Background Research on Australian cardiovascular disease secondary prevention and cardiac rehabilitation to guide practice needs updating to reflect current context of practice. It is timely ...therefore to review the core components that underpin effective services that deliver maximum benefits for participants. Methods The Australian Cardiovascular Health and Rehabilitation Association (ACRA) convened an inter-agency, multidisciplinary, nationally representative expert panel of Australia's leading cardiac rehabilitation clinicians, researchers and health advocates who reviewed the research evidence. Results Five core components for quality delivery and outcomes of services were identified and are recommended: 1) Equity and access to services, 2) Assessment and short-term monitoring, 3) Recovery and longer term maintenance, 4) Lifestyle/behavioural modification and medication adherence, and 5) Evaluation and quality improvement. Conclusions ACRA seeks to provide guidance on the latest evidence in cardiovascular disease secondary prevention and cardiac rehabilitation. Clinicians should use these core components to guide effective service delivery and promote high quality evidence based care. Directors of hospitals and health services should use these core components to aid decision-making about the development and maintenance of these services.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
BACKGROUND OSA is a common condition that has been associated with atrial fibrillation (AF), but there is a paucity of data from large longitudinal cohorts to establish whether OSA is a risk factor ...for AF independent of obesity and other established risk factors. METHODS We studied patients attending a sleep clinic referred for in-laboratory polysomnography for possible OSA between 1989 and 2001. Whole-population hospital data in Western Australia for 1970 to 2009 were linked to sleep study cases to determine incident AF hospitalization to 2009. Cox regression analyses were used to assess the independent association of OSA with incident AF. RESULTS Study case subjects (6,841) were predominantly middle aged (48.3 ± 12.5 years old) and men (77%), and 455 developed AF during a median 11.9 years of follow-up. Univariate predictors of AF included age, BMI, hypertension, diabetes, valvular heart disease, coronary or peripheral artery disease, heart failure, and COPD (all P .001). After multivariable adjustment, independent predictors of incident AF were an apnea/hypopnea index (AHI) > 5/h (hazard ratio HR, 1.55; 95% CI, 1.21-2.00), log (AHI 1 1) (HR, 1.15; 95% CI, 1.06-1.26), and log (time with oxygen saturation < 90% 1 1) (HR, 1.12; 95% CI, 1.06-1.19). There were no interactions between age, sex, or BMI and AHI for AF development. CONCLUSIONS OSA diagnosis and severity are independently associated with incident AF. Clinical trials are required to determine if treatment of OSA will reduce the burden of AF.
Background:
Coronary heart disease (CHD) is a major cause of death worldwide. Cardiac rehabilitation, an evidence-based CHD secondary prevention programme, remains underutilized. Telehealth may offer ...an innovative solution to overcome barriers to cardiac rehabilitation attendance. We aimed to determine whether contemporary telehealth interventions can provide effective secondary prevention as an alternative or adjunct care compared with cardiac rehabilitation and/or usual care for patients with CHD.
Methods:
Relevant randomized controlled trials evaluating telehealth interventions in CHD patients with at least three months’ follow-up compared with cardiac rehabilitation and/or usual care were identified by searching electronic databases. We checked reference lists, relevant conference lists, grey literature and keyword searching of the Internet. Main outcomes included all-cause mortality, rehospitalization/cardiac events and modifiable risk factors. (PROSPERO registration number 77507.)
Results:
In total, 32 papers reporting 30 unique trials were identified. Telehealth was not significant associated with a lower all-cause mortality than cardiac rehabilitation and/or usual care (risk ratio (RR)=0.60, 95% confidence interval (CI)=0.86 to 1.24, p=0.42). Telehealth was significantly associated with lower rehospitalization or cardiac events (RR=0.56, 95% CI=0.39 to 0.81, p<0.0001) compared with non-intervention groups. There was a significantly lower weighted mean difference (WMD) at medium to long-term follow-up than comparison groups for total cholesterol (WMD= −0.26 mmol/l, 95% CI= −0.4 to −0.11, p <0.001), low-density lipoprotein (WMD= −0.28, 95% CI = −0.50 to −0.05, p=0.02) and smoking status (RR=0.77, 95% CI =0.59 to 0.99, p=0.04.
Conclusions:
Telehealth interventions with a range of delivery modes could be offered to patients who cannot attend cardiac rehabilitation, or as an adjunct to cardiac rehabilitation for effective secondary prevention.
Traditional cardiac rehabilitation programs are centre-based and clinically supervised, with their safety and effectiveness well established. Notwithstanding the established benefits, cardiac ...rehabilitation remains underutilised. A possible alternative would be a hybrid approach where both centre-based and tele-based methods are combined to deliver cardiac rehabilitation to eligible patients. The objective of this study was to determine the long-term cost-effectiveness of a hybrid cardiac telerehabilitation and if it should be recommended to be implemented in the Australian context.
Following a comprehensive literature search, we chose the Telerehab III trial intervention that investigated the effectiveness of a long-term hybrid cardiac telerehabilitation program. We developed a decision analytic model to estimate the cost-effectiveness of the Telerehab III trial using a Markov process. The model included stable cardiac disease and hospitalisation health states and simulations were run using one-month cycles over a five-year time horizon. The threshold for cost-effectiveness was set at $AU 28,000 per quality-adjusted life-year (QALY). For the base analysis, we assumed that 80% completed the programme. We tested the robustness of the results using probabilistic sensitivity and scenario analyses.
Telerehab III intervention was more effective but more costly and was not cost-effective, at a threshold of $28,000 per QALY. For every 1,000 patients who undergo cardiac rehabilitation, employing the telerehabilitation intervention would cost $650,000 more, and 5.7 QALYs would be gained, over five years, compared to current practice. Under probabilistic sensitivity analysis, the intervention was cost-effective in only 18% of simulations. Similarly, if the intervention compliance was increased to 90%, it was still unlikely to be cost-effective.
Hybrid cardiac telerehabilitation is highly unlikely to be cost-effective compared to the current practice in Australia. Exploration of alternative models of delivering cardiac telerehabilitation is still required. The results presented in this study are useful for policymakers wanting to make informed decisions about investment in hybrid cardiac telerehabilitation programs.
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CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Participation in cardiac rehabilitation (CR) benefits patients with coronary heart disease (CHD), yet worldwide only some 15–30% of those eligible attend. To improve understanding of the reasons for ...poor participation we undertook a systematic review and meta-synthesis of the qualitative literature.
Qualitative studies identifying patient barriers and enablers to attendance at CR were identified by searching multiple electronic databases, reference lists, relevant conference lists, grey literature, and keyword searching of the Internet (1990–2010). Studies were selected if they included patients with CHD and reviewed experience or understanding about CR. Meta-synthesis was used to review the papers and to synthesize the data.
From 1165 papers, 34 unique studies were included after screening. These included 1213 patients from eight countries. Study methodology included interviews (n = 25), focus groups (n = 5), and mixed-methods (n = 4). Key reasons for not attending CR were physical barriers, such as lack of transport, or financial cost, and personal barriers, such as embarrassment about participation, or misunderstanding the reasons for onset of CHD or the purpose of CR.
There is a vast amount of qualitative research which investigates patients’ reasons for non-attendance at CR. Key issues include system-level and patient-level barriers, which are potentially modifiable. Future research would best be directed at investigating strategies to overcome these barriers.
Objectives: To characterise management of suspected acute coronary syndrome (ACS) in Australia and New Zealand, and to assess the application of recommended therapies according to published ...guidelines.
Design, setting and patients: All patients hospitalised with suspected or confirmed ACS between 14 and 27 May 2012 were enrolled from participating sites in Australia and New Zealand, which were identified through public records and health networks. Descriptive and logistic regression analysis was performed.
Main outcome measures: Rates of guideline‐recommended investigations and therapies, and inhospital clinical events (death, new or recurrent myocardial infarction MI, stroke, cardiac arrest and worsening congestive heart failure).
Results: Of 478 sites that gained ethics approval to participate, 286 sites provided data on 4398 patients with suspected or confirmed ACS. Patients’ mean age was 67 years (SD, 15 years), 40% were women, and the median Global Registry of Acute Coronary Events (GRACE) risk score was 119 (interquartile range, 96–144). Most patients (66%) presented to principal referral hospitals. MI was diagnosed in 1436 patients (33%), unstable angina or likely ischaemic chest pain in 929 (21%), unlikely ischaemic chest pain in 1196 (27%), and 837 patients (19%) had other diagnoses not due to ACS. Of the patients with MI, 1019 (71%) were treated with angiography, 610 (43%) with percutaneous coronary intervention and 116 (8%) with coronary artery bypass grafting. Invasive management was less likely with increasing patient risk (GRACE score < 100, 90.1% v 101–150, 81.3% v 151–200, 49.4% v > 200, 36.1%; P < 0.001). The inhospital mortality rate was 4.5% and recurrent MI rate was 5.1%. After adjusting for patient risk and other variables, significant variations in care and outcomes by hospital classification and jurisdiction were evident.
Conclusion: This first comprehensive combined Australia and New Zealand audit of ACS care identified variations in the application of the ACS evidence base and varying rates of inhospital clinical events. A focus on integrated clinical service delivery may provide greater translation of evidence to practice and improve ACS outcomes in Australia and New Zealand.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Purpose
Non-adherence to heart failure (HF) medications is associated with poor outcomes. We used restricted cubic splines (RCS) to assess the continuous relationship between adherence to ...renin-angiotensin system inhibitors (RASI) and β-blockers and long-term outcomes in senior HF patients.
Methods
We identified a population-based cohort of 4234 patients, aged 65–84 years, 56% male, who were hospitalised for HF in Western Australia between 2003 and 2008 and survived to 1-year post-discharge (landmark date). Adherence was calculated using the proportion of days covered (PDC) in the first year post-discharge. RCS Cox proportional-hazards models were applied to determine the relationship between adherence and all-cause death and death/HF readmission at 1 and 3 years after the landmark date.
Results
RCS analysis showed a curvilinear adherence-outcome relationship for both RASI and β-blockers which was linear above PDC 60%. For each 10% increase in RASI and β-blocker adherence above this level, the adjusted hazard ratio for 1-year all-cause death fell by an average of 6.6% and 4.8% respectively (trend
p
< 0.05) and risk of all-cause death/HF readmission fell by 5.4% and 5.8% respectively (trend
p
< 0.005). Linear reductions in adjusted risk for these outcomes at PDC ≥ 60% were also seen at 3 years after landmark date (all trend
p
< 0.05).
Conclusion
RCS analysis showed that for RASI and β-blockers, there was no upper adherence level (threshold) above 60% where risk reduction did not continue to occur. Therefore, interventions should maximise adherence to these disease-modifying HF pharmacotherapies to improve long-term outcomes after hospitalised HF.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
Introduction: The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key ...components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points.
Main recommendations: This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the:
diagnosis and risk stratification of ACS;
provision of acute reperfusion therapy and immediate post‐fibrinolysis care for patients with ST segment elevation myocardial infarction;
risk stratification informing the use of routine versus selective invasive management for patients with non‐ST segment elevation ACS;
administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and
implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation.
Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
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