Ischaemic heart disease and Australian immigrants: the influence of birthplace and language skills on treatment and use of health services

Admission rates for ischaemic heart disease (IHD), and the use of invasive cardiovascular procedures, separation mode and length of stay (LOS) were compared between Australians from non-English speaking background (NESB; n=8627) and English speaking background (ESB; n=13162) aged 20 years and over admitted to Victorian urban public hospitals. The study covered the period from 1993 to 1998. It was found that, compared with their ESB counterparts, the incidence of admission for acute myocardial infarction was significantly higher for NESB men and women before and after controlling for confounding factors. The age-adjusted ratios for NESB women compared with their ESB counterparts ranged from 1.23 to 1.89 for cardiac catheterisation, from 0.23 to 0.27 for percutaneous transluminal coronary angioplasty (PTCA), and from 1.04 to 1.80 for coronary artery bypass grafting (CABG).
Procedure rates were comparable in men for cardiac catheterisation and CABG but higher for PTA rates in NESB men (OR: 1.29, 95%CI: 1.11-1.50) than their ESB counterparts. Both NESB men (β=0.04, 95%CI: 0.01-0.07) and women (β=0.03, 95%CI: 0.02-0.08) experienced significantly longer hospital stays than their ESB counterparts. These findings indicate there may be systematic differences in patients’ treatment and service utilisation in Victorian public hospitals. The extent to which physicians’ bias and
patients’ choice could explain these differences requires further investigation.

Issues in the provision of nursing care to people undergoing cardiac surgery who also have type 2 diabetes

There has been little investigation of the issues associated with caring for patients presenting for cardiac surgery with a comorbid diagnosis of diabetes although there is some evidence that the diabetes management is suboptimal. This study aimed to identify issues that patients and cardiac specialist nurses experience with the provision of inpatient services for people undergoing cardiac surgery who also have type 2 diabetes. A qualitative interpretive design, using individual interviews with patients and nurses, provided data about some of these issues. The study found that nurses had high levels of confidence in their cardiac care but little confidence in diabetes management. Patients described concerns about their diabetes care and treatment regimens. A 'typical journey' for a person with diabetes undergoing cardiac surgery was identified. The findings support the need to build increased capacity in specialist nurses to support diabetes care as a secondary diagnosis.

Cardiac rehabilitation in south west Victoria : factors influencing attendance

Background : The benefits of cardiac rehabilitation (CR) programs are well established. Despite these benefits their utilisation remains sub-optimal, with an average of 24% of eligible cardiac patients attending outpatient CR programs across Victoria.
Aims & rationale/Objectives : The objectives of this study were to (a) identify local barriers and enablers to the uptake of hospital-based CR programs, and (b) identify preferred alternatives for the delivery of CR.
Methods : Six hospital-based CR programs within the region agreed to participate in this study. A consecutive series of patients referred to the programs were surveyed by the CR coordinators to identify the local barriers and enablers influencing CR program attendance. In addition, focus groups with CR participants and health professionals were conducted at two hospitals in order to ascertain their views on current programs, suggestions for improvements and alternative methods of CR delivery.
Principal findings : Survey data was obtained from a total of 97 patients referred to the CR programs during the study period, 27 (28%) females and 70 (72%) males. Main reasons given for CR non-attendance were related to distance to travel, cost of petrol, reliance on others for transport and lack of interest or motivation to attend. For CR attenders, main enablers included encouragement by family, medical and other health professionals, and having someone else to drive them. Suggestions for alternative methods of CR delivery included more programs in outlying communities, home and GP based programs, telephone support and a patient manual or workbook.
Discussion : The results of this study provide valuable information for designing strategies to increase utilisation of existing CR programs as well as pilot testing alternative modes of CR program delivery for cardiac patients in rural areas unable to access hospital-based CR.
Implications : These findings suggest that many of the barriers identified could be addressed by a more creative use of existing resources and the provision of CR services in primary care settings.
Presentation type : Poster

Clinical outcomes associated with screening and referral for depression in an acute cardiac ward

Aim.  The aim of this paper is to describe the implementation of a depression screening and referral tool in two cardiac wards of a major metropolitan public hospital. The tool consisted of two sections: (1) screening for depression risk (Cardiac Depression Scale-5) and (2) consequential referral actions.

Background.  Prior research has shown that depression in patients with heart disease is associated with significantly impaired quality of life, decreased medication adherence, increased morbidity and increased use of healthcare services.

Design.  A prospective in-patient study design.

Method.  A consecutive sample of 202 patients admitted to either the cardiac medical (n = 145) or surgical (n = 57) wards of a major Melbourne metropolitan hospital were recruited into the study over an 18-week period.

Results.  Just over half (54%) of the patients were identified as ‘at risk’ of depression. Of these, 19% were assessed as moderate risk and 35% high risk. Of those patients, 91% had the risk score documented in their medical history, 90% had engaged in discussions with clinicians regarding their risk score, 85% had their risk score communicated formally to the medical team and 25% were formally referred for appropriate follow-up – significantly more than prior to implementation of the screening and referral tool.

Conclusions.  By providing a formalised mechanism for detecting depression, documented screening and referral rates improved for those with comorbid depression and heart disease affording an opportunity for early intervention. These findings support a move towards integrated approaches to screening of depression to become standard practice in the acute cardiac setting.

Relevance to clinical practice.  Such mechanisms also have the potential to initiate the development of new models of care that acknowledge the complexity of comorbid depression and heart disease and provide pathways from speciality to primary care which integrate the physical and psychosocial domains inclusive of screening, referral, systematic monitoring and streamlined behavioural and physical care.

Comparison of not for resuscitation (NFR) forms across five Victorian health services

Background: 

A clustering-based multi-layer distributed ensemble for neurological diagnostics in cloud services

This paper investigates the problem of minimizing data transfer between different data centers of the cloud during the neurological diagnostics of cardiac autonomic neuropathy (CAN). This problem has never been considered in the literature before. All classifiers considered for the diagnostics of CAN previously assume complete access to all data, which would lead to enormous burden of data transfer during training if such classifiers were deployed in the cloud. We introduce a new model of clustering-based multi-layer distributed ensembles (CBMLDE). It is designed to eliminate the need to transfer data between different data centers for training of the classifiers. We conducted experiments utilizing a dataset derived from an extensive DiScRi database. Our comprehensive tests have determined the best combinations of options for setting up CBMLDE classifiers. The results demonstrate that CBMLDE classifiers not only completely eliminate the need in patient data transfer, but also have significantly outperformed all base classifiers and simpler counterpart models in all cloud frameworks.

The HEART mobile phone trial: the partial mediating effects of self-efficacy on physical activity among cardiac patients

BACKGROUND: The ubiquitous use of mobile phones provides an ideal opportunity to deliver interventions to increase physical activity levels. Understanding potential mediators of such interventions is needed to increase their effectiveness. A recent randomized controlled trial of a mobile phone and Internet (mHealth) intervention was conducted in New Zealand to determine the effectiveness on exercise capacity and physical activity levels in addition to current cardiac rehabilitation (CR) services for people (n = 171) with ischemic heart disease. Significant intervention effect was observed for self-reported leisure-time physical activity and walking, but not peak oxygen uptake at 24 weeks. There was also significant improvement in self-efficacy.

OBJECTIVE: To evaluate the mediating effect of self-efficacy on physical activity levels in an mHealth delivered exercise CR program.

METHODS: Treatment evaluations were performed on the principle of intention to treat. Adjusted regression analyses were conducted to evaluate the main treatment effect on leisure-time physical activity and walking at 24 weeks, with and without change in self-efficacy as the mediator of interest.

RESULTS: Change in self-efficacy at 24 weeks significantly mediated the treatment effect on leisure-time physical activity by 13%, but only partially mediated the effect on walking by 4% at 24 weeks.

CONCLUSION: An mHealth intervention involving text messaging and Internet support had a positive treatment effect on leisure-time physical activity and walking at 24 weeks, and this effect was likely mediated through changes in self-efficacy. Future trials should examine other potential mediators related to this type of intervention.

The remote exercise monitoring trial for exercise-based cardiac rehabilitation (REMOTE-CR): a randomised controlled trial protocol

BACKGROUND: Exercise is an essential component of contemporary cardiac rehabilitation programs for the secondary prevention of coronary heart disease. Despite the benefits associated with regular exercise, adherence with supervised exercise-based cardiac rehabilitation remains low. Increasingly powerful mobile technologies, such as smartphones and wireless physiological sensors, may extend the capability of exercise-based cardiac rehabilitation by enabling real-time exercise monitoring for those with coronary heart disease. This study compares the effectiveness of technology-assisted, home-based, remote monitored exercise-based cardiac rehabilitation (REMOTE) to standard supervised exercise-based cardiac rehabilitation in New Zealand adults with a diagnosis of coronary heart disease. METHODS/DESIGN: A two-arm, parallel, non-inferiority, randomised controlled trial will be conducted at two sites in New Zealand. One hundred and sixty two participants will be randomised at a 1:1 ratio to receive a 12-week program of technology-assisted, home-based, remote monitored exercise-based cardiac rehabilitation (intervention), or an 8-12 program of standard supervised exercise-based cardiac rehabilitation (control).The primary outcome is post-treatment maximal oxygen uptake (V̇O2max). Secondary outcomes include cardiovascular risk factors (blood lipid and glucose concentrations, blood pressure, anthropometry), self-efficacy, intentions and motivation to be active, objectively measured physical activity, self-reported leisure time exercise and health-related quality of life. Cost information will also be collected to compare the two modes of delivery. All outcomes are assessed at baseline, post-treatment, and 6 months, except for V̇O2max, blood lipid and glucose concentrations, which are assessed at baseline and post-treatment only. DISCUSSION: This novel study will compare the effectiveness of technology-supported exercise-based cardiac rehabilitation to a traditional supervised approach. If the REMOTE program proves to be as effective as traditional cardiac rehabilitation, it has potential to augment current practice by increasing access for those who cannot utilise existing services. TRIAL REGISTRATION: Australian New Zealand Clinical Trials RegistryStudy ID number: ACTRN12614000843651. Registered 7 August 2014.

Remotely delivered exercise-based cardiac rehabilitation: design and content development of a novel mHealth platform

BACKGROUND: Participation in traditional center-based cardiac rehabilitation exercise programs (exCR) is limited by accessibility barriers. Mobile health (mHealth) technologies can overcome these barriers while preserving critical attributes of center-based exCR monitoring and coaching, but these opportunities have not yet been capitalized on.

OBJECTIVE: We aimed to design and develop an evidence- and theory-based mHealth platform for remote delivery of exCR to any geographical location.

METHODS: An iterative process was used to design and develop an evidence- and theory-based mHealth platform (REMOTE-CR) that provides real-time remote exercise monitoring and coaching, behavior change education, and social support.

RESULTS: The REMOTE-CR platform comprises a commercially available smartphone and wearable sensor, custom smartphone and Web-based applications (apps), and a custom middleware. The platform allows exCR specialists to monitor patients' exercise and provide individualized coaching in real-time, from almost any location, and provide behavior change education and social support. Intervention content incorporates Social Cognitive Theory, Self-determination Theory, and a taxonomy of behavior change techniques. Exercise components are based on guidelines for clinical exercise prescription.

CONCLUSIONS: The REMOTE-CR platform extends the capabilities of previous telehealth exCR platforms and narrows the gap between existing center- and home-based exCR services. REMOTE-CR can complement center-based exCR by providing an alternative option for patients whose needs are not being met. Remotely monitored exCR may be more cost-effective than establishing additional center-based programs. The effectiveness and acceptability of REMOTE-CR are now being evaluated in a noninferiority randomized controlled trial.