Achieving coordinated care for people with heart disease

1. Achieving coordinated care for people with heart disease Dr Julie Redfern jredfern@georgeinstitute.org.au University of Sydney

2. Secondary prevention • Decrease events • Decrease hospitalisations • Decrease deaths • Australia by 75% (Taylor et al 2006) • US by 50% (Ford et al 2007) • UK by 50% (Unal et al 2004) • NZ by 50-80% (Tobias et al 2008)

3. Evidence-practice gap • 70% Australians hospitalised with heart events do not access existing programs (Scott 03, Walters 08) • Those at highest risk are least likely to attend (Redfern et al 2007) • Contrary to strong evidence for effectiveness individualised and patient-centred programs are not readily available (Briffa et al 2009)

4. What is my group doing…. • Randomised controlled trials of contemporary models of secondary prevention • Systematic reviews of telehealth interventions • Qualitative research to explore consumer needs and ideas for improving access and uptake • Taxonomy and model development for “complex interventions”

5. CHOICE Program: RCT • 208 patients • 3 groups – control, CHOICE, rehabilitation • Results – Significant improvement in risk factor levels and number of risk factors that were maintained at 1 and 4 year follow-up Redfern et al Heart 2009 Neubeck et al EJCVPR 2011

6. TEXT ME: RCT • 720 patients • 2 groups – control and regular lifestyle modification text messages for 4 months • Outcomes – risk factors, quality of life, feasibility, acceptability • Ethics approved, funded and due to commence

7. TORPEDO: Cluster RCT • General Practices’ (n=40) and Aboriginal Medical Services (n=20) • 2 groups – control and HealthTracker • Software system integrated with GP desktop and provides absolute risk calculation and management advice with 2 mouse clicks • Outcomes – risk factors, cost, process measures • Ethics approved, funded and due to commence

8. Telehealth: Systematic Review • 11 papers • Over 3000 patients • Telephone and Internet based interventions • Telehealth improves risk factors • Improves quality of life Neubeck et al EJCPR 2009

9. Other Systematic Reviews • Impact of risk reduction programs on risk factors in people with AF • Effectiveness of consumer directed internet-based programs for chronic disease management • Qualitative literature relating to uptake of cardiac rehabilitation (Neubeck et al In Press EJCPR)

10. Patient Internet Use: Qualitative Study • Survey results (n=64) • Clear distinction - either can/not use computer • Significant age differences (≤ 65 more confident) • Focus groups (n=16) • Challenges and perceived benefits • Relevant and practical advice • Simple website design Neubeck et al EJCVN 2010

11. Taxonomy • International group • Aim is to develop, evaluate, and implement a taxonomy for the classification, representation and retrieval of CHD management programs • Includes testing and reclassification of existing complex interventions • Eventual goal is for a publically available format

12. SPAN: Model Development • Knowledge translation is difficult as the volume of trial evidence of disparate models escalates • Core elements of SPAN are • 1. Assessment • 2. Disease management education • 3. Personal risk reduction program + ongoing support • 4. Reassessment • Programs are integrated according to content, contact, format, duration and setting Redfern et al IJC 2011

13. Conclusions • Contemporary models of secondary prevention delivery may improve access and uptake • Combination of reviews, quantitative and qualitative research is need to explore ways to close the evidence-practice gap • Integrated approach is needed

14. Achieving coordinated care for people with heart disease Dr Julie Redfern jredfern@georgeinstitute.org.au University of Sydney