Tag Archives: Canterbury Medical Research Foundation

Cheesecake files: A world second for heart attacks

Going to the Emergency Department with chest pain no longer means an almost certain night in hospital.  Friday saw the publication online of our randomised controlled trial comparing two different strategies to rapidly rule-out heart attacks in people who present with chest pain to hospitals.  Here’s a précis:

What’s the problem?

  • Chest pain is common – 10% or so of presentations to ED are for chest pain.
  • Heart attacks are not so common – only ~10-15% in NZ (and less overseas*) actually have a heart attack.
  • It is devilishly difficult for most chest pain to rapidly rule out the possibility of a heart attack.
  • Consequently, most people get admitted to hospital (in 2007 93% of those presenting with chest pain).

But – led by Dr Martin Than in Christchurch and an international group including Dr Louise Cullen in Brisbane – a series of observational studies and one randomised control trial have resulted in a gradual increase in the proportion discharged.  The trial was the first of its kind, it compared standard practice at assessing chest pain to a purpose built accelerated diagnostic pathway (ADP), which we called ADAPT.   In that study 11% of patients in the standard practice (control) arm and 19.3% in the ADAPT ADP arm (experimental arm) were discharged home from ED within 6 hours.  A great improvement which led to that ADP being adopted in Christchurch hospital.

So why another study?

Two reasons: First, 19% still means that there are many patients being admitted who potentially don’t need to be in hospital.  Second, the ADP was based around a risk assessment tool designed to rule-in heart attacks rather than rule-out.  In the meantime, the team had constructed a purpose build risk assessment tool that in observational studies looked like it could rule out 40-50% of patients.

What is the study just published?

The world’s second randomised controlled trial of assessment of chest pain compared the ADAPT ADP in use (now the control arm) with a new ADP based on the new Emergency Department Assessment of Chest pain Score (EDACS)[the experimental arm].  The only difference between the two arms of the study was the risk assessment tool used. The tool gave a risk score. Patients with a low score, no unusual electrical activity in the heart, and no elevated heart muscle injury proteins in either of two blood samples measured 2 hours apart, were considered low risk.

An important aspect of the study was that it was pragmatic.  This means that the doctors didn’t have to follow the ADP and could decide to send a patient home, or not send them home, based on any factors they thought clinically relevant.  This makes it very tough to run a trial, but it makes the trial more “real life.”

What were the results?

558 patients were recruited.  They all volunteered and are marvellous people.  I love volunteers.

The primary outcome was the proportion of patients safely discharged home within 6 hours.  We assessed safety by looking at all medical events that happened to a patients over 30 days to check to see if any patients discharged home had a major cardiac event that could potentially have been picked up in the ED.

34% of the control arm and 32% of the experimental arm were discharged within 6 hours.  In other words, there was no difference in early discharge rates between the two arms.  The surprising feature of this is that between 2012/3 (when the first trial was run) and 2014/15 the proportion of patients the first ADP ruled out increased from 19% to 34%.  This was unexpected, but pleasing. There were no safety concerns with any patients.

The secondary outcome was simply the proportion each arm of the study classified as low risk (ie not considering whether this led to early discharge or not).  The control (ADAPT ADP) classified 31% and the experimental (EDACS ADP) 42%.  This was a real and meaningful difference which suggests that there is “room for improvement” in early discharge rates as the clinicians become more familiar with the EDACS ADP.

Since 2007 in Christchurch hospital over three times more patients who present with chest pain can be reassured from within the ED that they are not having a heart attack and discharged home (see the infographic).EDACS infographic v2

What was your role?

My role: I managed aspects of the data collection for the later 2/3rds of the patients recruited, did the statistical analysis and co-wrote the manuscript.  In reality, there were a lot of people involved, not least of whom were the wonderful research nurses and database manager who did a lot of the “grunt work”.

What now?

Over the last year all EDs in New Zealand have implemented or in the process of implementing an accelerated diagnostic pathway.  The majority have chosen to use the EDACS pathway.  I am part of a team nationwide helping implement these pathways and monitor their efficacy and safety.

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This study was funded by the Health Research Committee of New Zealand. The work was carried out with the collaboration or the University of Otago Christchurch, Christchurch Heart Institute, and the Canterbury District Health Board Emergency Department, Cardiology Department, General Medicine, and Canterbury Health Laboratories. My salary is provided through a Senior Research Fellowship in Acute Care funded Canterbury Medical Research Foundation, Canterbury District Health Board and the Emergency Care Foundation.

*Not because we have more heart attacks, just an efficient and well funded primary care sector that keeps the very low risk patients out of the ED.

**Featured Image: Creative Commons Share-Alike 3.0 http://tcsmoking.wikispaces.com/heart%20attack

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Two minds about funding heart research

Recently I had a knock on the door from an enthusiastic young man talking about heart research. Given that has been the focus of my research for the last 18 months or so I was delighted that someone was out there trying to raise money for research. However, my delight was, in retrospect,was tempered somewhat when I realised that the man was not representing a New Zealand based research group.

The man was collecting donations for the Heart Research Institute, an independent research group based in Sydney Australia. This is a substantial and credible organisation. I would be happy to collaborate with any of their team leaders. Looking at their website I noted one (of 12) research groups mentioned New Zealand collaborators.   I’ve written to ask if they have more. The HRI have a very professional New Zealand website which gives information on heart disease statistics in New Zealand. They indicate that they support scholarships and fellowships for New Zealanders to work with their Australian counterparts. However, I am in two minds about this group door knocking in New Zealand – one mind thinks “great” they are keen to raise money for heart research, what a good cause. The other thinks “hmmm,” don’t we have some wonderful New Zealand based heart research groups and charities – why another (not New Zealand based) one in a crowded field seeking money from a limited pool of discretionary spending?

Perhaps, to help the people of Canterbury and wherever else funds are being solicited from to make up their own minds, I can remind people of four great charitable organisations supporting heart research in New Zealand.

Heart Foundation of New Zealand: This is a wonderful organisation with a long history of supporting research in New Zealand as well as supporting individuals within New Zealand. They are the group behind the “Heart Foundation Tick” on food labels. Their website is really worth checking out… I just learnt about the “Two Ticks” now appearing on some labels. For the likes of a researcher like me they provide small, but very important, grants that enable important questions to be answered. Indeed, I have just had a paper published which a Heart Foundation grant made possible. In that paper we show that one of the latest guidelines on how to use a blood marker (used in most New Zealand hospitals) to rule out someone having a heart attack are flawed. I note, that they have in large letters on their web site that they do not do door to door fund raising.

Christchurch Heart Institute: CHI is a research group and charitable organisation within my own department, the Department of Medicine, at the University of Otago Christchurch campus (known to most Cantabs as “the med school”). Headed by Professor Mark Richards it is a world renowned group. I have the privilege (a little daunting given just how incredibly intelligent these people are) to collaborate with CHI on a number of clinical projects. The publication I mentioned was one of them. Another project, just kicking off, is investigating markers of acute kidney injury within people who have acute heart failure. They have recently expanded into social media – so you can follow them on facebook.

Canterbury Medical Research Foundation:  CMRF is a wonderful organisation – they are one of the three major sponsors of my own fellowship. My own prejudice aside, CMRF have been supporting research in Canterbury for over 50 years. One aspect of the CMRF that really impresses me is that they understand the need to support researchers and just “let them get on with it.” Cantabrians may recognise their recent campaign that has included some impressive billboards. One important plank of CMRFs work in Canterbury is their subsidiary the New Zealand Brain Institute which does important research into stroke, Alzheimer’s and Parkinson’s disease.

Emergency Care Foundation: The ECF supports research in the Emergency Department of Christchurch hospital including research into the rapid rule-out of heart attacks for patients presenting with chest pain.  I’m fortunate enough to be involved in that research and the role out of new diagnostic pathways to all emergency department in the country.  ECF also support research into the health affects of the Christchurch earthquakes.  ECF are another of my major sponsors.

Some logos of the great local charitable organisations supporting heart research

Cantabrians, this is your life

There is little more precious than our health and that of those we love. “Research saves lives” is  Canterbury Medical Research Foundation’s (CMRF) proudly held motto. The CMRF has been supporting the people of Canterbury for 55 years thanks to the generosity of Cantabrians. In that time they have funded more than $22 million in grants.  Yesterday I attended the launch of their new logo and branding.  The logo depicts a medical cross and the four avenues of Christchurch.  This new logo is intended to signal CMRF’s intention to be fresh and more external facing with a broader appeal to the Canterbury donating community and a bigger emphasis on  partnerships with other funding organisations to leverage money to best effect.  My own fellowship, jointly funded by the CMRF, the Emergency Care Foundation, and the Canterbury District Health Board is an example of that.  CMRF are also expanding the breadth of research they will fund and are now working to expand their influence in the translational, population health and health education spaces. Their vision is to be giving $2 million in grants per annum within 5 years.  What a great boost that will be to Canterbury. A key partner largely funded through CMRF is the NZ Brain Research Institute – their logo has also changed to mirror that of CMRF.

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A funding model that works (for me)

I’ve been a strong critic of the bias towards project rather than people based funding in public grants for science research.  Now, I celebrate being the recipient of people based funding thanks to a combined initiative of the Emergency Care Foundation, the Canterbury Medical Research Foundation, and the Canterbury District Health Board. What has transpired is exactly what I believe the country needs much much more of, namely initiatives that get behind people and teams with broad goals and long term vision rather than narrow projects and annual funding angst.

Below is a press release.  Over the next 5 years I’ll share the ups and downs of the research we undertake.  I’ve already posted about a study I’m currently analysing the results of, which was designed to rapidly assess patients presenting to the ED with chest pain and to safely reduce unnecessary admissions to hospital.

On a more personal note I am grateful to Dr Martin Than (ED) who has championed this intiative and employed me to date this year, to Kate Russell and the CMRF board who have shown great support and helped to put this together, and to Carolyn Gullery and several others of CDHB Planning and Funding who have made possible those very important linkages and collaborations within the DHB. For the record, this is an 80%, 5 year, fellowship; I retain a 20% position with the University of Otago Christchurch, and will continue to undertake collaborative work with many research teams based there.

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MEDIA RELEASE

Health Board and Private Health and Research Foundations join forces to improve outcomes in Acute Care Delivery

The Canterbury Medical Research Foundation, The Emergency Care Foundation and the Canterbury District Health Board have put their collective might behind a new Senior Research Fellowship in Acute Care based at Christchurch Hospital.

The five-year fellowship will improve the quality of Acute and Emergency Care delivery at the hospital through targeted research and close collaboration with clinicians eager to see positive research outcomes translated into real-world clinical practice and, importantly, into improved patient outcomes.

The demand on acute services is large, around 140,000 patient visits a year across the health system. The challenge is to quickly, accurately and safely assess a patient’s condition and to ensure they access the services they need and don’t unnecessarily access the services they don’t need. The first projects this Fellowship supports will better identify which patients presenting to the emergency department with chest pain need admission and intensive monitoring, and who can be safely discharged home.

The Fellowship will be undertaken by Associate Professor John Pickering. Dr Pickering’s research has been cross-disciplinary. This began with the application of physics in dermatology and plastic surgery through the use of lasers in medicine, in particular he helped develop the use of lasers to remove birthmarks. Over the past seven years through he has advanced the diagnostic methods to detect acute kidney injury and most recently, has become involved in research to discover and translate into clinical practice, diagnostic protocols in the emergency department, particularly for patients presenting with chest pain and the possibility of a heart attack.

Dr Pickering sees medical science as a team effort involving, not only doctors, nurses, and scientists, but also the patients themselves, and funders. He is a keen advocate that publically funded research be made known and understandable to a lay audience through blogs and social media. He writes a blog on the Sciblogs.co.nz web site as “Kidney-punch.”

The Canterbury Medical Research Foundation and Emergency Care Foundation are delighted to be partnering with the DHB on a project that is likely to have long term effects on the delivery of acute care in the Canterbury Health system and further afield.

“This type of directly translational research that will give us definite and measureable improvements in patient care is something we are particularly interested in. Committing to five years will allow enough time for research findings to be properly utilized in improvement in practice patterns in real life clinical situations and that is very exciting.” Says Kate Russell, Chief Executive of the Foundation

“I believe that this is an excellent collaborative project to better integrate medical research with clinical care delivery. This initiative will actively facilitate the alignment of some excellent medical research that is taking place in Christchurch with the Canterbury District Health Board’s priorities and plans for improving care for patients with suspected acute, and particularly cardiovascular, illness” said Dr Martin Than, Emergency Care Foundation

For Canterbury DHB it represents an exciting era of partnering with private trusts and foundations to make inroads into issues of quality improvement and better outcomes for Canterbury people.

“We have already made significant progress in reducing acute demand on our hospitals, with more than 28,911 people receiving treatment and care in the community in the past year. This research will provide important evidence to support future decision-making about how, where and which services are funded and provided to ensure Canterbury people receive the right care, at the right time, in the right place, by the right person.” Said Carolyn Gullery, General Manager of Planning and Funding at the DHB.

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For further information please contact Dr Martin Than on Martin.Than@cdhb.health.nz