ANZACS-QI Heart Failure Registry: a new approach using age-stratified sampling of hospital discharges to guide quality improvement (ANZACS-QI 79).

Heart failure is a major healthcare problem in New Zealand. The Acute Decompensated Heart Failure (ADHF) Registry was introduced in 2015, and has identified the need for quality improvement strategies to improve care of patients hospitalised with heart failure. In this paper, we describe the implementation of the revised ANZACS-QI Heart Failure Registry, which has a primary aim to support evidence-based management of and quality improvement measures for patients who are hospitalised with heart failure in New Zealand. Taking the learnings from the initial experience with the ADHF Registry, the revised ANZACS-QI Heart Failure Registry i) utilises age-stratified sampling of hospital discharge coding to identify a representative heart failure cohort, ii) utilises existing ANZACS-QI infrastructure for data-linkage to reduce the burden of manual data entry, iii) receives governance from the Heart Failure Working Group, and iv) focusses on established quality improvement indicators for heart failure management.

An NP-led pilot telehealth programme to facilitate guideline-directed medical therapy for heart failure with reduced ejection fraction during the COVID-19 pandemic.

AIMS: Heart failure with reduced ejection fraction (HFrEF) is associated with poor outcomes. While several medications are beneficial, achieving optimal guideline-directed medical therapy (GDMT) is challenging. COVID-19 created a need to explore new ways to deliver care. METHODS: Fifty consecutive patients were taught to identify fluid congestion and monitor their vital signs using BP monitors and electronic scales with NP-led telephone support. Quantitative data were collected and a patient experience interview was performed. RESULTS: The majority (76%) of the cohort (male, 76%; Maori/Pacific, 58%) had a new diagnosis of HFrEF, with 90% having severe left ventricular (LV) dysfunction. There were 216 contacts (129 (60%) by telephone), which eliminated travelling, (time saved, 2.12 hours per patient), petrol costs ($58.17 per patient), traffic pollution (607 Kg of CO2) and time off work. Most (75%) received contact within two weeks and 75% were optimally titrated within two months. Improvements in systolic BP (SBP) (124mmHg to 116mmHg), pulse (78 bpm to 70 bpm) and N-terminal pro-brain natriuretic peptide (NT-proBNP) (292 to 65) were identified. Of the 43 patients who had a follow-up transthoracic echocardiogram (TTE), 33 (77%) showed important improvement in left ventricular ejection fraction (LVEF). CONCLUSIONS: Patients found the process acceptable and experienced rapid titration with less need for clinic review with titration rates comparable with most real-world reports.

Acute Predict: a clinician-led cardiovascular disease quality improvement project (Predict-CVD 12).

BACKGROUND: New Zealand data demonstrate major disparities in cardiovascular health, particularly by ethnicity and socioeconomic deprivation. ACUTE PREDICT AIM: Acute Predict, the secondary care arm of primary care based PREDICT, is a multidisciplinary project based in the coronary care unit, and is jointly led by nursing and medical staff. The project aim is to ensure patients with acute coronary syndromes (ACS) receive appropriate evidence-based secondary prevention management short- and long-term, regardless of age, socioeconomic status or ethnicity. METHODS AND RESULTS: Acute Predict utilises an electronic backbone to provide the following (1) guideline-based patient-specific decision support, (2) data collection as part of routine clinical workflow, (3) linkage of patients to cardiac rehabilitation and primary care chronic care management programs, (4) clinical and management data capture, (5) real-time whole group and sub-group Key Performance Indicators reporting with drill-down to individual patient data, and (6) long-term tracking of individual patient outcome via linkage to national databases. Over the four years of the project in-hospital provision of cardiac rehabilitation has improved and appropriate discharge medication is high. There are no differences according to ethnicity. Despite this, Maori patients in the Acute Predict ACS cohort are twice as likely as Europeans to have recurrent events post-discharge, even after adjustment for known risk factors. CONCLUSIONS: The built-in real-time data reporting and outcomes/prescribing linkage facilitate monitoring of the quality of CVD prevention activity across the continuum of care. It allows early identification of treatment gaps and of persistent disparities in outcome in our patients. We are learning how best to use this real-time data collection and reporting to support the design and assessment of targeted interventions to close gaps and reduce disparity.

Heart failure clinics improve use of evidence-based heart failure therapies in patients with reduced ejection fraction following acute coronary syndrome (ANZACS-QI 48).

AIMS: To describe the use of evidence-based heart failure therapies in patients with reduced left ventricular ejection fraction (LVEF) following acute coronary syndrome (ACS). METHODS: Patients with ACS and LVEF ≤40% were identified from the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry between June 2017 and May 2018. Data was obtained from retrospective review of clinical records. Dispensed medications were identified from pharmacy dispensing records and compared with target doses recommended in guidelines. RESULTS: Of 292 patients, 28% were seen in cardiology heart failure (HF) clinic, 54% seen in general cardiology clinic and 17% were not seen in cardiology clinic. At one year post-discharge, 52% and 39% were dispensed ≥50% target dose of angiotensin converting enzyme inhibitor (ACEi)/ angiotensin receptor blocker (ARB), and beta-blockers respectively. Seventy-one percent and 68% of patients were on maximally tolerated doses of ACEi/ARB and beta-blockers respectively. The highest rates of medication up-titration occurred in those seen in cardiology HF clinics. Seventy-four percent and 59% were dispensed ≥50% target dose of ACEi/ARB and beta-blocker respectively. Ninety-five percent and 89% were on maximally tolerated doses of ACEi/ARB and beta-blockers respectively. Thirteen percent were potentially eligible for primary prevention implantable cardiac defibrillator; however, only 24% of these eligible patients had one implanted by one year post-discharge. CONCLUSIONS: Evidence-based HF therapies were underutilised in this regional cohort of patients with reduced LVEF post-ACS. Strategies to improve use of these therapies should focus on increasing the number of patients seen by HF clinics and reducing clinic waiting times.

The electronic tracking of referral and attendance at cardiac rehabilitation in Counties Manukau Health: a potential model for New Zealand.

AIM: Cardiac rehabilitation (CR) programmes for patients surviving an acute coronary syndrome (ACS) event are important and recommended by clinical guidelines. Referral and attendance, however, remain suboptimal and tracking both of these aspects to inform quality improvement has been difficult. The aim of this study was to describe the use of an electronic registry to capture referral and attendance at CR in CMH and to report the characteristics of the initial cohort. METHOD: We developed and implemented an electronic tracking tool, designed to be compatible with ANZAC-QI to monitor referral and attendance in a cohort of patients with confirmed ACS between 1 January 2013 and 1 January 2015. RESULTS: Over 90% of patients with confirmed ACS had in-hospital phase 1 CR and three quarters were referred for post-discharge phase 2 CR. Of those with an ACS diagnosis, half attended at least one CR intervention but only a third completed their planned programme. Older patients and women were less likely to be referred for CR and those without in-hospital revascularisation, current smokers and with prior CVD were least likely to attend after referral. CONCLUSION: Despite offering a range of CR options including community, clinic one on one and home based CR, the uptake of CR in patients with ACS remains suboptimal. An electronic tracking process was easy to use and has identified referral and attendance deficits that can be improved. Exploring new models of structured secondary prevention process, alongside encouraging referral and supporting attendance at established CR programmes, will offer benefits.

Providing cardiovascular risk management information to acute coronary syndrome patients: a randomized trial.

OBJECTIVES: Cardiac patients have been shown to have inaccurate understanding of their cardiovascular risk. The purpose of the study was to investigate whether a guideline-based risk assessment and management intervention could facilitate understanding of cadiovascular risk and appropriate illness perceptions in cardiac patients. DESIGN: Randomized trial. METHODS: A total of 106 patients with MI or unstable angina were randomized to receive standard care with or without a 30-min nurse-led computerized Predict CVD-Diabetes (where CVD is cardiovascular disease) session. Patients' risk perceptions (using categorical and numerical measures), and perceptions of their heart condition were assessed at admission, discharge, and 3 months. RESULTS: The intervention group rated the risk information as more easily understood than the control group. At discharge, they had increased perceptions of personal control, higher perceptions that a low-fat diet and regular exercise could help their condition, and believed their current illness would be shorter compared to the control group. At 3 months, no group differences were significant. The intervention had no effect on risk perceptions, which were high in both groups. Patients' perceptions of 'high' risk corresponded to numerical estimates of over 50%, which differs from clinical guidelines (over 20%). CONCLUSIONS: A computerized cardiovascular risk assessment and management session can help acute coronary syndrome patients understand CVD risk information and improve perceptions of control in the short term, but not change risk perceptions. In-hospital risk factor assessment and management information may help patients understand the importance of key lifestyle changes. STATEMENT OF CONTRIBUTION: WHAT IS ALREADY KNOWN ON THIS SUBJECT?: • Many members of the public, as well as patients with diagnosed coronary heart disease (CHD), have poor understanding of their cardiovascular disease risk. • Giving risk information can improve accuracy of risk perceptions, and may increase intentions to start preventive risk reduction treatments but more research is needed with patients with established CHD. WHAT DOES THIS STUDY ADD?: • Providing acute coronary syndrome patients with individualised risk assessment and risk management information may be beneficial over the short term by increasing patients' perceptions of control and the importance of key lifestyle changes. • A difficulty in communicating cardiovascular risk levels is the poor correspondence between patients' understanding of very high risk and the clinical definition of very high risk.

Nurse-led cardiovascular disease risk management intervention for patients with gout.

BACKGROUND: Patients with gout are at high risk for cardiovascular disease (CVD), and this risk is frequently under-managed. AIMS: To evaluate a nurse-led multidisciplinary approach to improve CVD risk management in patients with gout. METHODS: Patients referred to rheumatology clinics for gout management received a structured nurse-led CVD risk assessment. For the patients with an initial 5 year risk >10%, interventions for CVD prevention were identified and goals developed. These patients were then reassessed approximately 6 months later to determine changes in CVD risk management and profile. RESULTS: Of 210 patients with gout, 73% had either a 5-year CVD risk >10% or had known CVD. Of these higher risk patients, 84% were available for follow-up. Compared with the initial visit there were improvements at follow-up in: the prescription of aspirin, statins, nicotine replacement therapy, uptake of self-reported activity levels, mean systolic and diastolic blood pressure, with a trend towards reduced cigarette smoking. CONCLUSION: A nurse-led intervention to assess and manage cardiovascular risk in patients with gout is effective in improving uptake of preventative interventions.

Does Your Heart Forecast help practitioner understanding and confidence with cardiovascular disease risk communication?

INTRODUCTION: Explaining what cardiovascular disease (CVD) risk means and engaging in shared decision-making regarding risk factor modification is challenging. An electronic CVD risk visualisation tool containing multiple risk communication strategies (Your Heart Forecast) was designed in 2009. AIM: To assess whether this tool facilitated explaining CVD risk to primary care patients. METHODS: Health professionals who accessed a Primary Health Organisation website or who attended educational peer groups over a three-month period were invited to complete questionnaires before and after viewing a four-minute video about the tool. Respondents were asked to make an informed guess of the CVD risk of a 35-year-old patient (actual CVD risk 5%) and rate the following sentence as being true or false: 'If there were 100 people like Mr Andrews, five would go on to have a cardiac event in the next five years.' They also were asked to rank their understanding of CVD risk and confidence in explaining the concept to patients. RESULTS: Fifty health professionals (37 GPs, 12 practice nurses, one other) completed before and after questionnaires. Respondents' CVD risk estimates pre-video ranged from <5% to 25% and nine rated the sentence as being false. After the video, all respondents answered these questions correctly. Personal rankings from zero to 10 about understanding CVD risk and confidence in explaining risk reduced in range and shifted towards greater efficacy. DISCUSSION: Whether this tool facilitates discussions of CVD risk with patients and improves patient understanding and lifestyle behaviour needs to be evaluated in a randomised trial.

Equity of access to CVD risk management using electronic clinical decision support in the coronary care unit.

BACKGROUND: Cardiovascular (CVD) risk management post myocardial infarction is inconsistently delivered with those who need the most receiving the least - the 'inverse care law.' The Acute PREDICT Initiative is a nurse led computerised decision support system (CDSS), to provide point-of-care guideline-based, patient-specific CVD risk management recommendations to all. METHODS: All patients admitted to Middlemore Hospital CCU over 2 years with acute CVD-related events potentially 'eligible' for PREDICT assessment were identified. Age, gender, ethnicity and a small area measure of socioeconomic status (NZDep01) were assessed. RESULTS: 1813/2246 (81%) of people admitted were eligible for a PREDICT assessment. Of those, 973 (54%) received a complete assessment. There were no important differences by quintile of deprivation or ethnicity between the patients receiving PREDICT and the rest. PREDICT assessments were less likely for the elderly (35.7% of >75years compared with 57.7% of <75years), for women (47.1% of women and 56.5% of men), and for those who had 5 or more previous admissions. CONCLUSIONS: Patients potentially at higher risk because of their ethnic or socioeconomic background received equitable access to in-hospital CVD risk management post MI using PREDICT. However, some other high-risk groups under-utilised the system.