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Davis TME, Colman PG, Hespe C, Heywood SE, d'Emden M. Cardiovascular disease management in Australian adults with type 2 diabetes: insights from the CAPTURE study. Intern Med J 2023; 53:1796-1805. [PMID: 36112472 DOI: 10.1111/imj.15929] [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: 06/21/2022] [Accepted: 08/30/2022] [Indexed: 10/21/2023]
Abstract
BACKGROUND Type 2 diabetes (T2D) is a well-recognised cardiovascular disease (CVD) risk factor, and recent guidelines for the management of T2D include consideration of CVD risk. AIM To assess whether contemporary clinical management of Australians with T2D is in accord with recent national and international guidelines. METHODS This Australia-specific analysis of the CAPTURE study, a non-interventional, cross-sectional study included adults diagnosed with T2D ≥180 days prior to providing informed consent and visiting primary or specialist care. Main outcome measures were the use of blood glucose-lowering medications (BGLMs), BGLMs with proven cardiovascular benefits and other CVD medications, stratified by CVD status and care setting. RESULTS Of 824 Australian participants in the CAPTURE sample, 332 (40.3%) had CVD. Oral BGLMs were used by 83.9% of all participants, most commonly metformin (76.0%), dipeptidyl peptidase-4 inhibitors (28.8%), sodium-glucose cotransporter-2 inhibitors (SGLT2is; 21.8%) and sulfonylureas (21.7%). Insulin was used by 29.2% of participants. BGLMs with proven CV benefit were used by 22.6%; glucagon-like peptide-1 receptor agonists (GLP-1 RAs) were less commonly used than SGLT2is in all CVD groups, but these drug classes were more often prescribed in specialist than primary care (SGLT2is 25.4 vs 20.7%, GLP-1 RAs 3.2 vs 0.8% respectively). Use of non-BGLMs for CVD risk reduction appeared consistent with guidelines. CONCLUSIONS Use of BGLMs with CVD benefits appears low in Australia, irrespective of CVD status. This likely reflects the delay in translation of clinical evidence into contemporary care and prescribing restrictions.
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Affiliation(s)
- Timothy M E Davis
- Medical School, University of Western Australia, and Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Charlotte Hespe
- General Practice and Primary Care Research, School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | | | - Michael d'Emden
- Department of Endocrinology and Diabetes, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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2
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Yue J, Kazi S, Nguyen T, Chow CK. Comparing secondary prevention for patients with coronary heart disease and stroke attending Australian general practices: a cross-sectional study using nationwide electronic database. BMJ Qual Saf 2023:bmjqs-2022-015699. [PMID: 37487712 DOI: 10.1136/bmjqs-2022-015699] [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: 11/03/2022] [Accepted: 05/11/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVES To compare secondary prevention care for patients with coronary heart disease (CHD) and stroke, exploring particularly the influences due to frequency and regularity of primary care visits. SETTING Secondary prevention for patients (≥18 years) in the National Prescription Service administrative electronic health record database collated from 458 Australian general practice sites across all states and territories. DESIGN Retrospective cross-sectional and panel study. Patient and care-level characteristics were compared for differing CHD/stroke diagnoses. Associations between the type of cardiovascular diagnosis and medication prescription as well as risk factor assessment were examined using multivariable logistic regression. PARTICIPANTS Patients with three or more general practice encounters within 2 years of their latest visit during 2016-2020. OUTCOME MEASURES Proportions and odds ratios (ORs) for (1) prescription of antihypertensives, antilipidaemics and antiplatelets and (2) assessment of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) in patients with stroke only compared against those with CHD only and those with both conditions. RESULTS There were 111 892 patients with CHD only, 27 863 with stroke only and 9791 with both conditions. Relative to patients with CHD, patients with stroke were underprescribed antihypertensives (70.8% vs 82.8%), antilipidaemics (63.1% vs 78.7%) and antiplatelets (42.2% vs 45.7%). With sociodemographic factors, comorbidities and level of care considered as covariates, the odds of non-prescription of any recommended secondary prevention medications were higher in patients with stroke only (adjusted OR 1.37; 95% CI (1.31, 1.44)) compared with patients with CHD only. Patients with stroke only were also more likely to have neither BP nor LDL-C monitored (adjusted OR 1.26; 95% CI (1.18, 1.34)). Frequent and regular general practitioner encounters were independently associated with the prescription of secondary prevention medications (p<0.001). CONCLUSIONS Secondary prevention management is suboptimal in cardiovascular disease patients and worse post-stroke compared with post-CHD. More frequent and regular primary care encounters were associated with improved secondary prevention.
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Affiliation(s)
- Jason Yue
- Westmead Applied Research Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Samia Kazi
- Westmead Applied Research Centre, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Tu Nguyen
- Westmead Applied Research Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Clara Kayei Chow
- Westmead Applied Research Centre, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
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Coorey G, Campain A, Mulley J, Usherwood T, Redfern J, Harris M, Zwar N, Peiris D. Management of cardiovascular disease risk in people with comorbid mental illness: A cross sectional study in Australian general practice. Aust N Z J Psychiatry 2023; 57:613-615. [PMID: 36314767 DOI: 10.1177/00048674221133043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Genevieve Coorey
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Anna Campain
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - John Mulley
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Tim Usherwood
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Julie Redfern
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Mark Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, Australia
| | - Nicholas Zwar
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, QLD, Australia
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Hespe CM, Brown E, Rychetnik L. Learning from the implementation of a quality improvement intervention in Australian general practice: a qualitative analysis of participants views of a CVD preventive care project. BMC PRIMARY CARE 2022; 23:79. [PMID: 35421935 PMCID: PMC9011978 DOI: 10.1186/s12875-022-01692-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/04/2022] [Indexed: 11/23/2022]
Abstract
Background Quality improvement collaborative projects aim to reduce gaps in clinical care provided in the healthcare system. This study evaluated the experience of key participants from a Quality Improvement Program (QPulse) that focussed on cardiovascular disease assessment and management. The study goal was to identify critical barriers and factors enabling the implementation of a quality improvement framework in Australian general practice. Methods This qualitative study examined in-depth semi-structured interviews with nineteen purposively-selected participants of the QPulse project. Interviewees were from General Practices and the local supporting organisation, a Primary Health Network. Interviews were analysed thematically using the Complex Systems Improvement framework, focusing on five domains: strategy, culture, structure, workforce and technology. Results Despite reported engagement with QPulse objectives to improve cardiovascular preventive care, implementation barriers associated with this program were considerable for all interviewees. Adoption of the quality improvement process was reliant on designated leadership, aligned practice culture, organised systems for clear communication, tailored education and utilisation of clinical audit and review processes. Rather than practice size and location, practice culture and governance alignment to quality improvement predicted successful implementation. Financial incentives for both general practice and the Primary Health Network were also identified as prerequisites for systematised quality improvement projects in the future, along with individualised support and education for each general practice. Technology was both an enabler and a barrier, and the Primary Health Network was seen as key to assisting the successful utilisation of the available tools. Conclusions Implementation of Quality Improvement programs remains a potential tool for achieving better health outcomes in General Practice. However, enablers such as financial incentives, individualised education and support provided via a supporting organisation, and IT tools and support are crucial if the full potential of Quality Improvement programs are to be realised in the Australian healthcare setting. Trial registration ACTRN12615000108516, UTN U1111-1163–7995. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01692-0.
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Schaffer AL, Chia J, Brett J, Pearson S, Falster MO. A nationwide study of multimedicine use in people treated with cardiovascular medicines in Australia. Pharmacotherapy 2022; 42:828-836. [PMID: 36239072 PMCID: PMC9828398 DOI: 10.1002/phar.2735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE Multimorbidity and multimedicine use are common in people with cardiovascular disease and can lead to harms, such as prescribing errors and drug interactions. We quantified multimedicine use in people treated with cardiovascular medicines in a national sample of Australians. DESIGN Cross-sectional study. DATA SOURCE Pharmaceutical dispensing claims for a 10% random sample of Australians. PATIENTS Australian adults dispensed any cardiovascular medicine between June and August 2019. INTERVENTION None. MEASUREMENTS We quantified the number and type of cardiovascular and non-cardiovascular medicines dispensed during the study period, and the number of unique prescribers, by age and sex. MAIN RESULTS We identified 493,081 people dispensed any cardiovascular medicine (median age = 67 years, 50.2% women). The population prevalence of cardiovascular medicine dispensing increased from 1.7% (n = 10,503) in people 18-34 years to 80.1% (n = 99,271) in people 75-84 years. Cardiovascular medicine dispensing varied by sex; women 18-34 years were more likely to be dispensed any cardiovascular medicine than men (male:female prevalence ratio [PR] = 0.84, 95% confidence interval [CI] = 0.81-0.87), whereas the prevalence of cardiovascular medicine dispensing was higher in men 35-44 years (PR = 1.27, 95% CI 1.24-1.30) and 45-54 years (PR = 1.24, 95% CI 1.22-1.26) and was similar between sexes in people ≥65 years. Overall, both women and men were dispensed a median of 2.0 (interquartile range [IQR] = 1.0-3.0) cardiovascular medicines. Two-thirds of people ≥65 years (73.5%; n = 208,524) were dispensed ≥2 cardiovascular medicines, with 16.6% (n = 6736) of people ≥85 years dispensed five or more. Women and men were dispensed a median of 2.0 (IQR = 1.0-5.0) and 2.0 (IQR = 0.0-4.0) non-cardiovascular medicines, respectively, to treat comorbid conditions, commonly gastroesophageal reflux disease medicines (32.2% of women and 26.6% of men), antibiotics (28.7% of women and 22.4% of men), and antidepressants (26.3% of women and 15.9% of men). One quarter of both sexes had multiple prescribers for their cardiovascular medicines alone, whereas 54.5% (n = 134,939) of women and 49.9% (n = 122,706) of men had multiple prescribers for all medicines. CONCLUSION Multimedicine use is common in people treated with cardiovascular medicines and presents a risk for inappropriate prescribing. Understanding the comorbid conditions commonly treated concurrently with cardiovascular disease can help improve co-prescribing guidelines and develop a person-centered approach to multimorbidity treatment.
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Affiliation(s)
- Andrea L. Schaffer
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia
| | - Joel Chia
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia
| | - Jonathan Brett
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia,St Vincent's Clinical SchoolUNSW SydneySydneyNew South WalesAustralia
| | - Sallie‐Anne Pearson
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia,Menzies Centre for Health PolicyThe University of SydneySydneyNew South WalesAustralia
| | - Michael O. Falster
- Centre for Big Data Research in HealthUNSW SydneySydneyNew South WalesAustralia
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Campain A, Hockham C, Sukkar L, Rogers K, Chow CK, Lung T, Jun M, Pollock C, Cass A, Sullivan D, Comino E, Peiris D, Jardine M. Prior Cardiovascular Treatments-A Key Characteristic in Determining Medication Adherence After an Acute Myocardial Infarction. Front Pharmacol 2022; 13:834898. [PMID: 35330840 PMCID: PMC8940291 DOI: 10.3389/fphar.2022.834898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/15/2022] [Indexed: 11/30/2022] Open
Abstract
Objective: To investigate long-term adherence to guideline-recommended cardioprotective medications following hospitalization for an acute myocardial infarction (AMI), and identify characteristics associated with adherence. Methods: An Australian population-based cohort study was used to identify participants who had their first AMI between 2006 and 2014 and were alive after 12 months. Linked routinely collected hospital, and prescription medication claims data was used to study adherence over time. Predictors and rates of adherence to both lipid-lowering medication and renin-angiotensin system blockade at 12 months post-AMI was assessed. Results: 14,200 people (mean age 69.9 years, 38.7% female) were included in our analysis. At 12 months post-AMI, 29.5% (95% CI: 28.8–30.3%) of people were adherent to both classes of medication. Individuals receiving treatment with both lipid-lowering medication and renin-angiotensin system blockade during the 6 months prior to their AMI were over 9 times more likely to be adherent to both medications at 12 months post-AMI (66.2% 95% CI: 64.8–67.5%) compared to those with no prior medication use (treatment naïve) (7.1%, 95% CI: 6.4–7.9%). Prior cardiovascular treatment was the strongest predictor of long-term adherence even after adjusting for age, sex, education and income. Conclusions: Despite efforts to improve long-term medication adherence in patients who have experienced an acute coronary event, considerable gaps remain. Of particular concern are people who are commencing guideline-recommended cardioprotective medication at the time of their AMI. The relationship between prior cardiovascular treatments and post AMI adherence offers insight into the support needs for the patient. Health care intervention strategies, strengthened by enabling policies, are needed to provide support to patients through the initial months following their AMI.
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Affiliation(s)
- Anna Campain
- The George Institute for Global Heath, UNSW, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Carinna Hockham
- School of Public Health, Imperial College London, The George Institute for Global Health, London, United Kingdom
| | - Louisa Sukkar
- The George Institute for Global Heath, UNSW, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Kris Rogers
- The George Institute for Global Heath, UNSW, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Clara K Chow
- The George Institute for Global Heath, UNSW, Sydney, NSW, Australia.,Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - Thomas Lung
- The George Institute for Global Heath, UNSW, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Min Jun
- The George Institute for Global Heath, UNSW, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Carol Pollock
- Renal Division, Kolling Institute for Medical Research, Sydney, NSW, Australia.,University of Sydney, Sydney, NSW, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - David Sullivan
- Department of Chemical Pathology Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,NSW Health Pathology, Newcastle, NSW, Australia.,Central Clinical School, University of Sydney, Camperdown, NSW, Australia
| | - Elizabeth Comino
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Heath, UNSW, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Meg Jardine
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia.,Concord Repatriation General Hospital, Sydney, NSW, Australia
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7
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Hespe CM, Giskes K, Harris MF, Peiris D. Findings and lessons learnt implementing a cardiovascular disease quality improvement program in Australian primary care: a mixed method evaluation. BMC Health Serv Res 2022; 22:108. [PMID: 35078460 PMCID: PMC8790896 DOI: 10.1186/s12913-021-07310-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/10/2021] [Indexed: 11/10/2022] Open
Abstract
Background There are discrepancies between evidence-based guidelines for screening and management of cardiovascular disease (CVD) and implementation in Australian general practice. Quality-improvement (QI) initiatives aim to reduce these gaps. This study evaluated a QI program (QPulse) that focussed on CVD assessment and management. Methods This mixed-methods study explored the implementation of guidelines and adoption of a QI program with a CVD risk-reduction intervention in 34 general practices. CVD screening and management were measured pre- and post-intervention. Qualitative analyses examined participants’ Plan-Do-Study-Act (PDSA) goals and in-depth interviews with practice stakeholders focussed on barriers and enablers to the program and were analysed thematically using Normalisation Process Theory (NPT). Results Pre- and post-intervention data were available from 15 practices (n = 19,562 and n = 20,249, respectively) and in-depth interviews from seven practices. At baseline, 45.0% of patients had their BMI measured and 15.6% had their waist circumference recorded in the past 2 years and blood pressure, lipids and smoking status were measured in 72.5, 61.5 and 65.3% of patients, respectively. Most high-risk patients (57.5%) were not prescribed risk-reducing medications. After the intervention there were no changes in the documentation and prevalence of risk factors, attainment of BP and lipid targets or prescription of CVD risk-reducing medications. However, there was variation in performance across practices with some showing isolated improvements, such as recording waist circumference (0.7-32.2% pre-intervention to 18.5-69.8% post-intervention), BMI and smoking assessment. Challenges to the program included: lack of time, need for technical support, a perceived lack of value for quality improvement work, difficulty disseminating knowledge across the practice team, tensions between the team and clinical staff and a part-time workforce. Conclusion The barriers associated with this QI program was considerable in Australian GP practices. Findings highlighted they were not able to effectively operationalise the intervention due to numerous factors, ranging from lack of internal capacity and leadership to competing demands and insufficient external support. Trial registration Australian New Zealand Clinical Trials Reference Number (ACTRN12615000108516), registered 06/02/2015. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07310-6.
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Affiliation(s)
- C M Hespe
- School of Medicine, Sydney, University of Note Dame Australia, 160 Oxford St, Darlinghurst, Sydney, NSW, 2010, Australia.
| | - K Giskes
- School of Medicine, Sydney, University of Note Dame Australia, 160 Oxford St, Darlinghurst, Sydney, NSW, 2010, Australia.,Heart Research Institute, University of Sydney, Sydney, Australia
| | - M F Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
| | - D Peiris
- The George Institute for Global Health, University of Sydney, Sydney, Australia
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Sarkies MN, Jones LK, Gidding SS, Watts GF. Improving clinical practice guidelines with implementation science. Nat Rev Cardiol 2022; 19:3-4. [PMID: 34799708 DOI: 10.1038/s41569-021-00645-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mitchell N Sarkies
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia. .,School of Public Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.
| | - Laney K Jones
- Genomic Medicine Institute, Geisinger, Danville, PA, USA.,Heart Institute, Geisinger, Danville, PA, USA
| | - Samuel S Gidding
- Genomic Medicine Institute, Geisinger, Danville, PA, USA.,Heart Institute, Geisinger, Danville, PA, USA
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
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Sturmberg JP, Martin CM. Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed. Med J Aust 2021; 215:189-189.e1. [PMID: 34291471 DOI: 10.5694/mja2.51193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Joachim P Sturmberg
- University of Newcastle, Newcastle, NSW.,International Society for Systems and Complexity Sciences for Health, Waitsfield, VT, USA
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Hespe CM, Harris MF, Peiris DP. Implementing cardiovascular disease preventive care guidelines in general practice: an opportunity missed. Med J Aust 2021; 215:189-189.e1. [PMID: 34291475 DOI: 10.5694/mja2.51190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Mark F Harris
- Centre for Primary Health Care and Equity, UNSW, Sydney, NSW
| | - David P Peiris
- Office of the Chief Scientist, The George Institute for Global Health, Sydney, NSW
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Webster R, Usherwood T, Joshi R, Saini B, Armour C, Critchley S, Di Tanna GL, Galgey S, Hespe CM, Jan S, Karia A, Kaur B, Krass I, Laba TL, Li Q, Lo S, Peiris DP, Reid C, Rodgers A, Shiel L, Strathdee J, Zamora N, Patel A. An electronic decision support-based complex intervention to improve management of cardiovascular risk in primary health care: a cluster randomised trial (INTEGRATE). Med J Aust 2021; 214:420-427. [PMID: 33899216 DOI: 10.5694/mja2.51030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/13/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine whether a multifaceted primary health care intervention better controlled cardiovascular disease (CVD) risk factors in patients with high risk of CVD than usual care. DESIGN, SETTING Parallel arm, cluster randomised trial in 71 Australian general practices, 5 December 2016 - 13 September 2019. PARTICIPANTS General practices that predominantly used an electronic medical record system compatible with the HealthTracker electronic decision support tool, and willing to implement all components of the INTEGRATE intervention. INTERVENTION Electronic point-of-care decision support for general practices; combination cardiovascular medications (polypills); and a pharmacy-based medication adherence program. MAIN OUTCOME MEASURES Proportion of patients with high CVD risk not on an optimal preventive medication regimen at baseline who had achieved both blood pressure and low-density lipoprotein (LDL) cholesterol goals at study end. RESULTS After a median 15 months' follow-up, primary outcome data were available for 4477 of 7165 patients in the primary outcome cohort (62%). The proportion of patients who achieved both treatment targets was similar in the intervention (423 of 2156; 19.6%) and control groups (466 of 2321; 20.1%; relative risk, 1.06; 95% CI, 0.85-1.32). Further, no statistically significant differences were found for a number of secondary outcomes, including risk factor screening, preventive medication prescribing, and risk factor levels. Use of intervention components was low; it was highest for HealthTracker, used at least once for 347 of 3236 undertreated patients with high CVD risk (10.7%). CONCLUSIONS Despite evidence for the efficacy of its individual components, the INTEGRATE intervention was not broadly implemented and did not improve CVD risk management in participating Australian general practices. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12616000233426 (prospective).
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Affiliation(s)
- Ruth Webster
- Centre for Health Economics Research and Evaluation, University of Technology, Sydney, NSW.,The George Institute for Global Health, Sydney, NSW
| | - Tim Usherwood
- Sydney Medical School, University of Sydney, Sydney, NSW
| | - Rohina Joshi
- The George Institute for Global Health, Sydney, NSW.,The George Institute for Global Health India, New Delhi, India
| | | | - Carol Armour
- The Woolcock Institute, University of Sydney, Sydney, NSW
| | | | | | - Shane Galgey
- The George Institute for Global Health, Sydney, NSW
| | | | - Stephen Jan
- The George Institute for Global Health, Sydney, NSW
| | | | - Baldeep Kaur
- The George Institute for Global Health, Sydney, NSW
| | | | - Tracey-Lea Laba
- Centre for Health Economics Research and Evaluation, University of Technology, Sydney, NSW
| | - Qiang Li
- The George Institute for Global Health, Sydney, NSW
| | - Serigne Lo
- Melanoma Institute, University of Sydney, Sydney, NSW
| | | | | | | | | | | | - Nuria Zamora
- The George Institute for Global Health, Sydney, NSW
| | - Anushka Patel
- The George Institute for Global Health, Sydney, NSW.,The University of Sydney, Sydney, NSW
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