To evaluate the proportion of patients hospitalised with acute coronary syndrome (ACS) in Australia and New Zealand who received optimal inpatient preventive care and to identify factors associated ...with preventive care.
All patients hospitalised bi-nationally with ACS were identified between 14-27 May 2012. Optimal in-hospital preventive care was defined as having received lifestyle advice, referral to rehabilitation, and prescription of secondary prevention pharmacotherapies. Multilevel multivariable logistic regression was used to determine factors associated with receipt of optimal preventive care.
For the 2299 ACS survivors, mean (SD) age was 69 (13) years, 46% were referred to rehabilitation, 65% were discharged on sufficient preventive medications, and 27% received optimal preventive care. Diagnosis of ST elevation myocardial infarction (OR: 2.64 95% CI: 1.88-3.71; p<0.001) and non-ST elevation myocardial infarction (OR: 1.99 95% CI: 1.52-2.61; p<0.001) compared with a diagnosis of unstable angina, having a percutaneous coronary intervention (PCI) (OR: 4.71 95% CI: 3.67-6.11; p<0.001) or coronary bypass (OR: 2.10 95% CI: 1.21-3.60; p=0.011) during the admission or history of hypertension (OR:1.36 95% CI: 1.06-1.75; p=0.017) were associated with greater exposure to preventive care. Age over 70 years (OR:0.53 95% CI: 0.35-0.79; p=0.002) or admission to a private hospital (OR:0.59 95% CI: 0.42-0.84; p=0.003) were associated with lower exposure to preventive care.
Only one-quarter of ACS patients received optimal secondary prevention in-hospital. Patients with UA, who did not have PCI, were over 70 years or were admitted to a private hospital, were less likely to receive optimal care.
Abstract
Potential benefits of precision medicine in cardiovascular disease (CVD) include more accurate phenotyping of individual patients with the same condition or presentation, using multiple ...clinical, imaging, molecular and other variables to guide diagnosis and treatment. An approach to realising this potential is the digital twin concept, whereby a virtual representation of a patient is constructed and receives real-time updates of a range of data variables in order to predict disease and optimise treatment selection for the real-life patient. We explored the term digital twin, its defining concepts, the challenges as an emerging field, and potentially important applications in CVD. A mapping review was undertaken using a systematic search of peer-reviewed literature. Industry-based participants and patent applications were identified through web-based sources. Searches of Compendex, EMBASE, Medline, ProQuest and Scopus databases yielded 88 papers related to cardiovascular conditions (28%,
n
= 25), non-cardiovascular conditions (41%,
n
= 36), and general aspects of the health digital twin (31%,
n
= 27). Fifteen companies with a commercial interest in health digital twin or simulation modelling had products focused on CVD. The patent search identified 18 applications from 11 applicants, of which 73% were companies and 27% were universities. Three applicants had cardiac-related inventions. For CVD, digital twin research within industry and academia is recent, interdisciplinary, and established globally. Overall, the applications were numerical simulation models, although precursor models exist for the real-time cyber-physical system characteristic of a true digital twin. Implementation challenges include ethical constraints and clinical barriers to the adoption of decision tools derived from artificial intelligence systems.
Introduction
Many hospital presentations for acute coronary syndrome (ACS) occur in people previously hospitalised with coronary heart disease (CHD), leading to increased costs and health burden. ...Secondary prevention education including a prehospital discharge plan is recommended for all individuals to reduce the risk of recurrence. However, many clinicians lack the time or support to provide education, and patients’ uptake of secondary prevention programmes is limited. An avatar-based education app is a novel and engaging way to provide self-delivered, evidence-based secondary prevention information during the hospital admission and remains accessible after discharge. This protocol aims to evaluate the effect of an avatar-based education app on individuals with ACS.
Methods and analysis
This protocol describes a prospective, randomised controlled trial with 3-month follow-up and blinded assessment of 72 participants. Intervention group participants will download the app onto their own device during the hospital admission and independently complete six interactive education modules based on the National Heart Foundation’s six steps to cardiac recovery. All participants will receive a text message reminder of the study after 3 weeks. Both groups will receive usual care consisting of bedside education and a pamphlet about cardiac rehabilitation. The primary outcome is knowledge of CHD, assessed using the Coronary Artery Disease Education Questionnaire II. Secondary outcomes include quality of life, response to heart attack symptoms, cardiac-related readmissions and mortality and modifiable cardiac risk factors. Engagement with the app will be evaluated objectively. Intention-to-treat analysis will be conducted, with between-group comparisons and 95% CIs of the primary outcome analysed using analysis of covariance, adjusting for baseline values.
Ethics and dissemination
This study protocol has been approved by the Western Sydney Local Health District Human Research Ethics Committee. The results of this study will be disseminated via a peer-reviewed journal and research thesis.
Trial registration number
Australian New Zealand Clinical Trials Registry (ACTRN12622001436763).
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.
Full text
Available for:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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.
Full text
Available for:
FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Maintaining engagement and support for patients with chronic diseases is challenging. SMS text messaging programs have complemented patient care in a variety of situations. However, such programs ...have not been widely translated into routine care.
We aimed to examine the implementation and utility of a customized SMS text message-based support program for patients with type 2 diabetes (T2D), coronary heart disease, or both within a chronic disease integrated care program.
We conducted a 6-month pragmatic parallel-group, single-blind randomized controlled trial that recruited people with T2D or coronary heart disease. Intervention participants received 4 semipersonalized SMS text messages per week providing self-management support to supplement standard care. Preprogrammed algorithms customized content based on participant characteristics, and the messages were sent at random times of the day and in random order by a fully automated SMS text messaging engine. Control participants received standard care and only administrative SMS text messages. The primary outcome was systolic blood pressure. Evaluations were conducted face to face whenever possible by researchers blinded to randomization. Participants with T2D were evaluated for glycated hemoglobin level. Participant-reported experience measures were evaluated using questionnaires and focus groups and summarized using proportions and thematic analysis.
A total of 902 participants were randomized (n=448, 49.7% to the intervention group and n=454, 50.3% to the control group). Primary outcome data were available for 89.5% (807/902) of the participants. At 6 months, there was no difference in systolic blood pressure between the intervention and control arms (adjusted mean difference=0.9 mm Hg, 95% CI -1.1 to 2.1; P=.38). Of 642 participants with T2D, there was no difference in glycated hemoglobin (adjusted mean difference=0.1%, 95% CI -0.1% to 0.3%; P=.35). Self-reported medication adherence was better in the intervention group (relative risk=0.82, 95% CI 0.68-1.00; P=.045). Participants reported that the SMS text messages were useful (298/344, 86.6%) and easily understood (336/344, 97.7%) and motivated change (217/344, 63.1%). The lack of bidirectional messaging was identified as a barrier.
The intervention did not improve blood pressure in this cohort, possibly because of high clinician commitment to improved routine patient care as part of the chronic disease management program as well as favorable baseline metrics. There was high program engagement, acceptability, and perceived value. Feasibility as part of an integrated care program was demonstrated. SMS text messaging programs may supplement chronic disease management and support self-care.
Australian New Zealand Clinical Trials Registry ACTRN12616001689460; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371769&isReview=true.
RR2-10.1136/bmjopen-2018-025923.
Full text
Available for:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Contemporary myocardial infarction (MI) care and management has evolved dramatically since the 1950's; yet outpatient rehabilitation remains underutilized. Deepening our understanding of the origins ...and history of cardiac rehabilitation highlights a contemporary shift required for policy and practice related to secondary prevention of coronary disease in light of societal changes as well as medical, digital and surgical advancements. Contemporary "cardiac rehabilitation" began when bed rest and physical inactivity was recommended and commonplace for MI survivors. Today, most patients who survive an MI, undergo reperfusion therapy, a short inpatient stay and are discharged with minimal physical morbidity. Despite this, the majority of modern day programs continue to be structured in the same way they have been for the past 50 years and this model has become incongruent with the contemporary context, especially in the COVID-19 era. This review aims to describe the historical foundations of cardiac rehabilitation to inform solutions and meet the demands of contemporary MI management. Delivering health systems reform to address modernization is current healthcare challenge where a united and interdisciplinary effort is needed.
Adolescence presents a window of opportunity to establish good nutrition and physical activity behaviours to carry throughout the life course. Adolescents are at risk of developing cardiovascular and ...other chronic diseases due to poor the complex interplay of physical and mental health lifestyle risk factors. Text messaging is adolescents main form of everyday communication and text message programs offer a potential solution for support and improvement of lifestyle health behaviours. The primary aim of this study is to determine effectiveness of the Health4Me text message program to improve adolescent's physical activity or nutrition behaviours among adolescents over 6-months, compared to usual care.
Health4Me is a virtual, two-arm, single-blind randomised controlled trial, delivering a 6-month healthy lifestyle text message program with optional health counselling. Recruitment will be through digital advertising and primary care services. In total, 330 adolescents will be randomised 1:1 to intervention or control (usual care) groups. The intervention group will receive 4-5 text messages per week for 6-months. All text messages have been co-designed with adolescents. Messages promote a healthy lifestyle by providing practical information, health tips, motivation and support for behaviour change for physical activity, nutrition, mental health, body image, popular digital media and climate and planetary health. Virtual assessments will occur at baseline and 6-months assessing physical health (physical activity, nutrition, body mass index, sleep), mental health (quality of life, self-efficacy, psychological distress, anxiety, depression, eating disorder risk) and lifestyle outcomes (food insecurity and eHealth literacy).
This study will determine the effectiveness of a 6-month healthy lifestyle text message intervention to improve physical activity and nutrition outcomes in adolescents.
Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12622000949785 , Date registered: 05/07/2022.
Full text
Available for:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Background Coronary heart disease (CHD) is the leading cause of deaths and disability worldwide. Cardiac rehabilitation (CR) effectively reduces the risk of future cardiac events and is ...strongly recommended in international clinical guidelines. However, CR program quality is highly variable with divergent data systems, which, when combined, potentially contribute to persistently low completion rates. The QUality Improvement in Cardiac Rehabilitation (QUICR) trial aims to determine whether a data-driven collaborative quality improvement intervention delivered at the program level over 12 months: (1) increases CR program completion in eligible patients with CHD (primary outcome), (2) reduces hospital admissions, emergency department presentations and deaths, and costs, (3) improves the proportion of patients receiving guideline-indicated CR according to national and international benchmarks, and (4) is feasible and sustainable for CR staff to implement routinely. Methods QUICR is a multi-centre, type-2, hybrid effectiveness-implementation cluster-randomized controlled trial (cRCT) with 12-month follow-up. Eligible CR programs ( n = 40) and the individual patient data within them ( n ~ 2,000) recruited from two Australian states (New South Wales and Victoria) are randomized 1:1 to the intervention (collaborative quality improvement intervention that uses data to identify and manage gaps in care) or control (usual care with data collection only). This sample size is required to achieve 80% power to detect a difference in completion rate of 22%. Outcomes will be assessed using intention-to-treat principles. Mixed-effects linear and logistic regression models accounting for clusters within allocated groupings will be applied to analyse primary and secondary outcomes. Discussion Addressing poor participation in CR by patients with CHD has been a longstanding challenge that needs innovative strategies to change the status-quo. This trial will harness the collaborative power of CR programs working simultaneously on common problem areas and using local data to drive performance. The use of data linkage for collection of outcomes offers an efficient way to evaluate this intervention and support the improvement of health service delivery. Ethics Primary ethical approval was obtained from the Northern Sydney Local Health District Human Research Ethics Committee (2023/ETH01093), along with site-specific governance approvals. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623001239651 (30/11/2023) ( https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386540&isReview=true ).
Online food delivery (OFD) platforms have become increasingly popular due to advanced technology, which is changing the way consumers purchase food prepared outside of the home. There is limited ...research investigating the healthiness of the digital food environment and its influence on consumer choice and dietary behaviours. This study is the first to examine the nutritional quality and marketing attributes of menu items from popular independent and franchise restaurants and takeaway outlets on New Zealand’s market leading OFD platform (UberEATS®). A total of 374 popular independent and franchise restaurants and takeaway outlets were identified to form a database of complete menus and marketing attributes. All 25,877 menu items were classified into 38 food and beverage categories based on the Australian Dietary Guidelines. Of complete menus, 73.3% (18,955/25,877) were discretionary. Thirty-six percent (9419/25,877) were discretionary cereal-based mixed meals, the largest of the 38 categories. Discretionary menu items were more likely to be categorized as most popular (OR: 2.0, 95% CI 1.7−2.2), accompanied by a photo (OR: 1.7, 95% CI 1.6−1.8), and offered as a value bundle (OR: 4.6, 95% CI 3.2−6.8). Two of the three discretionary mixed meal categories were significantly less expensive than their healthier counterparts (p < 0.001). The overwhelming availability and promotion of discretionary choices offered by restaurants and takeaway outlets on OFD platforms have implications for public health policy. Further research to explore direct associations between nutritional quality and consumers’ dietary choices is required.
PDF
