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Beleigoli A, Foote J, Gebremichael LG, Bulamu NB, Astley C, Keech W, Tavella R, Gulyani A, Nesbitt K, Pinero de Plaza MA, Ramos JS, Ludlow M, Nicholls SJ, Chew DP, Beltrame J, Clark RA. Clinical Effectiveness and Utilisation of Cardiac Rehabilitation After Hospital Discharge: Data Linkage Analysis of 84,064 Eligible Discharged Patients (2016-2021). Heart Lung Circ 2024; 33:1036-1045. [PMID: 38443278 DOI: 10.1016/j.hlc.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/12/2023] [Accepted: 01/11/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Despite the highest levels of evidence on cardiac rehabilitation (CR) effectiveness, its translation into practice is compromised by low participation. AIM This study aimed to investigate CR utilisation and effectiveness in South Australia. METHODS This retrospective cohort study used data linkage of clinical and administrative databases from 2016 to 2021 to assess the association between CR utilisation (no CR received, commenced without completing, or completed) and the composite primary outcome (mortality/cardiovascular re-admissions within 12 months after discharge). Cox survival models were adjusted for sociodemographic and clinical data and applied to a population balanced by inverse probability weighting. Associations with non-completion were assessed by logistic regression. RESULTS Among 84,064 eligible participants, 74,189 did not receive CR, with 26,833 of the 84,064 (31.9%) participants referred. Of these, 9,875 (36.8%) commenced CR, and 7,681 of the 9,875 (77.8%) completed CR. Median waiting time from discharge to commencement was 40 days (interquartile range, 23-79 days). Female sex (odds ratio [OR] 1.12; 95% CI 1.01-1.24; p=0.024), depression (OR 1.17; 95% CI 1.05-1.30; p=0.002), and waiting time >28 days (OR 1.15; 95% CI 1.05-1.26; p=0.005) were associated with higher odds of non-completion, whereas enrolment in a telehealth program (OR 0.35; 95% CI 0.31-0.40; p<0.001) was associated with lower odds of non-completion. Completing CR (hazard ratio [HR] 0.62; 95% CI 0.58-0.66; p<0.001) was associated with a lower risk of 12-month mortality/cardiovascular re-admissions. Commencing without completing was also associated with decreased risk (HR 0.81; 95% CI 0.73-0.90; p<0.001), but the effect was lower than for those completing CR (p<0.001). CONCLUSIONS Cardiac rehabilitation (CR) attendance is associated with lower all-cause mortality/cardiovascular re-admissions, with CR completion leading to additional benefits. Quality improvement initiatives should include promoting referral, women's participation, access to telehealth, and reduction of waiting times to increase completion.
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Affiliation(s)
- Alline Beleigoli
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.
| | - Jonathon Foote
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Lemlem G Gebremichael
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Norma B Bulamu
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Carolyn Astley
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Wendy Keech
- Health Translation SA, Adelaide, SA, Australia
| | - Rosanna Tavella
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Aarti Gulyani
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Katie Nesbitt
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | | | - Joyce S Ramos
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Marie Ludlow
- National Heart Foundation of Australia, Adelaide, SA, Australia
| | | | - Derek P Chew
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia; Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | - John Beltrame
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Robyn A Clark
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia; Southern Adelaide Local Health Network, SA, Australia
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Candelaria D, Redfern J, O'Neil A, Brieger D, Clark RA, Briffa T, Bauman A, Hyun K, Cunich M, Figtree GA, Cartledge S, Gallagher R. Data-driven collaborative QUality improvement in Cardiac Rehabilitation (QUICR) to increase program completion: protocol for a cluster randomized controlled trial. BMC Cardiovasc Disord 2024; 24:302. [PMID: 38877422 PMCID: PMC11177531 DOI: 10.1186/s12872-024-03971-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 06/05/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND Coronary heart disease (CHD) is the leading cause of deaths and disability worldwide. Cardiac rehabilitation (CR) effectively reduces the risk of future cardiac events and is strongly recommended in international clinical guidelines. However, CR program quality is highly variable with divergent data systems, which, when combined, potentially contribute to persistently low completion rates. The QUality Improvement in Cardiac Rehabilitation (QUICR) trial aims to determine whether a data-driven collaborative quality improvement intervention delivered at the program level over 12 months: (1) increases CR program completion in eligible patients with CHD (primary outcome), (2) reduces hospital admissions, emergency department presentations and deaths, and costs, (3) improves the proportion of patients receiving guideline-indicated CR according to national and international benchmarks, and (4) is feasible and sustainable for CR staff to implement routinely. METHODS QUICR is a multi-centre, type-2, hybrid effectiveness-implementation cluster-randomized controlled trial (cRCT) with 12-month follow-up. Eligible CR programs (n = 40) and the individual patient data within them (n ~ 2,000) recruited from two Australian states (New South Wales and Victoria) are randomized 1:1 to the intervention (collaborative quality improvement intervention that uses data to identify and manage gaps in care) or control (usual care with data collection only). This sample size is required to achieve 80% power to detect a difference in completion rate of 22%. Outcomes will be assessed using intention-to-treat principles. Mixed-effects linear and logistic regression models accounting for clusters within allocated groupings will be applied to analyse primary and secondary outcomes. DISCUSSION Addressing poor participation in CR by patients with CHD has been a longstanding challenge that needs innovative strategies to change the status-quo. This trial will harness the collaborative power of CR programs working simultaneously on common problem areas and using local data to drive performance. The use of data linkage for collection of outcomes offers an efficient way to evaluate this intervention and support the improvement of health service delivery. ETHICS Primary ethical approval was obtained from the Northern Sydney Local Health District Human Research Ethics Committee (2023/ETH01093), along with site-specific governance approvals. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623001239651 (30/11/2023) ( https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386540&isReview=true ).
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Affiliation(s)
- Dion Candelaria
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia.
| | - Julie Redfern
- Faculty of Medicine and Health, School of Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Adrienne O'Neil
- IMPACT - the Institute for Mental and Physical Health and Clinical Translation, Food & Mood Centre, School of Medicine, Deakin University, Barwon Health, Geelong, VIC, Australia
| | - David Brieger
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Cardiology Department, Concord Hospital, ANZAC Research Institute, Sydney, NSW, Australia
| | - Robyn A Clark
- Caring Futures Institute, Flinders University, Adelaide, SA, Australia
| | - Tom Briffa
- School of Population and Global Health, The University of Western Australia, Perth, WA, Australia
| | - Adrian Bauman
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Karice Hyun
- Faculty of Medicine and Health, School of Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Cardiology Department, Concord Hospital, ANZAC Research Institute, Sydney, NSW, Australia
| | - Michelle Cunich
- Faculty of Medicine and Health, Central Clinical School, Charles Perkins Centre, The University of Sydney, Boden Initiative, Sydney, NSW, Australia
- Sydney Local Health District, Camperdown, NSW, Australia
| | - Gemma A Figtree
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Susie Cartledge
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Robyn Gallagher
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia
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Turk-Adawi KI, Elshaikh U, Contractor A, Hashmi FA, Thomas E, Raidah F, Grace SL. Development and Evaluation of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) Program Certification for Low-Resource Settings. Int J Gen Med 2023; 16:5199-5214. [PMID: 38021048 PMCID: PMC10643168 DOI: 10.2147/ijgm.s423209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023] Open
Abstract
Background Cardiac rehabilitation (CR) is a proven model of secondary prevention, but new sites, providing quality care, are needed in low-resource settings. This study (1) described the development of International Council of Cardiovascular Prevention and Rehabilitation's (ICCPR) Program Certification and (2a) tested its implementation, considering (b) appropriateness of quality standards for these settings. Methods The Steering Committee finalized 13 standards, requiring 70% be met. They are assessed initially through International CR Registry (ICRR) program survey and patient data; if Certification appears possible, a two-hour virtual site assessment is arranged to corroborate. Standard operating procedures for Assessor training were developed. A multi-method pilot study was then undertaken with a quantitative (description of quality indicators) and qualitative (focus groups on MS Teams) component. ICRR sites with post-program data by April 2022 were invited to participate. Two team members independently analyzed focus group transcripts, using a deductive-thematic approach with NVIVO. Results Five CR programs from the Eastern Mediterranean, South-East Asian and American regions participated. Upon application, with some data cleaning, initially four programs were eligible to proceed to virtual site assessment. Ultimately, all five programs were certified, each meeting a minimum of 12/13 standards (peak MET increase and program completion rate were not met by some centres). Four themes resulted from the two focus groups of 13 site data stewards: motivation and benefits (eg, international recognition, additional program resources), logistics (eg, communication, cost, site visit process), the standards and their assessment (eg, balance of rigor and feasibility), and suggestions for improvement (eg, website). Conclusion ICCPR's Program Certification has been demonstrated to be feasible, rigorous, and acceptable. Standards are attainable in low-resource settings. Certified programs reap benefits including additional resources. This first international Certification is suitable for low-resource settings, to complement that from the American and European CR Societies.
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Affiliation(s)
- Karam I Turk-Adawi
- Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Usra Elshaikh
- Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Aashish Contractor
- Rehabilitation and Sports Medicine, Sir H.N. Reliance Foundation Hospital, Mumbai, India
| | - Farzana Amir Hashmi
- Preventive Cardiology and Rehabilitation, Tabba Heart Institute, Karachi, Pakistan
| | - Emma Thomas
- Centre for Online Health, Centre for Health Services Research, the University of Queensland, Brisbane, Queensland, Australia
| | - Fabbiha Raidah
- Faculty of Health, York University, Toronto, Ontario, Canada
| | - Sherry L Grace
- Faculty of Health, York University, Toronto, Ontario, Canada
- KITE - Toronto Rehabilitation Institute & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Senanayake S, Halahakone U, Abell B, Kularatna S, McCreanor V, McPhail SM, Redfern J, Tom Briffa, Parsonage W. Hybrid cardiac telerehabilitation for coronary artery disease in Australia: a cost-effectiveness analysis. BMC Health Serv Res 2023; 23:512. [PMID: 37208666 PMCID: PMC10198753 DOI: 10.1186/s12913-023-09546-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/14/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Traditional cardiac rehabilitation programs are centre-based and clinically supervised, with their safety and effectiveness well established. Notwithstanding the established benefits, cardiac rehabilitation remains underutilised. A possible alternative would be a hybrid approach where both centre-based and tele-based methods are combined to deliver cardiac rehabilitation to eligible patients. The objective of this study was to determine the long-term cost-effectiveness of a hybrid cardiac telerehabilitation and if it should be recommended to be implemented in the Australian context. METHODS Following a comprehensive literature search, we chose the Telerehab III trial intervention that investigated the effectiveness of a long-term hybrid cardiac telerehabilitation program. We developed a decision analytic model to estimate the cost-effectiveness of the Telerehab III trial using a Markov process. The model included stable cardiac disease and hospitalisation health states and simulations were run using one-month cycles over a five-year time horizon. The threshold for cost-effectiveness was set at $AU 28,000 per quality-adjusted life-year (QALY). For the base analysis, we assumed that 80% completed the programme. We tested the robustness of the results using probabilistic sensitivity and scenario analyses. RESULTS Telerehab III intervention was more effective but more costly and was not cost-effective, at a threshold of $28,000 per QALY. For every 1,000 patients who undergo cardiac rehabilitation, employing the telerehabilitation intervention would cost $650,000 more, and 5.7 QALYs would be gained, over five years, compared to current practice. Under probabilistic sensitivity analysis, the intervention was cost-effective in only 18% of simulations. Similarly, if the intervention compliance was increased to 90%, it was still unlikely to be cost-effective. CONCLUSION Hybrid cardiac telerehabilitation is highly unlikely to be cost-effective compared to the current practice in Australia. Exploration of alternative models of delivering cardiac telerehabilitation is still required. The results presented in this study are useful for policymakers wanting to make informed decisions about investment in hybrid cardiac telerehabilitation programs.
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Affiliation(s)
- Sameera Senanayake
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia.
| | - Ureni Halahakone
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia
| | - Bridget Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia
| | - Victoria McCreanor
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia
- Digital Health and Informatics, Metro South Health, Brisbane, QLD, Australia
| | - Julie Redfern
- School of Health Sciences, Faculty of Medicine and Health and Charles Perkins Centre, The University of Sydney, Sydney, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - William Parsonage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology (QUT), 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia
- Royal Brisbane and Women's Hospital, Metro North Health, Herston, QLD, Australia
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Cartledge S, Thomas EE, Murphy B, Abell B, Verdicchio C, Zecchin R, Cameron J, Gallagher R, Astley C. Impact of Early COVID-19 Waves on Cardiac Rehabilitation Delivery in Australia: A National Survey. Heart Lung Circ 2023; 32:353-363. [PMID: 36646580 PMCID: PMC9840063 DOI: 10.1016/j.hlc.2022.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/20/2022] [Accepted: 12/17/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND The novel coronavirus disease of 2019 (COVID-19) pandemic significantly disrupted health care, especially outpatient services such as cardiac rehabilitation (CR). We investigated the impact of early COVID-19 waves on the delivery of Australian CR programs, comparing this time period with usual practice prior to the pandemic (2019) and current practice (2021) once the early waves had subsided. Specifically, we aimed to understand how the delivery of programs during COVID-19 compared to usual practice. METHODS An anonymous online cross-sectional survey of Australian CR program staff was conducted, comprising three sections: program and respondent characteristics, COVID-19 impact on program delivery, and barriers to, and enablers of, program delivery. Respondents were asked to consider three key timepoints: 1) Pre-COVID-19 (i.e. usual practice in 2019), 2) Early COVID-19 waves (March-December 2020), and 3) Currently, at time of survey completion post early COVID-19 waves (May-July 2021). RESULTS Of the 314 Australian CR programs, 115 responses were received, of which 105 had complete data, representing a 33% response rate. All states and territories were represented. During early COVID-19 waves programs had periods of closure (40%) or reduced delivery (70%). The majority of programs reported decreased CR referrals (51.5%) and decreased participation (77.5%). The two core components of CR-exercise and education-were significantly impacted during early COVID-19 waves, affecting both the number and duration of sessions provided. Exercise session duration did not return to pre-pandemic levels (53.5 min compared to 57.7 min, p=0.02). The majority of respondents (77%) reported their CR program was inferior in quality to pre-pandemic and more organisational support was required across information technology, staffing, administration and staff emotional and social support. CONCLUSION Australian CR programs underwent significant change during the early COVID-19 waves, consistent with international CR reports. Fewer patients were referred and attended CR and those who did attend received a lower dose of exercise and education. It will be important to continue to monitor the long-term impacts of the COVID-19 pandemic to ensure CR programs return to pre-pandemic functioning and continue to deliver services in line with best practice and evidence-based recommendations.
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Affiliation(s)
- Susie Cartledge
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia.
| | - Emma E Thomas
- Centre for Online Health, Centre for Health Services Research, The University of Queensland, Brisbane, Qld, Australia
| | - Barbara Murphy
- Australian Centre for Heart Health, Melbourne, Vic, Australia; Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Vic, Australia
| | - Bridget Abell
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, Qld, Australia
| | - Christian Verdicchio
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Centre for Heart Rhythm Disorders, University of Adelaide, South Australian Health, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Macquarie Health Corporation, Sydney, NSW, Australia
| | - Robert Zecchin
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia; Western Sydney Local Health District, Sydney, NSW, Australia
| | - Jan Cameron
- Australian Centre for Heart Health, Melbourne, Vic, Australia; School of Clinical Sciences at Monash Health, Department of Medicine, Monash University, Melbourne, Vic, Australia
| | - Robyn Gallagher
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia
| | - Carolyn Astley
- College of Nursing and Health Science, Flinders University, Adelaide, SA, Australia
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Astley CM, Beleigoli A, Tavella R, Hendriks J, Gallagher C, Tirimacco R, Wilson G, Barry T, Clark RA. Correction to: Assessing the quality of cardiac rehabilitation programs by measuring adherence to the Australian quality indicators. BMC Health Serv Res 2022; 22:348. [PMID: 35296301 PMCID: PMC8925161 DOI: 10.1186/s12913-022-07726-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- C M Astley
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, University Drive, South Australia (SA), Bedford Park, 5042, Australia.
| | - A Beleigoli
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, University Drive, South Australia (SA), Bedford Park, 5042, Australia
| | - R Tavella
- Adelaide Medical School, University Adelaide, The Queen Elizabeth Hospital Campus, Woodville South, SA, 5011, Australia.,Department of Cardiology, Central Adelaide Local Health Network, SA Dept. of Health, Adelaide, SA, 5000, Australia
| | - J Hendriks
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, University Drive, South Australia (SA), Bedford Park, 5042, Australia.,Centre for Heart Rhythm Disorders, University Adelaide and Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | - C Gallagher
- Centre for Heart Rhythm Disorders, University Adelaide and Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
| | - R Tirimacco
- Integrated Cardiovascular Clinical Network SA, iCCnet, level 1 Administration Building, 1 Tonsley Boulevard, Tonsley, SA, 5042, Australia
| | - G Wilson
- Integrated Cardiovascular Clinical Network SA, iCCnet, level 1 Administration Building, 1 Tonsley Boulevard, Tonsley, SA, 5042, Australia
| | - T Barry
- Integrated Cardiovascular Clinical Network SA, iCCnet, level 1 Administration Building, 1 Tonsley Boulevard, Tonsley, SA, 5042, Australia
| | - R A Clark
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, University Drive, South Australia (SA), Bedford Park, 5042, Australia
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