New Zealand and U.S. Cath Labs: What does socialized interventional cardiology look like?
Jason Money, RN, RCIS Arkansas, United States, and Bay of Plenty, New Zealand
When I first accepted a job in an interventional cath lab in New Zealand (NZ), I had no idea what to expect. I arrived in Auckland in May 1999 to work at Ascot Angiography, a private, hospital-based cath lab. My fears of “third world” healthcare were very quickly allayed when I saw the gleaming new Ascot Hospital. It is still the most luxurious hospital I have ever worked in, with the feel of an office building, rather than a hospital.
I have lived and worked in NZ most of the last 12 years. My wife and I returned for two years to work in cath labs and radiology departments in California and Florida. Other than my wife having to adapt to the cross-training of the labs in which we worked, there was no step-up needed in nursing skills from NZ to America. Our NZ skills were actually more advanced in some areas, especially regarding radial access and exposure to some equipment in NZ before its release in America. I have been fortunate to work with some of the world’s leading interventional cardiologists in NZ. These are physicians who are often on the expert panels of conferences like TCT.
Still, I have found cath labs everywhere are similar in many ways. Turnaround times need to be quick, add-on cases are always around the corner; basically, never enough time in the day. In NZ, individual roles are more soundly defined. Nurses scrub and circulate cases, radiographers operate the x-ray, and traditionally, a physiologist does the hemodynamics (a position similar to a CVT/RCIS, but with BA and masters-level university training). There is very little cross-training; however, radiographers and nurses do tend to take on the hemodynamics in the tight fiscal climate of the “private” cath labs.
NZ has two basic healthcare systems:
Private: Care paid for by you or your insurance.
Disadvantages:
Public: Care that is free* to any New Zealand citizen or legal resident
*No, there is no such thing a “free.” There are taxes and levies that help to support the “free” system, but all in all, I pay the same or less in all taxes than I did living in Arkansas up till 1999 and get “free” healthcare. Is it better than the American system? Yes and no. With NZ’s population of only 4 million people, it’s hard to directly compare systems overall.
There are waiting lists for exams and procedures, but all acute surgeries are done as you would expect. Urgent surgeries are done in short time as well. It is the non-acute surgeries that can take a while. It is possible that you could have a NSTEMI, fail a treadmill, get a cath, find a lesion needing stenting, and then, if you stay in hospital, it could take a week to get PCI (if you have to be referred to a tertiary institute for PCI) or if you are deemed fit for discharge, it could take months (because you are “stable” on medications). CABG could take the same length of time. Acute things take priority and thus, the more “stable” you are, the less priority you have. Things like hip replacements can take up to a year if you are deemed low priority.
The physical state of the buildings may be very old and poorly maintained, depending on the last upgrade. Most hospitals have large rooms that may have up to four patients per area. Having said that, I have also worked in some rough places in the America as well.
I found the stability of the patients to initially be very impressive. They could have horrible disease, but evidence no acute symptoms. I was perplexed, as most were outpatients and looked like they had acute disease — so where were their symptoms? I then learned how good beta blockers can be at stabilizing patients. The scenario is basically as follows: you have some chest pain, see a GP who works you up for ACS. If you do not have ACS, then the process is: aspirin, metoprolol, statin, GTN spray, referral to a cardiologist, treadmill (or appropriate DX test), an assessment of how well the medications are controlling your symptoms, cath or CTCA, and intervention/surgery or medical management. This is a generic example, but the most common path taken. On paper, this is often how it is meant to work in the U.S. as well; however, in my experience we often jump to the cardiac cath, for better or worse. The same occular stenotic reflex (if I see a lesion, I must fix it) affects many interventionalists in NZ, especially private.
During my time in NZ, I have been exposed to a more conservative model of managing CAD than in the U.S. Patient management that shocked me at the time has since been shown to be backed up by sound studies. Such studies just aren’t there for some of the treatments I thought, from my experience in the U.S., were standard of care in 1999.
In general, the public system tends to be more conservative than private. I will let you form your own opinion on “cost saving” by the public system versus “monetary compensation per procedure” per private system on driving decisions. It should be noted that even though NZ interventionalists are very similar creatures to those in the U.S., they still tend to be more conservative. The public system often sends people to PCI as an alternate treatment, based on waiting lists for surgery.
I currently work in a radiology department, where a very interesting practice takes place regarding the requesting of imaging procedures. All procedures must be approved by a radiologist and then deemed as necessary or not. The American locum ED physicians have a hard time with this, as they actually have to come and present their case for justification to the radiologist and may actually be told no. This is a safety check regarding radiation exposure (something the U.S. will be dealing with very soon, if the media is a gauge) as well as a cost containment issue. Both are a check on reducing unnecessary scans. The traditional question presented to the requesting physician is, “How will this scan affect your management of the patient?”
After experiencing both NZ and U.S. systems of care, my personal opinion is that medical care is only as good as the doctor and team looking after you, as long as they have resources available.
Oh, and is New Zealand as beautiful as they say? Yes, actually — more.
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