Development and evaluation of a co-designed website for delivering interactive self-directed cardiac rehabilitation.

AIMS: The aim of this study is to report on the development and evaluation of the co-designed website for delivering interactive self-directed cardiac rehabilitation (CR). METHODS AND RESULTS: Multi-method user experience design framework was used to co-design the web application and complete usability testing. Participants were recruited based on their eligibility for CR. Thematic analysis collected the participants' design specifications and lived experiences. The System Usability Scale (SUS) was administered at the completion of the website development and the usability testing workshops. This collected the participants' perceptions of the website's effectiveness, efficiency, and their satisfaction. Website development and usability testing workshops included 39 and 35 participants with a mean age of 66.5 (SD 11.7) and 68.6 (SD 11.2), respectively. Both genders were equally represented across both workshops with 19 (48.7%) and 16 (45.7%) women. Workshop themes guided the design process. The mean SUS scores increased from 66.7 (SD 16.8) to 73.6 (21), P = 0.26. Easiness of use (P = 0.03), integration of the website functions (P ≤ 0.001), and consistency (P = 0.038) significantly improved from website development to usability testing. The proportion of participants rating it as excellent increased from 20.5% to 42.9%, P = 0.11. CONCLUSION: The evolution of our CR website development was completed with an improvement in usability. Upcoming evaluation of this intervention will report on its effectiveness.

A National Survey of Patient Data Capture, Management, Reporting Practice in Australian Cardiac Rehabilitation Programs.

BACKGROUND: Lack of service data for cardiac rehabilitation limits understanding of program delivery, benchmarking and quality improvement. This study aimed to describe current practices, management, utilisation and engagement with quality indicators in Australian programs. METHOD: Cardiac rehabilitation programs (n=396) were identified from national directories and networks. Program coordinators were surveyed on service data capture, management systems and adoption of published national quality indicators. Text responses were coded and classified. Logistic regression determined independent associates of the use of data for quality improvement. RESULTS: A total of 319 (81%) coordinators completed the survey. Annual patient enrolments/programs were >200 (31.0%), 51-200 (46%) and ≤50 (23%). Most (79%) programs used an electronic system, alongside paper (63%) and/or another electronic system (19%), with 21% completely paper. While 84% knew of the national quality indicators, only 52% used them. Supplementary to patient care, data were used for reports to managers (57%) and funders (41%), to improve quality (56%), support funding (43%) and research (31%). Using data for quality improvement was more likely when enrolments where >200 (Odds ratio [OR] 3.83, 95% Confidence Interval [CI] 1.76-8.34) and less likely in Victoria (OR 0.24 95%, CI 0.08-0.77), New South Wales (OR 0.25 95%, CI 0.08-0.76) and Western Australia (OR 0.16 95%, CI 0.05-0.57). CONCLUSIONS: The collection of service data for cardiac rehabilitation patient data and its justification is diverse, limiting our capacity to benchmark and drive clinical practice. The findings strengthen the case for a national low-burden approach to data capture for quality care.

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.

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.

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.

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.

User Experience (UX) Design as a co-design methodology: lessons learned during the development of a web-based portal for cardiac rehabilitation.

Person-centred care advocates for co-design of all healthcare services and research interventions by the end-user. Co-design is widely used, but the methodological approaches, evaluation, and reporting of outcomes are often poorly defined. One methodology for co-design is the User Experience Design which provides guidance and theoretical frameworks to inform development and reporting measures. This article outlines the application of this approach in the development of a web-based cardiac rehabilitation program and reports on the very positive experiences of the patients involved in the process and how their input strategically influenced outcomes.

A co-designed telehealth-based model of care to improve attendance and completion to cardiac rehabilitation of rural and remote Australians: The Country Heart Attack Prevention (CHAP) project.

We aim to report the co-design of the implementation strategy of a telehealth-enabled cardiac rehabilitation model of care in rural and remote areas of Australia. The goal of this model of care is to increase cardiac rehabilitation attendance and completion by country patients with cardiovascular diseases.We hypothesise that a model of care co-designed with stakeholders will address patients' needs and preferences and increase participation. We applied the Model for Large Scale Knowledge Translation and engaged with patients, clinicians and health service managers across six local health networks in rural South Australia. They informed the design of a web-based cardiac rehabilitation programme and the delivery of the expanded telehealth service.The stakeholders defined face-to-face, telephone, web-based or combinations as choices of mode of delivery to patients referred to cardiac rehabilitation. A case-managed programme supported by a web portal with an interface for patients and clinicians was considered more appropriate to the local context than a self-managed programme. A business model was developed to enable the sustainability of cardiac rehabilitation clinical assessments through primary care. The impact of the model of care on cardiac rehabilitation attendance/completion, clinical outcomes, patient-reported outcomes and patient-reported experiences and cost-effectiveness will be tested in a 12-month follow-up study.

Catering for the Point-of-Care Testing Explosion.

The ease of performing a laboratory test near to the patient, at the point-of-care, has resulted in the integration of point-of-care tests into healthcare treatment algorithms. However, their importance in patient care necessitates regular oversight and enforcement of best laboratory practices. This review discusses why this oversight is needed, it's importance in ensuring quality results and processes that can be placed to ensure point-of-care tests are chosen carefully so that both oversight can be maintained and patient care is improved. Furthermore, it highlights the importance of delivering focused webinars and continuing education in a variety of formats.

Optimising Secondary Prevention and Cardiac Rehabilitation for Atherosclerotic Cardiovascular Disease During the COVID-19 Pandemic: A Position Statement From the Cardiac Society of Australia and New Zealand (CSANZ).

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has introduced a major disruption to the delivery of routine health care across the world. This provides challenges for the use of secondary prevention measures in patients with established atherosclerotic cardiovascular disease (CVD). The aim of this Position Statement is to review the implications for effective delivery of secondary prevention strategies during the COVID-19 pandemic. CHALLENGES: The COVID-19 pandemic has introduced limitations for many patients to access standard health services such as visits to health care professionals, medications, imaging and blood tests as well as attendance at cardiac rehabilitation. In addition, the pandemic is having an impact on lifestyle habits and mental health. Taken together, this has the potential to adversely impact the ability of practitioners and patients to adhere to treatment guidelines for the prevention of recurrent cardiovascular events. RECOMMENDATIONS: Every effort should be made to deliver safe, ongoing access to health care professionals and the use of evidenced based therapies in individuals with CVD. An increase in use of a range of electronic health platforms has the potential to transform secondary prevention. Integrating research programs that evaluate the utility of these approaches may provide important insights into how to develop more optimal approaches to secondary prevention beyond the pandemic.

The Impact of Cardiac Rehabilitation and Secondary Prevention Programs on 12-Month Clinical Outcomes: A Linked Data Analysis.

BACKGROUND: Guidelines recommend referral to cardiac rehabilitation (CR) for cardiac event prevention and risk factor management, but poor attendance persists. Following the development of standardised data and uniform capture, CR services have contributed to three audits in South Australia, Australia. We aimed to determine if CR attendance impacts on cardiovascular readmission, morbidity and mortality. METHODS: In a retrospective cohort study, CR databases were linked to hospital administrative datasets to compare the characteristics and outcomes of CR patients between 2013 and 2015. Inverse probability weighting methods were used to measure associations between CR attendance versus non-attendance and cardiovascular readmission and the composite of death, new/re-myocardial infarction, atrial fibrillation, heart failure and stroke within 12-months. RESULTS: Of 49,909 eligible separations, 15,089/49,909 (30.2%) were referred to CR with an attendance rate of 4,286/15,089 (28.4%). Referred/declined patients were older (median: 67.3 vs 65.3 years, p < 0.001), more likely to be female (32.3% vs 26.5%, p < 0.001) with more heart failure (17.1% vs 10.9%, p < 0.001) and arrhythmia (6.1% vs 2.1%, p < 0.001) admissions and higher socio-economic disadvantage (median Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD): 950.1 vs 960.4, p < 0.001). Referred/attended patients had lower cardiovascular readmission, (referred/attended vs not referred: 15.6% vs 22.7% and referred/attended vs referred/declined: 15.6% vs 29.6%, p < 0.001). After clinical and social factors adjustment there was no difference in composite outcomes, but attendance was associated with reduced cardiovascular readmission (HR:0.68, 95% IQR: 0.58-0.81, p = 0.001). CONCLUSIONS: Audit can measure service effectiveness, identifying areas for improvement. This study highlights patient eligibility, system and program considerations for future CR services.

How to manage warfarin therapy.

Long-term treatment with warfarin is recommended for patients with atrial fibrillation at risk of stroke and those with recurrent venous thrombosis or prosthetic heart valves. Patient education before commencing warfarin - regarding signs and symptoms of bleeding, the impact of diet, potential drug interactions and the actions to take if a dose is missed - is pivotal to successful use. Scoring systems such as the CHADS2 score are used to determine if patients with atrial fibrillation are suitable for warfarin treatment. To rapidly achieve stable anticoagulation, use an age-adjusted protocol for starting warfarin. Regular monitoring of the anticoagulant effect is required. Evidence suggests that patients who self-monitor using point-of-care testing have better outcomes than other patients.

Internet support for point-of-care testing in primary care.

One of the few and largest randomised controlled trials of point-of-care testing (PoCT) in general practice was conducted in Australia. This trial showed PoCT provided the same or better clinical effectiveness than central laboratory testing for HbA1c, urinary albumin/creatinine ratio, cholesterol and triglyceride measurements but not for the international normalised ratio (INR) or high-density lipoprotein (HDL) cholesterol. For most tests, however, testing in the central laboratory was more cost-effective than PoCT. One factor that contributed to the higher cost of PoCT was the considerable amount of resources devoted to training and monitoring the PoCT operators throughout the trial, many of whom were in remote locations.

Alternative models of cardiac rehabilitation: a systematic review.

The traditional hospital-based model of cardiac rehabilitation faces substantial challenges, such as cost and accessibility. These challenges have led to the development of alternative models of cardiac rehabilitation in recent years. The aim of this study was to identify and critique evidence for the effectiveness of these alternative models. A total of 22 databases were searched to identify quantitative studies or systematic reviews of quantitative studies regarding the effectiveness of alternative models of cardiac rehabilitation. Included studies were appraised using a Critical Appraisal Skills Programme tool and the National Health and Medical Research Council's designations for Level of Evidence. The 83 included articles described interventions in the following broad categories of alternative models of care: multifactorial individualized telehealth, internet based, telehealth focused on exercise, telehealth focused on recovery, community- or home-based, and complementary therapies. Multifactorial individualized telehealth and community- or home-based cardiac rehabilitation are effective alternative models of cardiac rehabilitation, as they have produced similar reductions in cardiovascular disease risk factors compared with hospital-based programmes. While further research is required to address the paucity of data available regarding the effectiveness of alternative models of cardiac rehabilitation in rural, remote, and culturally and linguistically diverse populations, our review indicates there is no need to rely on hospital-based strategies alone to deliver effective cardiac rehabilitation. Local healthcare systems should strive to integrate alternative models of cardiac rehabilitation, such as brief telehealth interventions tailored to individual's risk factor profiles as well as community- or home-based programmes, in order to ensure there are choices available for patients that best fit their needs, risk factor profile, and preferences.

Impact of a regionalised clinical cardiac support network on mortality among rural patients with myocardial infarction.

OBJECTIVE: To evaluate the impact of the regionalised Integrated Cardiovascular Clinical Network (ICCNet) on 30-day mortality among patients with myocardial infarction (MI) in an Australian rural setting. DESIGN, SETTING AND PATIENTS: An integrated cardiac support network incorporating standardised risk stratification, point-of-care troponin testing and cardiologist-supported decision making was progressively implemented in non-metropolitan areas of South Australia from 2001 to 2008. Hospital administrative data and statewide death records from 1 July 2001 to 30 June 2010 were used to evaluate outcomes for patients diagnosed with MI in rural and metropolitan hospitals. MAIN OUTCOME MEASURE: Risk-adjusted 30-day mortality. RESULTS: 29 623 independent contiguous episodes of MI were identified. The mean predicted 30-day mortality was lower among rural patients compared with metropolitan patients, while actual mortality rates were higher (30-day mortality: rural, 705/5630 [12.52%] v metropolitan, 2140/23 993 [8.92%]; adjusted odds ratio [OR], 1.46; 95% CI, 1.33-1.60; P< 0.001). After adjustment for temporal improvement in MI outcome, availability of immediate cardiac support was associated with a 22% relative odds reduction in 30-day mortality (OR, 0.78; 95% CI, 0.65-0.93; P= 0.007). A strong association between network support and transfer of patients to metropolitan hospitals was observed (before ICCNet, 1102/2419 [45.56%] v after ICCNet, 2100/3211 [65.4%]; P< 0.001), with lower mortality observed among transferred patients. CONCLUSION: Cardiologist-supported remote risk stratification, management and facilitated access to tertiary hospital-based early invasive management are associated with an improvement in 30-day mortality for patients who initially present to rural hospitals and are diagnosed with MI. These interventions closed the gap in mortality between rural and metropolitan patients in South Australia.

A comparison of Australian rural and metropolitan cardiovascular risk and mortality: the Greater Green Triangle and North West Adelaide population surveys.

OBJECTIVES: Cardiovascular (CVD) mortality disparities between rural/regional and urban-dwelling residents of Australia are persistent. Unavailability of biomedical CVD risk factor data has, until now, limited efforts to understand the causes of the disparity. This study aimed to further investigate such disparities. DESIGN: Comparison of (1) CVD risk measures between a regional (Greater Green Triangle Risk Factor Study (GGT RFS, cross-sectional study, 2004-2006) and an urban population (North West Adelaide Health Study (NWAHS, longitudinal cohort study, 2004-2006); (2) Australian Bureau of Statistics (ABS) CVD mortality rates between these and other Australian regions; and (3) ABS CVD mortality rates by an area-level indicator of socioeconomic status, the Index of Relative Socioeconomic Disadvantage (IRSD). SETTING: Greater Green Triangle (GGT, Limestone Coast, Wimmera and Corangamite Shires) of South-Western Victoria and North-West Adelaide (NWA). PARTICIPANTS: 1563 GGT RFS and 3036 NWAHS stage 2 participants (aged 25-74) provided some information (self-administered questionnaire +/- anthropometric and biomedical measurements). PRIMARY AND SECONDARY OUTCOME MEASURES: Age-group specific measures of absolute CVD risk, ABS CVD mortality rates by study group and Australian Standard Geographical Classification (ASGC) region. RESULTS: Few significant differences in CVD risk between the study regions, with mean absolute CVD risk ranging from approximately 1% in the age group 35-39 years to 14% in the age group 70-74 years. [corrected]. Similar mean 2003-2007 (crude) mortality rates in GGT (98, 95% CI 87 to 111), NWA (103, 95% CI 96 to 110) and regional Australia (92, 95% CI 91 to 94). NWA mortality rates exceeded that of other city areas (70, 95% CI 69 to 71). Lower measures of socioeconomic status were associated with worse CVD outcomes regardless of geographic location. CONCLUSIONS: Metropolitan areas do not always have better CVD risk factor profiles and outcomes than rural/regional areas. Needs assessments are required for different settings to elucidate relative contributions of the multiple determinants of risk and appropriate cardiac healthcare strategies to improve outcomes.

Glucose meters - fit for clinical purpose.

Glucose meters have improved considerably since they were first introduced in 1960, but many questions are being asked about their accuracy and reliability in certain clinical situations. These questions have arisen because of the widespread use of these meters into clinical areas they have not been designed for such as critical care. The lack of understanding by some health professionals on factors that affect glucose results, such as sample type, glucose test strip methodologic limitations, calibration to recognized reference methods, and interferences, leads to misleading results that may affect patient care. Much debate continues on the quality specifications for glucose meters. Because there is an extensive use of these meters in different clinical scenarios, the setting of quality specifications will remain a challenge for regulatory and professional organizations. In this article, we have attempted to collect and provide relevant information addressing the limitations above. Pivotal to obtaining the best quality of results is education, particularly for diabetic patients monitoring their glucose. The International Federation of Clinical Chemistry and Laboratory Medicine through its Point-of-Care Testing Task Force and its Working Group on Glucose Point-of-Care Testing is actively working toward improving the quality of glucose results by improving education and working with the industry to improve strip performance and work toward the better standardization of strips.

A pilot study of the feasibility of an Internet-based electronic Outpatient Cardiac Rehabilitation (eOCR) program in rural primary care.

BACKGROUND: Interventions that facilitate access to cardiac rehabilitation and secondary prevention programs are in demand. METHODS: This pilot study used a mixed methods design to evaluate the feasibility of an Internet-based, electronic Outpatient Cardiac Rehabilitation (eOCR). Patients who had suffered a cardiac event and their case managers were recruited from rural primary practices. Feasibility was evaluated in terms of the number of patients enrolled and patient and case manager engagement with the eOCR website. RESULTS: Four rural general practices, 16 health professionals (cardiologists, general practitioners, nurses and allied health) and 24 patients participated in the project and 11 (46%) completed the program. Utilisation of the website during the 105 day evaluation period by participating health professionals was moderate to low (mean of 8.25 logins, range 0-28 logins). The mean login rate for patients was 16 (range 1-77 logins), mean time from first login to last (days using the website) was 51 (range 1-105 days). Each patient monitored at least five risk factors and read at least one of the secondary prevention articles. There was low utilisation of other tools such as weekly workbooks and discussion boards. CONCLUSIONS: It was important to evaluate how an eOCR website would be used within an existing healthcare setting. These results will help to guide the implementation of future internet based cardiac rehabilitation programs considering barriers such as access and appropriate target groups of participants.