Mortality disparities between geographic regions : results from a risk percentiles model for coronary heart disease

Background: Planning of disease prevention strategies requires information regarding the distribution of absolute risk in the population to allow targeting of people at high disease risk. It is well known that death rates from coronary heart disease (CHD) are higher in remote areas of Australia compared with major cities. Less well understood is the distribution of the absolute risk of CHD death within the different geographic regions. We present a mathematical model of CHD which projects the lifetime risk of death among individuals in different percentiles of CHD risk. We apply this to model the distribution of CHD risk within different geographic regions.

Methods: Using information from the Framingham1, MRFIT2 and AusDiab3 studies, the Australian population was divided into percentiles of CHD risk within age and gender groups by geographic location. Absolute mortality risk was determined at each percentile using current Australian mortality data. Survival curves were generated for each percentile using these risk estimates. Approximate confidence intervals were derived using bootstrap methods.

Conclusions: The difference in life expectancy at age 25 between those in the lowest decile of CHD risk compared to the highest was 5.8 years (95%CI:4.7,6.7) in major cities compared to 8.5 years (95%CI:7.6,9.7) in remote areas. The difference in risk of premature death (before age 75) was 12% (95%CI:10%,14%) in major cities compared to 33% (95%CI:28%,38%) in remote areas.

Cost effectiveness of a general practice chronic disease management plan for coronary heart disease in Australia

Background. The cost effectiveness of a general practice-based program for managing coronary heart disease (CHD) patients in Australia remains uncertain. We have explored this through an economic model.

Methods. A secondary prevention program based on initial clinical assessment and 3 monthly review, optimising of pharmacotherapies and lifestyle modification, supported by a disease registry and financial incentives for quality of care and outcomes achieved was assessed in terms of incremental cost effectiveness ratio (ICER), in Australian dollars per disability adjusted life year (DALY) prevented.

Results. Based on 2006 estimates, 263 487 DALYs were attributable to CHD in Australia. The proposed program would add $115 650 000 to the annual national heath expenditure. Using an estimated 15% reduction in death and disability and a 40% estimated program uptake, the program’s ICER is $8081 per DALY prevented. With more conservative estimates of effectiveness and uptake, estimates of up to $38 316 per DALY are observed in sensitivity analysis.

Conclusions. Although innovation in CHD management promises improved future patient outcomes, many therapies and strategies proven to reduce morbidity and mortality are available today. A general practice-based program for the optimal application of current therapies is likely to be cost-effective and provide substantial and sustainable benefits to the Australian community.

What is known about this topic? Chronic disease management programs are known to provide gains with respect to reductions in death and disability among patients with coronary heart disease. The cost effectiveness of such programs in the Australian context is not known.

What does this paper add? This paper suggests that implementing a coronary heart disease program in Australia is highly cost-effective across a broad range of assumptions of uptake and effectiveness.

What are the implications for practitioners? These data provide the economic rationale for the implementation of a chronic disease management program with a disease registry and regular review in Australia.

The relationship between coronary heart disease (CHD) and major depressive disorder (MDD) : key mechanisms and the role of quality of life

Various trials have been conducted evaluating depression management programs for patients with Coronary Heart Disease (CHD). However, to date, the most effective way to manage this co-morbidity in the real world setting remains unclear. To better understand the past successes and failures of previous trials and subsequently develop suitable interventions that target key components of health related quality of life (HRQOL) such as mental, physical and vocational functioning, we first need to understand the mechanisms underpinning the relationship between the two conditions. This paper will draw on the key literature in this field as identified by psychiatric, medical and social sciences databases (Cochrane Central Register of Controlled Trials, PubMed, OVID, Medline) available up to January 2012, with the aim to conduct a narrative review which explores: the aetiological relationship between depression and CHD; its association with HRQOL; the relationship between CHD, depression and vocational functioning; and the impact of depression treatment on these outcomes. Key recommendations are made regarding the management of this prevalent co-morbidity in clinical settings.

Effect of a telephone-delivered coronary heart disease secondary prevention program (ProActive Heart) on quality of life and health behaviours: primary outcomes of a randomised controlled trial

Background Participation in coronary heart disease secondary prevention programs is low. Innovative programs to meet this treatment gap are required.

Purpose To aim of this study is to describe the effectiveness of a telephone-delivered secondary prevention program for myocardial infarction patients.

Methods Four hundred and thirty adult myocardial infarction patients in Brisbane, Australia were randomised to a 6-month secondary prevention program or usual care. Primary outcomes were health-related quality of life (Short Form-36) and physical activity (Active Australia Survey).

Results Significant intervention effects were observed for health-related quality of life on the mental component summary score (p = 0.02), and the social functioning (p = 0.04) and role-emotional (p = 0.03) subscales, compared with usual care. Intervention participants were also more likely to meet recommended levels of physical activity (p = 0.02), body mass index (p = 0.05), vegetable intake (p = 0.04) and alcohol consumption (p = 0.05).

Conclusions Telephone-delivered secondary prevention programs can significantly improve health outcomes and could meet the treatment gap for myocardial infarction patients.

Auranofin increases apoptosis and ischaemia-reperfusion injury in the rat isolated heart

1. Auranofin, an antirheumatic gold compound, is an inhibitor of selenocysteine enzymes, such as thioredoxin reductase and glutathione peroxidase. These enzymes play an important role in protecting cardiac tissue from oxidative stress generated during ischaemia–reperfusion.

2. Auranofin (100 mg/kg) was administered to rats and their hearts were subjected to an in vitro model of ischaemia–reperfusion. The activity of thioredoxin reductase and glutathione peroxidase was determined in liver and heart tissues in an attempt to correlate enzymatic activity with heart recovery after ischaemia–reperfusion.

3. There was significantly less thioredoxin reductase activity in rat liver extracts, whereas the level of glutathione activity remained unchanged, demonstrating that the dose of auranofin used was able to selectively inhibit one of these enzyme systems. Rats administered auranofin displayed significantly impaired recovery from ischaemic insult. The end diastolic pressure was increased, whereas the rate pressure product was significantly decreased.

4. The level of postischaemic apoptosis was also assessed by examining caspase-3 activity in tissue homogenates. Auranofin significantly increased the degree of postischaemic apoptosis, leading to poor postischaemic recovery.

Telephone delivered health coaching improves anxiety outcomes after myocardial infarction : the 'ProActive Heart' trial

Background: Recently, we found a telephone-delivered secondary prevention programme using health coaching (‘ProActive Heart’) to be effective in improving a range of key behavioural outcomes for myocardial infarction (MI) patients. What remains unclear, however, is the extent to which these treatment effects translate to important psychological outcomes such as depression and anxiety outcomes, an issue of clinical significance due to the substantial proportion of MI patients who experience depression and anxiety. The objective of the study was to investigate, as a secondary hypothesis of a larger trial, the effects of a telephone-delivered health coaching programme on depression and anxiety outcomes of MI patients.

Design: Two-arm, parallel-group, randomized, controlled design with six-months outcomes.

Methods: Patients admitted to one of two tertiary hospitals in Brisbane, Australia following MI were assessed for eligibility. Four hundred and thirty patients were recruited and randomly assigned to usual care or an intervention group comprising up to 10 telephone-delivered ‘health coaching’ sessions (ProActive Heart). Regression analysis compared Hospital Anxiety and Depression Scale scores of completing participants at six months (intervention: n = 141 versus usual care: n = 156).

Results: The intervention yielded reductions in anxiety at follow-up (mean difference = -0.7, 95% confidence interval=-1.4,-0.02) compared with usual care. A similar pattern was observed in mean depression scores but was not statistically significant.

Conclusions: The ProActive Heart programme effectively improves anxiety outcomes of patients following myocardial infarction. If combined with psychological-specific treatment, this programme could impact anxiety of greater intensity in a clinically meaningful way.