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Bell F, Crabtree R, Wilson C, Miller E, Byrne R. Ambulance service recognition of health inequalities and activities for reduction: An evidence and gap map of the published literature. Br Paramed J 2024; 9:47-57. [PMID: 38946737 PMCID: PMC11210581 DOI: 10.29045/14784726.2024.6.9.1.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Background Emergency medical services (EMS) are often patients' first point of contact for urgent and emergency care needs. Patients are triaged over the phone and may receive an ambulance response, with potential conveyance to the hospital. A recent scoping review suggested disparities in EMS patient care in the United States. However, it is unknown how health inequalities impact EMS care in other developed countries and how inequalities are being addressed. Objectives This rapid evidence map of published literature aims to map known health inequalities in EMS patients and describe interventions reducing health inequalities in EMS patient care. Methods The search strategy consisted of EMS synonyms and health inequality synonyms. The MEDLINE/PubMed database was searched from 1 January 2010 to 26 July 2022. Studies were included if they described empirical research exploring health inequalities within ambulance service patient care. Studies were mapped on to the EMS care interventions framework and Core20PLUS5 framework. Studies evaluating interventions were synthesised using the United Kingdom Allied Health Professions Public Health Strategic Framework. Results The search strategy yielded 771 articles, excluding duplicates, with two more studies added from hand searches. One hundred studies met the inclusion criteria after full-text review. Inequalities in EMS patient care were predominantly situated in assessment, treatment and conveyance, although triage and response performance were also represented. Studies mostly explored EMS health inequalities within ethnic minority populations, populations with protected characteristics and the core issue of social deprivation. Studies evaluating interventions reducing health inequalities (n = 5) were from outside the United Kingdom and focused on older patients, ethnic minorities and those with limited English proficiency. Interventions included community paramedics, awareness campaigns, dedicated language lines and changes to EMS protocols. Conclusions Further UK-based research exploring health inequalities of EMS patients would support ambulance service policy and intervention development to reduce health inequality in urgent and emergency care delivery.
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Affiliation(s)
- Fiona Bell
- Yorkshire Ambulance Service NHS Trust ORCID iD: https://orcid.org/0000-0003-4503-1903
| | | | - Caitlin Wilson
- Yorkshire Ambulance Service NHS Trust ORCID iD: https://orcid.org/0000-0002-9854-4289
| | - Elisha Miller
- NIHR Coordinating Centre ORCID iD: https://orcid.org/0000-0003-4729-8572
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Beks H, Wood SM, Clark RA, Vincent VL. Spatial methods for measuring access to health care. Eur J Cardiovasc Nurs 2023; 22:832-840. [PMID: 37590972 DOI: 10.1093/eurjcn/zvad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 08/19/2023]
Abstract
Access to health care is a universal human right and key indicator of health system performance. Spatial access encompasses geographic factors mediating with the accessibility and availability of health services. Equity of health service access is a global issue, which includes access to the specialized nursing workforce. Nursing research applying spatial methods is in its infancy. Given the use of spatial methods in health research is a rapidly developing field, it is timely to provide guidance to inspire greater application in cardiovascular research. Therefore, the objective of this methods paper is to provide an overview of spatial analysis methods to measure the accessibility and availability of health services, when to consider applying spatial methods, and steps to consider for application in cardiovascular nursing research.
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Affiliation(s)
- Hannah Beks
- Deakin Rural Health, Deakin University, PO Box 423, Princes Highway, Warrnambool, Victoria 3280, Australia
| | - Sarah M Wood
- Deakin Rural Health, Deakin University, PO Box 423, Princes Highway, Warrnambool, Victoria 3280, Australia
| | - Robyn A Clark
- Caring Futures Institute, Flinders University, Adelaide, South Australia, Australia
| | - Versace L Vincent
- Deakin Rural Health, Deakin University, PO Box 423, Princes Highway, Warrnambool, Victoria 3280, Australia
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Coorey CP, Knibbs LD, Otton J. Social, Geographical and Income Inequality as Demonstrated by the Coronary Calcium Score: An Ecological Study in Sydney, Australia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095699. [PMID: 37174216 PMCID: PMC10178035 DOI: 10.3390/ijerph20095699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/06/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND The coronary calcium score is a non-invasive biomarker of coronary artery disease. The concept of "arterial age" transforms the coronary calcium score to an expected age based on the degree of coronary atherosclerosis. This study aimed to investigate the relationship of socioeconomic status with the burden of coronary artery disease within Sydney, Australia. METHODS This was an ecological study at the postcode level of patients aged 45 and above who had completed a CT coronary calcium scan within New South Wales (NSW), Australia from January 2012 to December 2020. Arterial age difference was calculated as arterial age minus chronological age. Socioeconomic data was obtained for median income, Index of Relative Socio-economic Advantage and Disadvantage (IRSAD) score and median property price. Linear regression was used for analysis. RESULTS There were 17,102 patients across 325 postcodes within NSW, comprising 9129 males with a median arterial age difference of 7 years and 7972 females with -9 years. Income, IRSAD score and property price each had an inverse relationship with arterial age difference (p-values < 0.05). CONCLUSIONS Income, socioeconomic status and local property prices are significantly correlated with premature coronary aging. Healthcare resource allocation and prevention should target the inequalities identified to reduce the burden of coronary artery disease.
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Affiliation(s)
- Craig Peter Coorey
- School of Medicine, Western Sydney University, Campbelltown, NSW 2560, Australia
- Royal North Shore Hospital, St Leonards, Sydney, NSW 2065, Australia
| | - Luke D Knibbs
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Camperdown, Sydney, NSW 2050, Australia
- Public Health Research Analytics and Methods for Evidence, Public Health Unit, Sydney Local Health District, Camperdown, Sydney, NSW 2050, Australia
| | - James Otton
- Department of Cardiology, Liverpool Hospital, Liverpool, NSW 2170, Australia
- Faculty of Medicine, South Western Sydney Clinical School, UNSW, Sydney, NSW 2170, Australia
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Fränti P, Mariescu-Istodor R, Akram A, Satokangas M, Reissell E. Can we optimize locations of hospitals by minimizing the number of patients at risk? BMC Health Serv Res 2023; 23:415. [PMID: 37120539 PMCID: PMC10148542 DOI: 10.1186/s12913-023-09375-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/06/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND To reduce risk of death in acute ST-segment elevation myocardial infraction (STEMI), patients must reach a percutaneous coronary intervention (PCI) within 120 min from the start of symptoms. Current hospital locations represent choices made long since and may not provide the best possibilities for optimal care of STEMI patients. Open questions are: (1) how the hospital locations could be better optimized to reduce the number of patients residing over 90 min from PCI capable hospitals, and (2) how this would affect other factors like average travel time. METHODS We formulated the research question as a facility optimization problem, which was solved by clustering method using road network and efficient travel time estimation based on overhead graph. The method was implemented as an interactive web tool and tested using nationwide health care register data collected during 2015-2018 in Finland. RESULTS The results show that the number of patients at risk for not receiving optimal care could theoretically be reduced significantly from 5 to 1%. However, this would be achieved at the cost of increasing average travel time from 35 to 49 min. By minimizing average travel time, the clustering would result in better locations leading to a slight decrease in travel time (34 min) with only 3% patients at risk. CONCLUSIONS The results showed that minimizing the number of patients at risk alone can significantly improve this single factor but, at the same time, increase the average burden of others. A more appropriate optimization should consider more factors. We also note that the hospitals serve also for other operators than STEMI patients. Although optimization of the entire health care system is a very complex optimization problems goal, it should be the aim of future research.
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Affiliation(s)
- Pasi Fränti
- School of Computing, University of Eastern Finland, P.O. Box 111, 80101, Joensuu, Finland.
| | | | - Awais Akram
- School of Computing, University of Eastern Finland, P.O. Box 111, 80101, Joensuu, Finland
| | - Markku Satokangas
- Finnish Institute for Health and Welfare (THL), P.O. Box 30, 00271, Helsinki, Finland
| | - Eeva Reissell
- Finnish Institute for Health and Welfare (THL), P.O. Box 30, 00271, Helsinki, Finland
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Wood SM, Alston L, Beks H, Mc Namara K, Coffee NT, Clark RA, Wong Shee A, Versace VL. The application of spatial measures to analyse health service accessibility in Australia: a systematic review and recommendations for future practice. BMC Health Serv Res 2023; 23:330. [PMID: 37005659 PMCID: PMC10066971 DOI: 10.1186/s12913-023-09342-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/27/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Australia's inequitable distribution of health services is well documented. Spatial access relates to the geographic limitations affecting the availability and accessibility of healthcare practitioners and services. Issues associated with spatial access are often influenced by Australia's vast landmass, challenging environments, uneven population concentration, and sparsely distributed populations in rural and remote areas. Measuring access contributes to a broader understanding of the performance of health systems, particularly in rural/remote areas. This systematic review synthesises the evidence identifying what spatial measures and geographic classifications are used and how they are applied in the Australian peer-reviewed literature. METHODS A systematic search of peer-reviewed literature published between 2002 and 2022 was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Search terms were derived from three major topics, including: [1] Australian population; [2] spatial analysis of health service accessibility; and [3] objective physical access measures. RESULTS Database searches retrieved 1,381 unique records. Records were screened for eligibility, resulting in 82 articles for inclusion. Most articles analysed access to primary health services (n = 50; 61%), followed by specialist care (n = 17; 21%), hospital services (n = 12; 15%), and health promotion and prevention (n = 3; 4%). The geographic scope of the 82 articles included national (n = 33; 40%), state (n = 27; 33%), metropolitan (n = 18; 22%), and specified regional / rural /remote area (n = 4; 5%). Most articles used distance-based physical access measures, including travel time (n = 30; 37%) and travel distance along a road network (n = 21; 26%), and Euclidean distance (n = 24; 29%). CONCLUSION This review is the first comprehensive systematic review to synthesise the evidence on how spatial measures have been applied to measure health service accessibility in the Australian context over the past two decades. Objective and transparent access measures that are fit for purpose are imperative to address persistent health inequities and inform equitable resource distribution and evidence-based policymaking.
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Affiliation(s)
- Sarah M Wood
- School of Medicine, Faculty of Health, Deakin Rural Health, Deakin University, Warrnambool Campus, PO Box 423, Warrnambool, VIC, 3280, Australia.
| | - Laura Alston
- School of Medicine, Faculty of Health, Deakin Rural Health, Deakin University, Warrnambool Campus, PO Box 423, Warrnambool, VIC, 3280, Australia
- Research Unit, Colac Area Health, Colac, Vic, Australia
| | - Hannah Beks
- School of Medicine, Faculty of Health, Deakin Rural Health, Deakin University, Warrnambool Campus, PO Box 423, Warrnambool, VIC, 3280, Australia
| | - Kevin Mc Namara
- School of Medicine, Faculty of Health, Deakin Rural Health, Deakin University, Warrnambool Campus, PO Box 423, Warrnambool, VIC, 3280, Australia
- Grampians Health, Ballarat, Vic, Australia
| | - Neil T Coffee
- School of Medicine, Faculty of Health, Deakin Rural Health, Deakin University, Warrnambool Campus, PO Box 423, Warrnambool, VIC, 3280, Australia
- University of Canberra, Canberra, ACT, Australia
| | - Robyn A Clark
- Caring Futures Institute, Flinders University, Adelaide, SA, Australia
| | - Anna Wong Shee
- School of Medicine, Faculty of Health, Deakin Rural Health, Deakin University, Warrnambool Campus, PO Box 423, Warrnambool, VIC, 3280, Australia
- Grampians Health, Ballarat, Vic, Australia
| | - Vincent L Versace
- School of Medicine, Faculty of Health, Deakin Rural Health, Deakin University, Warrnambool Campus, PO Box 423, Warrnambool, VIC, 3280, Australia
- Grampians Health, Ballarat, Vic, Australia
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Bowley JJ, Faulkner K, Finch J, Gavaghan B, Foster M. Understanding the Experiences of Rural- and Remote-Living Patients Accessing Sub-Acute Care in Queensland: A Qualitative Descriptive Analysi. J Multidiscip Healthc 2022; 15:2945-2955. [PMID: 36582587 PMCID: PMC9793724 DOI: 10.2147/jmdh.s391738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction The challenges associated with equitable healthcare access are often more pronounced for individuals living in rural and remote locations, compared to those in metropolitan locations. This study examined the health care transitions of rural- and remote-living patients with on-going sub-acute needs, following acute hospital discharge. This was done with the aim of exploring these patients' experiences of client-centeredness and continuity of care, and identifying common challenges faced by rural and remote sub-acute patients accessing and transitioning to and through sub-acute care in a non-metropolitan context. Materials and Methods Semi-structured interviews were conducted with 37 sub-acute patients. A qualitative descriptive approach was used to analyze the interview data and explore key emergent themes in relation to client-centeredness, continuity of care, and sub-acute transition challenges. Results Interview participants' average length of stay in sub-acute care was 31.6 days (range = 8-86 days), with most transitioning from larger regional and metropolitan hospitals to on-going rural or remote sub-acute care (n = 19; 53%). Client-centeredness was primarily characterized by the quality of interpersonal experiences with staff, patient and familial involvement in care planning, and the degree to which patients felt their wishes were respected and advocated for. Continuity of care was characterized by access to and participation in rehabilitation services, and access to family and social supports. Challenges associated with sub-acute transitions were explored. Discussion The findings suggest important implications for health care providers, including the need to implement earlier and more frequent opportunities for patient involvement throughout the sub-acute journey. The results offer a unique perspective on the way that continuity of care is experienced and conceptualized by rural and remote patients, suggesting a revision of what is required to achieve equitable care continuity for rural and remote residents receiving care far from home. Conclusion It is pertinent for health care providers to consider the unique complexities associated with accessing on-going health care as a rural or remote Australian resident, and to develop mechanisms that support equitable access and continuity and facilitate continuity of care closer to home.
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Affiliation(s)
- Jessica J Bowley
- The Hopkins Centre: Research for Rehabilitation and Resilience, Griffith University, Brisbane, Queensland, Australia,Correspondence: Jessica J Bowley, The Hopkins Centre, Griffith University, 170 Kessels Road, Brisbane, Queensland, Australia, Tel +61 3735 8136, Email
| | - Kirstie Faulkner
- Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Jennifer Finch
- Allied Health Professions’ Office of Queensland, Clinical Excellence Queensland, Brisbane, Queensland, Australia
| | - Belinda Gavaghan
- Allied Health Professions’ Office of Queensland, Clinical Excellence Queensland, Brisbane, Queensland, Australia
| | - Michele Foster
- The Hopkins Centre: Research for Rehabilitation and Resilience, Griffith University, Brisbane, Queensland, Australia
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Stephensen L, Greenslade J, Starmer K, Starmer G, Stone R, Bonnin R, Brazzale A, Drahm‐Butler T, Campbell V, Davis T, Mowatt E, Brown N, Proctor K, Ashover S, Milburn T, McCormack L, Graves N, Gatton M, Mahoney R, Parsonage W, Cullen L. Clinical characteristics of Aboriginal and Torres Strait Islander emergency department patients with suspected acute coronary syndrome. Emerg Med Australas 2022; 35:442-449. [PMID: 36410371 DOI: 10.1111/1742-6723.14138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/30/2022] [Accepted: 10/26/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To describe the demographics, presentation characteristics, clinical features and cardiac outcomes for Aboriginal and Torres Strait Islander patients who present to a regional cardiac referral centre ED with suspected acute coronary syndrome (ACS). METHODS This was a single-centre observational study conducted at a regional referral hospital in Far North Queensland, Australia from November 2017 to September 2018 and January 2019 to December 2019. Study participants were 278 Aboriginal and Torres Strait Islander people presenting to an ED and investigated for suspected ACS. The main outcome measure was the proportion of patients with ACS at index presentation and differences in characteristics between those with and without ACS. RESULTS ACS at presentation was diagnosed in 38.1% of patients (n = 106). The mean age of patients with ACS was 53.5 years (SD 9.5) compared with 48.7 years (SD 12.1) in those without ACS (P = 0.001). Patients with ACS were more likely to be male (63.2% vs 39.0%, P < 0.001), smokers (70.6% vs 52.3%, P = 0.002), have diabetes (56.6% vs 38.4%, P = 0.003) and have renal impairment (24.5% vs 10.5%, P = 0.002). CONCLUSIONS Aboriginal and Torres Strait Islander patients with suspected ACS have a high burden of traditional cardiac risk factors, regardless of whether they are eventually diagnosed with ACS. These patients may benefit from assessment for coronary artery disease regardless of age at presentation.
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Affiliation(s)
- Laura Stephensen
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Jaimi Greenslade
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Katrina Starmer
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
- Royal Flying Doctor Service Cairns Base Cairns Queensland Australia
| | - Greg Starmer
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Richard Stone
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Robert Bonnin
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Anthony Brazzale
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Tileah Drahm‐Butler
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Virginia Campbell
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Tania Davis
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Elizabeth Mowatt
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Nathan Brown
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
| | - Karlie Proctor
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Sarah Ashover
- Promoting Value‐Based Care in the Emergency Department Clinical Excellence Queensland, Queensland Health Brisbane Queensland Australia
| | - Tanya Milburn
- Promoting Value‐Based Care in the Emergency Department Clinical Excellence Queensland, Queensland Health Brisbane Queensland Australia
| | - Louise McCormack
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
| | | | - Michelle Gatton
- School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Ray Mahoney
- School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
- Australian e‐Health Research Centre Commonwealth Scientific and Industrial Research Organisation Canberra Australian Capital Territory Australia
- College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - William Parsonage
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Louise Cullen
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
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Champion S, Clark RA, Tirimacco R, Tideman P, Gebremichael L, Beleigoli A. The Impact of the SARS-CoV-2 Virus (COVID-19) Pandemic and the Rapid Adoption of Telehealth for Cardiac Rehabilitation and Secondary Prevention Programs in Rural and Remote Australia: A Multi-Method Study. Heart Lung Circ 2022; 31:1504-1512. [PMID: 35987722 PMCID: PMC9384540 DOI: 10.1016/j.hlc.2022.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/31/2022] [Accepted: 07/01/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Centre-based cardiac rehabilitation (CR) programs were disrupted and urged to adopt telehealth modes of delivery during the COVID-19 public health emergency. Previously established telehealth services may have faced increased demand. This study aimed to investigate a) the impact of the COVID-19 pandemic on CR attendance/completion, b) clinical outcomes of patients with cardiovascular (CV) diseases referred to CR and, c) how regional and rural centre-based services converted to a telehealth delivery during this time. METHODS A cohort of patients living in regional and rural Australia, referred to an established telehealth-based or centre-based CR services during COVID-19 first wave, were prospectively followed-up, for ≥90 days (February to June 2020). Cardiac rehabilitation attendance/completion and a composite of CV re-admissions and deaths were compared to a historical control group referred in the same period in 2019. The impact of mode of delivery (established telehealth service versus centre-based CR) was analysed through a competitive risk model. The adaption of centre-based CR services to telehealth was assessed via a cross-sectional survey. RESULTS 1,954 patients (1,032 referred during COVID-19 and 922 pre-COVID-19) were followed-up for 161 (interquartile range 123-202) days. Mean age was 68 (standard deviation 13) years and 68% were male. Referrals to the established telehealth program did not differ during (24%) and pre-COVID-19 (23%). Although all 10 centre-based services surveyed adopted telehealth, attendance (46.6% vs 59.9%; p<0.001) and completion (42.4% vs 75.4%; p<0.001) was significantly lower during COVID-19. Referral during vs pre-COVID-19 (sub hazard ratio [SHR] 0.77; 95% CI 0.68-0.87), and to a centre-based program compared to the established telehealth service (SHR 0.66; 95% CI 0.58-0.76) decreased the likelihood of CR uptake. DISCUSSION An established telehealth service and rapid adoption of telehealth by centre-based programs enabled access to CR in regional and rural Australia during COVID-19. However, further development of the newly implemented telehealth models is needed to promote CR attendance and completion.
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Affiliation(s)
- Stephanie Champion
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Robyn A Clark
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Rosy Tirimacco
- Integrated Cardiovascular Clinical Network SA, Rural and Remote Support Services, SA Department of Health, Adelaide, SA, Australia
| | - Philip Tideman
- Integrated Cardiovascular Clinical Network SA, Rural and Remote Support Services, SA Department of Health, Adelaide, SA, Australia
| | - Lemlem Gebremichael
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Alline Beleigoli
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.
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Kibret GD, Demant D, Hayen A. Geographical accessibility of emergency neonatal care services in Ethiopia: analysis using the 2016 Ethiopian Emergency Obstetric and Neonatal Care Survey. BMJ Open 2022; 12:e058648. [PMID: 35680267 PMCID: PMC9185593 DOI: 10.1136/bmjopen-2021-058648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Access to emergency neonatal health services has not been explored widely in the Ethiopian context. Accessibility to health services is a function of the distribution and location of services, including distance, travel time, cost and convenience. Measuring the physical accessibility of health services contributes to understanding the performance of health systems, thereby enabling evidence-based health planning and policies. The physical accessibility of Ethiopian health services, particularly emergency neonatal care (EmNeC) services, is unknown. OBJECTIVE To analyse the physical accessibility of EmNeC services at the national and subnational levels in Ethiopia. METHODS We analysed the physical accessibility of EmNeC services within 30, 60 and 120 min of travel time in Ethiopia at a national and subnational level. We used the 2016 Ethiopian Emergency Obstetric and Neonatal Care survey in addition to several geospatial data sources. RESULTS We estimated that 21.4%, 35.9% and 46.4% of live births in 2016 were within 30, 60 and 120 min of travel time of fully EmNeC services, but there was considerable variation across regions. Addis Ababa and the Hareri regional state had full access (100% coverage) to EmNeC services within 2 hours travel time, while the Afar (15.3%) and Somali (16.3%) regional states had the lowest access. CONCLUSIONS The physical access to EmNeC services in Ethiopia is well below the universal health coverage expectations stated by the United Nations. Increasing the availability of EmNeC to health facilities where routine delivery services currently are taking place would significantly increase physical access. Our results reinforce the need to revise service allocations across administrative regions and consider improving disadvantaged areas in future health service planning.
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Affiliation(s)
- Getiye Dejenu Kibret
- Department of Public Health, College of Health Science, Debre Markos, Ethiopia
- School of Public Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Daniel Demant
- School of Public Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Andrew Hayen
- School of Public Health, University of Technology Sydney, Sydney, New South Wales, Australia
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Beleigoli A, Nicholls SJ, Brown A, Chew DP, Beltrame J, Maeder A, Maher C, Versace VL, Hendriks JM, Tideman P, Kaambwa B, Zeitz C, Prichard IJ, Tavella R, Tirimacco R, Keech W, Astley C, Govin K, Nesbitt K, Du H, Champion S, Pinero de Plaza MA, Lynch I, Poulsen V, Ludlow M, Wanguhu K, Meyer H, Krollig A, Gebremichael L, Green C, Clark RA. Implementation and prospective evaluation of the Country Heart Attack Prevention model of care to improve attendance and completion of cardiac rehabilitation for patients with cardiovascular diseases living in rural Australia: a study protocol. BMJ Open 2022; 12:e054558. [PMID: 35173003 PMCID: PMC8852732 DOI: 10.1136/bmjopen-2021-054558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Despite extensive evidence of its benefits and recommendation by guidelines, cardiac rehabilitation (CR) remains highly underused with only 20%-50% of eligible patients participating. We aim to implement and evaluate the Country Heart Attack Prevention (CHAP) model of care to improve CR attendance and completion for rural and remote participants. METHODS AND ANALYSIS CHAP will apply the model for large-scale knowledge translation to develop and implement a model of care to CR in rural Australia. Partnering with patients, clinicians and health service managers, we will codevelop new approaches and refine/expand existing ones to address known barriers to CR attendance. CHAP will codesign a web-based CR programme with patients expanding their choices to CR attendance. To increase referral rates, CHAP will promote endorsement of CR among clinicians and develop an electronic system that automatises referrals of in-hospital eligible patients to CR. A business model that includes reimbursement of CR delivered in primary care by Medicare will enable sustainable access to CR. To promote CR quality improvement, professional development interventions and an accreditation programme of CR services and programmes will be developed. To evaluate 12-month CR attendance/completion (primary outcome), clinical and cost-effectiveness (secondary outcomes) between patients exposed (n=1223) and not exposed (n=3669) to CHAP, we will apply a multidesign approach that encompasses a prospective cohort study, a pre-post study and a comprehensive economic evaluation. ETHICS AND DISSEMINATION This study was approved by the Southern Adelaide Clinical Human Research Ethics Committee (HREC/20/SAC/78) and by the Department for Health and Wellbeing Human Research Ethics Committee (2021/HRE00270), which approved a waiver of informed consent. Findings and dissemination to patients and clinicians will be through a public website, online educational sessions and scientific publications. Deidentified data will be available from the corresponding author on reasonable request. TRIAL REGISTRATION NUMBER ACTRN12621000222842.
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Affiliation(s)
- Alline Beleigoli
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Alex Brown
- Indigenous Health, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - John Beltrame
- The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Anthony Maeder
- Flinders Digital Health Research Centre, Flinders University, Adelaide, South Australia, Australia
| | - Carol Maher
- Alliance for Research in Exercise, Nutrition and Activity, University of South Australia, Adelaide, South Australia, Australia
| | - Vincent L Versace
- Deakin Rural Health, School of Medicine, Deakin University, Melbourne, Victoria, Australia
| | - Jeroen M Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Philip Tideman
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Integrated Cardiovascular Clinical Network, Rural Support Service, Adelaide, South Australia, Australia
| | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Christopher Zeitz
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Ivanka J Prichard
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Rosanna Tavella
- The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rosy Tirimacco
- Integrated Cardiovascular Clinical Network, Rural Support Service, Adelaide, South Australia, Australia
| | - Wendy Keech
- Health Translation SA, Adelaide, South Australia, Australia
| | - Carolyn Astley
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Kay Govin
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Katie Nesbitt
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Huiyun Du
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Stephanie Champion
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | | | - Imelda Lynch
- National Heart Foundation of Australia, Mawson, Australia Central Territory, Australia
| | - Vanessa Poulsen
- National Heart Foundation of Australia, Mawson, Australia Central Territory, Australia
| | - Marie Ludlow
- National Heart Foundation of Australia, Mawson, Australia Central Territory, Australia
| | - Ken Wanguhu
- Royal Australian College of General Practitioners, Waikerie, Victoria, Australia
| | - Hendrika Meyer
- Rural Support Service, SA Health, Adelaide, South Australia, Australia
| | - Ali Krollig
- Rural Support Service, SA Health, Adelaide, South Australia, Australia
| | - Lemlem Gebremichael
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Chloe Green
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Robyn A Clark
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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11
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Baker T, Moore K, Lim J, Papanastasiou C, McCarthy S, Schreve F, Lawson M, Versace V. Rural emergency care facilities may be adapting to their context: A population-level study of resources and workforce. Aust J Rural Health 2022; 30:393-401. [PMID: 35171520 PMCID: PMC9305935 DOI: 10.1111/ajr.12846] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/21/2021] [Accepted: 01/11/2022] [Indexed: 11/27/2022] Open
Abstract
Objective To provide a structured understanding of rural hospital‐based emergency care facility workforce and resources. Design The resources of regional training hubs were used to survey eligible emergency care facilities in their surrounding region. Setting Rural emergency care facilities manage more than one third of Australia's emergency presentations. These emergency care facilities include emergency departments and less‐resourced facilities in smaller towns. Participants Hospital facilities located outside metropolitan areas that report emergency presentations to the Australian Institute of Health and Welfare. Interventions A survey tool was sent by email. Main outcome measures Presence of human, diagnostic and other resources as reported on a questionnaire. Results A completed questionnaire was received from 195 emergency care facilities. Over 60% of Small hospitals had on‐call doctors only. General practitioners/generalists and nurses with extended emergency skills were found in all hospital types. Emergency physicians were present across all remoteness areas, but more commonly seen in larger facilities. All Major/Large facilities and most Medium facilities reported having onsite pathology and radiology. Point of care testing and clinician radiography were more commonly reported in smaller facilities. Among Small hospitals, Very Remote hospitals were more likely than Inner Regional hospitals to have an onsite doctor in the emergency care facility and/or a high dependency unit. Conclusion Smaller and more remote facilities appear to adapt by using different workforce structures and bedside investigations.
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Affiliation(s)
- Tim Baker
- Deakin University Centre for Rural Emergency Medicine, Warrnambool, Victoria, Australia
| | - Katie Moore
- Australasian College for Emergency Medicine, West Melbourne, Victoria, Australia
| | - Jolene Lim
- Australasian College for Emergency Medicine, West Melbourne, Victoria, Australia
| | | | - Sally McCarthy
- University of New South Wales, Sydney, New South Wales, Australia
| | | | - Mary Lawson
- Deakin University School of Medicine, Geelong, Victoria, Australia
| | - Vincent Versace
- Deakin University Rural Health, Warrnambool, Victoria, Australia
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12
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Vaughan G, Dawson A, Peek M, Carapetis J, Wade V, Sullivan E. Caring for Pregnant Women with Rheumatic Heart Disease: A Qualitative Study of Health Service Provider Perspectives. Glob Heart 2021; 16:88. [PMID: 35141129 PMCID: PMC8698228 DOI: 10.5334/gh.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 11/15/2021] [Indexed: 11/20/2022] Open
Abstract
Background Rheumatic heart disease (RHD) persists in low-middle-income countries and in high-income countries where there are health inequities. RHD in pregnancy (RHD-P) is associated with poorer maternal and perinatal outcomes. Our study examines models of care for women with RHD-P from the perspectives of health care providers. Methods A descriptive qualitative study exploring Australian health professionals' perspectives of care pathways for women with RHD-P. Thematic analysis of semi-structured interviews with nineteen participants from maternal health and other clinical and non-clinical domains related to RHD-P. Results A constellation of factors challenged the provision of integrated women-centred care, related to health systems, workforces and culture. Themes that impacted on the provision of quality woman-centred care included conduits of care - helping to break down silos of information, processes and access; 'layers on layers' - reflecting the complexity of care issues; and shared understandings - factors that contributed to improved understandings of disease and informed decision-making. Conclusions Pregnancy for women with RHD provides an opportunity to strengthen health system responses, improve care pathways and address whole-of-life health. To respond effectively, structural and cultural changes are required including enhanced investment in education and capacity building - particularly in maternal health - to support a better informed and skilled workforce. Aboriginal Mothers and Babies programs provide useful exemplars to guide respectful effective models of care for women with RHD, with relevance for non-Indigenous women in high-risk RHD communities.For key goals to be met in the context of RHD, maternal health must be better integrated into RHD strategies and RHD better addressed in maternal health.
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Affiliation(s)
- Geraldine Vaughan
- Central Queensland University, College of Science and Sustainability, Sydney campus, AU
| | - Angela Dawson
- University of Technology Sydney, Faculty of Health, Sydney, AU
| | - Michael Peek
- The Australian National University, College of Health and Medicine, Canberra, AU
| | - Jonathan Carapetis
- Telethon Kids Institute, University of Western Australia, and Perth Children’s Hospital, Nedlands WA, AU
| | - Vicki Wade
- Menzies School of Health Research, NT, AU
| | - Elizabeth Sullivan
- The University of Newcastle, Faculty of Health and Medicine, Newcastle, AU
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13
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Freene N, Brown R, Collis P, Bourke C, Silk K, Jackson A, Davey R, Northam HL. An Aboriginal and Torres Strait Islander Cardiac Rehabilitation program delivered in a non-Indigenous health service (Yeddung Gauar): a mixed methods feasibility study. BMC Cardiovasc Disord 2021; 21:222. [PMID: 33932992 PMCID: PMC8088627 DOI: 10.1186/s12872-021-02016-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 04/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is limited evidence of Aboriginal and Torres Strait Islander people attending cardiac rehabilitation (CR) programs despite high levels of heart disease. One key enabler for CR attendance is a culturally safe program. This study evaluates improving access for Aboriginal and Torres Strait Islander women to attend a CR program in a non-Indigenous health service, alongside improving health workforce cultural safety. METHODS An 18-week mixed-methods feasibility study was conducted, with weekly flexible CR sessions delivered by a multidisciplinary team and an Aboriginal and/or Torres Strait Islander Health Worker (AHW) at a university health centre. Aboriginal and Torres Strait Islander women who were at risk of, or had experienced, a cardiac event were recruited. Data was collected from participants at baseline, and at every sixth-session attended, including measures of disease risk, quality-of-life, exercise capacity and anxiety and depression. Cultural awareness training was provided for health professionals before the program commenced. Assessment of health professionals' cultural awareness pre- and post-program was evaluated using a questionnaire (n = 18). Qualitative data from participants (n = 3), the AHW, health professionals (n = 4) and referrers (n = 4) was collected at the end of the program using yarning methodology and analysed thematically using Charmaz's constant comparative approach. RESULTS Eight referrals were received for the CR program and four Aboriginal women attended the program, aged from 24 to 68 years. Adherence to the weekly sessions ranged from 65 to 100%. At the program's conclusion, there was a significant change in health professionals' perception of social policies implemented to 'improve' Aboriginal people, and self-reported changes in health professionals' behaviours and skills. Themes were identified for recruitment, participants, health professionals and program delivery, with cultural safety enveloping all areas. Trust was a major theme for recruitment and adherence of participants. The AHW was a key enabler of cultural authenticity, and the flexibility of the program contributed greatly to participant perceptions of cultural safety. Barriers for attendance were not unique to this population. CONCLUSION The flexible CR program in a non-Indigenous service provided a culturally safe environment for Aboriginal women but referrals were low. Importantly, the combination of cultural awareness training and participation in the program delivery improved health professionals' confidence in working with Aboriginal people. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR) 12618000581268, http://www.ANZCTR.org.au/ACTRN12618000581268.aspx , registered 16 April 2018.
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Affiliation(s)
- Nicole Freene
- Physiotherapy, Faculty of Health, University of Canberra, Bruce, ACT, 2617, Australia.
- Health Research Institute, University of Canberra, Bruce, ACT, Australia.
| | - Roslyn Brown
- Ngunnawal Centre, Office of Aboriginal and Torres Strait Islander Leadership and Strategy, University of Canberra, Bruce, ACT, Australia
| | - Paul Collis
- Faculty of Arts and Design, University of Canberra, Bruce, ACT, Australia
| | - Chris Bourke
- Australian Healthcare and Hospitals Association, Deakin, ACT, Australia
| | - Katharine Silk
- Australian Healthcare and Hospitals Association, Deakin, ACT, Australia
| | - Alicia Jackson
- Physiotherapy, Faculty of Health, University of Canberra, Bruce, ACT, 2617, Australia
| | - Rachel Davey
- Health Research Institute, University of Canberra, Bruce, ACT, Australia
| | - Holly L Northam
- Nursing, Midwifery and Public Health, Faculty of Health, University of Canberra, Bruce, ACT, Australia
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14
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Zonneveld S, Versace VL, Krass I, Clark RA, Shih S, Detert Oude Weme S, Mc Namara KP. The Inverse Care Law might not apply to preventative health services in community pharmacy. Res Social Adm Pharm 2021; 17:875-884. [DOI: 10.1016/j.sapharm.2020.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 06/15/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
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15
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Tan EJ, Hayen A, Clarke P, Jackson R, Knight J, Hayes AJ. Trends in Ischaemic Heart Disease in Australia, 2001-2015: A Comparison of Urban and Rural Populations. Heart Lung Circ 2021; 30:971-977. [PMID: 33454212 DOI: 10.1016/j.hlc.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/24/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Ischaemic heart disease (IHD) is a major source of disease burden worldwide. Recent trends show incidence is declining but it is unclear whether the trends are similar in urban and rural populations. This study examines the trends of IHD events (i.e. hospitalisations and deaths) in New South Wales, Australia by rurality. METHODS This was a retrospective analysis of linked administrative data for hospitalisation and death records across NSW between 2001 and 2015. Participants were NSW residents aged 15-105 years who died or were hospitalised with a principal diagnosis of IHD. The main outcome measures were annual age-standardised mortality and hospitalisations for IHD by calendar year and rurality. RESULTS Between 2001 and 2015, age-standardised annual IHD hospitalisations declined in urban areas from 587 to 260 and in rural areas from 766 to 395 per 100,000 people. The annual decline in hospitalisations was greater in urban than rural areas, with Annual Percentage Change (APC) of -5.6% (95% CI, -6.1%, -5.0%) and -4.5% (95% CI, -5.0%, -4.0%), respectively (p=0.012). Ischaemic heart disease mortality declined at a similar rate in urban and rural regions (APC -7.6% and -6.7% per annum, p=0.28). Absolute inequalities in IHD deaths persisted until 2015 when there were 49 (urban) and 70 (rural) IHD deaths per 100,000 people. CONCLUSIONS Ischaemic heart disease hospitalisations and mortality have declined considerably between 2001 and 2015 in both rural and urban areas, yet inequalities persist, suggesting more intensive preventive efforts are required to further reduce the burden of IHD in rural populations.
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Affiliation(s)
- Eng Joo Tan
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney, NSW, Australia
| | - Andrew Hayen
- Discipline of Public Health, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Philip Clarke
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rod Jackson
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Josh Knight
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Vic, Australia
| | - Alison J Hayes
- The University of Sydney, Faculty of Medicine and Health, School of Public Health, Sydney, NSW, Australia.
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16
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Ferguson C, Inglis SC, Gallagher R, Davidson PM. Reflecting on the Impact of Cardiovascular Nurses in Australia and New Zealand in the International Year of the Nurse and Midwife. Heart Lung Circ 2020; 29:1744-1748. [PMID: 33067125 PMCID: PMC7553902 DOI: 10.1016/j.hlc.2020.09.921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Caleb Ferguson
- Western Sydney Nursing & Midwifery Research Centre, Western Sydney Local Health District & Western Sydney University, Blacktown Hospital, Sydney, NSW, Australia.
| | - Sally C Inglis
- IMPACCT and School of Nursing & Midwifery, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Robyn Gallagher
- Charles Perkins Centre & Sydney Nursing School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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17
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Ha FJ, Han HC, Sanders P, Fendel K, Teh AW, Kalman JM, O'Donnell D, Leong T, Farouque O, Lim HS. Sudden Cardiac Death in the Young: Incidence, Trends, and Risk Factors in a Nationwide Study. Circ Cardiovasc Qual Outcomes 2020; 13:e006470. [PMID: 33079584 DOI: 10.1161/circoutcomes.119.006470] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sudden cardiac death (SCD) in the young is devastating. Contemporary incidence remains unclear with few recent nationwide studies and limited data addressing risk factors for causes. We aimed to determine incidence, trends, causes, and risk factors for SCD in the young. METHODS AND RESULTS The National Coronial Information System registry was reviewed for SCD in people aged 1 to 35 years from 2000 to 2016 in Australia. Subjects were identified by the International Classification of Diseases, Tenth Revision code relating to circulatory system diseases (I00-I99) from coronial reports. Baseline demographics, circumstances, and cause of SCD were obtained from coronial and police reports, alongside autopsy and toxicology analyses where available. During the study period, 2006 cases were identified (median age, 28±7 years; men, 75%; mean body mass index, 29±8 kg/m2). Annual incidence ranged from 0.91 to 1.48 per 100 000 age-specific person-years, which was the lowest in 2013 to 2015 compared with previous 3-year intervals on Poisson regression model (P=0.001). SCD incidence was higher in nonmetropolitan versus metropolitan areas (0.99 versus 0.53 per 100 000 person-years; P<0.001). The most common cause of SCD was coronary artery disease (40%), followed by sudden arrhythmic death syndrome (14%). Incidence of coronary artery disease-related SCD decreased from 2001-2003 to 2013-2015 (P<0.001). Proportion of SCD related to sudden arrhythmic death syndrome increased during the study period (P=0.02) although overall incidence was stable (P=0.22). Residential remoteness was associated with coronary artery disease-related SCD (odds ratio, 1.44 [95% CI, 1.24-1.67]; P<0.001). For every 1-unit increase, body mass index was associated with increased likelihood of SCD from cardiomegaly (odds ratio, 1.08 [95% CI, 1.05-1.11]; P<0.001) and dilated cardiomyopathy (odds ratio, 1.04 [95% CI, 1.01-1.06]; P=0.005). CONCLUSIONS Incidence of SCD in the young and specifically coronary artery disease-related SCD has declined in recent years. Proportion of SCD related to sudden arrhythmic death syndrome increased over the study period. Geographic remoteness and obesity are risk factors for specific causes of SCD in the young.
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Affiliation(s)
- Francis J Ha
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia (F.J.H., H.-C.H., K.F., A.W.T., D.O., O.F., H.S.L.).,St. Vincent's Hospital Melbourne, Victoria, Australia (F.J.H.)
| | - Hui-Chen Han
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia (F.J.H., H.-C.H., K.F., A.W.T., D.O., O.F., H.S.L.).,University of Melbourne, Victoria, Australia (H.-C.H., A.W.T., J.M.K., O.F., H.S.L.)
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australia Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital Adelaide, South Australia, Australia (P.S.)
| | - Kim Fendel
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia (F.J.H., H.-C.H., K.F., A.W.T., D.O., O.F., H.S.L.)
| | - Andrew W Teh
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia (F.J.H., H.-C.H., K.F., A.W.T., D.O., O.F., H.S.L.).,University of Melbourne, Victoria, Australia (H.-C.H., A.W.T., J.M.K., O.F., H.S.L.)
| | - Jonathan M Kalman
- University of Melbourne, Victoria, Australia (H.-C.H., A.W.T., J.M.K., O.F., H.S.L.).,Melbourne Heart Centre, Royal Melbourne Hospital, Victoria, Australia (J.M.K.)
| | - David O'Donnell
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia (F.J.H., H.-C.H., K.F., A.W.T., D.O., O.F., H.S.L.)
| | - Trishe Leong
- Department of Anatomical Pathology, St. Vincent's Hospital, Melbourne, Victoria, Australia (T.L.)
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia (F.J.H., H.-C.H., K.F., A.W.T., D.O., O.F., H.S.L.).,University of Melbourne, Victoria, Australia (H.-C.H., A.W.T., J.M.K., O.F., H.S.L.)
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia (F.J.H., H.-C.H., K.F., A.W.T., D.O., O.F., H.S.L.).,University of Melbourne, Victoria, Australia (H.-C.H., A.W.T., J.M.K., O.F., H.S.L.).,Department of Cardiology, Northern Health, Melbourne, Victoria, Australia (H.S.L.)
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18
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Bell SC, Mall MA, Gutierrez H, Macek M, Madge S, Davies JC, Burgel PR, Tullis E, Castaños C, Castellani C, Byrnes CA, Cathcart F, Chotirmall SH, Cosgriff R, Eichler I, Fajac I, Goss CH, Drevinek P, Farrell PM, Gravelle AM, Havermans T, Mayer-Hamblett N, Kashirskaya N, Kerem E, Mathew JL, McKone EF, Naehrlich L, Nasr SZ, Oates GR, O'Neill C, Pypops U, Raraigh KS, Rowe SM, Southern KW, Sivam S, Stephenson AL, Zampoli M, Ratjen F. The future of cystic fibrosis care: a global perspective. THE LANCET RESPIRATORY MEDICINE 2020; 8:65-124. [DOI: 10.1016/s2213-2600(19)30337-6] [Citation(s) in RCA: 351] [Impact Index Per Article: 87.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/19/2019] [Accepted: 08/14/2019] [Indexed: 02/06/2023]
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19
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Re-examining the effect of door-to-balloon delay on STEMI outcomes in the context of unmeasured confounders: a retrospective cohort study. Sci Rep 2019; 9:19978. [PMID: 31882674 PMCID: PMC6934575 DOI: 10.1038/s41598-019-56353-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 12/10/2019] [Indexed: 11/08/2022] Open
Abstract
Literature studying the door-to-balloon time-outcome relation in coronary intervention is limited by the potential of residual biases from unobserved confounders. This study re-examines the time-outcome relation with further consideration of the unobserved factors and reports the population average effect. Adults with ST-elevation myocardial infarction admitted to one of the six registry participating hospitals in Australia were included in this study. The exposure variable was patient-level door-to-balloon time. Primary outcomes assessed included in-hospital and 30 days mortality. 4343 patients fulfilled the study criteria. 38.0% (1651) experienced a door-to-balloon delay of >90 minutes. The absolute risk differences for in-hospital and 30-day deaths between the two exposure subgroups with balanced covariates were 2.81 (95% CI 1.04, 4.58) and 3.37 (95% CI 1.49, 5.26) per 100 population. When unmeasured factors were taken into consideration, the risk difference were 20.7 (95% CI −2.6, 44.0) and 22.6 (95% CI −1.7, 47.0) per 100 population. Despite further adjustment of the observed and unobserved factors, this study suggests a directionally consistent linkage between longer door-to-balloon delay and higher risk of adverse outcomes at the population level. Greater uncertainties were observed when unmeasured factors were taken into consideration.
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20
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Versace VL, Coffee NT, Franzon J, Turner D, Lange J, Taylor D, Clark R. Comparison of general and cardiac care-specific indices of spatial access in Australia. PLoS One 2019; 14:e0219959. [PMID: 31344082 PMCID: PMC6657861 DOI: 10.1371/journal.pone.0219959] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 07/05/2019] [Indexed: 11/19/2022] Open
Abstract
Objective To identity differences between a general access index (Accessibility/ Remoteness Index of Australia; ARIA+) and a specific acute and aftercare cardiac services access index (Cardiac ARIA). Research design and methods Exploratory descriptive design. ARIA+ (2011) and Cardiac ARIA (2010) were compared using cross-tabulations (chi-square test for independence) and map visualisations. All Australian locations with ARIA+ and Cardiac ARIA values were included in the analysis (n = 20,223). The unit of analysis was Australian locations. Results Of the 20,223 locations, 2757 (14% of total) had the highest level of acute cardiac access coupled with the highest level of general access. There were 1029 locations with the poorest access (5% of total). Approximately two thirds of locations in Australia were classed as having the highest level of cardiac aftercare. Locations in Major Cities, Inner Regional Australia, and Outer Regional Australia accounted for approximately 98% of this category. There were significant associations between ARIA+ and Cardiac ARIA acute (χ2 = 25250.73, df = 28, p<0.001, Cramer’s V = 0.559, p<0.001) and Cardiac ARIA aftercare (χ2 = 17204.38, df = 16, Cramer’s V = 0.461, p<0.001). Conclusions Although there were significant associations between the indices, ARIA+ and Cardiac ARIA are not interchangeable. Systematic differences were apparent which can be attributed largely to the underlying specificity of the Cardiac ARIA (a time critical index that uses distance to the service of interest) compared to general accessibility quantified by the ARIA+ model (an index that uses distance to population centre). It is where the differences are located geographically that have a tangible impact upon the communities in these locations–i.e. peri-urban areas of the major capital cities, and around the more remote regional centres. There is a strong case for specific access models to be developed and updated to assist with efficient deployment of resources and targeted service provision. The reasoning behind the differences highlighted will be generalisable to any comparison between general and service-specific access models.
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Affiliation(s)
- Vincent Lawrence Versace
- Deakin Rural Health, School of Medicine, Deakin University, Geelong, Victoria, Australia
- National Centre for Farmer Health, Western District Health Service, Hamilton, Victoria, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- * E-mail:
| | - Neil T. Coffee
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Centre for Research and Action in Public Health (CeRAPH), University of Canberra, Canberra, ACT, Australia
| | - Julie Franzon
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Dorothy Turner
- Spatial Sciences Group, School of Biological Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jarrod Lange
- Hugo Centre for Migration and Population Research, The University of Adelaide, Adelaide, South Australia, Australia
| | - Danielle Taylor
- Basil Hetzel Institute for Translational Health Research, Discipline of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Robyn Clark
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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21
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The Keeping on Track Study: Exploring the Activity Levels and Utilization of Healthcare Services of Acute Coronary Syndrome (ACS) Patients in the First 30-Days after Discharge from Hospital. Med Sci (Basel) 2019; 7:medsci7040061. [PMID: 31010168 PMCID: PMC6524056 DOI: 10.3390/medsci7040061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/07/2019] [Accepted: 04/10/2019] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to investigate the impact of bedside discharge education on activity levels and healthcare utilization for patients with acute coronary syndrome (ACS) in the first 30 days post-discharge. Knowledge recall and objective activity and location data were collected by global positioning systems (GPS). Participants were asked to carry the tracking applications (apps) for 30–90 days. Eighteen participants were recruited (6 metropolitan 12 rural) 61% ST elevation myocardial infarction (STEMI), mean age 55 years, 83% male. Recall of discharge education included knowledge of diagnosis (recall = 100%), procedures (e.g., angiogram = 40%), and comorbidities (e.g., hypertension = 60%, diabetes = 100%). In the first 30 days post-discharge, median steps per day was 2506 (standard deviation (SD) ± 369) steps (one participant completed 10,000 steps), 62% visited a general practitioner (GP) 16% attended cardiac rehabilitation, 16% visited a cardiologist, 72% a pharmacist, 27% visited the emergency department for cardiac event, and 61% a pathology service (blood tests). Adherence to using the activity tracking apps was 87%. Managing Big Data from the GPS and physical activity tracking apps was a challenge with over 300,000 lines of raw data cleaned to 90,000 data points for analysis. This study was an example of the application of objective data from the real world to help understand post-ACS discharge patient activity. Rates of access to services in the first 30 days continue to be of concern.
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Dent E, van Gaans D. Improving health care accessibility for older adults with frailty: the role of Geographical Information Systems. Aging Clin Exp Res 2018; 30:1257-1258. [PMID: 29302795 DOI: 10.1007/s40520-017-0884-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022]
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Sepehrvand N, Alemayehu W, Kaul P, Pelletier R, Bello AK, Welsh RC, Armstrong PW, Ezekowitz JA. Ambulance use, distance and outcomes in patients with suspected cardiovascular disease: a registry-based geographic information system study. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:45-58. [PMID: 29652166 DOI: 10.1177/2048872618769872] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite guideline recommendations, the majority of patients with symptoms suggestive of acute coronary syndrome do not use emergency medical services to reach the emergency department (ED). The aim of this study was to investigate the factors associated with EMS utilisation and subsequent patient outcomes. METHODS Using administrative data, all patients who presented to an ED in the metropolitan areas of Edmonton and Calgary in the years of 2007-2013 with main ED diagnosis of acute coronary syndrome, stable angina or chest pain were included. The travel distance was estimated using the geographic information system method to approximate the distance between the ED and patient home. The clinical endpoints were the 7-day and 30-day all-cause events (death, re-hospitalisation and repeat ED visit). RESULTS Of 50,881 patients, 30.5% presented by emergency medical services. Patients with older age, female sex, ED diagnosis of acute coronary syndrome, more comorbidities and lower household income were more likely to use emergency medical services to reach the hospital. Longer travel distance was associated with higher emergency medical services use (odds ratio 1.09, 95% confidence interval 1.09-1.10), but it was not a predictor of clinical events. After adjustment for covariates and inverse propensity score weighting, emergency medical services use was associated with a higher risk of 7-day and 30-day clinical events. CONCLUSION Several demographic and clinical features were associated with higher emergency medical services use including geographical variation. Although longer travel distance was shown to be linked to higher emergency medical services use, it was not an independent predictor of patient outcome. This has implications for the design of emergency medical services systems, triage and early diagnosis and treatment options.
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Affiliation(s)
- Nariman Sepehrvand
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada
| | | | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada
| | - Rick Pelletier
- Department of Renewable Resources, University of Alberta, Canada
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Canada
| | - Robert C Welsh
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada.,Mazankowski Alberta Heart Institute, Canada
| | | | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada.,Mazankowski Alberta Heart Institute, Canada
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Viana M, Borges A, Araújo C, Rocha A, Ribeiro AI, Laszczyńska O, Dias P, Maciel MJ, Moreira I, Lunet N, Azevedo A. Inequalities in access to cardiac rehabilitation after an acute coronary syndrome: the EPiHeart cohort. BMJ Open 2018; 8:e018934. [PMID: 29301762 PMCID: PMC5781051 DOI: 10.1136/bmjopen-2017-018934] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES To estimate cardiac rehabilitation (CR) referral and participation rates among patients with acute coronary syndrome (ACS) and to identify their determinants, in two Portuguese regions. DESIGN Prospective cohort study. SETTING Patients consecutively admitted to the cardiology department of two hospitals, one in the district of Porto and one in the north-east region (NER) of Portugal, were enrolled in the EPIHeart cohort and then followed up for 6 months. PARTICIPANTS Between August 2013 and December 2014, 939 patients were included in the cohort, and 853 were re-evaluated at 6-month follow-up. OUTCOME MEASURES Referral rate was defined as the proportion of eligible patients who were referred to a CR programme, whereas participation rate was defined as the proportion of eligible patients who completed a CR programme, as was recommended by their physicians. RESULTS Patients referred were 32.3% and 10.7% of those eligible in Porto and NER, respectively. In both regions, referral to CR decreased with age and with longer travel times to CR centres and increased with education or social class. At follow-up, 128 patients from Porto (26.2% of those eligible and 81.0% of those referred) and 26 from NER (7.1% of those eligible and 66.7% of those referred) reported actually participating in a CR programme. In Porto, the main barriers to participation were the long time until a programme was available and lack of perceived benefit. Patients in NER identified distance to CR and costs as the main barriers. CONCLUSIONS CR remains clearly underused in Portugal, with major inequalities in access between regions. Achieving equitable and greater use of CR requires a multilevel approach addressing barriers related to healthcare system, providers and patients in order to improve provision, referral and participation.
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Affiliation(s)
- Marta Viana
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Centro de Epidemiologia Hospitalar, Centro Hospitalar de São João, Porto, Portugal
| | - Andreia Borges
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Carla Araújo
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Serviço de Cardiologia, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Afonso Rocha
- Serviço de Medicina Física e Reabilitação, Centro Hospitalar de São João, Porto, Portugal
| | - Ana I Ribeiro
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Olga Laszczyńska
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Paula Dias
- Serviço de Cardiologia, Centro Hospitalar de São João, Porto, Portugal
| | - Maria J Maciel
- Serviço de Cardiologia, Centro Hospitalar de São João, Porto, Portugal
| | - Ilídio Moreira
- Serviço de Cardiologia, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Nuno Lunet
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Ana Azevedo
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Centro de Epidemiologia Hospitalar, Centro Hospitalar de São João, Porto, Portugal
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Carrington MJ, Zimmet P. Nurse health and lifestyle modification versus standard care in 40 to 70 year old regional adults: study protocol of the Management to Optimise Diabetes and mEtabolic syndrome Risk reduction via Nurse-led intervention (MODERN) randomized controlled trial. BMC Health Serv Res 2017; 17:813. [PMID: 29212477 PMCID: PMC5719565 DOI: 10.1186/s12913-017-2769-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/27/2017] [Indexed: 11/10/2022] Open
Abstract
Background Metabolic syndrome (MetS), the clustering of multiple leading risk factors, predisposes individuals to increased risk for developing type 2 diabetes and/or cardiovascular disease (CVD). Cardio-metabolic disease risk increases with greater remoteness where specialist services are scarce. Nurse-led interventions are effective for the management of chronic disease. The aim of this clinical trial is to determine whether a nurse-implemented health and lifestyle modification program is more beneficial than standard care to reduce cardio-metabolic abnormalities and future risk of CVD and diabetes in individuals with MetS. Methods MODERN is a multi-centre, open, parallel group randomized controlled trial in regional Victoria, Australia. Participants were self-selected and individuals aged 40 to 70 years with MetS who had no evidence of CVD or other chronic disease were recruited. Those attending a screening visit with any 3 or more risk factors of central obesity, dyslipidemia (high triglycerides or low high density lipoprotein cholesterol) elevated blood pressure and dysglycemia were randomized to either nurse-led health and lifestyle modification (intervention) or standard care (control). The intervention included risk factor management, health education, care planning and scheduled follow-up commensurate with level of risk. The primary cardio-metabolic end-point was achievement of risk factor thresholds to eliminate MetS or minimal clinically meaningful changes for at least 3 risk factors that characterise MetS over 2 year follow-up. Pre-specified secondary endpoints to evaluate between group variations in cardio-metabolic risk, general health and lifestyle behaviours and new onset CVD and type 2 diabetes will be evaluated. Key outcomes will be measured at baseline, 12 and 24 months via questionnaires, physical examinations, pathology and other diagnostic tests. Health economic analyses will be undertaken to establish the cost-effectiveness of the intervention. Discussion The MODERN trial will provide evidence for the potential benefit of independent nurse-run clinics in the community and their cost-effectiveness in adults with MetS. Findings will enable more nurse-led clinics to be adopted outside of major cities and encompassing other chronic diseases as a key primary preventative initiative. Trial registration MODERN is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616000229471) on 19 February 2016 (retrospectively registered). Secondary identifiers: MODERN is an investigator-initiated trial funded by the National Health and Medical Research Council of Australia from 2014 to 2017 via a Project Grant (ID No. APP1069043) and was approved by the Australian Catholic University Human Research Ethics Committee (Project No: 2014 244 V) and the Department of Health Human Research Ethics Committee (Project No:38/2014) for the release of Medicare claims information.
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Affiliation(s)
- Melinda J Carrington
- Pre-Clinical Disease and Prevention Unit, Baker Heart and Diabetes Institute, PO Box 6492, Melbourne, Victoria, 3004, Australia. .,Centre for Primary Care and Prevention, MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia.
| | - Paul Zimmet
- Department of Diabetes, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Love AD, Kinner SA, Young JT. Social Environment and Hospitalisation after Release from Prison: A Prospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:E1406. [PMID: 29149091 PMCID: PMC5708045 DOI: 10.3390/ijerph14111406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/09/2017] [Accepted: 11/14/2017] [Indexed: 11/16/2022]
Abstract
This study examined the association between remoteness and area disadvantage, and the rate of subsequent hospitalisation, in a cohort of adults released from prisons in Queensland. A baseline survey of 1267 adult prisoners within 6 weeks of expected release was prospectively linked with hospital, mortality and reincarceration records. Postcodes were used to assign remoteness and area disadvantage categories. Multivariate Andersen-Gill regression models were fitted to test for associations between remoteness, area disadvantage and hospitalisation after release from prison. Over a total of 3090.9 person-years of follow-up, the highest crude incidence rates were observed in areas characterised by remoteness and area disadvantage (crude incidence rate (IR) = 649; 95%CI: 526-791), followed by remoteness only (IR = 420; 95%CI: 349-501), severe area disadvantage only (IR = 403; 95%CI: 351-461), and neither of these factors (IR = 361; 95%CI: 336-388). Unadjusted analyses indicated that remoteness (hazard ratio (HR) = 1.32; 95%CI: 1.04-1.69; p = 0.024) was associated with increased risk of hospitalisation; however, this attenuated to the null after adjustment for covariate factors. The incidence of hospitalisation for those who live in remote or socio-economically disadvantaged areas is increased compared to their counterparts in more urban and less socio-economically disadvantaged areas. Experiencing both these factors together may compound the hospitalisation in the community.
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Affiliation(s)
- Alexander D Love
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Melbourne 3010, Australia.
| | - Stuart A Kinner
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Melbourne 3010, Australia.
- Centre for Adolescent Health, Murdoch Children's Research Institute, Melbourne 3052, Australia.
- Mater Research Institute-UQ, University of Queensland, Brisbane 4072, Australia.
- Griffith Criminology Institute, Griffith University, Brisbane 4222, Australia.
- School of Public Health and Preventive Medicine, Monash University, Melbourne 3800, Australia.
| | - Jesse T Young
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Melbourne 3010, Australia.
- Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth 6009, Australia.
- National Drug Research Institute, Curtin University, Perth 6008, Australia.
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Mathew A, Abdullakutty J, Sebastian P, Viswanathan S, Mathew C, Nair V, Mohanan PP, George Koshy A. Population access to reperfusion services for ST-segment elevation myocardial infarction in Kerala, India. Indian Heart J 2017; 69 Suppl 1:S51-S56. [PMID: 28400039 PMCID: PMC5388050 DOI: 10.1016/j.ihj.2017.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/13/2017] [Accepted: 02/20/2017] [Indexed: 01/17/2023] Open
Abstract
Background Population access to timely reperfusion is a decisive factor in determining the success and acceptability of any regional system of ST-segment elevation myocardial infarction (STEMI) care. We sought to determine the proportion of population of the southern Indian state of Kerala having timely access to STEMI reperfusion. Methods We identified the STEMI reperfusion facilities available at all acute-care hospitals, in Kerala, by conducting a cross-sectional survey. We mapped the geographical catchment areas of these hospitals using historical travel speeds and appropriate Geospatial Information Systems (GIS) analyses. Subsequently, using block level population data, we estimated the proportion of the population residing within these geographies. Results We estimated that 23.33 million people, forming 69.84% of the state population, resided in the green zone (within half-hour travel distance of a percutaneous coronary intervention [PCI]-capable hospital), which covered 47.94% of the geographical area of the state. Outside this green zone, 21.87% of the state population resided within 1 hr travel distance of a thrombolysis-capable hospital. Finally, 8.28% of the state population resided in the red zone, where access to any reperfusion-capable hospital took >1 hr, which covered 22.15% of the geographical area of the state. Conclusions A majority of the population of Kerala had timely access to PCI-capable hospitals. GIS-based mapping of Indian states, in terms of access to STEMI reperfusion, may help devise protocols to achieve seamless transfer of patients to reperfusion-capable hospitals. Such regionalization of STEMI care would enhance organizational synergies to achieve better access to reperfusion, especially in remote areas.
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Affiliation(s)
- Anoop Mathew
- MOSC Medical College Hospital, Kolenchery, Kerala, India.
| | | | | | | | - Cibu Mathew
- Government Medical College Hospital, Thrissur, Kerala, India
| | | | | | - A George Koshy
- Government Medical College Hospital, Thiruvanathapuram, Kerala, India
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Wechkunanukul K, Grantham H, Clark RA. Global review of delay time in seeking medical care for chest pain: An integrative literature review. Aust Crit Care 2017; 30:13-20. [DOI: 10.1016/j.aucc.2016.04.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 04/07/2016] [Accepted: 04/08/2016] [Indexed: 01/09/2023] Open
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Wade V, Stocks N. The Use of Telehealth to Reduce Inequalities in Cardiovascular Outcomes in Australia and New Zealand: A Critical Review. Heart Lung Circ 2016; 26:331-337. [PMID: 27993487 DOI: 10.1016/j.hlc.2016.10.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 10/07/2016] [Accepted: 10/25/2016] [Indexed: 11/17/2022]
Abstract
Telehealth, the delivery of health care services at a distance using information and communications technology, is one means of redressing inequalities in cardiovascular outcomes for disadvantaged groups in Australia. This critical review argues that there is sufficient evidence to move to larger-scale implementation of telehealth for acute cardiac, acute stroke, and cardiac rehabilitation services. For cardiovascular chronic disease and risk factor management, telehealth-based services can deliver value but the evidence is less compelling, as the outcomes of these programs are variable and depend upon the context of their implementation.
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Affiliation(s)
- Victoria Wade
- Discipline of General Practice, School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA, Australia.
| | - Nigel Stocks
- Discipline of General Practice, School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA, Australia
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Xanthos PD, Gordon BA, Begg S, Nadurata V, Kingsley MIC. A comparison of age-standardised event rates for acute and chronic coronary heart disease in metropolitan and regional/remote Victoria: a retrospective cohort study. BMC Public Health 2016; 16:391. [PMID: 27169563 PMCID: PMC4865014 DOI: 10.1186/s12889-016-3081-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 05/04/2016] [Indexed: 11/11/2022] Open
Abstract
Background Acute and chronic coronary heart disease (CHD) pose different burdens on health-care services and require different prevention and treatment strategies. Trends in acute and chronic CHD event rates can guide service implementation. This study evaluated changes in acute and chronic CHD event rates in metropolitan and regional/remote Victoria. Methods Victorian hospital admitted episodes with a principal diagnosis of acute CHD or chronic CHD were identified from 2005 to 2012. Acute and chronic CHD age-standardised event rates were calculated in metropolitan and regional/remote Victoria. Poisson log-link linear regression was used to estimate annual change in acute and chronic CHD event rates. Results Acute CHD age-standardised event rates decreased annually by 2.9 % (95 % CI, −4.3 to −1.4 %) in metropolitan Victoria and 1.7 % (95 % CI, −3.2 to −0.1 %) in regional/remote Victoria. In comparison, chronic CHD age-standardised event rates increased annually by 4.8 % (95 % CI, +3.0 to +6.5 %) in metropolitan Victoria and 3.1 % (95 % CI, +1.3 to +4.9 %) in regional/remote Victoria. On average, age-standardised event rates for regional/remote Victoria were 30.3 % (95 % CI, 23.5 to 37.2 %) higher for acute CHD and 55.3 % (95 % CI, 47.1 to 63.5 %) higher for chronic CHD compared to metropolitan Victoria from 2005 to 2012. Conclusion Annual decreases in acute CHD age-standardised event rates might reflect improvements in primary prevention, while annual increases in chronic CHD age-standardised event rates suggest a need to improve secondary prevention strategies. Consistently higher acute and chronic CHD age-standardised event rates were evident in regional/remote Victoria compared to metropolitan Victoria from 2005 to 2012.
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Affiliation(s)
- Paul D Xanthos
- Discipline of Exercise Physiology, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Brett A Gordon
- Discipline of Exercise Physiology, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Stephen Begg
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Voltaire Nadurata
- Department of Cardiology, Bendigo Health Care Group, Bendigo, Victoria, Australia
| | - Michael I C Kingsley
- Discipline of Exercise Physiology, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia.
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Ferguson WJ, Kemp K, Kost G. Using a geographic information system to enhance patient access to point-of-care diagnostics in a limited-resource setting. Int J Health Geogr 2016; 15:10. [PMID: 26932155 PMCID: PMC4774034 DOI: 10.1186/s12942-016-0037-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 02/05/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Rapid and accurate diagnosis drives evidence-based care in health. Point-of-care testing (POCT) aids diagnosis by bringing advanced technologies closer to patients. Health small-world networks are constrained by natural connectivity in the interactions between geography of resources and social forces. Using a geographic information system (GIS) we can understand how populations utilize their health networks, visualize their inefficiencies, and compare alternatives. METHODS This project focuses on cardiac care resource in rural Isaan, Thailand. A health care access analysis was created using ArcGIS Network Analyst 10.1 from data representing aggregated population, roads, health resource facilities, and diagnostic technologies. The analysis quantified cardiac health care access and identified ways to improve it using both widespread and resource-limited strategies. RESULTS Results indicated that having diagnostic technologies closer to populations streamlines critical care paths. GIS allowed us to compare the effectiveness of the implementation strategies and put into perspective the benefits of adopting rapid POCT within health networks. CONCLUSIONS Geospatial analyses derive high impact by improving alternative diagnostic placement strategies in limited-resource settings and by revealing deficiencies in health care access pathways. Additionally, the GIS provides a platform for comparing relative costs, assessing benefits, and improving outcomes. This approach can be implemented effectively by health ministries seeking to enhance cardiac care despite limited resources.
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Affiliation(s)
- William J Ferguson
- UC Davis Point of Care Testing Center for Teaching and Research, School of Medicine, University of California, Davis, 3488 Tupper Hall, Davis, CA, 95616, USA.
| | - Karen Kemp
- Spatial Sciences Institute, Dana and Davis Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA, USA.
| | - Gerald Kost
- UC Davis Point of Care Testing Center for Teaching and Research, School of Medicine, University of California, Davis, 3488 Tupper Hall, Davis, CA, 95616, USA.
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Bihan H, Backholer K, Peeters A, Stevenson CE, Shaw JE, Magliano DJ. Socioeconomic Position and Premature Mortality in the AusDiab Cohort of Australian Adults. Am J Public Health 2016; 106:470-7. [PMID: 26794164 DOI: 10.2105/ajph.2015.302984] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine the association of socioeconomic position indicators with mortality, without and with adjustment for modifiable risk factors. METHODS We examined the relationships of 2 area-based indices and educational level with mortality among 9338 people (including 8094 younger than 70 years at baseline) of the Australian Diabetes Obesity and Lifestyle (AusDiab) from 1999-2000 until November 30, 2012. RESULTS Age- and gender-adjusted premature mortality (death before age 70 years) was more likely among those living in the most disadvantaged areas versus least disadvantaged (hazard ratio [HR] = 1.48; 95% confidence interval [CI] = 1.08, 2.01), living in inner regional versus major urban areas (HR = 1.36; 95% CI = 1.07, 1.73), or having the lowest educational level versus the highest (HR = 1.64; 95% CI = 1.17, 2.30). The contribution of modifiable risk factors (smoking status, diet quality, physical activity, stress, cardiovascular risk factors) in the relationship between 1 area-based index or educational level and mortality was more apparent as age of death decreased. CONCLUSIONS The relation of area-based socioeconomic position to premature mortality is partly mediated by behavioral and cardiovascular risk factors. Such results could influence public health policies.
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Affiliation(s)
- Hélène Bihan
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
| | - Kathrin Backholer
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
| | - Anna Peeters
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
| | - Christopher E Stevenson
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
| | - Jonathan E Shaw
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
| | - Dianna J Magliano
- Hélène Bihan is with the Department of Endocrinology, Diabetology and Metabolic Diseases, Avicenne Hospital, Bobigny, France. Kathrin Backholer, Anna Peeters, Jonathan E. Shaw, and Dianna J. Magliano are with the Baker IDI Heart and Diabetes Institute, Melbourne, Australia. Christopher E. Stevenson is with the School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne
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Lu TH, Huang YT, Lee JC, Yang LT, Liang FW, Yin WH, Kawachi I. Characteristics of Early and Late Adopting Hospitals Providing Percutaneous Coronary Intervention in Taiwan. J Am Heart Assoc 2015; 4:JAHA.115.002840. [PMID: 26702079 PMCID: PMC4845258 DOI: 10.1161/jaha.115.002840] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Studies in the United States suggested that the characteristics of hospitals providing percutaneous coronary intervention (PCI) differed from those not providing PCI. However, little is known on the differences between the characteristics of early-adopting hospitals and those of late-adopting hospitals, and on their potential impacts on PCI volume and access. METHODS AND RESULTS We used inpatient claims data from 1997 to 2012 from the Taiwan National Health Insurance program to identify the hospitals offering PCI. Geographic information systems (GIS) were used to determine the population access to PCI hospital. As of 2012, 88 hospitals were capable of providing PCI. On the basis of the year that the hospitals started providing PCI, 32 hospitals were designated as early adopters (before 1998), 23 as early majority (1998-2002), 24 as late majority (2003-2007), and 16 as laggards (2008-2012). Hospitals that adopted PCI later were smaller in size and closer to an existing PCI hospital and had lower PCI volumes performed and less bypass surgery support. The median PCI volumes in 2012 were n=706, 330, 138, and 81 in early adopters, early majority, late majority, and laggards, respectively. Despite the low volume of PCI performed in laggard hospitals, the percentage with ST-elevation myocardial infarction and acute myocardial infarction as principal discharge diagnosis was higher than their early-adopting hospital counterparts. The percentage of the Taiwanese population living within 40 km of PCI hospitals (appropriate access defined in this study) was 95.7% in 1997 and 98.0% in 2002, and this has remained unchanged since 2002. CONCLUSIONS The characteristics of early-adopting hospitals differed from those of late-adopting hospitals. Despite lower PCI volume performed in late-adopting hospitals, many of them are in remote areas and provide needed and timely services for patients with acute myocardial infarction.
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Affiliation(s)
- Tsung-Hsueh Lu
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan (T.H.L., J.C.L., F.W.L.)
| | - Yu-Tung Huang
- Program in Ageing and Long-term Care, Kaohsiuang Medical University, Kaohsiung, Taiwan (Y.T.H.)
| | - Jo-Chi Lee
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan (T.H.L., J.C.L., F.W.L.)
| | - Li-Tan Yang
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan (L.T.Y.)
| | - Fu-Wen Liang
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan (T.H.L., J.C.L., F.W.L.)
| | - Wei-Hsian Yin
- Division of Cardiology, Cheng Hsin General Hospital and Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan (W.H.Y.)
| | - Ichiro Kawachi
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Harvard University, Boston, MA (I.K.)
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Cost-Effectiveness of a Home Based Intervention for Secondary Prevention of Readmission with Chronic Heart Disease. PLoS One 2015; 10:e0144545. [PMID: 26657844 PMCID: PMC4684189 DOI: 10.1371/journal.pone.0144545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 11/19/2015] [Indexed: 12/22/2022] Open
Abstract
The aim of this study is to consider the cost-effectiveness of a nurse-led, home-based intervention (HBI) in cardiac patients with private health insurance compared to usual post-discharge care. A within trial analysis of the Young @ Heart multicentre, randomized controlled trial along with a micro-simulation decision analytical model was conducted to estimate the incremental costs and quality adjusted life years associated with the home based intervention compared to usual care. For the micro-simulation model, future costs, from the perspective of the funder, and effects are estimated over a twenty-year time horizon. An Incremental Cost-Effectiveness Ratio, along with Incremental Net Monetary Benefit, is evaluated using a willingness to pay threshold of $50,000 per quality adjusted life year. Sub-group analyses are conducted for men and women across three age groups separately. Costs and benefits that arise in the future are discounted at five percent per annum. Overall, home based intervention for secondary prevention in patients with chronic heart disease identified in the Australian private health care sector is not cost-effective. The estimated within trial incremental net monetary benefit is -$3,116 [95% CI: -11,145, $4,914]; indicating that the costs outweigh the benefits. However, for males and in particular males aged 75 years and above, home based intervention indicated a potential to reduce health care costs when compared to usual care (within trial: -$10,416 [95% CI: -$26,745, $5,913]; modelled analysis: -$1,980 [95% CI: -$22,843, $14,863]). This work provides a crucial impetus for future research to understand for whom disease management programs are likely to benefit most.
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Tuttle CSL, Carrington MJ, Stewart S, Brown A. Overcoming the tyranny of distance: An analysis of outreach visits to optimise secondary prevention of cardiovascular disease in high-risk individuals living in Central Australia. Aust J Rural Health 2015; 24:99-105. [PMID: 27087389 DOI: 10.1111/ajr.12222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2015] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES We examined the logistical challenges of conducting an outreach, secondary prevention program for adults discharged from Alice Springs Hospital following an acute presentation of cardiovascular disease. DESIGN AND SETTING This represents a sub-study of the Central Australian Heart Protection Study (CAHPS). Clinical, logistic and demographic data were used to examine the characteristics of outreach visits in the intervention arm of the study. PARTICIPANTS Fifty subjects initially allocated to the intervention arm of the trial were studied. MAIN OUTCOME MEASURES Completion of scheduled, plus additional outreach visits according to the intervention protocol. RESULTS The majority of subjects presented with an acute coronary syndrome (44/50 (88%)) and 31 (62%) were of Indigenous ethnicity. However, Indigenous subjects being younger (53.1 ± 11.1 versus 58.0 ± 11.0 years non-Indigenous) had a more complex risk factor and co-morbid profile, with significantly more diabetes (77% versus 26% P < 0.001), hypertension (81% versus 53% P = 0.04) and renal failure (52% versus 21% P = 0.03). Community of origin of Indigenous subjects was 230 ± 208 km from the hospital versus 61 ± 150 km for non-Indigenous subjects (P = 0.004). Indigenous subjects missed a significantly higher number of scheduled visits at six months (1.39 ± 2.14 versus 0.16 ± 0.50 visits; P = 0.02). However, multivariate analyses suggested that distance did not influence successful completion of visits. CONCLUSIONS These early findings from CAHPS are invaluable to understanding and improving the feasibility of secondary prevention programs for Indigenous adults living with heart disease in remote communities.
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Affiliation(s)
- Camilla S L Tuttle
- Baker IDI Central Australia, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Melinda J Carrington
- Baker IDI Central Australia, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Simon Stewart
- Baker IDI Central Australia, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Alex Brown
- Baker IDI Central Australia, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
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A comparison of the cost-effectiveness of two pedometer-based telephone coaching programs for people with cardiac disease. Heart Lung Circ 2015; 24:471-9. [PMID: 25705032 DOI: 10.1016/j.hlc.2015.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 01/05/2015] [Accepted: 01/06/2015] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Following a cardiac event it is recommended that cardiac patients participate in cardiac rehabilitation (CR) programs. However, little is known about the relative cost-effectiveness of lifestyle-related interventions for cardiac patients. This study aimed to compare the cost-effectiveness of a telephone-delivered Healthy Weight intervention to a telephone-delivered Physical Activity intervention for patients referred to CR in urban and rural Australia. METHODS A cost-utility analysis was conducted alongside a randomised controlled trial of the two interventions. Outcomes were measured as Quality Adjusted Life Years (QALYs) gained. RESULTS The estimated cost of delivering the interventions was $201.48 per Healthy Weight participant and $138.00 per Physical Activity participant. The average total cost (cost of health care utilisation plus patient costs) was $1,260 per Healthy Weight participant and $2,112 per Physical Activity participant, a difference of $852 in favour of the Healthy Weight intervention. Healthy Weight participants gained an average of 0.007 additional QALYs than did Physical Activity participants. Thus, overall the Healthy Weight intervention dominated the Physical Activity intervention (Healthy Weight intervention was less costly and more effective than the Physical Activity intervention). Subgroup analyses showed the Healthy Weight intervention also dominated the Physical Activity intervention for rural participants and for participants who did not attend CR. CONCLUSIONS The low-contact pedometer-based telephone coaching Healthy Weight intervention is overall both less costly and more effective compared to the Physical Activity intervention, including for rural cardiac patients and patients that do not attend CR.
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Baker T, Dawson SL. What small rural emergency departments do: a systematic review of observational studies. Aust J Rural Health 2014; 21:254-61. [PMID: 24118147 DOI: 10.1111/ajr.12046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2013] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Small rural emergency facilities are an important part of emergency care in many countries. We performed a systematic review of observational studies to determine what is known about the patients these small rural emergency facilities treat, what types of interventions they undertake and how well they perform. METHODS Pubmed/Medline and Embase databases were systematically reviewed between 1980 and the present. Studies were included if they described hospital-affiliated emergency care facilities which were open 24-hours every day, and described themselves as rural, non-urban or non-metropolitan. Studies were excluded if facilities saw more than 15,000 patients annually. Study quality was assessed using 12 previously described indicators. Key activity and performance data were reported for individual studies but not numerically combined between studies. RESULTS The search strategy found 19 studies that included quantitative data on activity and performance. Nine studies were from Canada, six were from Australia and four from the United States. The settings and scales used varied widely. Few studies adhered to methodological recommendations. The most common presentation was for injury or poisoning (30-53%). The number of patients requiring attention within 15 min was small (2.5-2.8%). Nurses treated many patients without physician input. CONCLUSIONS There is only enough evidence in the literature to make the most basic inferences about what small rural emergency departments do. To allow evidence-based improvement, descriptive studies must employ measures and methods validated in the wider emergency medicine literature, and other research techniques should be considered.
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Affiliation(s)
- Tim Baker
- Centre for Rural Emergency Medicine, Deakin University, Warrnambool, Victoria, Australia
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Close GR, Newton PJ, Fung SC, Denniss AR, Halcomb EJ, Kovoor P, Stewart S, Davidson PM. Socioeconomic status and heart failure in Sydney. Heart Lung Circ 2013; 23:320-4. [PMID: 24434191 DOI: 10.1016/j.hlc.2013.10.056] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 08/14/2013] [Accepted: 10/03/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Socioeconomic disadvantage is associated with an increased risk of developing heart failure and with inferior health outcomes following diagnosis. METHODS Data for hospitalisations and deaths due to heart failure in the Sydney metropolitan region were extracted from New South Wales hospital records and Australian Bureau of Statistics databases for 1999-2003. Standardised rates were analysed according to patients' residential local government area and correlated with an index of socioeconomic disadvantage. RESULTS Eight of the 13 local government areas with standardised separation rate ratios significantly higher than all NSW, and those with the six highest standardised separation rate ratios, were in Greater Western Sydney. Rates of heart failure hospitalisations per local government area were inversely correlated with level of socioeconomic status. CONCLUSIONS Higher rates of heart failure hospitalisations among residents of socioeconomically disadvantaged regions within Sydney highlight the need for strategies to lessen the impact of disadvantage and strategies to improve cardiovascular health.
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Affiliation(s)
| | - Phillip J Newton
- Centre for Cardiovascular and Chronic Care, University of Technology Sydney, Australia
| | | | - A Robert Denniss
- Western Sydney Local Health District, Australia; University of Western Sydney, Australia
| | | | - Pramesh Kovoor
- Western Sydney Local Health District, Australia; University of Sydney, Australia
| | - Simon Stewart
- Baker IDI Heart and the Diabetes Institute, Australia
| | - Patricia M Davidson
- Centre for Cardiovascular and Chronic Care, University of Technology Sydney, Australia; Cardiovascular Nursing Research, St Vincent's, Sydney, Australia.
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Langabeer JR, Henry TD, Kereiakes DJ, Dellifraine J, Emert J, Wang Z, Stuart L, King R, Segrest W, Moyer P, Jollis JG. Growth in percutaneous coronary intervention capacity relative to population and disease prevalence. J Am Heart Assoc 2013; 2:e000370. [PMID: 24166491 PMCID: PMC3886741 DOI: 10.1161/jaha.113.000370] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The access to and growth of percutaneous coronary intervention (PCI) has not been fully explored with regard to geographic equity and need. Economic factors and timely access to primary PCI provide the impetus for growth in PCI centers, and this is balanced by volume standards and the benefits of regionalized care. Methods and Results Geospatial and statistical analyses were used to model capacity, growth, and access of PCI hospitals relative to population density and myocardial infarction (MI) prevalence at the state level. Longitudinal data were obtained for 2003–2011 from the American Hospital Association, the U.S. Census, and the Centers for Disease Control and Prevention (CDC) with geographical modeling to map PCI locations. The number of PCI centers has grown 21.2% over the last 8 years, with 39% of all hospitals having interventional cardiology capabilities. During the same time, the US population has grown 8.3%, from 217 million to 235 million, and MI prevalence rates have decreased from 4.0% to 3.7%. The most densely concentrated states have a ratio of 8.1 to 12.1 PCI facilities per million of population with significant variability in both MI prevalence and average distance between PCI facilities. Conclusions Over the last decade, the growth rate for PCI centers is 1.5× that of the population growth, while MI prevalence is decreasing. This has created geographic imbalances and access barriers with excess PCI centers relative to need in some regions and inadequate access in others.
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Chew DP, French J, Briffa TG, Hammett CJ, Ellis CJ, Ranasinghe I, Aliprandi‐Costa BJ, Astley CM, Turnbull FM, Lefkovits J, Redfern J, Carr B, Gamble GD, Lintern KJ, Howell TEJ, Parker H, Tavella R, Bloomer SG, Hyun KK, Brieger DB. Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study. Med J Aust 2013; 199:185-91. [DOI: 10.5694/mja12.11854] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 05/02/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Derek P Chew
- Department of Cardiovascular Medicine, Flinders University, Adelaide, SA
| | - John French
- Department of Cardiology, Liverpool Hospital, Sydney, NSW
| | - Tom G Briffa
- School of Population Health, University of Western Australia, Perth, WA
| | | | | | | | | | | | | | | | | | | | - Greg D Gamble
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | | | - Tegwen E J Howell
- Clinical Access and Redesign Unit, Queensland Department of Health, Brisbane, QLD
| | - Hella Parker
- Clinical Service Development, Victoria Health, Melbourne, VIC
| | | | - Stephen G Bloomer
- Health Networks Branch, Department of Health of Western Australia, Perth, WA
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Concannon TW, Nelson J, Kent DM, Griffith JL. Evidence of systematic duplication by new percutaneous coronary intervention programs. Circ Cardiovasc Qual Outcomes 2013; 6:400-8. [PMID: 23838110 DOI: 10.1161/circoutcomes.111.000019] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence suggests that recent and projected future investments in percutaneous coronary intervention (PCI) programs at US hospitals fail to increase access to timely reperfusion for patients with ST-segment elevation myocardial infarction. METHODS AND RESULTS We set out to estimate the annual number and costs of new PCI programs in US hospitals from 2004 to 2008 and identify the characteristics of hospitals, neighborhoods, and states where new PCI programs have been introduced. We estimated a discrete-time hazard model to measure the influence of these characteristics on the decision of a hospital to introduce a new PCI program. In 2008, 1739 US hospitals were capable of performing PCI, a relative increase of 16.5% (251 hospitals) over 2004. The percentage of the US population with projected access to timely PCI grew by 1.8%. New PCI programs were more likely to be introduced in areas that already had a PCI program with more competition for market share, near populations with higher rates of private insurance, in states that had weak or no regulation of new cardiac catheterization laboratories, and in wealthier and larger hospitals. CONCLUSIONS Our data show that new PCI programs were systematically duplicative of existing programs and did not help patients gain access to timely PCI. The total cost of recent US investments in new PCI programs is large and of questionable value for patients.
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Carrington MJ, Chan YK, Calderone A, Scuffham PA, Esterman A, Goldstein S, Stewart S. A Multicenter, Randomized Trial of a Nurse-Led, Home-Based Intervention for Optimal Secondary Cardiac Prevention Suggests Some Benefits for Men but Not for Women. Circ Cardiovasc Qual Outcomes 2013; 6:379-89. [DOI: 10.1161/circoutcomes.111.000006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
We examined the impact of a prolonged secondary prevention program on recurrent hospitalization in cardiac patients with private health insurance.
Methods and Results—
The Young at Heart multicenter, randomized, controlled trial compared usual postdischarge care (UC) with nurse-led, home-based intervention (HBI). The primary end point was rate of all-cause hospital stay (31.5±7.5 months follow-up). In total, 602 patients (aged 70±10 years, 72% men) were randomized to UC (n=296) or HBI (n=306, 96% received ≥1 home visit). Overall, 42 patients (7.0%) died, and 492 patients (82%) accumulated 2397 all-cause hospitalizations associated with 10 258 hospital days costing >$17 million. There were minimal group differences (HBI versus UC) in the primary end point of all-cause hospital stay (5405 versus 4853 days; median [interquartile range], 0.08 [0.03–0.17] versus 0.07 [0.03–0.13]/patient per month). There were similar trends with respect to all hospitalizations (1197 versus 1200;
P
=0.802) and associated costs ($8.66 versus $8.58 million;
P
=0.375). At 2 years, however, more HBI versus UC (39% versus 27%; odds ratio, 1.67; 95% confidence interval, 1.15–2.41;
P
=0.007) patients were assessed as stable and optimally managed. For women, HBI outcomes were predominantly worse than UC outcomes. In men, HBI was associated with reduced risk of cardiovascular hospitalization (adjusted hazard ratio, 0.68; 95% confidence interval, 0.46–0.99;
P
=0.044) with less cardiovascular hospitalizations (192 versus 269;
P
=0.054) and costs ($2.49 versus $3.53 million;
P
=0.046).
Conclusions—
HBI did not reduce recurrent all-cause hospitalization compared with UC in privately insured cardiac patients overall. However, it did convey some benefits in cardiac outcomes for men.
Clinical Trial Registration—
Australian New Zealand Clinical Trials Registry Unique Identifier: 12608000014358. URL:
http://www.anzctr.org.au/trial_view.aspx?id=82509
.
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Affiliation(s)
- Melinda J. Carrington
- From the Preventative Health and NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease (M.J.C., Y.K.C., A.C., S.S.), Baker IDI Heart and Diabetes Institute, Melbourne, Australia; School of Medicine, Griffith University, Brisbane, Australia (P.A.S.); Division of Health Sciences, University of South Australia, Adelaide, Australia (A.E.); and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (S.G.)
| | - Yih-Kai Chan
- From the Preventative Health and NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease (M.J.C., Y.K.C., A.C., S.S.), Baker IDI Heart and Diabetes Institute, Melbourne, Australia; School of Medicine, Griffith University, Brisbane, Australia (P.A.S.); Division of Health Sciences, University of South Australia, Adelaide, Australia (A.E.); and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (S.G.)
| | - Alicia Calderone
- From the Preventative Health and NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease (M.J.C., Y.K.C., A.C., S.S.), Baker IDI Heart and Diabetes Institute, Melbourne, Australia; School of Medicine, Griffith University, Brisbane, Australia (P.A.S.); Division of Health Sciences, University of South Australia, Adelaide, Australia (A.E.); and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (S.G.)
| | - Paul A. Scuffham
- From the Preventative Health and NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease (M.J.C., Y.K.C., A.C., S.S.), Baker IDI Heart and Diabetes Institute, Melbourne, Australia; School of Medicine, Griffith University, Brisbane, Australia (P.A.S.); Division of Health Sciences, University of South Australia, Adelaide, Australia (A.E.); and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (S.G.)
| | - Adrian Esterman
- From the Preventative Health and NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease (M.J.C., Y.K.C., A.C., S.S.), Baker IDI Heart and Diabetes Institute, Melbourne, Australia; School of Medicine, Griffith University, Brisbane, Australia (P.A.S.); Division of Health Sciences, University of South Australia, Adelaide, Australia (A.E.); and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (S.G.)
| | - Stan Goldstein
- From the Preventative Health and NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease (M.J.C., Y.K.C., A.C., S.S.), Baker IDI Heart and Diabetes Institute, Melbourne, Australia; School of Medicine, Griffith University, Brisbane, Australia (P.A.S.); Division of Health Sciences, University of South Australia, Adelaide, Australia (A.E.); and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (S.G.)
| | - Simon Stewart
- From the Preventative Health and NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease (M.J.C., Y.K.C., A.C., S.S.), Baker IDI Heart and Diabetes Institute, Melbourne, Australia; School of Medicine, Griffith University, Brisbane, Australia (P.A.S.); Division of Health Sciences, University of South Australia, Adelaide, Australia (A.E.); and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia (S.G.)
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Sangster J, Furber S, Phongsavan P, Allman-Farinelli M, Redfern J, Bauman A. Where you live matters: Challenges and opportunities to address the urban-rural divide through innovative secondary cardiac rehabilitation programs. Aust J Rural Health 2013; 21:170-7. [DOI: 10.1111/ajr.12031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2013] [Indexed: 01/05/2023] Open
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Alter DA, Franklin B, Ko DT, Austin PC, Lee DS, Oh PI, Stukel TA, Tu JV. Socioeconomic status, functional recovery, and long-term mortality among patients surviving acute myocardial infarction. PLoS One 2013; 8:e65130. [PMID: 23755180 PMCID: PMC3670842 DOI: 10.1371/journal.pone.0065130] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 04/22/2013] [Indexed: 11/18/2022] Open
Abstract
Objectives To examine the relationship between socio-economic status (SES), functional recovery and long-term mortality following acute myocardial infarction (AMI). Background The extent to which SES mortality disparities are explained by differences in functional recovery following AMI is unclear. Methods We prospectively examined 1368 patients who survived at least one-year following an index AMI between 1999 and 2003 in Ontario, Canada. Each patient was linked to administrative data and followed over 9.6 years to track mortality. All patients underwent medical chart abstraction and telephone interviews following AMI to identify individual-level SES, clinical factors, processes of care (i.e., use of, and adherence, to evidence-based medications, physician visits, invasive cardiac procedures, referrals to cardiac rehabilitation), as well as changes in psychosocial stressors, quality of life, and self-reported functional capacity. Results As compared with their lower SES counterparts, higher SES patients experienced greater functional recovery (1.80 ml/kg/min average increase in peak V02, P<0.001) after adjusting for all baseline clinical factors. Post-AMI functional recovery was the strongest modifiable predictor of long-term mortality (Adjusted HR for each ml/kg/min increase in functional capacity: 0.91; 95% CI: 0.87–0.94, P<0.001) irrespective of SES (P = 0.51 for interaction between SES, functional recovery, and mortality). SES-mortality associations were attenuated by 27% after adjustments for functional recovery, rendering the residual SES-mortality association no longer statistically significant (Adjusted HR: 0.84; 95% CI:0.70–1.00, P = 0.05). The effects of functional recovery on SES-mortality associations were not explained by access inequities to physician specialists or cardiac rehabilitation. Conclusions Functional recovery may play an important role in explaining SES-mortality gradients following AMI.
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Affiliation(s)
- David A Alter
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Clark RA, Coffee N, Turner D, Eckert KA, van Gaans D, Wilkinson D, Stewart S, Tonkin AM. Access to cardiac rehabilitation does not equate to attendance. Eur J Cardiovasc Nurs 2013; 13:235-42. [PMID: 23598464 DOI: 10.1177/1474515113486376] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS Timely access to appropriate cardiac care is critical for optimizing positive outcomes after a cardiac event. Attendance at cardiac rehabilitation (CR) remains less than optimal (10%-30%). Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services after a cardiac event in Australia. METHODS An expert panel defined a single patient care pathway and a hierarchy of the minimum health services for CR and secondary prevention. Using geographic information systems a numeric/alpha index was modelled to describe access before and after a cardiac event. The aftercare phase was modelled into five alphabetical categories: from category A (access to medical service, pharmacy, CR, pathology within 1 h) to category E (no services available within 1 h). RESULTS Approximately 96% or 19 million people lived within 1 h of the four basic services to support CR and secondary prevention, including 96% of older Australians and 75% of the indigenous population. Conversely, 14% (64,000) indigenous people resided in population locations that had poor access to health services that support CR after a cardiac event. CONCLUSION Results demonstrated that the majority of Australians had excellent 'geographic' access to services to support CR and secondary prevention. Therefore, it appears that it is not the distance to services that affects attendance. Our 'geographic' lens has identified that more research on socioeconomic, sociological or psychological aspects to attendance is needed.
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Affiliation(s)
- Robyn A Clark
- 1School of Nursing and Midwifery, Flinders University, South Australia, Australia
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Lampropulos JF, Gupta A, Kulkarni VT, Mody P, Chen R, Bikdeli B, Dharmarajan K. Most important outcomes research papers on variation in cardiovascular disease. Circ Cardiovasc Qual Outcomes 2013; 6:e9-16. [PMID: 23481532 DOI: 10.1161/circoutcomes.113.000185] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Dunbar JA, Peach E. The disparity called rural health: What is it, and what needs to be done? Aust J Rural Health 2012. [DOI: 10.1111/ajr.12000] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- James A. Dunbar
- Greater Green Triangle University; Department of Rural Health, Flinders and Deakin Universities
| | - Elizabeth Peach
- Greater Green Triangle University; Department of Rural Health, Flinders and Deakin Universities
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Giugliano RP, Braunwald E. The Year in Non–ST-Segment Elevation Acute Coronary Syndrome. J Am Coll Cardiol 2012; 60:2127-39. [DOI: 10.1016/j.jacc.2012.08.972] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 08/06/2012] [Accepted: 08/13/2012] [Indexed: 10/27/2022]
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Stewart S. Nurse-Led Care of Heart Failure: Will it Work in Remote Settings? Heart Lung Circ 2012; 21:644-7. [DOI: 10.1016/j.hlc.2012.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 07/04/2012] [Indexed: 12/01/2022]
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