsland Health Service [Sale]         624     651     700     490     529                                     -95          -4.0%            1%
Wimmera Base Hospital [Horsham]                 468     508     516     474     514                                      46           2.4%            1%
West Gippsland Healthcare Group [Warragul]      516     549     517     463     448                                     -68          -3.5%            1%
Other                                         7,879   7,636   7,734   7,666   7,170                                  -709            -2.3%           12%
Total                                        55,974  58,169  58,824  59,871  62,007                                 6,033             2.6%         100%



By region of patient and hospital
Table 38 shows the region of residence of all public hospital Other Cardiology patients. It shows that
83% of patients have their service in the same region where they live. For rural patients 91% of patients
have their service in the same region where they live. Detail at CRG level is shown in Appendix O

Table 38: Public hospital other cardiology admissions by hospital
                                                                   Hospital Region
  Patient Region    Barwon_SW      Eastern_Metro   Gippsland Grampians Hume Loddon_Mallee   North_West_Metro   Southern_Metro    Total  own region   other
    Barwon-SW              5,098              22           5        34       8          8                126                6     5,307    5,098        209
   Eastern Metro              28           7,713          19         8      25        14               1,301              320     9,428    7,713      1,715
      Gippsland                6              66      3,509          5       7          2                126              166     3,887    3,509        378
     Grampians                73               9           1     2,461       5        67                 161                4     2,781    2,461        320
        Hume                   5              43           3         5   4,158        43                 324               14     4,595    4,158        437
      Interstate              40              72          23        25     239       327                 330               89     1,145
   Loddon Mallee              10              16           6        65     145     3,880                 364               11     4,497    3,880        617
 North-West Metro             60             147          20        21      37        30              16,002               93    16,410   16,002        408
   Southern Metro             21           2,523          73         9      18        19               2,298            8,996    13,957    8,996      4,961
        Total              5,341          10,611      3,659      2,633   4,642     4,390              21,032            9,699    62,007   51,817      9,045
own region                 5,098           7,713      3,509      2,461   4,158     3,880              16,002            8,996    51,817
other                        243           2,898        150        172     484       510               5,030              703    10,190




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                                              115
Appendix E                     Admitted patient activity – Cardiothoracic
                               surgery
Background
The Cardiothoracic Surgery Major Clinical Related Group (MCRG) consists of the following Clinical
Related Groups (CRGs) and Diagnosis Related Groups (DRGs):

Table 39: Cardiothoracic surgery CRGs and DRGs


            CRG                  DRG    DRG name
Coronary Bypass                  F05A   Coronary Bypass W Inv Cardiac Inves W Cat CC
                                 F05B   Coronary Bypass W Inv Cardiac Inves W/O Cat CC
                                 F06A   Coronary Bypass W/O Inv Cardiac Inves W Cat or Severe CC
                                 F06B   Coronary Bypass W/O Inv Cardiac Inves W/O Cat or Severe CC
Other Cardiothoracic Surgery     E01A   Major Chest Proc W Cat CC
                                 E01B   Major Chest Proc W/O Cat CC
                                 F03Z   Cardiac Valve Proc W CPB Pump W Inv Cardiac Invest
                                 F04A   Cardiac Valve Proc W CPB Pump W/O Inv Cardiac Invest W Cat CC
                                 F04B   Cardiac Valve Proc W CPB Pump W/O Inv Cardiac Invest W/O Cat CC
                                 F07A   Other Cardiothoracic/Vascular Proc W CPB Pump W Cat CC
                                 F07B   Other Cardiothoracic/Vascular Proc W CPB Pump W/O Cat CC
                                 F09A   Other Cardiothoracic Proc W/O CPB Pump W Cat CC
                                 F09B   Other Cardiothoracic Proc W/O CPB Pump W/O Cat CC



Overall activity – Public/private split
Cardiothoracic Surgery admissions have fallen by 7% over the past five years, with a reduction of 4% in
public hospitals and 11% in private hospitals, as shown in Table 40.

Table 40: Public and private hospital cardiothoracic surgery admissions

  Financial Year          Public Hospitals         Private Hospitals          %Public        Grand Total
 2001/02                               3,794                     3,010            56%               6,804
 2002/03                               3,727                     2,793            57%               6,520
 2003/04                               3,872                     2,771            58%               6,643
 2004/05                               3,576                     2,719            57%               6,295
 2005/06                               3,644                     2,687            58%               6,331
Increase                                 -150                      -323                               -473
% increase p.a.                        -1.0%                     -2.8%                              -1.8%


By CRG and DRG
Both public and private hospitals have shown a reduction in Coronary Bypass surgery with increases in
Other Cardiothoracic Surgery:

Table 41: Public hospital cardiothoracic surgery admissions by CRG

             CRG                2001-02 2002-03 2003-04 2004-05 2005-06 Difference            %Change p.a.
Coronary Bypass                    2,035   2,086   1,998   1,723   1,785      -250                    -3.2%
Other Cardiothoracic Surgery       1,759   1,641   1,874   1,853   1,859       100                     1.4%
Total                              3,794   3,727   3,872   3,576   3,644      -150                    -1.0%




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                              116
Admitted patient activity – Cardiothoracic surgery




Table 42: Private hospital cardiothoracic surgery admissions

             CRG                                         2001-02        2002-03        2003-04        2004-05      2005-06   Difference      %Change p.a.
Coronary Bypass                                              1,621          1,424          1,323          1,243        1,122        -499             -8.8%
Other Cardiothoracic Surgery                                 1,389          1,369          1,448          1,476        1,565         176              3.0%
Total                                                        3,010          2,793          2,771          2,719        2,687        -323             -2.8%


Activity in each CRG for public hospitals is shown in the following charts:

                                         Coronary Bypass - Public Hospital
                       2,500


                       2,000
         Separations




                       1,500


                       1,000


                        500


                          0
                                2001-02        2002-03       2003-04       2004-05          2005-06
                                                               Year




                                Other Cardiothoracic Surgery - Public Hospital

                  1,900
                  1,850
                  1,800
 Separations




                  1,750
                  1,700
                  1,650
                  1,600
                  1,550
                  1,500
                               2001-02        2002-03       2003-04        2004-05          2005-06
                                                             Year




Public hospital admissions by DRG are shown in Table 36.

Table 43: Public hospital cardiothoracic surgery admissions by DRG
  DRG                     DRG name                                                             2001-02 2002-03   2003-04 2004-05 2005-06 Difference   %Change p.a.
F06A                      Coronary Bypass W/O Inv Cardiac Inves W Cat or Severe CC                 1,317   1,371    1,319   1,173   1,279       -38           -0.7%
E01A                      Major Chest Proc W Cat CC                                                  357     342      396     430     486       129            8.0%
F04A                      Cardiac Valve Proc W CPB Pump W/O Inv Cardiac Invest W Cat CC              492     458      413     486     470       -22           -1.1%
E01B                      Major Chest Proc W/O Cat CC                                                570     495      488     496     458      -112           -5.3%
F05A                      Coronary Bypass W Inv Cardiac Inves W Cat CC                               290     311      302     308     300        10            0.9%
F09A                      Other Cardiothoracic Proc W/O CPB Pump W Cat CC                             67      94      118     114     136        69          19.6%
F06B                      Coronary Bypass W/O Inv Cardiac Inves W/O Cat or Severe CC                 281     237      203     158     123      -158         -18.7%
F04B                      Cardiac Valve Proc W CPB Pump W/O Inv Cardiac Invest W/O Cat CC             56      29      183     113      86        30          11.3%
F07A                      Other Cardiothoracic/Vascular Proc W CPB Pump W Cat CC                      34      37       58      65      85        51          25.3%
F05B                      Coronary Bypass W Inv Cardiac Inves W/O Cat CC                             147     167      174      84      83       -64         -13.3%
F03Z                      Cardiac Valve Proc W CPB Pump W Inv Cardiac Invest                          57      58      101      70      61         4            1.7%
F09B                      Other Cardiothoracic Proc W/O CPB Pump W/O Cat CC                           70      71       79      61      55       -15           -6.0%
F07B                      Other Cardiothoracic/Vascular Proc W CPB Pump W/O Cat CC                    56      57       38      18      22       -34         -20.7%
Total                     Total                                                                    3,794   3,727    3,872   3,576   3,644      -150           -1.0%




By hospital
The top 6 public hospitals represent 88% of cardiothoracic surgery activity as shown in Table 44:




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                                                      117
Admitted patient activity – Cardiothoracic surgery




Table 44: Public hospital cardiothoracic surgery admissions by hospital
                                                                                                                             % of total
                   Hospital                  2001-02 2002-03 2003-04 2004-05 2005-06           Diff          %Change p.a.    (2005-06)
Royal Melbourne Hospital - City Campus            831     858     785     777     771              -60               -1.9%          21%
Monash Medical Centre [Clayton]                   446     557     540     458     532               86                4.5%          15%
St Vincents Hospital                              598     599     602     518     509              -89               -3.9%          14%
Alfred, The [Prahran]                             651     558     588     516     501             -150               -6.3%          14%
Geelong Hospital                                  354     398     451     447     452               98                6.3%          12%
Austin Hospital                                   537     434     519     443     443              -94               -4.7%          12%
Box Hill Hospital                                  70      59     109      93     113               43              12.7%            3%
Western Hospital [Footscray]                       78      69      78      99      95               17                5.1%           3%
Peter MacCallum Cancer Institute [East Melbo        9      19      13      24      60               51              60.7%            2%
Frankston Hospital                                 44      44      42      47      50                6                3.2%           1%
Bendigo Hospital, The                              29      55      55      42      36                7                5.6%           1%
Northern Hospital, The [Epping]                    50      18      24      32      26              -24             -15.1%            1%
Ballarat Health Services [Base Campus]             16      21      15      25      25                9              11.8%            1%
Other                                              81      38      51      55      31              -50             -21.3%            1%
Total                                           3,794   3,727   3,872   3,576   3,644             -150               -1.0%        100%




By CRG and hospital
Table 45 shows that all Coronary Bypass surgery is performed by the six major cardiac units:

Table 45: Public hospital coronary bypass surgery admissions by hospital
                                                                                                                             % of total
                      Hospital                      2001-02 2002-03 2003-04 2004-05 2005-06    Diff          %Change p.a.    (2005-06)
Royal Melbourne Hospital - City Campus                   530     540     464     418     446       -84               -4.2%          25%
Monash Medical Centre [Clayton]                          283     367     341     269     303        20                1.7%          17%
Geelong Hospital                                         246     256     275     283     280        34                3.3%          16%
St Vincents Hospital                                     348     389     368     265     278       -70               -5.5%          16%
Alfred, The [Prahran]                                    401     331     342     293     275      -126               -9.0%          15%
Austin Hospital                                          226     203     208     195     203       -23               -2.6%          11%
Frankston Hospital                                         1       0       0       0       0        -1            -100.0%            0%
Total                                                  2,035   2,086   1,998   1,723   1,785      -250               -3.2%          49%


Table 46 shows that 80% of other Cardiothoracic surgery is performed by the six major cardiac units:

Table 46: Public hospital other cardiothoracic surgery admissions by hospital
                                                                                                                %Change      % of total
                        Hospital                       2001-02 2002-03 2003-04 2004-05 2005-06        Diff        p.a.       (2005-06)
Royal Melbourne Hospital - City Campus                      301     318     321     359     325           24          1.9%          18%
Austin Hospital                                             311     231     311     248     240          -71         -6.3%          13%
St Vincents Hospital                                        250     210     234     253     231          -19         -2.0%          13%
Monash Medical Centre [Clayton]                             163     190     199     189     229           66          8.9%          13%
Alfred, The [Prahran]                                       250     227     246     223     226          -24         -2.5%          13%
Geelong Hospital                                            108     142     176     164     172           64        12.3%           10%
Box Hill Hospital                                            70      59     109      93     113           43        12.7%            6%
Western Hospital [Footscray]                                 78      69      78      99      95           17          5.1%           5%
Peter MacCallum Cancer Institute [East Melbourne]             9      19      13      24      60           51        60.7%            3%
Frankston Hospital                                           43      44      42      47      50            7          3.8%           3%
Bendigo Hospital, The                                        29      55      55      42      36            7          5.6%           2%
Northern Hospital, The [Epping]                              50      18      24      32      26          -24       -15.1%            1%
Ballarat Health Services [Base Campus]                       16      21      15      25      25            9        11.8%            1%
Other                                                        81      38      51      55      31          -50       -21.3%            2%
Total                                                     1,759   1,641   1,874   1,853   1,859          100          1.4%          51%




By region of patient and hospital
Table 49 shows the region of residence of all cardiothoracic surgery patients. It shows that 49% of
patients have their service in the same region where they live. As Barwon-SW is the only rural region
where cardiothoracic surgery is performed, it is the only rural region where patients have cardiothoracic
surgery in their region of residence. Detail at CRG level is shown in Appendix O




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                          118
Admitted patient activity – Cardiothoracic surgery




Table 47: Public hospital other cardiology admissions by hospital
                                                                   Hospital Region
  Patient Region    Barwon_SW      Eastern_Metro   Gippsland Grampians Hume Loddon_Mallee   North_West_Metro   Southern_Metro   Total  own region   other
    Barwon-SW               407                1         -         -        -        -                    61             -         469       407        62
   Eastern Metro            -               188          -         -        -        -                   293                2      483       188       295
      Gippsland             -                89            5       -        -        -                   139                1      234         5       229
     Grampians                31               2         -           26     -        -                   101             -         160        26       134
        Hume                   1               5         -         -          2      -                   195             -         203         2       201
      Interstate               2               7         -         -        -           3                 76             -          88
   Loddon Mallee               2               4         -         -        -          36                157             -         199        36       163
 North-West Metro             11               3         -         -        -        -                 1,011             -       1,025    1,011         14
   Southern Metro           -               351          -         -        -        -                   377               55      783        55       728
        Total               454             650            5         26       2        39              2,410               58    3,644    1,730      1,826
own region                  407             188            5         26       2        36              1,011               55    1,730
other                         47            462          -         -        -           3              1,399                3    1,914




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Appendix F                            Admitted patient activity – Interventional
                                      cardiology
Background
The Interventional Cardiology Major Clinical Related Group (MCRG) consists of the following Clinical
Related Groups (CRGs) and Diagnosis Related Groups (DRGs):

Table 48: Interventional cardiology CRGs and DRGs

                          CRG                       DRG    DRG name
 Invasive Cardiac Inves Pro                         F41A   Circ Disorders W AMI W Inv Cardiac Invest Proc W Cat/Sev CC
                                                    F41B   Circ Disorders W AMI W Inv Cardiac Invest Proc W/O Cat/Sev CC
                                                    F42A   Circ Disorders W/O AMI W Inv Cardiac Invest Proc W Complex DX/Pr
                                                    F42B   Circ Disorders W/O AMI W Inv Cardiac Invest Proc W/O Complex DX/Pr
 Perc Coronary Angioplasty                          F10Z   Percutaneous Coronary Intervention W AMI
                                                    F16Z   Percutaneous Coronary Intervention W/O AMI W/O Stent Impl
 Perc Coronary Angioplasty W/O AMI W Stent Impl     F15Z   Percutaneous Coronary Intervention W/O AMI W Stent Impl
 Other Interventional Cardiology                    F01A   Impl or Replacement of AICD Total System W Cat/Sev CC
                                                    F01B   Impl or Replacement of AICD Total System W/O Cat/Sev CC
                                                    F02Z   AICD Component Impl/Replacement
                                                    F12Z   Cardiac Pacemaker Impl
                                                    F17Z   Cardiac Pacemaker Replacement
                                                    F18Z   Cardiac Pacemaker Revision Except Device Replacement
                                                    F19Z   Other Trans-Vascular Percutaneous Cardiac Intervention




Overall activity – Public/private split
Interventional Cardiology admissions have increased by 33% over the past five years, with an increase
of 42% in public hospitals and 26% in private hospitals, as shown in Table 49.

Table 49: Public and private hospital interventional cardiology admissions


  Financial Year                Public Hospitals              Private Hospitals %Public Grand Total
 2001/02                                   10,876                        13,060    45%       23,936
 2002/03                                   12,137                        15,222    44%       27,359
 2003/04                                   12,994                        16,073    45%       29,067
 2004/05                                   14,279                        16,350    47%       30,629
 2005/06                                   15,442                        16,483    48%       31,925
Increase                                    4,566                         3,423               7,989
% increase p.a.                              9.2%                          6.0%                7.5%


By CRG and DRG
All CRGs within Interventional Cardiology have increased significantly over the past four years:

Table 50: Public hospital interventional cardiology admissions by CRG

                                                                                                                                % Change
                 CRG                              2001-02 2002-03 2003-04 2004-05 2005-06 Difference                               p.a.
Inv Cardiac Inves Pro                                5,681   6,211   6,686   7,475   8,441     2,760                                 10.4%
PCI                                                  1,211   1,606   1,868   2,051   2,366     1,155                                 18.2%
PCI W/O AMI W Stent Implantation                     2,121   2,210   2,351   2,530   2,325       204                                  2.3%
Other Intervent Cardiology                           1,863   2,110   2,089   2,223   2,310       447                                  5.5%
Total                                               10,876  12,137  12,994  14,279  15,442     4,566                                  9.2%




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Admitted patient activity – Interventional cardiology




Table 51: Private hospital interventional cardiology admissions

                                                                                                                           % Change
                 CRG                                                  2001-02 2002-03 2003-04 2004-05 2005-06 Difference      p.a.
Inv Cardiac Inves Pro                                                    7,842   8,996   9,476   9,842   9,573     1,731         5.1%
PCI                                                                        825     961     942   1,031   1,206       381        10.0%
PCI W/O AMI W Stent Implantation                                         2,584   3,126   3,398   3,169   3,209       625         5.6%
Other Intervent Cardiology                                               1,809   2,139   2,257   2,308   2,495       686         8.4%
Total                                                                   13,060  15,222  16,073  16,350  16,483     3,423         6.0%


Invasive cardiac investigative procedures have increased by 49% over the last four years:

                                               Inv Cardiac Inves Pro - Public Hospital

                           9,000
                           8,000
                           7,000
                           6,000
             Separations




                           5,000
                           4,000
                           3,000
                           2,000
                           1,000
                                 0
                                      2001-02          2002-03      2003-04      2004-05    2005-06
                                                                      Year




Percutaneous Coronary Angioplasty has increased by 95% over the last five years:

                                                       PCI - Public Hospital

                    2,500

                    2,000
   Separations




                    1,500

                    1,000

                           500

                             0
                                     2001-02         2002-03       2003-04      2004-05    2005-06
                                                                    Year




Percutaneous Coronary Angioplasty without AMI with Stent implantation has generally increased with a
dip of 206 admissions in 2005-06:

                                     PCI W/O AMI W Stent Implantation - Public Hospital

                    3,000

                    2,500
   Separations




                    2,000

                    1,500

                    1,000

                           500

                             0
                                     2001-02         2002-03       2003-04      2004-05    2005-06
                                                                    Year




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Admitted patient activity – Interventional cardiology




Other Interventional Cardiology has increased by 24% over the last four years:

Public hospital admissions by DRG are shown in Table 52. This shows the greatest increase in
admissions over the period to be in PCI and Circ Disorders W/O AMI W Inv Cardiac Invest Proc W/O
Complex DX/Pr.

Table 52: Public hospital interventional cardiology admissions by DRG
                                                                                                                                    % Change
  DRG   DRG name                                                             2001-02 2002-03   2003-04 2004-05 2005-06 Difference      p.a.
F42B    Circ Disorders W/O AMI W Inv Cardiac Invest Proc W/O Complex DX/Pr       2,620   2,918    3,026   3,529   4,332     1,712        13.4%
F15Z    Percutaneous Coronary Intervention W/O AMI W Stent Impl                  2,121   2,210    2,351   2,530   2,325       204         2.3%
F10Z    Percutaneous Coronary Intervention W AMI                                 1,045   1,414    1,741   1,971   2,278     1,233        21.5%
F42A    Circ Disorders W/O AMI W Inv Cardiac Invest Proc W Complex DX/Pr         1,886   1,933    2,236   2,300   2,278       392         4.8%
F12Z    Cardiac Pacemaker Impl                                                   1,213   1,317    1,375   1,361   1,330       117         2.3%
F41B    Circ Disorders W AMI W Inv Cardiac Invest Proc W/O Cat/Sev CC              654     802      797     940     964       310        10.2%
F41A    Circ Disorders W AMI W Inv Cardiac Invest Proc W Cat/Sev CC                521     558      627     706     867       346        13.6%
F17Z    Cardiac Pacemaker Replacement                                              367     470      379     404     470       103         6.4%
F01A    Impl or Replacement of AICD Total System W Cat/Sev CC                       61      66       73     169     200       139        34.7%
F01B    Impl or Replacement of AICD Total System W/O Cat/Sev CC                     80      95      124     141     159        79        18.6%
F16Z    Percutaneous Coronary Intervention W/O AMI W/O Stent Impl                  166     192      127      80      88       -78       -14.7%
F18Z    Cardiac Pacemaker Revision Except Device Replacement                        65      84       88      83      79        14         5.0%
F19Z    Other Trans-Vascular Percutaneous Cardiac Intervention                      69      69       42      54      59       -10        -3.8%
F02Z    AICD Component Impl/Replacement                                              8       9        8      11      13         5        12.9%
Total   Total                                                                   10,876  12,137   12,994  14,279  15,442     4,566         9.2%




By Hospital

The top 10 public hospitals represent 91% of Other Cardiology activity as shown in Table 53:

Table 53: Public hospital interventional cardiology admissions by hospital
                                                                                                                     % Change     % of total
                   Hospital                       2001-02 2002-03 2003-04 2004-05 2005-06                 Diff          p.a.      (2005-06)
Royal Melbourne Hospital - City Campus               2,298   2,296   2,186   2,269   2,129                  -169          -1.9%          14%
Western Hospital [Footscray]                           682     803   1,041   1,364   1,810                 1,128          27.6%          12%
St Vincents Hospital                                 1,492   1,590   1,584   1,595   1,662                   170           2.7%          11%
Austin Hospital                                      1,324   1,464   1,476   1,563   1,427                   103           1.9%           9%
Geelong Hospital                                       871   1,099   1,374   1,411   1,410                   539          12.8%           9%
Monash Medical Centre [Clayton]                      1,000   1,150   1,219   1,346   1,388                   388           8.5%           9%
Alfred, The [Prahran]                                1,560   1,631   1,466   1,351   1,331                  -229          -3.9%           9%
Box Hill Hospital                                      502     799   1,029   1,182   1,185                   683          24.0%           8%
Northern Hospital, The [Epping]                          1       1       1     176     873                   872         443.6%           6%
Bendigo Hospital, The                                  289     239     300     535     817                   528          29.7%           5%
Frankston Hospital                                     458     605     683     771     760                   302          13.5%           5%
Ballarat Health Services [Base Campus]                  42     160     344     400     416                   374          77.4%           3%
Dandenong Campus                                       178     130     128     176     134                     -44        -6.9%           1%
Other                                                  179     170     163     140     100                     -79       -13.5%           1%
Total                                               10,876  12,137  12,994  14,279  15,442                 4,566           9.2%         100%


Table 53 shows that there has been a slight drop at Royal Melbourne and the Alfred, with significant
increases at Western, Box Hill and Northern.


By region of patient and hospital
Table 54 shows the region of residence of all Interventional Cardiology patients. It shows that 63% of
patients have their service in the same region where they live. 47% of rural patients have their service in
the region in which they live. Detail at CRG level is shown in Appendix O.




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Admitted patient activity – Interventional cardiology




Table 54: Public hospital interventional cardiology admissions by hospital
                                                                   Hospital Region
  Patient Region    Barwon_SW      Eastern_Metro   Gippsland Grampians Hume Loddon_Mallee   North_West_Metro   Southern_Metro    Total  own region   other
    Barwon-SW              1,301               9         -           39     -           1                149             -        1,499    1,301        198
   Eastern Metro               3           1,217         -         -        -        -                   575               10     1,805    1,217        588
      Gippsland                2             272           2       -        -        -                   399               37       712         2       710
     Grampians                74              15         -        357       -           7                292                1       746       357       389
        Hume                   1              21         -         -          2        11                793                1       829         2       827
      Interstate               8              36         -            2       1        60                361                9       477
   Loddon Mallee               6              20         -           37     -       765                  589             -        1,417       765       652
 North-West Metro             48              70         -            1     -           1              5,214                4     5,338    5,214        124
   Southern Metro              5             915         -            1     -        -                   866             832      2,619       832     1,787
        Total              1,448           2,575           2      437         3     845                9,238             894     15,442    9,690      5,275
own region                 1,301           1,217           2      357         2     765                5,214             832      9,690
other                        147           1,358         -           80       1        80              4,024               62     5,752




Percutaneous coronary intervention usage
Percutaneous Coronary Interventions (PCIs) are becoming an increasingly common intervention.
Currently these are performed at nine public metropolitan hospitals, as well as a number of private
hospitals, as shown in Table 55:

Table 55: Number of PCI admissions by hospital

                                                                                                                                                 %
                                                                                                                                               Change
                  Hospital                                  2001-02 2002-03 2003-04 2004-05 2005-06                                Diff         p.a.
Private                                                        3,409   4,087   4,340   4,200   4,415                                1,006         6.7%
St Vincents Hospital                                             736     652     720     729     814                                    78        2.6%
Monash Medical Centre [Clayton]                                  436     450     574     667     700                                  264        12.6%
Austin Hospital                                                  528     634     617     698     645                                  117         5.1%
Western Hospital [Footscray]                                     232     321     447     568     623                                  391        28.0%
Box Hill Hospital                                                 12     293     441     486     496                                  484       153.6%
Royal Melbourne Hospital - City Campus                           430     475     447     494     427                                    -3       -0.2%
Alfred, The [Prahran]                                            610     538     457     427     417                                 -193        -9.1%
Frankston Hospital                                               126     213     275     297     299                                  173        24.1%
Geelong Hospital                                                 221     237     235     211     263                                    42        4.4%
Other public                                                       1       3       6       4       7                                     6       62.7%
Total                                                          6,741   7,903   8,559   8,781   9,106                                2,365         7.8%


The number of PCIs has been increasing significantly over recent years. The number performed by
region of residence of patient is shown in Table 56. Table 56 excludes interstate patients (of whom there
were 314 in 2005/06).

Table 56: Number of PCI admissions by region

                                                                                                                                               %
                                                                                                                                             Change
        Region                           2001-02 2002-03 2003-04 2004-05 2005-06                                                Diff          p.a.
North-West Metro                            1,848   2,253   2,321   2,420   2,546                                                  698          8.3%
Southern Metro                              1,553   1,759   2,007   2,083   2,134                                                  581          8.3%
Eastern Metro                               1,437   1,684   1,776   1,717   1,758                                                  321          5.2%
Loddon Mallee                                 438     479     577     642     713                                                  275         13.0%
Barwon-SW                                     332     426     417     417     463                                                  131          8.7%
Hume                                          339     392     427     451     431                                                    92         6.2%
Gippsland                                     319     403     433     426     404                                                    85         6.1%
Grampians                                     268     276     343     365     343                                                    75         6.4%
Total                                       6,534   7,672   8,301   8,521   8,792                                                2,258          7.7%

Table 56 shows that a relatively significant number of PCIS are performed for rural patients, with 2,354
performed in 2005/06. Rural admissions by hospital are shown in Table 57.




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Admitted patient activity – Interventional cardiology




Table 57: Number of rural PCI admissions by hospital

                                                                                                                                            % Change
                         Hospital                         2001-02 2002-03 2003-04 2004-05 2005-06                                 Diff         p.a.
Private                                                        794     967   1,033   1,077   1,059                                   265         7.5%
St Vincents Hospital                                           303     299     386     429     482                                   179        12.3%
Geelong Hospital                                               206     214     224     199     245                                     39        4.4%
Royal Melbourne Hospital - City Campus                         143     154     155     187     166                                     23        3.8%
Monash Medical Centre [Clayton]                                 80      88     106      98     107                                     27        7.5%
Alfred, The [Prahran]                                           92      99      93      79     105                                     13        3.4%
Austin Hospital                                                 68     101     137     132      91                                     23        7.6%
Western Hospital [Footscray]                                     8      12      23      26      41                                     33       50.5%
Box Hill Hospital                                                1      31      32      52      39                                     38     149.9%
Frankston Hospital                                               1      11       8      20      14                                     13       93.4%
Bendigo Hospital, The                                            0       0       0       2       3                                      3
Ballarat Health Services [Base Campus]                           0       0       0       0       1                                      1
Latrobe Regional Hospital [Traralgon]                            0       0       0       0       1                                      1
Total                                                        1,696   1,976   2,197   2,301   2,354                                   658        8.5%


The proportion of PCIs which result from emergency admissions where the patient has transferred from
another hospital is higher for rural patients than for metro patients as shown in Table 58:

Table 58: Total PCI admissions by admission type
                                                                                                                                    %     % of 2005-
                                                                                                                                  Change   06 sub
                    Admission type                   2001-02 2002-03 2003-04 2004-05 2005-06                         Diff          p.a.     total
Metro      Emergency - Same Hospital                        0       0   1,395   1,544   1,662                         1,662                    26%
           Other admission                              3,442   3,848   2,782   2,738   2,953                          -489         -3.8%      46%
           Other emergency admission                    1,396   1,848     828     697     682                          -714        -16.4%      11%
           Planned Admission from Waiting List              0       0   1,099   1,241   1,141                         1,141                    18%
Metro sub total                                         4,838   5,696   6,104   6,220   6,438                         1,600          7.4%     100%
Rural      Emergency - Same Hospital                        0       0     173     183     242                           242                    10%
           Other admission                              1,370   1,486   1,189   1,299   1,302                             -68       -1.3%      55%
           Other emergency admission                      326     490     457     455     489                           163         10.7%      21%
           Planned Admission from Waiting List              0       0     378     364     321                           321                    14%
Rural sub total                                         1,696   1,976   2,197   2,301   2,354                           658          8.5%     100%
Total                                                   6,534   7,672   8,301   8,521   8,792                         2,258          7.7%


26% of PCIs for metro patients in 2005/06 were for patients admitted from emergency within the same
hospital, while only 10% of PCIs for rural patients in 2005/06 were for patients admitted from emergency
within the same hospital.

Hospital Catchment Areas

Table 59 shows the split of public hospital PCI admissions by hospital. The table shows that the majority
of services performed by Box Hill, Frankston, MMC Clayton and Western Hospitals relate to metro
patients, while Royal Melbourne and St Vincents provide services to a much larger number of rural
patients.

Table 59: Public hospital PCI admissions by hospital
 Region of patient residence   Alfred     Austin     Box Hill    Frankston       Geelong MMC Clayton   RMH         St Vincent’s     Western Grand Tota
Barwon-SW                             2          4           2                         225         1           2             39             1     276
Eastern Metro                        49         56         391                           1      132           14             22             2     667
Gippsland                            42          3          19           13              1      102            2             66             4     252
Grampians                            31          8           5                          17         1          18             77            21     178
Hume                                  7         24           7               1                     2         104             85             6     236
Loddon Mallee                        23         52           6                           2         1          40           215              9     348
North-West Metro                     42        483          31            3             13         4         228           195            575   1,574
Southern Metro                      213          6          29          279              1      449           13             20             2   1,012
Grand Total                         409        636         490          296            260      692          421           719            620   4,543



The proportion of public hospital PCI admissions for each region occurring at each hospital are shown in
Table 54:




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Admitted patient activity – Interventional cardiology




Table 60: Proportion of region’s public hospital PCI admissions by hospital

The following maps show the PCI separations for Royal Melbourne and St Vincents hospitals by SLA.
Maps for other hospitals are shown in Appendix I.


   RMH PC Angioplasty seps
             2005-06                                              Moira (S) West
                                                                  Moira (S) -- West


             21 to 26 (5)                                                                   Moira (S) East
                                                                                            Moira (S) -- East

             16 to 21 (2)
             11 to 16 (3)                 Campaspe (S) Kyabram
                                          Campaspe (S) -- Kyabram

              6 to 11 (13)
                                                                                                       Wangaratta (RC) Central
                                                                                                       Wangaratta (RC) -- Central
              1 to 6 (67)                                      Gr. Shepparton (C) Pt A
                                                               Gr. Shepparton (C) -- Pt A




                                                                                                                             Alpine (S) West
                                                                                                                             Alpine (S) -- West

                                                                     Strathbogie (S)
                                                                     Strathbogie (S)




                                Macedon Ranges (S) Romsey
                                Macedon Ranges (S) -- Romsey




                                                                                                         0         20        40

                                                       Royal Melbourne Hospital
                                                       Royal Melbourne Hospital                                 kilometers




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Admitted patient activity – Interventional cardiology




                     Gannawarra (S)
                     Gannawarra (S)



                                                         Moira (S) West
                                                         Moira (S) -- West
                                                                                           Wodonga (RC)
                                                                                           Wodonga (RC)


                                                     Gr. Shepparton (C) - Pt A
                                                     Gr. Shepparton (C) - Pt A

                    Loddon (S) South
                    Loddon (S) -- South



                                    Gr. Bendigo (C) Pt B
                                    Gr. Bendigo (C) -- Pt B




                                                                                  Wellington (S) Maffra
                                                                                  Wellington (S) -- Maffra
                     Ballarat (C) South
                     Ballarat (C) -- South
                                                       St Vincents Hospital
                                                       St Vincents Hospital
                                      Wyndham (C) North
                                      Wyndham (C) -- North

                                                                Baw Baw (S) Pt B West
                                                                Baw Baw (S) -- Pt B West                          St Vincent's Hospital PC Angioplasty seps
  Warrnambool (C)
  Warrnambool (C)                                                                    Wellington (S) Rosedale
                                                                                     Wellington (S) -- Rosedale                   2005-06
                                                                                                                              0
                                                                                                                                  25 to50
                                                                                                                                        33       100
                                                                                                                                               (4)
                                                                                                                                  19kilometers (4)
                                                                                                                                     to 25
                                                                                                                                  13 to 19     (4)
                                                                                                                                   7 to 13 (21)
                                                                                                                                   1 to 7 (114)




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                                       126
Appendix G                Utilisation
Background
Utilisation is the number of admissions divided by the population. The State utilisation rate is 21
admissions per 1000 population. The metropolitan utilisation is 19 admissions per 1000 population and
rural is 27 per 1000 population. In general rural regions have higher utilisation for cardiac services at
public hospitals. If we include private hospital separations the rural regions still have higher utilisation
than metropolitan regions. This is opposite for other hospitalisations such as renal dialysis and
chemotherapy.


Public hospital utilisation
Table 61 shows the public hospital utilisation by region. The relative utilisation is shown both unadjusted
and adjusted for differences in age and sex:

Table 61: Public hospital utilisation by region



                                          Seps per 1000                  Relative     Age-sex adjusted relative
        Region           Separations          pop       Expected Seps   utilisation          utilisation
Hume                              5,627            29.3         4,018            1.40                     1.23
Barwon-SW                         7,275            27.7         5,500            1.32                     1.22
Loddon Mallee                     6,113            27.4         4,666            1.31                     1.16
Gippsland                         4,833            26.4         3,829            1.26                     1.09
Grampians                         3,687            23.5         3,290            1.12                     1.03
North-West Metro                22,773             20.2       23,560             0.97                     0.94
Southern Metro                  17,359             19.2       18,975             0.91                     0.89
Eastern Metro                   11,716             15.8       15,544             0.75                     0.73
Total                           79,383             20.9       79,383
Rural Total                     27,535             27.1       21,304           1.29                       1.12
Metro Total                     51,848             18.7       58,079           0.89                       0.96
Victorian Total                 79,383             20.9       79,383

Raw utilisation is significantly higher for rural Victoria than for metro Victoria. After adjusting for age and
sex, utilisation is higher for rural Victoria than for metro Victoria although to a lesser extent. This results
from a higher proportion of the rural population being older (and therefore having a higher expected level
of utilisation of cardiology services). This is shown in the following chart:




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                  127
Utilisation




                                                  Age Distribution for Metro and Rural Victoria

                              12%


                              10%
   Proportion of population




                              8%


                              6%


                              4%


                              2%


                              0%
                                    20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84      85+
                                                                         Age Group

                                                                        Metro        Rural



Of the metro population aged 20 and over, 51% is aged 44 and below, while only 42% of the rural
population aged 20 and over is aged 44 and below.


Private hospital utilisation
Table 62 shows the public hospital utilisation by region. The relative utilisation is shown both unadjusted
and adjusted for differences in age and sex:

Table 62: Private hospital utilisation by region



                                                                      Seps per 1000                     Relative             Age-sex adjusted
        Region                                       Separations          pop        Expected Seps     utilisation           relative utilisation
Eastern Metro                                                 7,742            10.4          6,072              1.27                            1.23
Southern Metro                                                9,127            10.1          7,413              1.23                            1.15
Grampians                                                     1,451              9.2         1,285              1.13                            1.00
Hume                                                          1,741              9.1         1,570              1.11                            0.98
Loddon Mallee                                                 1,885              8.5         1,823              1.03                            0.88
Barwon-SW                                                     1,857              7.1         2,149              0.86                            0.87
North-West Metro                                              6,416             5.7          9,204              0.70                            0.87
Gippsland                                                       792              4.3         1,496              0.53                            0.41
Total                                                       31,011               8.2       31,011
Metro Total                                                 23,285               8.4       22,689             1.03                            1.06
Rural Total                                                   7,726              7.6         8,322            0.93                            0.83
Victorian Total                                             31,011               8.2       31,011

Metro utilisation of private hospitals is higher than rural utilisation, with the difference being even greater
after adjusting for differences in age and sex. Age-sex adjusted private hospital usage by Gippsland
residents is particularly low.


Combined utilisation
Table 63 shows the public hospital utilisation by region. The relative utilisation is shown both unadjusted
and adjusted for differences in age and sex:




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Utilisation




Table 63: Combined utilisation by region



                                          Seps per 1000                  Relative       Age-sex adjusted
         Region          Separations          pop       Expected Seps   utilisation     relative utilisation
Hume                              7,368            38.4         5,588            1.32                      1.15
Loddon Mallee                     7,998            35.9         6,489            1.23                      1.13
Barwon-SW                         9,132            34.8         7,649            1.19                      1.08
Grampians                         5,138            32.7         4,575            1.12                      1.03
Gippsland                         5,625            30.8         5,325            1.06                      0.96
Southern Metro                  26,486             29.2       26,388             1.00                      0.95
Eastern Metro                   19,458             26.2       21,616             0.90                      0.87
North-West Metro                29,189             25.9       32,764             0.89                      0.85
Total                          110,394             29.1      110,394
Rural Total                     35,261             34.7       29,626           1.19                      1.03
Metro Total                     75,133             27.1       80,768           0.93                      0.99
Victorian Total               110,394              29.1      110,394

Including both public and private hospital admissions, raw utilisation is higher for rural Victoria than for
metro Victoria. After adjusting for age and sex the utilisation is quite similar.


Utilisation by statistical local area
The highest utilisation in the Victoria occurred in Corangamite (S) - North at 57 admissions per 1000
population (Figure 7 and Table 43). The top 10 public hospital utilisation rates belong to rural SLA. The
lowest utilisation was Melbourne (C) - S'bank-D'lands with 3.5 admissions per 1000 population.




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Utilisation




Figure 6: Public hospital cardiac utilisation by statistical local area 2005-06


                                                                                                     Cardiac public hospital utilisation
                                                                                                                         2005-06
                                                                                                                        46 to 57           (6)
                                                                                                                        35 to 46          (22)
                                                                                                                        25 to 35          (45)
                                                                                                                        14 to 25          (91)
                                                                                                                         3.4 to 14        (32)




           Hindmarsh (S)
           Hindmarsh (S)

                                                                                                   Towong (S) Pt A
                                                                                                   Towong (S) -- Pt A


                                                                         Delatite (S) Benalla
                                                                         Delatite (S) -- Benalla




                                        C. Goldfields (S) M'borough
                                        C. Goldfields (S) -- M'borough




    S. Grampians (S) Wannon
    S. Grampians (S) -- Wannon




                                 Corangamite (S) North
                                 Corangamite (S) -- North




                                                                                                                          0          50          100

                                                                                                                               kilometers




Adjusting the separations by the SLA age sex profile highlights differences to the State age-sex profile.
That is for example, if an SLA has many older people, then we would expect more admissions to
hospital. If we age sex adjusted this activity then it would decrease the number of admissions and
utilisation rate.

In general, rural SLAs with high utilisation decrease after age sex adjusting. Rural SLA with initially low
utilisation, increase after age-sex adjusting (Table 22 to Table 25). With metropolitan SLA many have
increased utilisation after age-sex adjusting. This change in utilisation reflects a different age-sex
structure than the State.




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Utilisation




Figure 7: Public hospital cardiac age sex adjusted utilisation by statistical local area 2005-06


                                                                                             Cardiac public hospital age-sex adjusted utilisation
                                                                                                                         2005-06

                                                                                                                     46 to 48.1   (1)
                                                                                                                     35 to 46    (11)
                                                                                                                     25 to 35    (56)
                                                                                                                     14 to 25   (100)
                                                                                                                      5.1 to 14  (28)




                                                                                                              Towong (S) Pt A
                                                                                                              Towong (S) -- Pt A




                                                                  Melton (S) East
                                                                  Melton (S) -- East

                            Moyne (S) North-East
                           Moyne (S) -- North-East
                                    Corangamite (S) North
                                    Corangamite (S) -- North
              Moyne (S) North-West
              Moyne (S) -- North-West




                                                                                                                                   0        50      100

                                                                                                                                       kilometers




Table 64: Cardiac utilisation by top 20 rural statistical local areas 2005-06
                                                                Age-sex adjusted                                       Age-sex adjusted
              SLA                           Separations           separations              Difference Utilisation         Utilisation       Difference
Corangamite (S) - North                              400                               293         107          57                     42           15
Hindmarsh (S)                                        238                               153          85          50                     32           18
Towong (S) - Pt A                                     87                                62          25          48                     34           14

S. Grampians (S) - Wannon                                  82                           55          27          47                     32           16
Benalla (RC) - Benalla                                    326                          228          98          47                     33           14

C. Goldfields (S) - M'borough                             280                          178         102          47                     30           17
Moyne (S) - North-East                                     78                           63          15          46                     37            9
Gannawarra (S)                                            386                          317          69          46                     37            8
Loddon (S) - South                                        171                          120          51          45                     31           13
Wangaratta (RC) - Central                                 525                          436          89          43                     35            7
Campaspe (S) - South                                      117                          105          12          42                     38            4
Colac-Otway (S) - Colac                                   313                          246          67          41                     32            9

West Wimmera (S)                                          138                          102          36          40                     30           11
Campaspe (S) - Kyabram                                    358                          317          41          39                     35            4
Ararat (RC)                                               345                          277          68          39                     31            8
S. Grampians (S) - Hamilton                               267                          201          66          39                     29           10
Yarriambiack (S) - North                                   58                           42          16          38                     28           11
Yarriambiack (S) - South                                  160                          115          45          38                     27           11
Moyne (S) - North-West                                     68                           61           7          36                     32            4




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Utilisation




Table 65: Cardiac utilisation by bottom 20 rural statistical local areas 2005-06

                 SLA             Separations sex adjusted separat Difference Utilisation -sex adjusted Utilisa Difference
Ballarat (C) - Inner North                349                358           -9          17                  18            0
Murrindindi (S) - West                     93                101           -8          16                  18           -1
Golden Plains (S) - South-East             96                113          -17          16                  19           -3
Gr. Bendigo (C) - S'saye                   67                 81          -14          16                  19           -3
Bass Coast (S) - Phillip Is.              103                 77           26          15                  11            4
Baw Baw (S) - Pt B East                    44                 42            2          15                  14            1
Greater Geelong (C) - Pt C                 31                635         -604          15                303          -288
Wellington (S) - Avon                      42                 42            0          15                  15            0
Moorabool (S) - Ballan                     64                 66           -2          14                  15            0
Golden Plains (S) - North-West             78                 89          -11          14                  16           -2
E. Gippsland (S) - South-West              36                 35            1          14                  14            0
Gr. Bendigo (C) - Inner North              88                 95           -7          14                  15           -1
Macedon Ranges (S) - Romsey               107                133          -26          14                  17           -3
Ballarat (C) - North                       10                  8            2          12                  10            3
Colac-Otway (S) - North                    55                 60           -5          11                  12           -1
Horsham (RC) Bal                           41                 41            0          11                  11            0
Macedon Ranges (S) Bal                    161                191          -30          11                  13           -2
Moorabool (S) - West                       27                 22            5          10                    8           2
La Trobe (C) Bal                           16                 16            0           9                    9           0
Indigo (S) - Pt B                          18                 13            5           7                    5           2


Table 66: Cardiac utilisation by top 20 metropolitan statistical local areas 2005-06

               SLA               Separations sex adjusted separat Difference Utilisation -sex adjusted Utilisa Difference
Brimbank (C) - Sunshine                 2,465              2,478          -13          41                  41            0
Mornington P'sula (S) - South          1,460                 958          502          37                  25          13
Hobsons Bay (C) - Altona                1,106              1,053           53          27                  26            1
Frankston (C) - West                    1,597              1,402          195          27                  24            3
Hume (C) - Broadmeadows                1,234               1,465         -231          27                  32           -5
Darebin (C) - Preston                  1,712               1,518          194          27                  24            3
Wyndham (C) - North                     1,391              1,732         -341          24                  30           -6
Whittlesea (C) - South                  1,796              2,209         -413          24                  29           -5
Moreland (C) - North                      869                735          134          24                  20            4
Melton (S) Bal                            637                762         -125          23                  27           -5

Hobsons Bay (C) - Williamstown            524                 536          -12         23                  23          -1
Moreland (C) - Coburg                     847                 769           78         22                  20           2
Gr. Dandenong (C) Bal                   1,169               1,134           35         22                  22           1
Frankston (C) - East                      627                 903         -276         22                  32         -10

Gr. Dandenong (C) - Dandenong             942                 903           39         22                  21            1
Banyule (C) - North                       915                 922           -7         22                  22            0
Maribyrnong (C)                         1,078               1,150          -72         22                  23           -1
Mornington P'sula (S) - East              581                 657          -76         22                  24           -3
Yarra Ranges (S) - North                  199                 185           14         21                  20            1
Whitehorse (C) - Box Hill                 847                 754           93         21                  19            2




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Utilisation




Table 67: Cardiac utilisation by bottom 20 metropolitan statistical local area 2005-06

                 SLA             Separations sex adjusted separat Difference Utilisation -sex adjusted Utilisa Difference
Port Phillip (C) - West                   399                434          -35          13                  14           -1
Stonnington (C) - Prahran                 526                541          -15          13                  13            0
Yarra (C) - North                         466                571         -105          12                  15           -3
Wyndham (C) - South                       118                269         -151          12                  26          -15
Port Phillip (C) - St Kilda               500                613         -113          11                  14           -3
Boroondara (C) - Camberwell S.            424                409           15          11                  11            0
Nillumbik (S) Bal                          74                 94          -20          11                  14           -3
Yarra (C) - Richmond                      236                315          -79          11                  15           -4
Nillumbik (S) - South                     209                285          -76          11                  14           -4
Monash (C) - Waverley West                508                434           74          10                    9           2
Knox (C) - South                          281                463         -182          10                  17           -7
Stonnington (C) - Malvern                 346                348           -2          10                  10            0
Nillumbik (S) - South-West                154                262         -108          10                  17           -7
Melbourne (C) - Remainder                 348                508         -160           9                  14           -4
Wyndham (C) - West                        123                187          -64           9                  14           -5
Manningham (C) - East                      96                114          -18           9                  10           -2
Boroondara (C) - Camberwell N.            265                231           34           8                    7           1
Boroondara (C) - Kew                      190                172           18           8                    7           1
Boroondara (C) - Hawthorn                 172                189          -17           6                    7          -1
Melbourne (C) - S'bank-D'lands             32                 58          -26           3                    6          -3




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                             133
Appendix H                                  Sameday/non sameday and average length of
                                            stay trends
Other cardiology
Table 68 shows the proportion of Other Cardiology admissions which were Sameday admissions. This
proportion has been increasing since 2001/02 for public hospitals, while it has been reducing for private
hospitals.

Table 68: Other cardiology sameday proportion

                                                                         Year                                       % Change
  Hospital Type                                  2001_02       2002_03   2003_04 2004_05     2005_06       Diff        p.a.
Public                           Sameday            17,623        19,579   19,754 20,656        22,250      4,627         6.0%
                                 Multiday           38,351        38,590   39,070 39,215        39,757      1,406         0.9%
                                 % Sameday             31%           34%      34%    35%           36%
Private                          Sameday             2,987         2,900    3,033  3,240         2,492 -     495        -4.4%
                                 Multiday           10,110        10,340   10,132  9,875        10,190        80         0.2%
                                 % Sameday             23%           22%      23%    25%           20%


This is also shown in the following chart:

                                           Cardiology Sameday Seps
             40%
             35%
             30%
 % of total seps




             25%
             20%
             15%
             10%
                   5%
                   0%
                           2001_02        2002_03        2003_04        2004_05    2005_06
                                                           Year
                                                     Public          Private


Table 69 shows the total bed days, average length of stay (excluding hospital in the home (HITH) days)
and total separations split between “Complex” and “Non-Complex” for multi-day admissions. “Complex”
separations, as defined by Hart and Deanvi are those where the diagnosis codes on the admission
record include 3 or more diseases. Complexity is a high level indicator of whether patients are becoming
more or less “serious” over time. It is worth noting that complexity also depends on consistent coding of
diseases.




         vi
                   “How Complex was that patient”, Michael Hart and David Dean




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                 134
Sameday/non sameday and average length of stay trends




Table 69: Other cardiology average length of stay and complexity

                                                        Year                                                  % Change
Hospital Type                         2001_02 2002_03 2003_04 2004_05 2005_06    Diff                            p.a.
Public        Complex Seps              11,697  11,880  12,369  12,894  13,574    1,877                             3.8%
              Non-complex Seps          26,654  26,710  26,701  26,321  26,183 -    471                            -0.4%
              Total Seps                38,351  38,590  39,070  39,215  39,757    1,406                             0.9%
              Total Bed Days           158,845 152,359 151,938 150,218 145,770 - 13,075                            -2.1%
              ALOS                        4.14    3.95    3.89    3.83    3.67 -   0.48                            -3.0%
              %Complex Separations         30%     31%     32%     33%     34%
Private       Complex Seps               2,829   2,884   2,999   2,902   3,118      289                            2.5%
              Non-complex Seps           7,281   7,456   7,133   6,973   7,072 -    209                           -0.7%
              Total Seps                10,110  10,340  10,132   9,875  10,190        80                           0.2%
              Total Bed Days            55,913  57,494  56,881  52,980  54,155 -  1,758                           -0.8%
              ALOS                        5.53    5.56    5.61    5.37    5.31 -   0.22                           -1.0%
              %Complex Separations         28%     28%     30%     29%     31%


Table 69 shows that the average length of stay for public hospitals has been reducing while the
complexity has been slightly increasing. This is also shown in the following chart:

                  Cardiology Multiday ALOS and % complex bed days

         6                                                                       35%
                                                                                 34%
         5
                                                                                 33%




                                                                                       %complex separations
                                                                                 32%
         4
                                                                                 31%
  ALOS




         3                                                                       30%
                                                                                 29%
         2
                                                                                 28%
                                                                                 27%
         1
                                                                                 26%
         0                                                                       25%
              1             2              3             4                5
                                               Year
                                Public ALOS                  Private ALOS
                                Public % Complex             Private % Complex



Cardiothoracic surgery
Table 70 shows the total bed days, average length of stay (excluding hospital in the home (HITH) days)
and total separations split between “Complex” and “Non-Complex” for multi-day admissions.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                           135
Sameday/non sameday and average length of stay trends




Table 70: Cardiothoracic surgery average length of stay and complexity

                                                     Year                                                           % Change
Hospital Type                      2001_02 2002_03 2003_04 2004_05 2005_06                                  Diff       p.a.
Public        Complex Seps            2,093   2,258   2,435   2,433   2,577                                   484         5.3%
              Non-complex Seps        1,671   1,449   1,400   1,106   1,023 -                                 648       -11.5%
              Total Seps              3,764   3,707   3,835   3,539   3,600 -                                 164        -1.1%
              Total Bed Days         37,899  37,675  40,192  37,252  38,452                                   553         0.4%
              ALOS                    10.07   10.16   10.48   10.53   10.68                                  0.61         1.5%
              %Complex Separations      56%     61%     63%     69%     72%
Private       Complex Seps            1,205   1,145   1,145   1,278   1,349                                   144        2.9%
              Non-complex Seps        1,801   1,635   1,610   1,429   1,327 -                                 474       -7.4%
              Total Seps              3,006   2,780   2,755   2,707   2,676 -                                 330       -2.9%
              Total Bed Days         32,853  30,058  30,361  29,522  29,898 -                               2,955       -2.3%
              ALOS                    10.93   10.81   11.02   10.91   11.17                                  0.24        0.6%
              %Complex Separations      40%     41%     42%     47%     50%


Table 70 shows that the average length of stay for public hospitals has been increasing slightly, with
complexity having increased significantly. This is also shown in the following chart:

               Cardiothoracic Surgery Multiday ALOS and % complex bed
                                        days
         12                                                                    80%
         11                                                                    70%




                                                                                     %complex separations
         10                                                                    60%
         9                                                                     50%
  ALOS




         8                                                                     40%
         7                                                                     30%
         6                                                                     20%
         5                                                                     10%
         4                                                                     0%
              2001_02    2002_03       2003_04          2004_05      2005_06
                                                 Year
                            Public ALOS                    Private ALOS
                            Public % Complex               Private % Complex



Interventional cardiology
Table 71 shows the proportion of Interventional Cardiology admissions which were Sameday
admissions. This proportion has been increasing since 2001/02 for public hospitals, while it has been
stable for private hospitals.

Table 71: Interventional cardiology sameday proportion

                                                      Year                                                          % Change
      Hospital Type                 2001_02 2002_03 2003_04 2004_05 2005_06                                 Diff       p.a.
Public                  Sameday        1,832   2,474   2,576   3,294   4,083                                2,251       22.2%
                        Multiday       9,044   9,663  10,418  10,985  11,359                                2,315         5.9%
                        % Sameday        17%     20%     20%     23%     26%
Private                 Sameday        1,666   1,973   2,189   2,352   2,169                                  503        6.8%
                        Multiday      11,394  13,249  13,884  13,998  14,314                                2,920        5.9%
                        % Sameday        13%     13%     14%     14%     13%




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                 136
Sameday/non sameday and average length of stay trends




This is also shown in the following chart:

                              Interventional Cardiology Sameday Seps
                   30%

                   25%
 % of total seps




                   20%

                   15%

                   10%

                   5%

                   0%
                         2001_02    2002_03            2003_04        2004_05   2005_06
                                                        Year
                                              Public             Private


Table 72 shows the total bed days, average length of stay (excluding hospital in the home (HITH) days)
and total separations split between “Complex” and “Non-Complex” for multi-day admissions.

Table 72: Interventional cardiology average length of stay and complexity

                                                                  Year                             % Change
Hospital Type                                   2001_02 2002_03 2003_04 2004_05 2005_06    Diff       p.a.
Public        Complex Seps                         1,555   1,860   2,083   2,404   2,713   1,158        14.9%
              Non-complex Seps                     7,489   7,803   8,335   8,581   8,646   1,157         3.7%
              Total Seps                           9,044   9,663  10,418  10,985  11,359   2,315         5.9%
              Total Bed Days                      31,905  35,565  37,287  39,298  41,045   9,140         6.5%
              ALOS                                  3.53    3.68    3.58    3.58    3.61    0.09         0.6%
              %Complex Separations                   17%     19%     20%     22%     24%
Private       Complex Seps                           936   1,099   1,255   1,369   1,730     794       16.6%
              Non-complex Seps                    10,458  12,150  12,629  12,629  12,584   2,126        4.7%
              Total Seps                          11,394  13,249  13,884  13,998  14,314   2,920        5.9%
              Total Bed Days                      32,731  38,201  39,354  39,103  41,165   8,434        5.9%
              ALOS                                  2.87    2.88    2.83    2.79    2.88    0.00        0.0%
              %Complex Separations                    8%      8%      9%     10%     12%


Table 72 shows that the average length of stay for public hospitals has been stable while the complexity
has been increasing. This is also shown in the following chart:




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                137
Sameday/non sameday and average length of stay trends




                 Interventional Cardiology Multiday ALOS and % complex bed
                                            days
            4                                                                   30%

                                                                                25%




                                                                                      %complex separations
           3.5

                                                                                20%
            3
    ALOS




                                                                                15%
           2.5
                                                                                10%

            2                                                                   5%

           1.5                                                                  0%
                  2001_02      2002_03       2003_04     2004_05      2005_06
                                                  Year
                                   Public ALOS              Private ALOS
                                   Public % Complex         Private % Complex



Comparison of major hospitals
Table 73 shows the minimum, maximum and average sameday proportion for major DRGs for the ten
major hospitals. Table 74 shows the minimum, maximum and average multiday average length of stay
for major DRGs for the ten major hospitals, ie

•          Royal Melbourne Hospital - City Campus

•          Western Hospital [Footscray]

•          Geelong Hospital

•          Northern Hospital, The [Epping]

•          Frankston Hospital

•          Alfred, The [Prahran]

•          St Vincents Hospital

•          Austin Hospital

•          Box Hill Hospital

•          Monash Medical Centre [Clayton]

Sameday proportion and multiday average length of stay for all DRGs for each of these hospitals is
shown in Appendix N.




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Sameday/non sameday and average length of stay trends




Table 73: Sameday proportion by DRG for major hospitals
                                                                                                                           Multiday ALOS

              MCRG                                           DRG                              Total Separations   Min          Max         Average
 Cardiology                  Chest Pain                                                                  10,689         1.2          1.5         1.4
                             Non-Major Arrhythmia and Cond Disorders W/O Cat/Sev CC                       3,524         1.6          2.5         2.0
                             Heart Failure and Shock W/O Cat CC                                           2,867         3.4          5.4         4.5
                             Unstable Angina W/O Cat/Sev CC                                               2,335         1.6          2.7         2.0
                             Heart Failure and Shock W Cat CC                                             1,313         7.6         12.9         9.6
                             Coronary Atherosclerosis W/O CC                                              1,294         1.1          1.4         1.3
                             Other Circulatory System Diagnoses W/O Cat/Sev CC                            1,164         2.0          3.2         2.6
                             Circ Dis W AMI W/O Inv Cardiac Inves Proc W Cat/Sev CC                       1,094         6.3          9.7         7.6
 Interventional Cardiology   Circ Dis W/O AMI W Inv Cardiac Invest Proc W/O Complex DX/Pr                 3,676         1.3          3.7         2.1
                             PCI W/O AMI W Stent Implantation                                             2,323         1.4          2.3         1.8
                             PCI W AMI                                                                    2,274         2.8          6.2         4.2
                             Circ Dis W/O AMI W Inv Cardiac Invest Proc W Complex DX/Pr                   1,995         2.4          6.3         4.1
                             Cardiac Pacemaker Implantation                                               1,190         3.1          7.4         4.7
                             Circ Dis W AMI W Inv Cardiac Invest Proc W/O Cat/Sev CC                        809         2.4          5.3         4.1
                             Circ Dis W AMI W Inv Cardiac Invest Proc W Cat/Sev CC                          751         3.9          8.2         6.2



Table 74: Multiday ALOS by DRG for major hospitals
                                                                                                                         Multiday ALOS

             MCRG                                            DRG                             Total Separations    Min         Max          Average
Cardiology                   Chest Pain                                                                 10,689       1.2           1.5           1.4
                             Non-Major Arrhythmia and Cond Disorders W/O Cat/Sev CC                      3,524       1.6           2.5           2.0
                             Heart Failure and Shock W/O Cat CC                                          2,867       3.4           5.4           4.5
                             Unstable Angina W/O Cat/Sev CC                                              2,335       1.6           2.7           2.0
                             Heart Failure and Shock W Cat CC                                            1,313       7.6          12.9           9.6
                             Coronary Atherosclerosis W/O CC                                             1,294       1.1           1.4           1.3
                             Other Circulatory System Diagnoses W/O Cat/Sev CC                           1,164       2.0           3.2           2.6
                             Circ Dis W AMI W/O Inv Cardiac Inves Proc W Cat/Sev CC                      1,094       6.3           9.7           7.6
Cardiothoracic Surgery       Coronary Bypass W/O Inv Cardiac Inves W Cat/Sev CC                          1,279       8.3          10.4           8.9
                             Cardiac Valve Proc W CPB Pump W/O Inv Cardiac Invest W Cat CC                 469      10.4          14.1          11.4
                             Major Chest Procs W Cat CC                                                    408      11.4          19.8          14.8
                             Major Chest Procs W/O Cat CC                                                  392       6.1          10.3           7.7
                             Coronary Bypass W Inv Cardiac Inves W Cat CC                                  300      15.5          17.5          16.4
Interventional Cardiology    Circ Dis W/O AMI W Inv Cardiac Invest Proc W/O Complex DX/Pr                3,676       1.3           3.7           2.1
                             PCI W/O AMI W Stent Implantation                                            2,323       1.4           2.3           1.8
                             PCI W AMI                                                                   2,274       2.8           6.2           4.2
                             Circ Dis W/O AMI W Inv Cardiac Invest Proc W Complex DX/Pr                  1,995       2.4           6.3           4.1
                             Cardiac Pacemaker Implantation                                              1,190       3.1           7.4           4.7
                             Circ Dis W AMI W Inv Cardiac Invest Proc W/O Cat/Sev CC                       809       2.4           5.3           4.1
                             Circ Dis W AMI W Inv Cardiac Invest Proc W Cat/Sev CC                         751       3.9           8.2           6.2




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                                       139
Appendix I                    Self sufficiency and catchment areas
Self sufficiency
Self-sufficiency is a measure of independence. This may be calculated for any geographical area. If all
residents of a particular region go to hospitals within a region then the self-sufficiency is 100%. For
example admissions from people that reside in the Geelong Hospital catchment is 4,430. Of this 4,430,
4,150 go to Geelong hospital. Self-sufficiency for Geelong Hospital is therefore calculated as 4,150/
4,430, which is 94%.

The catchments were calculated as the hospital that had the most separations for each SLA.


Total cardiology
Self Sufficiency by hospital for all cardiology services is shown in Table 75:

Table 75: Self sufficiency by hospital for all cardiology services
                                                                         Seps from
                                                                         catchment
                                                            Number of     going to      Total seps
 Metro/Rural                                                  SLA in      specific         from           Self-
  Hospital                       Campus                     Catchment     hospital      catchment      sufficiency
Rural          Geelong Hospital                                     13          4,150          4,430            94%
Rural          Ballarat Health Services [Base Campus]               10          1,225          1,601            77%
Rural          Bendigo Hospital, The                                10          1,697          2,287            74%
Metro          Royal Melbourne Hospital - City Campus                9          2,676          4,734            57%
Metro          Alfred, The [Prahran]                                 8          2,181          3,199            68%
Metro          Maroondah Hospital [East Ringwood]                    7          1,886          3,340            56%
Metro          St Vincent’s Hospital                                 7          1,007          1,776            57%
Metro          Western Hospital [Footscray]                          7          3,720          6,909            54%
Metro          Austin Hospital                                       6          2,725          3,988            68%
Metro          Box Hill Hospital                                     6          2,849          4,381            65%
Metro          Dandenong Campus                                      6          2,108          4,026            52%
Metro          Frankston Hospital                                    6          3,605          4,534            80%
Rural          Goulburn Valley Health [Shepparton]                   6          1,504          2,270            66%
Metro          Monash Medical Centre [Clayton]                       6          3,145          5,070            62%
Metro          Northern Hospital, The [Epping]                       6          2,493          4,350            57%
Rural          Northeast Health Wangaratta                           5            594            769            77%
Rural          Central Gippsland Health Service [Sale]               4            450            649            69%
Rural          Latrobe Regional Hospital [Traralgon]                 4          1,062          1,516            70%
Rural          South West Healthcare [Warrnambool]                   4            800          1,169            68%
Rural          Bairnsdale Regional Health Service                    3            508            720            71%
Rural          West Gippsland Healthcare Group [Warragul]            3            325            490            66%
Rural          Wimmera Base Hospital [Horsham]                       3            409            640            64%
Rural          Wodonga Regional Health Service                       3            641            919            70%
Metro          Angliss Hospital                                      2            811          1,715            47%
Rural          Bass Coast Regional Health                            2            347            614            57%
               Other Hospitals                                      52          7,053         13,287            53%
               Total                                               198        49,971          79,383            63%



Other cardiology
Self Sufficiency by hospital for Other Cardiology is shown in Table 76.




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Self sufficiency and catchment areas




Table 76: Self sufficiency by hospital for other cardiology services
                                                                      Seps from
                                                                      catchment
                                                         Number of     going to      Total seps
 Metro/Rural                                               SLA in      specific         from           Self-
  Hospital                        Campus                 Catchment     hospital      catchment      sufficiency
Rural          Geelong Hospital                                  12          2,837          3,013            94%
Rural          Ballarat Health Services [Base Campus]             9            931          1,056            88%
Rural          Bendigo Hospital, The                              9          1,136          1,357            84%
Metro          Royal Melbourne Hospital - City Campus             9          1,919          3,492            55%
Metro          Alfred, The [Prahran]                              8          1,630          2,469            66%
Metro          Maroondah Hospital [East Ringwood]                 7          1,881          2,724            69%
Metro          Austin Hospital                                    6          2,043          2,949            69%
Metro          Box Hill Hospital                                  6          2,370          3,510            68%
Metro          Dandenong Campus                                   6          2,400          3,902            62%
Metro          Frankston Hospital                                 6          3,043          3,648            83%
Rural          Goulburn Valley Health [Shepparton]                6          1,501          1,916            78%
Metro          Northern Hospital, The [Epping]                    6          1,891          2,932            64%
Metro          Monash Medical Centre [Clayton]                    5          2,089          3,111            67%
Rural          Northeast Health Wangaratta                        5            594            634            94%
Metro          St Vincents Hospital                               5            760          1,315            58%
Rural          Central Gippsland Health Service [Sale]            4            449            529            85%
Rural          Latrobe Regional Hospital [Traralgon]              4          1,058          1,211            87%
Rural          South West Healthcare [Warrnambool]                4            780            934            84%
Metro          Western Hospital [Footscray]                       4          1,382          2,362            59%
Rural          Wodonga Regional Health Service                    4            644            767            84%
Metro          Angliss Hospital                                   3            896          1,648            54%
Rural          Bairnsdale Regional Health Service                 3            508            589            86%
Rural          Colac Area Health                                  3            249            306            81%
Rural          Maryborough District Health Service                3            227            328            69%
Rural          Mercy Public Hospitals Inc [Werribee]              3            694          1,136            61%
               Other Hospitals                                   58          8,245         13,060            63%
               Total                                            189        42,157          60,898            69%


These two tables show that, when Other Cardiology services are included, a large number of hospitals
have at least one SLA to whom they provide the majority of services.


Cardiothoracic surgery
Self Sufficiency by hospital for cardiothoracic surgery is shown in Table 77. The table shows that
Geelong hospital has the highest level of self sufficiency with The Alfred having the lowest:

Table 77: Self sufficiency by hospital for cardiothoracic surgery
                                                                      Seps from
                                                                      catchment
                                                         Number of     going to      Total seps
 Metro/Rural                                               SLA in      specific         from           Self-
  Hospital                         Campus                Catchment     hospital      catchment      sufficiency
Metro          Royal Melbourne Hospital - City Campus            45           555            880            63%
Metro          St Vincents Hospital                              31           132            245            54%
Metro          Alfred, The [Prahran]                             26           270            572            47%
Metro          Geelong Hospital                                  24           415            472            88%
Metro          Austin Hospital                                   23           279            481            58%
Metro          Monash Medical Centre [Clayton]                   23           430            659            65%
Rural          Bendigo Hospital, The                              6            20             47            43%
Metro          Box Hill Hospital                                  6            43             97            44%
Rural          Ballarat Health Services [Base Campus]             3            15             37            41%
Metro          Frankston Hospital                                 1            15             49            31%
               Total                                            188         2,174          3,539            61%




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Self sufficiency and catchment areas




Interventional cardiology
Self Sufficiency by hospital for Interventional Cardiology is shown in Table 78. The table shows that
Geelong hospital again has the highest level of self sufficiency with St Vincents having the lowest:

Table 78: Self sufficiency by hospital for interventional cardiology
                                                                     Seps from
                                                                     catchment
                                                        Number of     going to     Total seps
 Metro/Rural                                              SLA in      specific        from          Self-
  Hospital                         Campus               Catchment     hospital     catchment     sufficiency
Metro          Royal Melbourne Hospital - City Campus           29           992         1,554           64%
Metro          St Vincents Hospital                             26           450           841           54%
Rural          Geelong Hospital                                 23         1,287         1,475           87%
Metro          Monash Medical Centre [Clayton]                  21         1,077         1,794           60%
Rural          Bendigo Hospital, The                            17           703         1,086           65%
Rural          Ballarat Health Services [Base Campus]           16           339           612           55%
Metro          Box Hill Hospital                                15           873         1,331           66%
Metro          Alfred, The [Prahran]                            14           633           966           66%
Metro          Western Hospital [Footscray]                     12         1,613         2,351           69%
Metro          Frankston Hospital                                8           670           858           78%
Metro          Austin Hospital                                   6           551           865           64%
Metro          Northern Hospital, The [Epping]                   6           582         1,214           48%
Rural          South West Healthcare [Warrnambool]               1             3             9           33%
               Total                                           193         9,773        14,956           65%



Catchment areas
A Statistical Local Area (SLA) is considered part of the “catchment area” of a hospital when the largest
number of the inpatient admissions for that SLA are treated at that hospital. This can be calculated at
various levels, eg

•     Total cardiology – the hospital which treats the largest number of total cardiology admissions from
      a particular SLA will have that SLA within its total cardiology catchment area;

•     Interventional cardiology - the hospital which treats the largest number of interventional cardiology
      admissions from a particular SLA will have that SLA within its interventional cardiology catchment
      area;

•     Etc.


Interventional cardiology
The following map shows the catchment areas for major hospitals for Interventional Cardiology. The map
shows that the majority of rural SLAs utilise St Vincents, Royal Melbourne and Geelong Hospitals:




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Self sufficiency and catchment areas



                                                                       Interventional cardiology catchments
                                                                                            2005-06

                                                                                       St Vincent's    (26)
                                                                                       RMH             (29)
                                                                                       Geelong         (23)
                                                                                       MMC Clyton      (21)
                                                                                       Ballarat        (16)
                                                                                       Bendigo         (17)
                                                                                       Alfred          (14)
                                                                                       Box Hill        (15)
                                                                                       Western         (12)
                                                                                       Frankston        (8)
                                                                                       Austin           (6)
                                                                                       Northern         (6)
                                                                                       SW Healthcare    (1)




                                                                   0        50        100

                                                                         kilometers




Cardiothoracic surgery
The following map shows the catchment areas for major hospitals for Cardiothoracic Surgery. The map
shows that, again, St Vincents and Royal Melbourne are used predominantly by a large number of rural
SLAs:




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Self sufficiency and catchment areas




                                                                           Cardiothoracic catchments
                                                                                           2005-06

                                                                                       RMH            (45)
                                                                                       St Vincent's   (31)
                                                                                       Alfred         (26)
                                                                                       Geelong        (24)
                                                                                       Austin         (23)
                                                                                       MMC Clayton    (23)
                                                                                       Bendigo         (6)
                                                                                       Box Hill        (6)
                                                                                       Ballarat        (3)
                                                                                       Frankston       (1)




                                                                    0      50        100

                                                                        kilometers




Other cardiology
Catchment areas for Other Cardiology are not shown as over 70 different hospitals have at least one
SLA for which they provide the majority of services. In general most hospitals have the area surrounding
the hospital as their local “Other Cardiology” catchment.


Metropolitan catchment areas – Total cardiac
Metropolitan Catchment Areas by hospital for total cardiac are shown in the following maps:




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Self sufficiency and catchment areas




Figure 8: Alfred Hospital cardiac separations 2005-06


                                                                                                                    Alfred cardiac separations
      Port Phillip (C) -- West
      Port Phillip (C) West                                                                                                               2005-06

                                          Alfred, The
                                          Alfred, The
                                                                                                                                   453 to 565   (1)
                                        Stonnington (C) Prahran
                                        Stonnington (C) -- Prahran
                                                                                                                                   340 to 453   (2)
                                                                                                                                   227 to 340   (1)
                                                                    Stonnington (C) Malvern
                                                                    Stonnington (C) -- Malvern                                     114 to 227   (4)
                          Port Phillip (C) -- St Kilda
                          Port Phillip (C) St Kilda                                                                                  1 to 114 (156)



                                                               Glen Eira (C) Caulfield
                                                               Glen Eira (C) -- Caulfield




                                            Bayside (C) Brighton
                                            Bayside (C) -- Brighton




                                                         Bayside (C) South
                                                         Bayside (C) -- South

                                                                                                         Kingston (C) North
                                                                                                         Kingston (C) -- North




                                                                                                                        0           1.5       3

                                                                                                                                 kilometers




Figure 9 Austin Hospital cardiac separations 2005-06

                                                                                                     Austin Hospital cardiac separations
                                                                                                                                 2005-06
                                                                                                                            701 to 877   (3)
                                                                                                                            351 to 526   (2)
                                 Whittlesea (C) South
                                 Whittlesea (C) -- South
                                                                                                                            176 to 351   (1)
                                                                                                                              1 to 176 (134)




                                                                                  Banyule (C) North
                                                                                  Banyule (C) -- North



                          Darebin (C) Preston
                          Darebin (C) -- Preston




                                                          Banyule (C) Heidelberg
                                                          Banyule (C) -- Heidelberg


                                                                   Austin & Repatriation Medical Centre
                                                                   Austin & Repatriation Medical Centre

                     Darebin (C) Northcote
                     Darebin (C) -- Northcote


                                                                                                   Manningham (C) West
                                                                                                   Manningham (C) -- West




                                                                                                                                                    0      1.5       3
                                                                                                                                                        kilometers




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Self sufficiency and catchment areas




Figure 10 Box Hill Hospital cardiac separations 2005-06



                                                                                                Box Hill Hospital cardiac separations
                                                                                                                         2005-06

                                                                                                                     605 to 754   (3)
                                                                                                                     303 to 454   (1)
                                                                                                                     152 to 303   (4)
                                                                                                                       1 to 152 (109)
                      Manningham (C) -- West
                      Manningham (C) West
                                                                                                                    Yarra Ranges (S) South-West
                                                                                                                    Yarra Ranges (S) -- South-West


         Boroondara (C)
        Boroondara (C)
           Camberwell N.
        -- Camberwell N.
                           Box Hill Hospital
                           Box Hill Hospital
                                    Whitehorse (C)
                                   Whitehorse (C)
                                     Nunawading W.
                                  -- Nunawading W.
                    Whitehorse (C)
                   Whitehorse (C)

        Boroondara (C) Box Hill
       Boroondara (C) -- Box Hill             Whitehorse (C)
                                             Whitehorse (C)
          Camberwell S.
       -- Camberwell S.                         Nunawading E.
                                             -- Nunawading E.

                                                                Knox (C) North
                                                                Knox (C) -- North




                                                                                                                               0            2.5       5

                                                                                                                                       kilometers




Figure 11: Frankston Hospital cardiac separations 2005-06


                                                                                Kingston (C) South
                                                                                Kingston (C) -- South




       Frankston Hospital cardiac separations                                                    Frankston (C) East
                                                                                                 Frankston (C) -- East
                                 2005-06

                            1,120 to 1,400 (1)
                                                                                             Frankston Hospital
                                                                                             Frankston Hospital
                              560 to 840 (1)
                                                                                    Frankston (C) West
                                                                                    Frankston (C) -- West
                              280 to 560 (4)
                                0 to 280 (70)



                                                                Mornington P'sula (S) West
                                                                Mornington P'sula (S) -- West




                                                                                    Mornington P'sula (S) East
                                                                                    Mornington P'sula (S) -- East




                                   Mornington P'sula (S) South
                                   Mornington P'sula (S) -- South




                                                                                                                                0     2.5         5

                                                                                                                                    kilometers




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Self sufficiency and catchment areas




Figure 12: Geelong Hospital cardiac separations 2005-06


                                                                                            Geelong Hospital cardiac separations
                                                                                                                      2005-06

                                                                                                                  960 to 1,200 (1)
                                                                                                                  720 to 960 (1)
                                                                                                                  480 to 720 (2)
                                                Corio -- Inner
                                                Corio Inner                                                         0 to 240 (96)




                                                                 Geelong Hospital
                                                                 Geelong Hospital



                                                                           Bellarine Inner
                                                                           Bellarine -- Inner
                                                                                                                  Greater Geelong (C) Pt B
                                                                                                                  Greater Geelong (C) -- Pt B

                                          South Barwon Inner
                                          South Barwon -- Inner




                                                                                                              0        2.5       5
                                                                                                                    kilometers




Figure 13: MMC Clayton Hospital cardiac separations 2005-06




                                                             Monash (C) Waverley East
                                                             Monash (C) -- Waverley East

                                    Monash (C) South-West
                                    Monash (C) -- South-West

                 Glen Eira (C) -- South
                 Glen Eira (C) South                 Monash Medical Centre Clayton
                                                     Monash Medical Centre -- Clayton




             Bayside (C) South
             Bayside (C) -- South


                                    Kingston (C) North
                                    Kingston (C) -- North
                                                                                            Casey (C) Hallam
                                                                                            Casey (C) -- Hallam



                                                                                                                     Casey (C) Berwick
                                                                                                                     Casey (C) -- Berwick




                                                                    Gr. Dandenong (C) Bal
                                                                    Gr. Dandenong (C) Bal
      MMC Clayton cardiac separations
                      2005-06
                   665 to 830   (1)
                   499 to 665   (2)
                   333 to 499   (2)                                                             Casey (C) Cranbourne
                                                                                                Casey (C) -- Cranbourne
                   167 to 333   (7)
                     1 to 167 (104)                                                                                                  0      2.5       5

                                                                                                                                         kilometers




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Self sufficiency and catchment areas




Figure 14: Northern Hospital cardiac separations 2005-06


                                                                                          Northern Hospital cardiac separations
                                                                                                                       2005-06
                                                                                                                  920 to 1,170 (1)
                                                                                                                  460 to 690 (2)
                                                                                                                  230 to 460 (2)
                                                                                                                    0 to 230 (71)




                                          Hume (C) Craigieburn
                                          Hume (C) -- Craigieburn




                                                                                                   Northern Hospital
                                                                                                   Northern Hospital



                                                                                             Whittlesea (C) South
                                                                                             Whittlesea (C) -- South
                                                  Hume (C) Broadmeadows
                                                  Hume (C) -- Broadmeadows




                                                          Moreland (C) North
                                                          Moreland (C) -- North

                                                                                         Darebin (C) Preston
                                                                                         Darebin (C) -- Preston
                                                                                                                               0               2.5       5

                                                                                                                                            kilometers




Figure 15: Royal Melbourne Hospital cardiac separations 2005-06



                                                                                                          RMH cardiac separations
                                                                                                                         2005-06
         Hume (C) Sunbury
         Hume (C) -- Sunbury
                                                                                                                       437 to 548   (3)
                                                                                                                       328 to 437   (2)
                                                                                                                       219 to 328   (1)
                                                                                                                       110 to 219   (7)
                                                   Hume (C) Craigieburn
                                                   Hume (C) -- Craigieburn
                                                                                                                         1 to 110 (166)




                                                        Hume (C) Broadmeadows
                                                        Hume (C) -- Broadmeadows



                                                              Moreland (C) North
                                                              Moreland (C) -- North

                               Brimbank (C) Keilor
                               Brimbank (C) -- Keilor                              Darebin (C) Preston
                                                                                   Darebin (C) -- Preston

                                                                    Moreland (C) Coburg
                                                                    Moreland (C) -- Coburg

                                                        Moonee Valley (C)
                                                        Moonee Valley (C)
                               Brimbank (C)                   Essendon
                                                           -- Essendon
                               Brimbank (C)                              Moreland (C)
                                                                        Moreland (C)
                                   Sunshine
                                -- Sunshine                                  Brunswick
                                                                          -- Brunswick

                                                  Maribyrnong (C)
                                                  Maribyrnong (C)
                                                                              Royal Melbourne Hospital
                                                                              Royal Melbourne Hospital


                                                                     Melbourne (C) Remainder
                                                                     Melbourne (C) -- Remainder                            0       2.5          5
                                                                                                                               kilometers




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Figure 16: St Vincent’s Hospital cardiac separations 2005-06


      St Vincent's Hospital cardiac separations
                          2005-06
                                                                                              Darebin (C) Preston
                                                                                              Darebin (C) -- Preston
                       297 to 372  (2)
                       149 to 223  (2)                               Moreland (C) Coburg
                                                                     Moreland (C) -- Coburg

                        75 to 149  (8)
                         1 to 75 (172)                 Moonee Valley (C)
                                                       Moonee Valley (C)
                                                             Essendon
                                                          -- Essendon
                                                                           Moreland (C) Darebin (C) Northcote
                                                                           Moreland (C) Darebin (C) -- Northcote
                                                                              Brunswick
                                                                           -- Brunswick




                                                                                        Yarra (C) North
                                                                                        Yarra (C) -- North
                                                                                                     Boroondara (C) Kew
                                                                                                     Boroondara (C) -- Kew
                                                           Melbourne (C) Remainder
                                                           Melbourne (C) -- Remainder
                                                                                        St Vincents Hospital
                                                                                        St Vincents Hospital

                                                                                                         Boroondara (C)
                                                                                                         Boroondara (C)
                                                                                                              Hawthorn
                                                                                                           -- Hawthorn
                                                                                        Yarra (C) Richmond
                                                                                        Yarra (C) -- Richmond


              Wyndham (C) North
              Wyndham (C) -- North




                                                                                                         0         2.5       5

                                                                                                               kilometers




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Self sufficiency and catchment areas




Figure 17: Western Hospital cardiac separations 2005-06




                           Melton (S) Bal
                           Melton (S) Bal
                                                               Brimbank (C) Keilor
                                                               Brimbank (C) -- Keilor
                                                                                            Moonee Valley (C) West
                                                                                            Moonee Valley (C) -- West


  Western Hospital cardiac separations
                 2005-06
                                                            Brimbank (C) Sunshine
                                                            Brimbank (C) -- Sunshine
              1,000 to 1,250 (1)
                750 to 1,000 (1)                                                             Western Hospital- Footscray
                                                                                             Western Hospital- Footscray
                500 to 750 (1)
                250 to 500 (5)                                                                    Maribyrnong (C)
                                                                                                  Maribyrnong (C)
                  0 to 250 (92)



                                     Wyndham (C) North
                                     Wyndham (C) -- North


                                                              Hobsons Bay (C) Altona
                                                              Hobsons Bay (C) -- Altona




                                                                                        0          2.5        5

                                                                                                kilometers




Metropolitan catchment areas – Percutaneous angioplasty (PCI)
Metropolitan Catchment Areas by hospital for PCIs are shown in the following maps:




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Self sufficiency and catchment areas




Figure 18: Alfred Hospital percutaneous angioplasty separations 2005-06

     Alfred, The
     Alfred, The
 5
rs                                                                                                                                    E. Gippsland (S) -- Bairnsdale
                                                                                                                                      E. Gippsland (S) Bairnsdale




                                                                       Latrobe (C) Traralgon
                                                                       Latrobe (C) -- Traralgon



                                                        Latrobe (C) -- Morwell
                                                        Latrobe (C) Morwell




          Alfred PC Angioplasty seps
                     2005-06

                    32 to 40 (1)
                                                                                                            0            15           30
                    24 to 32 (3)                                                                                    kilometers
                    16 to 24 (1)
                     8 to 16 (7)
                     1 to 8 (78)



Figure 19: Austin Hospital percutaneous angioplasty separations 2005-06




                   Hume (C) Broadmeadows
                   Hume (C) -- Broadmeadows            Whittlesea (C) South
                                                       Whittlesea (C) -- South




                                                                                                  Banyule (C) North
                                                                                                  Banyule (C) -- North


                                              Darebin (C) Preston
                                              Darebin (C) -- Preston




                                                             Banyule (C) Heidelberg
                                                             Banyule (C) -- Heidelberg

                                                                              Austin Hospital
                                                                              Austin Hospital
          Austin Hospital PC Angioplasty seps
                           2005-06
                          93 to 114 (2)                                                                             Manningham (C) West
                                                                                                                    Manningham (C) -- West

                          47 to 70 (2)
                          24 to 47 (2)
                           1 to 24 (75)
                                                                                                                0             1.5       3
                                                                                                                         kilometers




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Figure 20: Box Hill Hospital percutaneous angioplasty separations 2005-06




                               Manningham (C) West
                               Manningham (C) -- West
                                                                                                                              Yarra Ranges (S) South-West
                                                                                                                              Yarra Ranges (S) -- South-West




                                                                                            Maroondah (C) Croydon
                                                                                            Maroondah (C) -- Croydon
                        Box Hill Hospital
                        Box Hill Hospital                           Maroondah (C) Ringwood
                                                                    Maroondah (C) -- Ringwood


                           Whitehorse (C) Nunawading W.
                           Whitehorse (C) -- Nunawading W.


                                               Whitehorse (C) Nunawading E.
                                               Whitehorse (C) -- Nunawading E.
         Whitehorse (C) Box Hill
         Whitehorse (C) -- Box Hill




                                                                                        Knox (C) North
                                                                                        Knox (C) -- North
   Box Hill Hospital PC Angioplasty seps
                        2005-06
                        61 to 77 (1)
                        46 to 61 (2)
                        31 to 46 (2)
                                                                                                                              0           2.5           5
                        16 to 31 (3)
                         1 to 16 (60)                                                                                                  kilometers




Figure 21: Frankston Hospital percutaneous angioplasty separations 2005-06


       Frankston Hospital PC Angioplasty seps
                                   2005-06

                                   65 to 79 (1)                                             Frankston (C) West
                                                                                            Frankston (C) -- West
                                   49 to 65 (1)
                                   33 to 49 (2)
                                                                                                   Frankston Hospital
                                                                                                   Frankston Hospital
                                   17 to 33 (1)
                                    1 to 17 (20)
                                                                                                      Frankston (C) East
                                                                                                      Frankston (C) -- East




                                                                            Mornington P'sula (S) West
                                                                            Mornington P'sula (S) -- West

                                                                                             Mornington P'sula (S) East
                                                                                             Mornington P'sula (S) -- East




                                           Mornington P'sula (S) South
                                           Mornington P'sula (S) -- South



               0          5           10

                      kilometers




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Self sufficiency and catchment areas




Figure 22: Geelong Hospital percutaneous angioplasty separations 2005-06




                                                                                                                                     Corio Inner
                                                                                                                                     Corio -- Inner




                                                                                                                                               Geelong Hospital
                                                                                                                                              Geelong Hospital
                                                                                                                                          Bellarine Inner
                                                                                                                                         Bellarine -- Inner
                                                                                                                               South Barwon Inner
                                                                                                                               South Barwon -- Inner

                                                                                                                                             Greater Geelong (C) Pt B
                                                                                                                                             Greater Geelong (C) -- Pt B


                                                                           Colac-Otway (S) Colac
                                                                           Colac-Otway (S) -- Colac


 Warrnambool (C)
 Warrnambool (C)
                                                                                                                                                                           M
                                                                                                                                                                           M




                                                                                                      Geelong Hospital PC Angioplasty seps
                                                                                                                           2005-06

                                                                                                                           41 to 51 (1)
       0          10          20

               kilometers
                                                                                                                           21 to 31 (3)
                                                                                                                           11 to 21 (2)
                                                                                                                            1 to 11 (34)




Figure 23: MMC Clayton Hospital percutaneous angioplasty separations 2005-06




                            MMC Clayton
                            MMC -- Clayton

           Kingston (C) North
           Kingston (C) -- North



                   Gr. Dandenong (C) Bal
                   Gr. Dandenong (C) Bal                                                        Baw Baw (S) Pt B West
                                                                                                Baw Baw (S) -- Pt B West




                                                                                                                                      Latrobe (C) Moe
                                                                                                                                      Latrobe (C) -- Moe




                                                                                                             MMC Clayton PC Angioplasty seps
                                                                                                                               2005-06
                                                                                                                               61 to 75 (2)
                                                                                                                               46 to 61 (2)
                                                              Bass Coast (S) Bal
                                                              Bass Coast (S) Bal
                                                                                                                               31 to 46 (5)
                                                                                                                               16 to 31 (4)
                                             0      7.5        15
                                                 kilometers
                                                                                                                                1 to 16 (44)




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Self sufficiency and catchment areas




Figure 24: RMH Hospital percutaneous angioplasty separations 2005-06


           RMH PC Angioplasty seps
                                                                                  Moira (S) West
                                                                                  Moira (S) -- West
                         2005-06
                                                                                                                Moira (S) East
                                                                                                                Moira (S) -- East
                        21 to 26 (5)
                        16 to 21 (2)                  Campaspe (S) Kyabram
                                                      Campaspe (S) -- Kyabram
                        11 to 16 (3)
                         6 to 11 (13)                                                                                      Wangaratta (RC) Central
                                                                                                                           Wangaratta (RC) -- Central
                                                                             Gr. Shepparton (C) Pt A
                                                                             Gr. Shepparton (C) -- Pt A
                         1 to 6 (67)


                                                                                                                                                 Alpine (S) West
                                                                                                                                                 Alpine (S) -- West

                                                                                     Strathbogie (S)
                                                                                     Strathbogie (S)




                                          Macedon Ranges (S) Romsey
                                          Macedon Ranges (S) -- Romsey




                                                                                                                             0         20        40

                                                                     Royal Melbourne Hospital
                                                                     Royal Melbourne Hospital                                       kilometers




Figure 25: St Vincent’s Hospital percutaneous angioplasty separations 2005-06




                     Gannawarra (S)
                     Gannawarra (S)



                                                         Moira (S) West
                                                         Moira (S) -- West
                                                                                             Wodonga (RC)
                                                                                             Wodonga (RC)


                                                     Gr. Shepparton (C) Pt A
                                                     Gr. Shepparton (C) -- Pt A

                    Loddon (S) South
                    Loddon (S) -- South



                                    Gr. Bendigo (C) Pt B
                                    Gr. Bendigo (C) -- Pt B




                                                                                     Wellington (S) Maffra
                                                                                     Wellington (S) -- Maffra
                     Ballarat (C) South
                     Ballarat (C) -- South
                                                       St Vincents Hospital
                                                       St Vincents Hospital
                                      Wyndham (C) North
                                      Wyndham (C) -- North
                                                                                                                                 St Vincent's Hospital PC Angioplasty seps
                                                                Baw Baw (S) Pt B West
                                                                Baw Baw (S) -- Pt B West
                                                                                                                                                             2005-06
  Warrnambool (C)
  Warrnambool (C)                                                                      Wellington (S) Rosedale
                                                                                       Wellington (S) -- Rosedale

                                                                                                                                             0          50
                                                                                                                                                                   33
                                                                                                                                                            25 to 100  (4)
                                                                                                                                                            19 to 25
                                                                                                                                                      kilometers
                                                                                                                                                                       (4)
                                                                                                                                                            13 to 19   (4)
                                                                                                                                                              7 to 13 (21)
                                                                                                                                                              1 to 7 (114)




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Self sufficiency and catchment areas




Figure 26: Western Hospital percutaneous angioplasty separations 2005-06



                                                                                   Western Hospital PC Angioplasty seps
                                                                                                             2005-06
                                                                                                            105 to 131 (1)
                                                                                                             53 to 79 (4)
                  Melton (S) Bal
                  Melton (S) Bal                                                                             27 to 53 (1)
                                                                                                              1 to 27 (44)

                                                                        Brimbank (C) Keilor
                                                                        Brimbank (C) -- Keilor




                                                               Brimbank (C) Sunshine
                                                               Brimbank (C) -- Sunshine

                                                                                                     Western Hospital
                                                                                                     Western Hospital

                                                                                          Maribyrnong (C)
                                                                                          Maribyrnong (C)




                                   Wyndham (C) -- North                Hobsons Bay (C) Altona
                                                                       Hobsons Bay (C) -- Altona
                                   Wyndham (C) North



                                         0       2.5       5
                                              kilometers




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Appendix J                 ICU and CCU, MAPU and SOU usage
Intensive care unit (ICU) usage
Table 79 shows by hospital

•     the number of separations which involved some time in ICU,
•     total days in ICU
•     average length of stay in ICU (in hours) and
•     implied ICU beds (assuming 80% occupancy)

Table 79: ICU separations, total days, average length of stay (hours) and implied beds


                                                                                 ALOS in Beds @ 80%
                      Campus                         Separations    ICU Days       ICU     Occupancy
Alfred The [Prahran]                                          484          940          47          3
Austin Hospital                                               425          878          50          3
Ballarat Health Services [Base Campus]                         16           29          43          0
Bendigo Hospital The                                           12            8          16          0
Box Hill Hospital                                              66          150          54          1
Central Gippsland Health Service [Sale]                       208          362          42          1
Dandenong Campus                                               73          164          54          1
Frankston Hospital                                             54          129          57          0
Geelong Hospital                                              478        1,039          52          4
Goulburn Valley Health [Shepparton]                           235          531          54          2
Hamilton Base Hospital                                        119          213          43          1
Latrobe Regional Hospital [Traralgon]                         117          229          47          1
Maroondah Hospital [East Ringwood]                             72          152          51          1
Mildura Base Hospital                                         147          264          43          1
Monash Medical Centre [Clayton]                               469          696          36          2
Northeast Health Wangaratta                                   233          450          46          2
Northern Hospital The [Epping]                                 87          149          41          1
Peter MacCallum Cancer Institute [East Melbourne]              28           87          74          0
Royal Childrens Hospital [Parkville]                            3           17         137          0
Royal Melbourne Hospital - City Campus                       734         1,201          39          4
South West Healthcare [Warrnambool]                            17           42          59          0
St Vincents Hospital                                          447          683          37          2
Western Hospital [Footscray]                                  110          240          52          1
Wimmera Base Hospital [Horsham]                               287          420          35          1
Total                                                      4,921         9,069                     31

Table 79 shows the split of cardiac ICU admissions between specialties and admission types. 55% of
ICU hours related to cardiothoracic surgery, while 63% related to emergency admissions.

Table 80: ICU split between specialty and admission type


                                                                               Beds Required @
        Speciality               Emergency   Elective         Other % of Total 80% Occupancy
Cardiology                             3,550        26           133      41%               13
Cardiothoracic Surgery                 1,833    2,594            534      55%               17
Interventional Cardiology                369        20             11      4%                1
Total                                  5,752    2,640            678    100%                31




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ICU and CCU, MAPU and SOU usage




Table 80 shows the trend in the proportion of total separations which included some time in ICU, as well
as the trend in the time spent in ICU. In total a reducing proportion of admissions have included some
time in ICU, while the average length of stay in ICU has remained steady.

Table 81: Trend in ICU as % of separations and ICU ALOS


                         Non-ICU       Total
  Year       ICU Seps     Seps         Seps       % ICU ICU Days ICU ALOS
2001/02          5,615     65,029       70,644       7.9%  10,109     1.80
2002/03          5,541     68,492       74,033       7.5%   9,959     1.80
2003/04          5,615     70,075       75,690       7.4%   9,987     1.78
2004/05          5,179     72,547       77,726       6.7%   9,470     1.83
2005/06          4,921     76,172       81,093       6.1%   9,069     1.84
Total           26,871    352,315      379,186       7.1%  48,595     1.81

Table 81 shows the trend in the proportion of ICU hours represented by each specialty. In 2005/06 there
was an increase in the proportion of hours spent by cardiothoracic admissions in ICU.

Table 82: Trend in specialties as a % of total ICU hours


                           Cardiothoracic Interventional
  Year       Cardiology       Surgery      Cardiology              Total
2001/02            4,688            5,096            326            10,109
2002/03            4,681            4,750            529             9,959
2003/04            4,500            4,822            664             9,987
2004/05            4,262            4,643            565             9,470
2005/06            3,709            4,961            400             9,069
Total            21,840            24,270          2,485            48,595
2001/02             46%              50%             3%              100%
2002/03             47%              48%             5%              100%
2003/04             45%              48%             7%              100%
2004/05             45%              49%             6%              100%
2005/06             41%              55%             4%              100%
Total               45%              50%             5%              100%


Coronary care unit (CCU) usage
Table 82 shows by hospital

•     the number of separations which involved some time in CCU,
•     total days in CCU
•     average length of stay in CCU (in hours) and
•     implied CCU beds (assuming 70% occupancy)




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Table 83: CCU separations, total days, average length of stay (hours) and implied beds


                                                                            ALOS in Beds @ 80%
                  Campus                       Separations     CCU Days      CCU     Occupancy
Alfred The [Prahran]                                    603         1,696         68          6
Angliss Hospital                                        303           743         59          3
Austin Hospital                                      1,205          2,198         44          8
Ballarat Health Services [Base Campus]                  312           471         36          2
Bendigo Hospital The                                    197           351         43          1
Box Hill Hospital                                       976         1,972         48          7
Dandenong Campus                                     1,087          2,966         65         10
Frankston Hospital                                   1,024          3,161         74         11
Geelong Hospital                                          2             5         62          0
Latrobe Regional Hospital [Traralgon]                  146            350         58          1
Maroondah Hospital [East Ringwood]                     161            313         47          1
Monash Medical Centre [Clayton]                      1,553          5,692         88         19
Northern Hospital The [Epping]                          497           982         47          3
Royal Melbourne Hospital - City Campus                 994          2,502         60          9
South West Healthcare [Warrnambool]                     270           495         44          2
St Vincents Hospital                                 1,095          1,863         41          6
Western Hospital [Footscray]                         1,605          2,950         44         10
Total                                               12,030         28,711                    98

Table 83 shows the split of CCU admissions between specialties and admission types. 57% of CCU
hours related to Interventional Cardiology, while 85% related to emergency admissions.

Table 84: CCU split between specialty and admission type


                                                                               Beds Required @
        Speciality              Emergency   Elective          Other % of Total 80% Occupancy
Cardiology                            9,031      251              998     36%               35
Cardiothoracic Surgery                1,707      175              179      7%                7
Interventional Cardiology            13,577    1,763            1,029     57%               56
Total                                24,315    2,189            2,207   100%                98

Table 84 shows the trend in the proportion of total separations which included some time in CCU, as well
as the trend in the time spent in CCU. In total a reducing proportion of admissions have included some
time in CCU, while again the average length of stay in CCU has remained steady.

Table 85: Trend in CCU as % of separations and CCU ALOS


               CCU     Non-CCU         Total                   CCU       CCU
  Year         Seps      Seps          Seps       % CCU        Days      ALOS
2001/02         12,697    57,947        70,644       18%        32,306      2.5
2002/03         12,874    61,159        74,033       17%        32,253      2.5
2003/04         12,273    63,417        75,690       16%        30,488      2.5
2004/05         12,171    65,555        77,726       16%        30,057      2.5
2005/06         12,030    69,063        81,093       15%        28,711      2.4
Total           62,045 317,141         379,186       16%       153,814      2.5




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ICU and CCU, MAPU and SOU usage




Table 85 shows the trend in the proportion of CCU hours represented by each specialty. Interventional
cardiology has represented an increasing proportion of hours over the past five years:

Table 86: Trend in specialties as a % of total CCU hours


                           Cardiothoracic Interventional
  Year       Cardiology       Surgery      Cardiology              Total
2001/02          15,188             2,135        14,982             32,306
2002/03          14,256             2,103        15,894             32,253
2003/04          12,457             2,364        15,667             30,488
2004/05          10,851             2,151        17,054             30,057
2005/06          10,281             2,060        16,370             28,711
Total            63,033            10,814        79,966            153,814
2001/02             47%               7%            46%              100%
2002/03             44%               7%            49%              100%
2003/04             41%               8%            51%              100%
2004/05             36%               7%            57%              100%
2005/06             36%               7%            57%              100%
Total               41%               7%            52%              100%


Medical assessment and planning unit (MAPU) and short stay observation unit
(SOU) usage
Table 86 shows the number of public hospital admissions which include time spent in the Medical
Assessment and Planning Unit (MAPU) or Short Stay Observation Unit (SOU).

Table 87: Trend in usage of MAPU and SOU



Financial Year             No. MAPU No. SOU %MAPU %SOU
2001-02                          1275    1210  1.8%  1.7%
2002-03                          1721    2166  2.3%  2.9%
2003-04                          2000    2635  2.6%  3.5%
2004-05                          2229    4409  2.9%  5.7%
2005-06                          2602    8129  3.2% 10.1%

SOU and MAPU usage have increased significantly over recent years, with an increasing number of
hospitals making use of these facilities.




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                    159
Appendix K                Emergency department presentations
Background
In the context of emergency department services “cardiac services” or “cardiac care” includes all
presentations included in the Victorian Emergency Minimum Dataset (VEMD) with any one of the
following ICD-10 diagnoses:

Table 88: Cardiac services diagnoses



     Code                                      Diagnosis Name
 I10             Hypertension, unspecified
 I200            Angina pectoris, unstable
 I209            Angina pectoris, not unstable
 I219            Myocardial infarction, acute
 I2510           Coronary artery disease, unspecified vessel
 I269            Pulmonary embolism
 I313            Pericardial effusion
 I319            Pericarditis
 I409            Myocarditis, acute
 I429            Cardiomyopathy
 I459            Conduction disorder / Heart block
 I469            Cardiac arrest
 I471            Supraventricular tachycardia
 I472            Paroxysmal ventricular tachycardia
 I479            Paroxysmal tachycardia, unspecified
 I48             Atrial fibrillation & flutter
 I495            Sick sinus syndrome
 I499            Arrhythmia
 I500            Congestive cardiac failure
 I519            Heart disease
 I711            Thoracic aneurysm with rupture
 I712            Thoracic aneurysm without rupture
 I959            Hypotension
 Q249            Congenital heart disease
 R011            Cardiac / Heart murmur
 R060            Respiratory distress / Dyspnoea / Orthopnoea / Shortness of breath
 R074            Chest pain, NEC


Activity
In 2005-06, there were 85,133 adult cardiology presentations to Victorian emergency departments
compared to 76,878 in 2003-04, a growth of 11% over three years (Table 89). 58,890, or 69% of these
were patients residing in the metropolitan area, with 24,561 from rural areas.

Data in the remainder of this section is derived from the Victorian Emergency Minimum Dataset (VEMD).




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Emergency department presentations




Table 89: Cardiac presentations by region to Victoria emergency departments 2003-04 to 2005-06

                                                                                                  %
                                                                                                Change % of total
           Region                         2003-04 2004-05 2005-06                    Diff        p.a.   (2005-06)
North-West Metro                            22,409  23,904  25,115                    2,706        5.9%      30%
Southern Metro                              17,261  18,207  20,119                    2,858        8.0%      24%
Eastern Metro                               12,330  12,561  13,656                    1,326        5.2%      16%
Barwon-SW                                    5,915   6,193   6,231                      316        2.6%       7%
Loddon Mallee                                5,454   5,844   5,899                      445        4.0%       7%
Hume                                         4,295   4,750   4,726                      431        4.9%       6%
Gippsland                                    4,708   4,580   4,653                        -55     -0.6%       5%
Grampians                                    3,059   2,927   3,052                         -7     -0.1%       4%
Interstate                                   1,446   1,506   1,682                      236        7.8%       2%
Total                                       76,878  80,472  85,133                    8,255        5.2%     100%

Unspecified Chest Pain accounts for 46% of all presentations at emergency departments. The top 10
primary diagnoses account for 92% of all presentations (Table 90).

Table 90: Top 20 diagnoses for cardiology presentations at emergency departments
                                                                                                             %
                                                                                                           Change    % of total
                         Primary Diagnosis                           2003-04 2004-05 2005-06    Diff        p.a.     (2005-06)
Chest pain, NEC                                                        33,706  36,230  38,901    5,195        7.4%          46%
Angina pectoris, unstable                                               7,474   6,719   6,510     -964       -6.7%           8%
Respiratory distress / Dyspnoea / Orthopnoea / Shortness of breath      6,149   6,157   6,445      296        2.4%           8%
Atrial fibrillation & flutter                                           4,742   5,497   5,952    1,210       12.0%           7%
Congestive cardiac failure                                              4,973   5,126   5,571      598        5.8%           7%
Myocardial infarction, acute                                            4,403   4,627   4,975      572        6.3%           6%
Arrhythmia                                                              3,783   4,148   4,233      450        5.8%           5%
Angina pectoris, not unstable                                           2,294   2,154   2,270        -24     -0.5%           3%
Hypertension, unspecified                                               1,901   2,131   2,246      345        8.7%           3%
Supraventricular tachycardia                                            1,438   1,441   1,427        -11     -0.4%           2%
Pulmonary embolism                                                      1,236   1,292   1,326         90      3.6%           2%
Hypotension                                                             1,051   1,096   1,186      135        6.2%           1%
Heart disease                                                             917     922     965         48      2.6%           1%
Cardiac arrest                                                            822     799     809        -13     -0.8%           1%
Conduction disorder / Heart block                                         359     370     430         71      9.4%           1%
Pericarditis                                                              356     402     417         61      8.3%           0%
Paroxysmal tachycardia, unspecified                                       352     315     396         44      6.0%           0%
Coronary artery disease, unspecified vessel                               231     262     272         41      8.6%           0%
Paroxysmal ventricular tachycardia                                        184     212     203         19      5.0%           0%
Other                                                                     508     572     599         91      8.6%           1%
Total                                                                  76,878  80,472  85,133    8,255        5.2%        100%


The top 10 hospitals accounted for 56% of the presentations in 2005/06 (Table 91).




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Emergency department presentations




Table 91: Cardiac presentations by hospital to Victoria emergency departments 2003-04 to 2005-
06


                                                                                        % Change
                     Hospital                    2003-04 2004-05 2005-06     Diff          p.a.
Monash Medical Centre [Clayton]                     5,620   5,639   6,439       819           7.0%
Northern Hospital, The [Epping]                     4,471   4,996   5,349       878           9.4%
Frankston Hospital                                  4,851   4,991   5,236       385           3.9%
Austin Hospital                                     4,088   4,664   4,930       842           9.8%
Royal Melbourne Hospital - City Campus              4,953   5,048   4,925         -28        -0.3%
Geelong Hospital                                    4,459   4,620   4,740       281           3.1%
Box Hill Hospital                                   4,067   4,200   4,487       420           5.0%
Dandenong Campus                                    4,048   4,040   3,953         -95        -1.2%
Alfred, The [Prahran]                               3,462   3,567   3,942       480           6.7%
Western Hospital [Footscray]                        3,822   3,864   3,806         -16        -0.2%
Maroondah Hospital [East Ringwood]                  2,899   3,014   3,232       333           5.6%
St Vincents Hospital                                2,646   2,935   3,127       481           8.7%
Bendigo Hospital, The                               2,691   2,734   2,772          81         1.5%
Sunshine Hospital                                   2,072   2,422   2,689       617         13.9%
Ballarat Health Services [Base Campus]              2,071   2,034   2,179       108           2.6%
Goulburn Valley Health [Shepparton]                 1,717   2,011   2,000       283           7.9%
Angliss Hospital                                    1,984   1,845   1,995          11         0.3%
Mildura Base Hospital                               1,617   1,806   1,912       295           8.7%
Mercy Public Hospitals Inc [Werribee]               1,454   1,624   1,811       357         11.6%
Latrobe Regional Hospital [Traralgon]               1,854   1,802   1,736      -118          -3.2%
Rosebud Hospital                                    1,238   1,310   1,467       229           8.9%
Casey Hospital                                          0     263   1,368     1,368
Northeast Health Wangaratta                         1,236   1,295   1,296          60        2.4%
Wodonga Regional Health Service                     1,192   1,179   1,265          73        3.0%
South West Healthcare [Warrnambool]                 1,264   1,345   1,245         -19       -0.8%
Sandringham & District Memorial Hospital              871   1,090   1,124       253         13.6%
Bairnsdale Regional Health Service                    920   1,003     995          75        4.0%
West Gippsland Healthcare Group [Warragul]          1,046     934     941      -105         -5.2%
Central Gippsland Health Service [Sale]               918     817     880         -38       -2.1%
Echuca Regional Health                                754     785     753          -1       -0.1%
Other                                               2,593   2,595   2,539         -54       -1.0%
Total                                              76,878  80,472  85,133     8,255          5.2%

In 2005-06, 39% of people who presented to Victorian emergency departments were discharged home
(Table 92). From 2003-04 to 2005-06 numbers discharged home and to the ward were relatively stable.

In 2005-06, 12% of patients were admitted to the Short Stay Observation Unit. Not surprisingly there was
significant growth in the use of Short Stay and Emergency Medical Units.

It is noteworthy there are approximately 65,000 total adult inpatient cardiac admissions for 2005/06
(Table 31) which are recorded in VAED with an admission type of “Emergency - Same Hospital” or
“Other emergency admission”, while there were only 52,000 cardiac emergency presentations in
2005/06 which are shown as being admitted to hospital. This may suggest that a number of cardiac
admissions are not being correctly coded within Emergency Departments.

More patients are now being transferred to another hospital than three years ago and less patients are
leaving before treatment is complete.




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Emergency department presentations




Table 92: Departure status for people presenting for cardiology conditions to emergency
departments

                                                                                          %
                                                                                        Change    % of total
     Departure Status          2003-04       2004-05       2005-06          Diff         p.a.     (2005-06)
Home                              35,190        33,175        32,941         -2,249       -3.2%          39%
Ward*                             31,388        33,206        32,285             897       1.4%          38%
Short Stay Unit**                  2,815         6,008        10,280          7,465       91.1%          12%
Other Hospital                     5,670         5,833         6,400             730       6.2%           8%
Emergency Medical Unit***            530           928         1,807          1,277       84.6%           2%
Left at Own Risk                     669           738           846             177      12.5%           1%
Died                                 446           422           395             -51      -5.9%           0%
Other                                170           162           179               9       2.6%           0%
Total                             76,878        80,472        85,133          8,255        5.2%        100%

*     Includes HITH and MAPU; excludes SOU
**    Includes Chest Pain Evaluation Unit; excludes MAPU
***   Includes NH, hostel, psychiatric NH, residential care respite bed

Over the period 2003-4 to 2005-6, the acuity of patients presenting to emergency departments has
remained stable. Table 93 shows that emergency, urgent and semi-urgent presentations have each
risen by 10-12%.

Table 93: Cardiac emergency department presentations by triage category

                                                                                     %
                                                                                   Change     % of total
    Triage Category           2003-04 2004-05 2005-06                     Diff      p.a.      (2005-06)
Resuscitation                    1,660   1,571   1,448                      -212     -6.6%            2%
Emergency                       30,196  31,926  33,835                     3,639      5.9%           40%
Urgent                          32,788  34,027  36,611                     3,823      5.7%           43%
Semi-urgent                     11,016  11,770  12,132                     1,116      4.9%           14%
Non-urgent                       1,219   1,177   1,107                      -112     -4.7%            1%
Total                           76,878  80,471  85,133                     8,255      5.2%         100%

In 2005/06 54% of all presentations to emergency departments arrived using their own method of
transport. The majority of the remaining emergency presentations arrived by road ambulance (45%)
(Table 94).

Table 94: Cardiology emergency presentation by arrival mode

                                                                                          %
                                                                                        Change    % of total
   Arrival Transport Mode           2003-04 2004-05 2005-06                  Diff        p.a.     (2005-06)
Other                                 39,964  42,521  44,727                  4,763        5.8%          53%
Road Ambulance Service                35,965  37,077  39,547                  3,582        4.9%          46%
Ambulance private car                    879     812     797                      -82     -4.8%           1%
Helicopter/Air Ambulance                  70      62      62                       -8     -5.9%           0%
Total                                 76,878  80,472  85,133                  8,255        5.2%        100%

Note: Other includes private car




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Emergency department presentations




Waiting times for treatment
Average waiting times to treatment by hospital are shown in Table 95. Average waiting time has
increased from 15 to 18 minutes between 2003/04 and 2005/06:

Table 95: Waiting times by hospital and year (minutes)

                                                                                         %
                                                                                       Change
                  Hospital                 2003-04 2004-05 2005-06         Diff         p.a.
Monash Medical Centre [Clayton]                  19      20      22                2      5.3%
Northern Hospital, The [Epping]                   6       6       5                0     -2.2%
Frankston Hospital                                5       7      10                4     33.7%
Austin Hospital                                  28      30      32                4      6.8%
Royal Melbourne Hospital - City Campus           21      19      21                1      1.4%
Geelong Hospital                                  5       7       8                4     31.1%
Box Hill Hospital                                37      29      28               -9    -13.2%
Dandenong Campus                                  8      10       7               -1     -3.4%
Alfred, The [Prahran]                            15      16      16                1      3.1%
Western Hospital [Footscray]                     12      12      15                3     13.8%
Maroondah Hospital [East Ringwood]               23      24      22               -2     -3.4%
St Vincents Hospital                             25      24      17               -8    -17.4%
Bendigo Hospital, The                            10      19      23               13     50.2%
Sunshine Hospital                                19      22      30               11     25.4%
Ballarat Health Services [Base Campus]           16      15      14               -2     -6.0%
Goulburn Valley Health [Shepparton]              12      12      13                1      2.4%
Angliss Hospital                                 22      21      20               -2     -5.8%
Mildura Base Hospital                             6       5       6                0     -2.8%
Mercy Public Hospitals Inc [Werribee]            28      27      30                2      3.8%
Latrobe Regional Hospital [Traralgon]            15      13      17                2      4.8%
Rosebud Hospital                                 14      16      16                2      6.9%
Casey Hospital                                           14      12               12
Northeast Health Wangaratta                      11      14      16                5     22.8%
Wodonga Regional Health Service                   9       8      10                1      3.9%
South West Healthcare [Warrnambool]               6      17      18               11     67.4%
Sandringham & District Memorial Hospital         12      15      38               27     79.8%
Bairnsdale Regional Health Service                8      34      31               23     94.3%
West Gippsland Healthcare Group [Warragul]        2      22      37               35    305.7%
Central Gippsland Health Service [Sale]           7      27      25               18     85.4%
Echuca Regional Health                           18      22      16               -1     -4.1%
Other                                            11      10      13                2      9.1%
Total                                            15      17      18                3      8.3%

Average waiting times to treatment by primary diagnosis are shown in Table 96




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Emergency department presentations




Table 96: Waiting times by diagnosis and year (minutes)

                                                                                                                  %
                                                                                                                Change
                              Primary Diagnosis                    2003-04 2004-05 2005-06          Diff         p.a.
Chest pain, NEC                                                          15      16      17                 2      8.1%
Angina pectoris, unstable                                                 9      10      10                 1      7.0%
Respiratory distress / Dyspnoea / Orthopnoea / Shortness of breath       21      22      24                 3      6.4%
Atrial fibrillation & flutter                                            14      16      16                 2      7.3%
Congestive cardiac failure                                               24      25      25                 1      2.7%
Myocardial infarction, acute                                             10      11      12                 2      8.3%
Arrhythmia                                                               17      20      21                 4     10.7%
Angina pectoris, not unstable                                            12      13      15                 3     10.4%
Hypertension, unspecified                                                29      35      40                11     17.1%
Supraventricular tachycardia                                              9       9      10                 1      4.6%
Pulmonary embolism                                                       21      20      23                 2      5.2%
Hypotension                                                              23      24      26                 2      4.9%
Heart disease                                                            13      14      14                 1      5.4%
Cardiac arrest                                                            1       1       1                 0      8.8%
Conduction disorder / Heart block                                        16      14      17                 1      4.6%
Pericarditis                                                             16      25      26                10     26.9%
Paroxysmal tachycardia, unspecified                                      18      20      21                 3      8.7%
Coronary artery disease, unspecified vessel                              11      10      13                 2      6.6%
Paroxysmal ventricular tachycardia                                        8       9      11                 4     20.7%
Other                                                                    21      22      21                 0     -0.5%
Total                                                                    15      17      18                 3      8.3%


Average waiting times to treatment by departure status are shown in Table 97.

Table 97: Waiting times by departure status and year (minutes)

                                                                                                %
                                                                                              Change
       Departure Status                2003-04 2004-05 2005-06                    Diff         p.a.
Home                                         19      22      25                           6     13.9%
Ward*                                        12      13      14                           2      7.7%
Short Stay Unit**                            18      14      13                          -5    -13.9%
Other Hospital                               11      12      13                           3     11.1%
Emergency Medical Unit***                    20      10      17                          -2     -5.6%
Left at Own Risk                             15      22      22                           6     18.3%
Died                                          2       2       3                           0      8.9%
Other                                        14      15      14                           1      1.8%
Total                                        15      17      18                           3      8.3%


How many presentations were of primary care treatment type?
Primary care treatmentvii (PCT) is defined as patients that present to emergency departments that could
have been treated in the community. At this stage the grouping is based on five criteria and is not
clinically based:

•         Patient did not arrive by ambulance
•         Patient was not referred to hospital by a GP



    vii
      The PCT definition was provided by the Hospital Demand Management Unit, Metropolitan Health and Aged Care Services Division,
     Department of Human Services




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Emergency department presentations




•     The triage category was 4 or 5
•     Patient was not admitted to hospital
•     The total ED LOS was less than 12 hours.

In 2005-06 7.4% of cardiac presentations were classified as PCT. In 2005-06 the minimum PCT
percentage for hospitals with at least 1000 cardiac presentations was 1.5% and the maximum was
19.6%.




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Appendix L                List of attendees at focus groups
Melbourne
Danny McGennisken                     Metropolitan Ambulance service
Mandy Parish                          Community health nurse
Mirella Moppi                         Hospital contract manager
Alan Eade                             Metropolitan Ambulance service
Robyn English                         Clinical Service & Business Development manager
Lisa Moulday                          Cardiac rehabilitation and heart failure program
Lyndon Hawke                          Physiologist
Rob Whitbourn                         Director of Coronary Care
Lisa Jenkins                          Cardiac Rehabilitation
Neil Strathmore                       Associate Professor
Alison Beauchamp                      Monash University
Christine Belfour                     Austin Hospital
Leanne Grigg                          Director of cardiology
Jeremy Wrobel                         Advanced trainee
Bill Barger                           Paramedic Education and Training
Andrew MacIsaac                       Director of Cardiac Services
Chloe Fast                            Dietician
Michael Jelinek                       Cardiologist
Bill Kelly                            Medical director
Karlheinz Peter                       Professor
Michael Yii                           Acting director
Susie Hooper                          VCRA


Hamilton
Vicki Barbary                         Community health nurse
Megan McLeish                         HARP manager
Robyn Beaton                          Cardiac rehabilitation
Suzie Staude                          Pharmacist
Lyn Holden                            Department head of Physiotherapy
Kate Leahy                            Social worker




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                         167
List of attendees at focus groups




Andrew Bowman                         Physician
Nick Abbott                           Physician
Geoff Coggins                         Physician
Jennifer Paton
Meredith Finnigan                     Director of nursing
Grant Hocking                         Rural Ambulance Victoria
Tina Ivanov                           Rural Ambulance Victoria
Deidre Harrington                     Wimmera Health Care Group
Susan Furness                         Rural Ambulance Victoria
Anne Richards                         CRC member
Carolyn Coate                         Community rehabilitation center coordinator


Consumer group
Graeme Chaplin
David Milburn
Clive Jones
Gaylyn Pinniger
Alistair Kerr
Joan Kerr
Leo Bottcher


Heidelberg
Kim Gray                              Physiotherapist
Serina Cecchin                        Nurse Unit Manager
Kath Cowie                            Nurse Unit Manager
Stephen Gow                           Director, Southern Health
Tina Asker                            Community Health Nurse
Carina Martin                         Strategy Projects Manager
Ian Jarvie                            Metropolitan ambulance Service
Alexander Rosalion                    Cardiothoracic surgeon
Steve Mulholland                      Metropolitan Ambulance Service
Eddy Watkins                          Metropolitan Ambulance Service
Hillary Stedman                       Nurse Manager




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List of attendees at focus groups




Janet Mcallister                      Nurse Manager
Steve Selig                           Associate Professor and Coordinator
Maria Murphy                          Clinical Nurses Specialist
Glen Bail                             Metropolitan Ambulance Service
Anthony McGillion                     Manager of Education, Vice president of VCNA
Kerrie Daniels                        Clinical support nurse
Marcia George                         Professor
John Scott                            Nurse Unit Manager
Tracy Heart                           Cardiac rehabilitation coordinator
Heather Storen                        CNS cardiac cath lab
Jane Lohrey                           Darebin Community Health
Lauren Kerr                           Cardiac coach
Joanne McKenna                        Cardiac technologist
Jonathan Hunt                         Unit manager of cath lab
Elia Petzierides                      Metropolitan Ambulance Service
Jane Taylor                           Heart failure CNC
Janine Gray                           HARP- heart failure CNC




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Appendix M                Survey results
Service                                                 Metro            Rural            Private       Total
Emergency care                                                      10               17             2               29
Chest pain assessment area in ED                                     7               11             1               19
Cardiac surgery                                                      5                1             2                8
CCU                                                                  9                7             7               23
ICU                                                                  9                5             4               18
HDU                                                                  7                9             6               22
Day hospital places                                                  7                6             6               19
Step down facilities                                                 7                3             3               13
Electrophysiology labs                                               5                2             2                9
Catheterization lab                                                  9                2             7               18
Coronary angiography                                                 9                2             7               18
Angioplasty                                                          9                1             5               15
Elective PCI                                                         9                1             5               15
Primary PCI                                                          9                1             5               15
Pacemaker insertion                                                  9                5             7               21
AICD insertion                                                       9                3             7               19
Biventricular pacemaker                                              9                2             7               18
AF ablation                                                          4                1             3                8
SVT ablation                                                         4                1             3                8
VT ablation                                                          4           -                  3                7
Balloon valvuloplasty                                                4                1         -                    5
Percutaneous valve replacement                                  -                -              -               -
Group cardiac rehabilitation (post coronary event)                  9                10             4               23
Individual rehabilitation (post coronary event)                     5                 6             2               13
Rehabilitation for Heart Failure patients                           9                 8             2               19
Stress Echo                                                         9                 3             3               15
Dobutamine Stress Echo                                              9                 3             2               14
Nuclear Medicine Stress testing                                     9                 5             1               15
Cardiac MRI                                                         3            -              -                    3
CT Coronary Angiography                                             5                 1         -                    6
Coronary Bypass Graft Surgery                                       5                 1             2                8
Aortic Surgery                                                      5                 1             3                9
Valve Repair or Replacement Surgery                                 5                 1             2                8
Congenital heart disease clinics                                    2            -                  1                3




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Survey results




Service                                              Metro        Rural        Private       Total
Emergency care                                           100.00%        94.44%       25.00%        80.56%
Chest pain assessment area in ED                           70.00%       61.11%       12.50%        52.78%
Cardiac surgery                                            50.00%        5.56%       25.00%        22.22%
CCU                                                        90.00%       38.89%       87.50%        63.89%
ICU                                                        90.00%       27.78%       50.00%        50.00%
HDU                                                        70.00%       50.00%       75.00%        61.11%
Day hospital places                                        70.00%       33.33%       75.00%        52.78%
Step down facilities                                       70.00%       16.67%       37.50%        36.11%
Electrophysiology labs                                     50.00%       11.11%       25.00%        25.00%
Catheterization lab                                        90.00%       11.11%       87.50%        50.00%
Coronary angiography                                       90.00%       11.11%       87.50%        50.00%
Angioplasty                                                90.00%        5.56%       62.50%        41.67%
Elective PCI                                               90.00%        5.56%       62.50%        41.67%
Primary PCI                                                90.00%        5.56%       62.50%        41.67%
Pacemaker insertion                                        90.00%       27.78%       87.50%        58.33%
AICD insertion                                             90.00%       16.67%       87.50%        52.78%
Biventricular pacemaker                                    90.00%       11.11%       87.50%        50.00%
AF ablation                                                40.00%        5.56%       37.50%        22.22%
SVT ablation                                               40.00%        5.56%       37.50%        22.22%
VT ablation                                                40.00%        0.00%       37.50%        19.44%
Balloon valvuloplasty                                      40.00%        5.56%         0.00%       13.89%
Percutaneous valve replacement                              0.00%        0.00%         0.00%        0.00%
Group cardiac rehabilitation (post coronary event)         90.00%       55.56%       50.00%        63.89%
Individual rehabilitation (post coronary event)            50.00%       33.33%       25.00%        36.11%
Rehabilitation for Heart Failure patients                  90.00%       44.44%       25.00%        52.78%
Stress Echo                                                90.00%       16.67%       37.50%        41.67%
Dobutamine Stress Echo                                     90.00%       16.67%       25.00%        38.89%
Nuclear Medicine Stress testing                            90.00%       27.78%       12.50%        41.67%
Cardiac MRI                                                30.00%        0.00%         0.00%        8.33%
CT Coronary Angiography                                    50.00%        5.56%         0.00%       16.67%
Coronary Bypass Graft Surgery                              50.00%        5.56%       25.00%        22.22%
Aortic Surgery                                             50.00%        5.56%       37.50%        25.00%
Valve Repair or Replacement Surgery                        50.00%        5.56%       25.00%        22.22%
Congenital heart disease clinics                           20.00%        0.00%       12.50%         8.33%

                                                           Metro       Rural         Private       Total
Cardiologists                                                    42             4              7        53
Interventional cardiologists                                     10             1              3        14
Cardiac surgeons                                                 15             2              1        18
Registrars                                                       17             6              3        26
Accredited trainee post (1 year)                                 10         -             -             10
Accredited trainee post (2 year)                                 15             3         -             18
Electrophysiology                                                 3         -             -              3
Intervention                                                     10         -             -             10
echo                                                              4         -             -              4
other                                                             5         -                  1         6
non accredited trainee positions                                 10              1        -             11
Physicians with an interest in cardiology                      -                 6          4           10
Specialist nurses                                              169              71        106          346
Perfusionists                                                    11              3          1           14
Technicians                                                      47             26          3           76
Electrophysiologists                                              4              5          1           10
Dedicated Allied health physiotherapists                          6              2          4           12
Dedicated Allied health occupational therapists                   1              0          1            2
Dedicated Allied health Other                                     3              0          1            3
Nurse Practitioners                                            -            -              22           22
Clinical Nurse Consultants                                        5           3             3           11
Case Managers                                                     4         -               2            6
Total                                                          391          134           160          685




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Survey results




Total Outpatient Activity                               Metro           Rural           Private         Total
Cardiology Outpatient Services
   Cardiology General                                       24,838          16,222                -         41,060
   Cardiology Subspecialty                                  12,991             152                -         13,143
   Pacemaker Clinic                                          8,517           4,019                -         12,536
   Heart Failure                                             4,669             106                -          4,775
Cardiology Outpatients Subtotal                             51,015          20,499                -         71,514
Cardiac Surgery Outpatient Services
   Outpatients                                                  3,114             577             -             3,691
   Preadmission                                                 2,846             200             450           3,496
   Same day angioplasty                                         1,504             682             450           2,636
   Catheterisation lab                                          2,372           1,511             -             3,883
Cardiac Surgery Outpatients Subtotal                            5,960             777             450           7,187
Diagnostic Outpatient Tests
   Exercise ECG                                              5,743           5,337             864          11,944
   Stress Echo                                               5,061             750               16          5,827
   Dobutamine stress Echo                                      594               45            996           1,635
   Transthoracic echo                                       24,615           8,687             128          33,430
   Transoesophageal echo                                     1,726           1,155             -             2,881
   Holter monitoring                                         6,512           5,173             -            11,685
   Event monitoring                                            239             252             -               491
   ECG                                                      46,474          11,786             -            58,260
   Ambulatory BP                                               709           2,110             -             2,819
   Nuclear cardiology                                       12,734             500             450          13,684
   Coronary angiography                                      8,323             174             -             8,497
   Cardiac CT                                                  277             -               -               277
   Cardiac MR                                                  387             -               -               387
   Other                                                       157             210             -               367
Diagnostic Outpatient Tests Subtotal                       113,551          36,179           2,454         152,184
Rehabilitation services
   Group cardiac rehabilitation (post coronary event)       12,556           2,919             987          16,462
   Individual rehabilitation (post coronary event)           4,796           1,963             106           6,865
   Rehabilitation for Heart Failure patients                 4,412             384             -             4,796
Rehabilitation services Subtotal                            21,764           5,266           1,093          28,123
Grand Total                                                192,290          62,721           3,997         259,008




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Appendix N                                  Average length of stay by hospital
Sameday percentages and average length of stay for multiday proportions are shown by hospital in the
following tables for the ten major hospitals as described in Appendix H.
                                                                                                      Hospital 1                                Hospital 2

                                                                                                       Multi-day Average                        Multi-day Average
MCRG                       DRG                                                             % SD         ALOS     complex.               % SD     ALOS     complex.
Cardiology                 Chest Pain                                                           47%            1.5           1.4          49%         1.5      1.5
Interventional
Cardiology                 Circ Dis No AMI W Card Inv No Comp Dx/Pr                             21%            2.8           1.6          85%         2.7      1.4
Cardiology                 Non-Maj Arrhythmia+ Conduct Dis No C/S CC                            51%            2.2           1.3          45%           2      1.5
Cardiology                 Heart Failure & Shock no Catastrophic CC                             30%            4.7           2.2          23%         5.1      2.5
Cardiology                 Unstable Angina W/O Catastroph/Severe CC                             55%            1.7           1.3          19%         2.2      1.5
Interventional
Cardiology                 Percut Coron Angioplasty W/O AMI W Stent                              0%            2.2           1.4           1%         1.7      1.6
Interventional
Cardiology                 Percutaneous Coronary Angioplasty W AMI                               0%            4.2           1.7           1%         4.2      1.8
Interventional
Cardiology                 Circ Dis No AMI + Inv Card Inv Pr+ Cx Dx/Pr                           1%            4.7           1.9          45%         4.6      1.8
Cardiology                 Heart Failure & Shock W Catastrophic CC                               1%            8.8           4.4           0%        12.9        5
Cardiology                 Coronary Atherosclerosis W/O CC                                      47%            1.4           1.2          53%         1.4      1.2
Cardiothoracic Surgery     Coron Bypass No Inv Card Inv Pr W C/S CC
Interventional
Cardiology                 Cardiac Pacemaker Implantation                                        4%            4.2           1.8           0%         3.7      2.3
Cardiology                 Oth Circulatory Sys Diags W/O Cat/Sev CC                             39%            2.5           1.4          57%         2.8        2
Cardiology                 Circ Dis W AMI No Inv Card Inv Pr+C/S CC                              6%            7.4           3.5           0%         8.6      3.9
Cardiology                 Non-Maj Arrhythmia + Conduct Dis W C/S CC                            14%            6.5           3.3           2%         5.6      3.5
Cardiology                 Circ Dis + AMI W/O Card Inv W/O Cat/Sev CC                           46%            3.4           1.4          12%         3.4      1.7
Cardiology                 Venous Thrombosis W/O Catast/Severe CC                               12%            1.5           1.4          33%         2.1      1.3
Interventional
Cardiology                 Circ Dis W AMI W Inv Car Inv Pr NoC/S CC                              4%            4.6           1.5          10%         4.2      1.5
Cardiology                 Valvular Disorders W/O Catast/Severe CC                              58%            1.7           1.3          73%         3.4      1.3
Interventional
Cardiology                 Circ Dis W AMI W Inv Card Inv Pr+ C/S CC                              4%            7.2           2.2           1%         6.9      2.8
Cardiology                 Coronary Atherosclerosis W CC                                        35%            2.8           2.4          28%         2.7      2.4
Cardiothoracic Surgery     Card Valve Pr + Pump No Inv Inv Pr+ C/S CC
Cardiology                 Unstable Angina W Catastrophic/Severe CC                             27%            4.7             3           7%         4.2        3
Cardiology                 Maj Arrhythmia + Cardiac Arr No Cat/Sev CC                           43%            3.1           1.4          46%         3.2      1.5
Cardiothoracic Surgery     Major Chest Procedures W Catastrophic CC                                                          4.6           4%        19.8      4.9

          (1)   Best practice hospital is shaded and highlighted in bold and had to have more than 20 separations in the selected DRG
          (2)   ALOS excludes HITH length of stay




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                                                     173
Average length of stay by hospital




                                                                                                      Hospital 3                                 Hospital 4

                                                                                                       Multi-day Average                         Multi-day Average
MCRG                       DRG                                                             % SD         ALOS     complex.               % SD      ALOS     complex.
Cardiology                 Chest Pain                                                           61%            1.4           1.5           45%         1.4      1.5
Interventional
Cardiology                 Circ Dis No AMI W Card Inv No Comp Dx/Pr                             40%            2.6           1.7           15%         1.3      1.6
Cardiology                 Non-Maj Arrhythmia+ Conduct Dis No C/S CC                            58%            1.9           1.4           41%         1.6      1.5
Cardiology                 Heart Failure & Shock no Catastrophic CC                             42%            3.4           2.3           22%         3.4      2.5
Cardiology                 Unstable Angina W/O Catastroph/Severe CC                             52%            2.1           1.4           29%         1.9      1.5
Interventional
Cardiology                 Percut Coron Angioplasty W/O AMI W Stent                              9%            2.3           1.8            0%         1.8      1.8
Interventional
Cardiology                 Percutaneous Coronary Angioplasty W AMI                              21%            5.2           2.1            1%         5.3      2.2
Interventional
Cardiology                 Circ Dis No AMI + Inv Card Inv Pr+ Cx Dx/Pr                          19%            6.2           2.3           15%         2.4      1.8
Cardiology                 Heart Failure & Shock W Catastrophic CC                               1%            8.4           4.8            1%         9.1      4.8
Cardiology                 Coronary Atherosclerosis W/O CC                                      63%            1.3           1.1           55%         1.1      1.3
Cardiothoracic Surgery     Coron Bypass No Inv Card Inv Pr W C/S CC                              0%            8.4           3.1            0%         8.7      3.7
Interventional
Cardiology                 Cardiac Pacemaker Implantation                                       51%            6.5           1.9            0%         3.1      2.1
Cardiology                 Oth Circulatory Sys Diags W/O Cat/Sev CC                             52%              2           1.8           48%         2.8      1.9
Cardiology                 Circ Dis W AMI No Inv Card Inv Pr+C/S CC                              9%            7.8           4.3            3%         7.3        4
Cardiology                 Non-Maj Arrhythmia + Conduct Dis W C/S CC                            19%            5.3           3.6            6%         4.7      3.2
Cardiology                 Circ Dis + AMI W/O Card Inv W/O Cat/Sev CC                           59%            2.7           1.5           47%         3.5      1.6
Cardiology                 Venous Thrombosis W/O Catast/Severe CC                               19%              1           1.5           12%         0.6      1.4
Interventional
Cardiology                 Circ Dis W AMI W Inv Car Inv Pr NoC/S CC                             58%            4.8           1.4            2%         3.4      1.4
Cardiology                 Valvular Disorders W/O Catast/Severe CC                              66%            0.9           1.5           79%           1      1.3
Interventional
Cardiology                 Circ Dis W AMI W Inv Card Inv Pr+ C/S CC                             19%            8.2           3.2            2%         5.2      2.6
Cardiology                 Coronary Atherosclerosis W CC                                        50%            1.8           2.2           30%         2.2      2.5
Cardiothoracic Surgery     Card Valve Pr + Pump No Inv Inv Pr+ C/S CC                            0%           10.4           3.6            0%        10.5      4.1
Cardiology                 Unstable Angina W Catastrophic/Severe CC                             15%            4.5           3.3            5%         4.1      3.2
Cardiology                 Maj Arrhythmia + Cardiac Arr No Cat/Sev CC                           70%            2.4           1.5           53%           3      1.4
Cardiothoracic Surgery     Major Chest Procedures W Catastrophic CC                              0%           13.3           4.8            0%        11.4      5.1

          (1)   Best practice hospital is shaded and highlighted in bold and had to have more than 20 separations in the selected DRG
          (2)   ALOS excludes HITH length of stay



                                                                                                      Hospital 5                                 Hospital 6

                                                                                                       Multi-day Average                                  Average
MCRG                       DRG                                                             % SD         ALOS     complex.               % SD ulti-day ALOcomplex.
Cardiology                 Chest Pain                                                         47%              1.3           1.8           59%        1.3      1.5
Interventional
Cardiology                 Circ Dis No AMI W Card Inv No Comp Dx/Pr                             68%            2.2           1.8          48%          2.4      1.5
Cardiology                 Non-Maj Arrhythmia+ Conduct Dis No C/S CC                            43%            2.1           1.8          43%          2.5      1.5
Cardiology                 Heart Failure & Shock no Catastrophic CC                             21%            3.5           2.8          23%          5.1      2.4
Cardiology                 Unstable Angina W/O Catastroph/Severe CC                             27%            1.6           1.7          48%          1.8      1.5
Interventional
Cardiology                 Percut Coron Angioplasty W/O AMI W Stent                              1%            2.1           2.1            0%         1.4      1.6
Interventional
Cardiology                 Percutaneous Coronary Angioplasty W AMI                               0%            4.8           2.6            0%         2.8      1.8
Interventional
Cardiology                 Circ Dis No AMI + Inv Card Inv Pr+ Cx Dx/Pr                          27%            5.3           2.4          14%            4        2
Cardiology                 Heart Failure & Shock W Catastrophic CC                               4%            7.6           5.1           0%          9.3      5.1
Cardiology                 Coronary Atherosclerosis W/O CC                                      57%            1.2           1.3          87%          1.3      1.1
Cardiothoracic Surgery     Coron Bypass No Inv Card Inv Pr W C/S CC                              0%            8.3             4           0%         10.4      3.2
Interventional
Cardiology                 Cardiac Pacemaker Implantation                                        3%            6.1           2.8           2%          3.9        2
Cardiology                 Oth Circulatory Sys Diags W/O Cat/Sev CC                             73%            2.4           1.6          54%          3.2      2.1
Cardiology                 Circ Dis W AMI No Inv Card Inv Pr+C/S CC                              6%            6.3           4.5           0%          7.5      3.8
Cardiology                 Non-Maj Arrhythmia + Conduct Dis W C/S CC                            12%            4.1           3.8          11%          5.7      3.5
Cardiology                 Circ Dis + AMI W/O Card Inv W/O Cat/Sev CC                           27%            2.8             2          18%          3.7      1.9
Cardiology                 Venous Thrombosis W/O Catast/Severe CC                               21%            1.1           1.5          23%            1      1.3
Interventional
Cardiology                 Circ Dis W AMI W Inv Car Inv Pr NoC/S CC                              7%            3.2           2.1           7%          2.4      1.4
Cardiology                 Valvular Disorders W/O Catast/Severe CC                              57%            1.5           1.5          83%          3.1      1.3
Interventional
Cardiology                 Circ Dis W AMI W Inv Card Inv Pr+ C/S CC                              0%            6.1           3.3           3%          3.9      2.8
Cardiology                 Coronary Atherosclerosis W CC                                        24%            2.4           2.8          45%          2.8      2.3
Cardiothoracic Surgery     Card Valve Pr + Pump No Inv Inv Pr+ C/S CC                            0%           12.5           5.2           0%         14.1      4.1
Cardiology                 Unstable Angina W Catastrophic/Severe CC                             15%            2.5           3.7          24%            5      3.1
Cardiology                 Maj Arrhythmia + Cardiac Arr No Cat/Sev CC                           52%            2.7             2          52%          1.7      1.5
Cardiothoracic Surgery     Major Chest Procedures W Catastrophic CC                              2%           17.6           5.3           0%         18.9      5.5

          (1)   Best practice hospital is shaded and highlighted in bold and had to have more than 20 separations in the selected DRG
          (2)   ALOS excludes HITH length of stay




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                                                      174
Average length of stay by hospital




                                                                                                      Hospital 7                                 Hospital 8

                                                                                                       Multi-day Average                         Multi-day Average
MCRG                       DRG                                                             % SD         ALOS     complex.               % SD      ALOS     complex.
Cardiology                 Chest Pain                                                         57%              1.3           1.4           55%          1.3     1.4
Interventional
Cardiology                 Circ Dis No AMI W Card Inv No Comp Dx/Pr                             81%            3.7           1.4          52%           2.3     1.6
Cardiology                 Non-Maj Arrhythmia+ Conduct Dis No C/S CC                            41%            2.4           1.6          42%           1.7     1.5
Cardiology                 Heart Failure & Shock no Catastrophic CC                             21%            5.4           2.6          26%           3.8     2.3
Cardiology                 Unstable Angina W/O Catastroph/Severe CC                             28%            2.7           1.6          39%           1.8     1.5
Interventional
Cardiology                 Percut Coron Angioplasty W/O AMI W Stent                                                                        0%           1.5     1.9
Interventional
Cardiology                 Percutaneous Coronary Angioplasty W AMI                                                                         2%           3.8     2.3
Interventional
Cardiology                 Circ Dis No AMI + Inv Card Inv Pr+ Cx Dx/Pr                          32%            5.8           1.9          17%           3.6     2.2
Cardiology                 Heart Failure & Shock W Catastrophic CC                               2%           10.1           4.8           1%          10.3     4.5
Cardiology                 Coronary Atherosclerosis W/O CC                                      59%            1.3           1.1          67%           1.2     1.1
Cardiothoracic Surgery     Coron Bypass No Inv Card Inv Pr W C/S CC
Interventional
Cardiology                 Cardiac Pacemaker Implantation                                        0%            3.1           2.1           1%           4.9     2.1
Cardiology                 Oth Circulatory Sys Diags W/O Cat/Sev CC                             40%            2.9           1.5          43%             2     1.5
Cardiology                 Circ Dis W AMI No Inv Card Inv Pr+C/S CC                              6%            9.7           4.2           4%             7       4
Cardiology                 Non-Maj Arrhythmia + Conduct Dis W C/S CC                             5%            6.8           3.4           8%           5.8     3.6
Cardiology                 Circ Dis + AMI W/O Card Inv W/O Cat/Sev CC                           44%            3.1           1.5          28%           2.8     1.6
Cardiology                 Venous Thrombosis W/O Catast/Severe CC                               12%            1.6           1.4          10%           0.9     1.4
Interventional
Cardiology                 Circ Dis W AMI W Inv Car Inv Pr NoC/S CC                              5%            4.9           1.6          29%           3.3     1.4
Cardiology                 Valvular Disorders W/O Catast/Severe CC                              63%            4.7           1.4          71%             1     1.4
Interventional
Cardiology                 Circ Dis W AMI W Inv Card Inv Pr+ C/S CC                              0%            6.3           2.9           6%             5     2.8
Cardiology                 Coronary Atherosclerosis W CC                                        44%            3.3           2.3          47%           2.6     2.2
Cardiothoracic Surgery     Card Valve Pr + Pump No Inv Inv Pr+ C/S CC
Cardiology                 Unstable Angina W Catastrophic/Severe CC                              3%            4.7           3.7           8%           4.8     3.3
Cardiology                 Maj Arrhythmia + Cardiac Arr No Cat/Sev CC                           46%            2.5           1.8          67%           2.8     1.5
Cardiothoracic Surgery     Major Chest Procedures W Catastrophic CC                                                          5.5           0%            13     4.6

          (1)   Best practice hospital is shaded and highlighted in bold and had to have more than 20 separations in the selected DRG
          (2)   ALOS excludes HITH length of stay



                                                                                                      Hospital 9                                 Hospital 10

                                                                                                       Multi-day Average                         Multi-day Average
MCRG                       DRG                                                             % SD         ALOS     complex.               % SD      ALOS     complex.
Cardiology                 Chest Pain                                                           63%            1.2           1.4           37%          1.3     1.5
Interventional
Cardiology                 Circ Dis No AMI W Card Inv No Comp Dx/Pr                             28%            1.8           1.6          79%           2.7     1.5
Cardiology                 Non-Maj Arrhythmia+ Conduct Dis No C/S CC                            57%            1.8           1.4          51%           2.1     1.3
Cardiology                 Heart Failure & Shock no Catastrophic CC                             25%            4.6           2.7          34%             5     2.4
Cardiology                 Unstable Angina W/O Catastroph/Severe CC                             48%            1.8           1.4          28%           1.8     1.4
Interventional
Cardiology                 Percut Coron Angioplasty W/O AMI W Stent                              1%            1.8           1.9           2%           2.1     1.7
Interventional
Cardiology                 Percutaneous Coronary Angioplasty W AMI                               1%            3.1           2.1           1%           6.2     2.2
Interventional
Cardiology                 Circ Dis No AMI + Inv Card Inv Pr+ Cx Dx/Pr                           4%            3.1           1.9          41%           6.3     1.8
Cardiology                 Heart Failure & Shock W Catastrophic CC                               1%            9.8           5.3           2%            11     4.6
Cardiology                 Coronary Atherosclerosis W/O CC                                      64%            1.1           1.1          36%           1.2     1.2
Cardiothoracic Surgery     Coron Bypass No Inv Card Inv Pr W C/S CC                              0%            8.5           3.8           0%           9.7     3.6
Interventional
Cardiology                 Cardiac Pacemaker Implantation                                       22%            5.4           2.3           1%           7.4     2.4
Cardiology                 Oth Circulatory Sys Diags W/O Cat/Sev CC                             55%              3           1.6          36%           2.6     1.7
Cardiology                 Circ Dis W AMI No Inv Card Inv Pr+C/S CC                              2%            6.9           4.7           7%           8.8     3.7
Cardiology                 Non-Maj Arrhythmia + Conduct Dis W C/S CC                            11%            6.2           4.1          15%           5.9     3.3
Cardiology                 Circ Dis + AMI W/O Card Inv W/O Cat/Sev CC                           38%            2.8           1.8          27%           3.6     1.6
Cardiology                 Venous Thrombosis W/O Catast/Severe CC                               17%            2.2           1.5           9%           2.5     1.5
Interventional
Cardiology                 Circ Dis W AMI W Inv Car Inv Pr NoC/S CC                              2%            3.5           1.6          12%           5.3     1.6
Cardiology                 Valvular Disorders W/O Catast/Severe CC                              61%            1.3           1.5          46%           1.9     1.4
Interventional
Cardiology                 Circ Dis W AMI W Inv Card Inv Pr+ C/S CC                              0%            5.9           3.5           6%           7.6     2.9
Cardiology                 Coronary Atherosclerosis W CC                                        46%            2.6           2.6          30%           2.4     2.3
Cardiothoracic Surgery     Card Valve Pr + Pump No Inv Inv Pr+ C/S CC                            0%           11.3           3.9           0%          11.1       4
Cardiology                 Unstable Angina W Catastrophic/Severe CC                              9%            3.4           3.9           9%           5.1     3.4
Cardiology                 Maj Arrhythmia + Cardiac Arr No Cat/Sev CC                           71%            2.3           1.4          23%           1.8     1.4
Cardiothoracic Surgery     Major Chest Procedures W Catastrophic CC                              0%           13.6           5.1           0%          17.2     5.2

          (1)   Best practice hospital is shaded and highlighted in bold and had to have more than 20 separations in the selected DRG
          (2)   ALOS excludes HITH length of stay




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                                                      175
Appendix O                                        Public hospital admissions by CRG, hospital
                                                  region and patient region
Appendix P.1         Public hospital Chest Pain admissions by hospital region and patient region

                                                                                  Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians         Hume          Loddon_Mallee     North_West_Metro    Southern_Metro     Total       own region   other
      Barwon-SW             1,667                8             3                11               3                  1                 25                   1       1,719        1,667        52
    Eastern Metro               8            3,011             5                 3               9                  3                374                 112       3,525        3,011       514
       Gippsland                1               13           732                 1               2               -                    12                  37         798          732        66
      Grampians                31                4             1             578                 1                 25                 42                   1         683          578       105
         Hume                   2               14             1                 1           1,099                 15                 95                   5       1,232        1,099       133
       Interstate              10               22             7                 4              69                 87                110                  24         333                    333
    Loddon Mallee               6                4             3                12              38              964                  103                   2       1,132         964        168
  North-West Metro             28               55             5                 6              12                  9              5,598                  20       5,733       5,598        135
   Southern Metro               9              835            11              -                  8                  5                737               2,664       4,269       2,664      1,605
          Total             1,762            3,966           768             616             1,241            1,109                7,096               2,866      19,424      16,313      3,111
own region                  1,667            3,011           732             578             1,099              964                5,598               2,664      16,313
other                          95              955            36                38             142              145                1,498                 202       3,111


Appendix P.2         Public hospital Unstable Angina admissions by hospital region and patient region

                                                                                  Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians         Hume          Loddon_Mallee     North_West_Metro    Southern_Metro     Total       own region   other
      Barwon-SW               439                 1               1               4            -                 -                      6                  1         452         439         13
    Eastern Metro                2            570            -                    2               4                 3                 88                  28         697         570        127
       Gippsland              -                   3          529              -                -                    1                   9                 28         570         529         41
      Grampians                  5             -             -                354                 1                 6                   5                  1         372         354         18
         Hume                 -                   4          -                   1            464                -                    28                   2         499         464         35
       Interstate                2                3             2                2               23                25                 15                  13          85                     85
    Loddon Mallee             -                   1          -                   9               22             470                   21                   2         525         470         55
  North-West Metro               6               13             4                1                2                 3              1,271                  10       1,310       1,271         39
   Southern Metro                2            255               9                2                2              -                   100               1,257       1,627       1,257        370
          Total               456             850            545              375             518               508                1,543               1,342       6,137       5,354        783
own region                    439             570            529              354             464               470                1,271               1,257       5,354
other                           17            280              16               21               54                38                272                  85         783


Appendix P.3         Public hospital Heart Failure and Shock admissions by hospital region and patient region

                                                                                  Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians         Hume          Loddon_Mallee     North_West_Metro    Southern_Metro     Total       own region   other
      Barwon-SW               693              -                1                 1            -                 -                      4                -           699         693          6
    Eastern Metro                1             914              2                 1            -                 -                   171                  44       1,133         914        219
       Gippsland                 3                3          483              -                   1              -                    10                  14         514         483         31
      Grampians                  8             -             -                322              -                    1                 20                 -           351         322         29
         Hume                    1                5             1             -               572                   4                 21                 -           604         572         32
       Interstate                3                8             3                2               23                38                 17                   8         102                    102
    Loddon Mallee                1             -             -                   9               14             544                   30                 -           598         544         54
  North-West Metro               3               11             1                3                4                 3              2,479                  15       2,519       2,479         40
   Southern Metro             -                297             11                1             -                    4                333              1,105        1,751       1,105        646
          Total               713            1,238           502              339             614               594                3,085              1,186        8,271       7,112      1,159
own region                    693              914           483              322             572               544                2,479              1,105        7,112
other                           20             324             19               17               42                50                606                  81       1,159


Appendix P.4         Public hospital Non-Major Arrhythmia and Conduction Disorders admissions by hospital region and patient region

                                                                                  Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians         Hume          Loddon_Mallee     North_West_Metro    Southern_Metro     Total       own region   other
      Barwon-SW               771                2            -                   8            -                    2                 11                 -           794          771        23
    Eastern Metro                5           1,101              6             -                   5                 2                184                  32       1,335        1,101       234
       Gippsland                 2              12           613              -                -                 -                    17                  16         660          613        47
      Grampians                 10               1           -                365                 1                 8                 14                 -           399          365        34
         Hume                 -                  8           -                   1            750                   5                 34                 -           798          750        48
       Interstate                9              17              4                7               40                57                 57                  20         211                    211
    Loddon Mallee                1               3              1               11               25             555                   54                   2         652         555         97
  North-West Metro               8              24              3                4                4                 4              2,110                  15       2,172       2,110         62
   Southern Metro                3             355             16                2                2                 5                356              1,222        1,961       1,222        739
          Total               809            1,523           643              398             827               638                2,837              1,307        8,982       7,487      1,495
own region                    771            1,101           613              365             750               555                2,110              1,222        7,487
other                           38             422             30               33               77                83                727                  85       1,495


Appendix P.5         Public hospital AMI W/O Invasive Cardiac Inves Pro admissions by hospital region and patient region

                                                                                  Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians         Hume          Loddon_Mallee     North_West_Metro    Southern_Metro     Total       own region   other
      Barwon-SW               432                3            -                   1              4                  2                   6                  3         451         432         19
    Eastern Metro                5            686               2             -                  5                  3                 82                  43         826         686        140
       Gippsland              -                  2           393                 3               1               -                      5                 42         446         393         53
      Grampians                  6               2           -                275                1                  9                   5                -           298         275         23
         Hume                 -                  5           -                -               468                   7                 17                   3         500         468         32
       Interstate                3               5              1                3              36                 59                 26                   6         139                    139
    Loddon Mallee                1               4              2                8              23              468                   28                   1         535         468         67
  North-West Metro               3              16              2                4               9                  4              1,260                  15       1,313       1,260         53
   Southern Metro                2            215              11                1               2               -                   263               1,032       1,526       1,032        494
          Total               452             938            411              295             549               552                1,692               1,145       6,034       5,014      1,020
own region                    432             686            393              275             468               468                1,260               1,032       5,014
other                           20            252              18               20              81                 84                432                 113       1,020


Appendix P.6         Public hospital Other Cardiology admissions by hospital region and patient region

                                                                                  Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians         Hume          Loddon_Mallee     North_West_Metro    Southern_Metro     Total       own region   other
      Barwon-SW             1,096                8            -                 9                1                 3                  74                   1       1,192        1,096        96
    Eastern Metro                7           1,431              4               2                2                 3                 402                  61       1,912        1,431       481
       Gippsland              -                 33           759                1                3                 1                  73                  29         899          759       140
      Grampians                 13               2           -                567                1                18                  75                   2         678          567       111
         Hume                    2               7              1               2             805                 12                 129                   4         962          805       157
       Interstate               13              17              6               7               48                61                 105                  18         275                    275
    Loddon Mallee                1               4           -                 16               23              879                  128                   4       1,055         879        176
  North-West Metro              12              28              5               3                6                 7               3,284                  18       3,363       3,284         79
   Southern Metro                5             566             15               3                4                 5                 509               1,716       2,823       1,716      1,107
          Total             1,149            2,096           790              610             893               989                4,779               1,853      13,159      10,537      2,622
own region                  1,096            1,431           759              567             805               879                3,284               1,716      10,537
other                           53             665             31              43               88              110                1,495                 137       2,622




PricewaterhouseCoopers | Cardiac Services Framework for Victoria                                                                                                                                  176
Public hospital admissions by CRG, hospital region and patient region




Appendix P.7         Public hospital Invasive Cardiac Inves Pro admissions by hospital region and patient region

                                                                                  Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians         Hume         Loddon_Mallee     North_West_Metro   Southern_Metro       Total       own region    other
      Barwon-SW               884                3            -                 37             -                   1                 82                -           1,007         884         123
    Eastern Metro                1            505             -               -                -                -                   289                 8            803         505         298
       Gippsland              -                 74                1           -                -                -                   192                21            288            1        287
      Grampians                 51               7           -               282               -                   7                112                 1            460         282         178
         Hume                    1               8           -                -                  1                11                432               -              453            1        452
       Interstate                5              13           -                   2             -                  48                179                 6            253                     253
    Loddon Mallee                4              12           -                  30             -               649                  205               -              900          649        251
  North-West Metro              28              23           -                -                -                   1              3,057                 1          3,110        3,057          53
   Southern Metro                4            279            -                   1             -                -                   451               432          1,167          432        735
          Total               978             924                 1          352                 1             717                4,999               469          8,441        5,811      2,630
own region                    884             505                 1          282                 1             649                3,057               432          5,811
other                           94            419            -                  70             -                  68              1,942                37          2,630


Appendix P.8         Public hospital Percutaneous Coronary Angioplasty admissions by hospital region and patient region

                                                                                   Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians          Hume        Loddon_Mallee     North_West_Metro   Southern_Metro       Total       own region    other
      Barwon-SW               125                1            -               -                 -               -                    28                -             154         125          29
    Eastern Metro                1            307             -               -                 -               -                    64                    1         373         307          66
       Gippsland                 1              48                1           -                 -               -                    60                    4         114            1        113
      Grampians                  8               5           -                    1             -               -                    64                -              78            1         77
         Hume                 -                  4           -                -                 -               -                    90                    1          95          -           95
       Interstate                3              11           -                -                 -               -                    72                    2          88                      88
    Loddon Mallee                1               6           -                -                 -                 1                 114                -             122            1        121
  North-West Metro               6              20           -                -                 -               -                   774                 3            803          774         29
   Southern Metro                1            252            -                -                 -               -                   157               129            539          129        410
          Total               146             654                 1               1             -                 1               1,423               140          2,366        1,338      1,028
own region                    125             307                 1               1             -                 1                 774               129          1,338
other                           21            347            -                -                 -               -                   649                11          1,028


Appendix P.9         Public hospital Percutaneous Coronary Angioplasty W/O AMI W Stent Implantation admissions by hospital region and patient region

                                                                                  Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians         Hume         Loddon_Mallee     North_West_Metro   Southern_Metro       Total       own region    other
      Barwon-SW               100                2            -               -                -                -                    20                -             122         100          22
    Eastern Metro             -               217             -               -                -                -                    79                -             296         217          79
       Gippsland              -                 73            -               -                -                -                    57                    9         139          -          139
      Grampians                  9               1            -               -                -                -                    91                -             101          -          101
         Hume                 -                  5            -               -                -                -                   136                -             141          -          141
       Interstate             -                  3            -               -                -                -                    49                 1             53                      53
    Loddon Mallee                1               1            -               -                -                  2                 225               -              229            2        227
  North-West Metro               7              15            -               -                -                -                   749               -              771          749         22
   Southern Metro             -               226             -               -                -                -                    97               150            473          150        323
          Total               117             543             -               -                -                  2               1,503               160          2,325        1,218      1,107
own region                    100             217             -               -                -                  2                 749               150          1,218
other                           17            326             -               -                -                -                   754                10          1,107


Appendix P.10        Public hospital Other Interventional Cardiology admissions by hospital region and patient region

                                                                                  Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians         Hume         Loddon_Mallee     North_West_Metro   Southern_Metro       Total       own region    other
      Barwon-SW               192                3            -                   2            -                -                    19                -             216         192          24
    Eastern Metro                1            188             -               -                -                -                   143                    1         333         188         145
       Gippsland                 1              77            -               -                -                -                    90                    3         171          -          171
      Grampians                  6               2            -                 74             -                -                    25               -              107            74        33
         Hume                 -                  4            -               -                  1              -                   135               -              140             1       139
       Interstate             -                  9            -               -                  1                12                 61               -               83                      83
    Loddon Mallee             -                  1            -                  7             -               113                   45               -              166          113         53
  North-West Metro               7              12            -                  1             -                -                   634               -              654          634         20
   Southern Metro             -               158             -               -                -                -                   161               121            440          121        319
          Total               207             454             -                 84               2             125                1,313               125          2,310        1,323        987
own region                    192             188             -                 74               1             113                  634               121          1,323
other                           15            266             -                 10               1                12                679                 4            987


Appendix P.11        Public hospital Coronary Bypass admissions by hospital region and patient region

                                                                                  Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians         Hume         Loddon_Mallee     North_West_Metro   Southern_Metro       Total       own region    other
      Barwon-SW               246              -              -               -                -                -                    18                -             264         246          18
    Eastern Metro             -                  45           -               -                -                -                   161                -             206            45       161
       Gippsland              -                  57           -               -                -                -                    65                -             122          -          122
      Grampians                 24             -              -               -                -                -                    60                -              84          -           84
         Hume                 -                   2           -               -                -                -                   108                -             110          -          110
       Interstate                1                2           -               -                -                -                    32                -              35                      35
    Loddon Mallee                2             -              -               -                -                -                    91                -              93          -           93
  North-West Metro               7                1           -               -                -                -                   484                -             492          484          8
   Southern Metro             -               196             -               -                -                -                   183                -             379          -          379
          Total               280             303             -               -                -                -                 1,202                -           1,785          775      1,010
own region                    246                45           -               -                -                -                   484                -             775
other                           34            258             -               -                -                -                   718                -           1,010


Appendix P.12        Public hospital Other Cardiothoracic Surgery admissions by hospital region and patient region

                                                                                  Hospital Region
   Patient Region     Barwon_SW      Eastern_Metro    Gippsland       Grampians         Hume         Loddon_Mallee     North_West_Metro   Southern_Metro       Total       own region    other
      Barwon-SW               161                1            -               -                -                -                    43                -             205         161          44
    Eastern Metro             -               143             -               -                -                -                   132                    2         277         143         134
       Gippsland              -                 32                5           -                -                -                    74                    1         112            5        107
      Grampians                  7               2           -                  26             -                -                    41                -              76           26         50
         Hume                    1               3           -                -                  2              -                    87                -              93            2         91
       Interstate                1               5           -                -                -                   3                 44                -              53                      53
    Loddon Mallee             -                  4           -                -                -                  36                 66                -             106           36         70
  North-West Metro               4               2           -                -                -                -                   527                -             533          527          6
   Southern Metro             -               155            -                -                -                -                   194                 55           404           55        349
          Total               174             347                 5             26               2                39              1,208                 58         1,859          955        904
own region                    161             143                 5             26               2                36                527                 55           955
other                           13            204            -                -                -                   3                681                  3           904




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Appendix P                Data survey




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Data survey




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Data survey




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