Improving community-based first response to out of hospital cardiac arrest (FirstCPR): protocol for a cluster randomised controlled trial.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is associated with poor survival outcomes, but prompt bystander action can more than double survival rates. Being trained, confident and willing-to-perform cardiopulmonary resuscitation (CPR) are known predictors of bystander action. This study aims to assess the effectiveness of a community organisation targeted multicomponent education and training initiative on being willing to respond to OHCAs. The study employs a novel approach to reaching community members via social and cultural groups, and the intervention aims to address commonly cited barriers to training including lack of availability, time and costs. METHODS AND ANALYSIS: FirstCPR is a cluster randomised trial that will be conducted across 200 community groups in urban and regional Australia. It will target community groups where CPR training is not usual. Community groups (clusters) will be stratified by region, size and organisation type, and then randomly assigned to either immediately receive the intervention programme, comprising digital and in-person education and training opportunities about CPR and OHCA over 12 months, or a delayed programme implementation. The primary outcome is self-reported 'training and willingness-to-perform CPR' at 12 months. It will be assessed through surveys of group members that consent in intervention versus control groups and administered prior to control groups receiving the intervention. The primary analysis will follow intention-to-treat principles, use log binomial regression accounting for baseline covariates and be conducted at the individual level, while accounting for clustering within communities. Focus groups and interviews will be conducted to examine barriers and enablers to implementation and costs will also be examined. ETHICS AND DISSEMINATION: Ethical approval was obtained from The University of Sydney. Findings from this study will be disseminated via presentations at scientific conferences, publications in peer-reviewed journals, scientific and lay reports. TRIAL REGISTRATION NUMBER: ACTRN12621000367842.

A Smartphone-Based Model of Care to Support Patients With Cardiac Disease Transitioning From Hospital to the Community (TeleClinical Care): Pilot Randomized Controlled Trial.

BACKGROUND: Patients hospitalized with acute coronary syndrome (ACS) or heart failure (HF) are frequently readmitted. This is the first randomized controlled trial of a mobile health intervention that combines telemonitoring and education for inpatients with ACS or HF to prevent readmission. OBJECTIVE: This study aims to investigate the feasibility, efficacy, and cost-effectiveness of a smartphone app-based model of care (TeleClinical Care [TCC]) in patients discharged after ACS or HF admission. METHODS: In this pilot, 2-center randomized controlled trial, TCC was applied at discharge along with usual care to intervention arm participants. Control arm participants received usual care alone. Inclusion criteria were current admission with ACS or HF, ownership of a compatible smartphone, age ≥18 years, and provision of informed consent. The primary end point was the incidence of unplanned 30-day readmissions. Secondary end points included all-cause readmissions, cardiac readmissions, cardiac rehabilitation completion, medication adherence, cost-effectiveness, and user satisfaction. Intervention arm participants received the app and Bluetooth-enabled devices for measuring weight, blood pressure, and physical activity daily plus usual care. The devices automatically transmitted recordings to the patients' smartphones and a central server. Thresholds for blood pressure, heart rate, and weight were determined by the treating cardiologists. Readings outside these thresholds were flagged to a monitoring team, who discussed salient abnormalities with the patients' usual care providers (cardiologists, general practitioners, or HF outreach nurses), who were responsible for further management. The app also provided educational push notifications. Participants were followed up after 6 months. RESULTS: Overall, 164 inpatients were randomized (TCC: 81/164, 49.4%; control: 83/164, 50.6%; mean age 61.5, SD 12.3 years; 130/164, 79.3% men; 128/164, 78% admitted with ACS). There were 11 unplanned 30-day readmissions in both groups (P=.97). Over a mean follow-up of 193 days, the intervention was associated with a significant reduction in unplanned hospital readmissions (21 in TCC vs 41 in the control arm; P=.02), including cardiac readmissions (11 in TCC vs 25 in the control arm; P=.03), and higher rates of cardiac rehabilitation completion (20/51, 39% vs 9/49, 18%; P=.03) and medication adherence (57/76, 75% vs 37/74, 50%; P=.002). The average usability rating for the app was 4.5/5. The intervention cost Aus $6028 (US $4342.26) per cardiac readmission saved. When modeled in a mainstream clinical setting, enrollment of 237 patients was projected to have the same expenditure compared with usual care, and enrollment of 500 patients was projected to save approximately Aus $100,000 (approximately US $70,000) annually. CONCLUSIONS: TCC was feasible and safe for inpatients with either ACS or HF. The incidence of 30-day readmissions was similar; however, long-term benefits were demonstrated, including fewer readmissions over 6 months, improved medication adherence, and improved cardiac rehabilitation completion. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618001547235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375945.

Shorter Wait Times to Cardiac Rehabilitation Associated With Greater Exercise Capacity Improvements: A MULTISITE STUDY.

PURPOSE: Comprehensive exercise-based cardiac rehabilitation (CR) results in improved, though highly variable, exercise capacity outcomes. Whether modifiable factors such as CR program wait time and session duration are associated with exercise capacity outcomes has not been adequately investigated. METHODS: Patients with coronary heart disease (±primary and elective percutaneous coronary interventions, cardiac surgery) who participated in CR programs involved in a three-state audit (n = 32 sites) were eligible. Exercise capacity was measured using the 6-min walk test before and after a 6- to 12-wk supervised exercise program. CR program characteristics were also recorded (wait time, number of sessions). Correlations and linear mixed-effects models were used to identify associations between sociodemographic and CR program characteristics and change in exercise capacity. RESULTS: Patients (n = 894) had a mean age of 65.9 ± 11.8 yr, 71% were males, 33% were referred for cardiac surgery, and median wait time was 16 d (interquartile range 9, 26). Exercise capacity improved significantly and clinically (mean increase 70.4 ± 61.8 m). After adjusting for statistically significant factors including younger age (<50 vs ≥80 yr [ß = 52.07]), female sex (ß = -15.86), exercise capacity at CR entry (ß = 0.22) and those nonsignificant (ethnicity, risk factors, and number of sessions), shorter wait time was associated with greater exercise capacity improvement (ß = 0.23). CONCLUSIONS: This study confirms that greater exercise capacity improvements occur with shorter wait times. Coordinators should prioritize implementing strategies to shorten wait time to optimize the benefits of CR.

Evaluation of Cardiac Rehabilitation Performance and Initial Benchmarks for Australia: An Observational Cross-State and Territory Snapshot Study.

BACKGROUND: Australia, unlike most high-income countries, does not have published benchmarks for cardiac rehabilitation (CR) delivery. This study provides cross-state data on CR delivery for initial benchmarks and assesses performance against international minimal standards. METHODS: A prospective observational study March-May 2017 of CR programs in NSW (n=36), Tasmania (n=2) and ACT (n=1) was undertaken. Data were collected on 11 indicators (published dictionary), then classified as higher or lower performing using the UK National Audit of Cardiac Rehabilitation (NACR) criteria. Equity of access to higher performing CR was assessed using logistic regression. RESULTS: Participants (n=2,436) had a mean age of 66.06±12.54 years, 68.9% were male, 16.2% culturally and linguistically diverse (CALD) and 2.6% Aboriginal and Torres Strait Islander peoples. At patient level, waiting time was median 15 (Interquartile range [IQR] 9-25) days, 24.3% had an assessment before starting, 41.8% on completion, a median 12 sessions (IQR 6-16) were delivered, which 59.1% completed and 75.4% were linked to ongoing care. At program level, using NACR criteria, 18.0% were classified as higher performing and ≥87.1% met waiting time criteria, however, only 20.5% met duration criteria. Evidence of inequitable access to higher performing programs was present with substantially higher odds for participants living in major cities (OR 28.11 95%CI 18.41, 44.92) and with every decade younger age (OR 1.89-2.94) and lower odds by 89.0% for principal referral hospital-based services (OR 0.11 95%CI 0.08, 0.14) and 31.0% for people having a CALD background (OR 0.69 95%CI 0.49, 0.97). CONCLUSIONS: This study provides initial national CR performance benchmarks for quality improvement in Australia. While wait times are minimised, few programs are higher performing or met minimum duration standards. There is an urgent need to resource and support CR quality and access outside of major cities, in principal referral hospitals and for older and diverse patients.

Design and rationale of the MyHeartMate study: a randomised controlled trial of a game-based app to promote behaviour change in patients with cardiovascular disease.

INTRODUCTION: Recurrence of cardiac events is common after a first event, leading to hospitalisations and increased health burden. Patients have difficulties achieving the lifestyle changes required for secondary prevention and access to secondary prevention programs is limited. This study aims to evaluate the impact of a game-based mobile app, MyHeartMate, which is designed to motivate engagement in secondary prevention behaviours for cardiovascular risk factors. METHODS AND ANALYSIS: The MyHeartMate study is a randomised controlled trial with 6-month follow-up and blinded assessment of the primary outcome. Participants (n=394) with coronary heart disease will be recruited from hospitals in metropolitan Sydney and randomly allocated to standard care or the MyHeartMate app intervention. The intervention group will receive the app, which uses game techniques to promote engagement and lifestyle behaviour change for secondary prevention. The primary outcome is difference between the groups in physical activity (metabolic equivalent of task minutes/week) at 6 months. Secondary outcomes include change in low-density lipoprotein cholesterol, systolic blood pressure, medication adherence, body mass index, waist circumference, mood and dietary changes at 6 months. Data on app engagement, and patient perspectives of usability and acceptability, will also be analysed. ETHICS AND DISSEMINATION: The study has received ethics approval from Northern Sydney Local Health District Human Research Ethics Committee. The study findings will be disseminated via peer-reviewed publications and presentation at international scientific meetings/conferences. TRIAL REGISTRATION NUMBER: ACTRN12617000869370; Pre-results.

ITM support for patients with chronic respiratory and cardiovascular diseases: a protocol for a randomised controlled trial.

INTRODUCTION: Simple and scalable strategies are needed to improve 'out-of-hospital' support and management for people living with cardiovascular disease (CVD) and respiratory disease. Text messaging via mobile phones has been shown to be effective in helping promote lifestyle change and is supported by quantitative and qualitative evidence. The aim of this study is to test the effectiveness and implementation of a 6-month text messaging support programme for people with CVD and respiratory disease as an addition to cardiac and pulmonary outpatient rehabilitation. METHODS AND ANALYSIS: Pragmatic randomised controlled trial (n=310) to test the effectiveness of a 6-month text message support programme on clinical outcomes in people with CVD and chronic respiratory disease who are attending outpatient cardiac and pulmonary rehabilitation. The study includes a nested process evaluation to inform scalability and implementation across settings. The intervention group will receive a text message support programme comprising five messages per week for 26 weeks and the control group will continue with standard care. The primary outcome is exercise capacity (6 min walk distance). Secondary outcomes include clinical measures (proportion of people meeting the Australian guideline-recommended blood pressure and cholesterol targets), lifestyle outcomes (smoking rates, achievement of national guidelines for nutrition and physical activity), quality of life, mood (Hospital Anxiety and Depression Scale), medication adherence and attendance at and completion of rehabilitation. ETHICS AND DISSEMINATION: Primary ethics approval was received from the Sydney Local Health District Hospital Human Research Ethics Committee and associated Governance committees at sites. Results will be disseminated via the usual scientific forums including peer-reviewed publications and presentations at international conferences. At its conclusion, the study will determine the effectiveness and implementation of a simple programme that aims to improve health outcomes and attendance at rehabilitation for people with CVD and chronic respiratory disease. TRIAL REGISTRATION NUMBER: ACTRN12616001167459.

Development of Quality Indicators for Cardiac Rehabilitation in Australia: A Modified Delphi Method and Pilot Test.

BACKGROUND: International guidelines recommend cardiac rehabilitation (CR) for secondary prevention of cardiovascular disease, however, it is underutilised and the quality of content and delivery varies widely. Quality indicators (QIs) for CR are used internationally to measure clinical practice performance, but are lacking in the Australian context. This study reports the development of QIs for minimum dataset (MDS) for CR and the results of a pilot test for feasibility and applicability in clinical practice in Australia. METHODS: A modified Delphi method was used to develop initial QIs which involved a consensus approach through a series of face-to-face and teleconference meetings of an expert multidisciplinary panel (n=8), supplemented by an environmental scan of the literature and a multi-site pilot test. RESULTS: Eight (8) QIs were proposed and sent to CR clinicians (n=250) electronically to rate importance, current data collection status, and feasibility of future collection. The top six of these QIs were selected with an additional two key performance indicators from the New South Wales (NSW) Ministry of Health and two QIs from international registers for a draft MDS. The pilot test in 16 sites (938 patient cases) demonstrated median performance of 93% (IQR 47.1-100%). All 10 QIs were retained and one further QI related to diabetes was added for a final draft MDS. CONCLUSIONS: The MDS of 11 QIs for CR provides an important foundation for collection of data to promote the quality of CR nationally and the opportunity to participate in international benchmarking.

Evaluation of an mHealth-Based Adjunct to Outpatient Cardiac Rehabilitation.

A pilot study was conducted to determine if a smartphone-based adjunct to standard care could increase the completion rate of a cardiac rehabilitation program (CRP). Based on historical completion rates, 66 participants who were about to commence a hospital-based CRP were randomized so that half received three devices embedded with near-field communication, namely, a smartphone [pre-installed with an application (app) designed specifically for cardiac rehabilitation], portable blood pressure monitor, and weight scale while completing the CRP. The completion rate among participants who were randomized to the intervention group was 88%, compared to 67% in the control group ( = 0.038). This combined with the week-to-week frequency with which participants in the intervention group measured their blood pressure ( 5/week) demonstrated the ability of the intervention to increase the proportion of patients who completed the CRP. No significant differences were found between the treatment groups for the measurements taken at baseline and prior to discharge from the CRP. A statistically significant correlation ( = 0.472; = 0.013) was found between the average time participants walked each day (as estimated via the smartphone app) and participants' six minute walking distance (6MWD) before they were discharged from the CRP (a clinically validated measurement).

What does the Development of the European Core Curriculum for Cardiovascular Nurses Mean for Australia?

A core curriculum for the continuing professional development of nurses has recently been published by the Council on Cardiovascular Nursing and Allied Professions of the European Society of Cardiology. This core curriculum was envisaged to bridge the educational gap between qualification as a nurse and an advance practice role. In addition, the shared elements and international consensus on core themes creates a strong pathway for nursing career development that is directly relevant to Australia. Education programs for nurses in Australia must meet the mandatory standards of the Australian Nursing and Midwifery Accreditation Council (ANMAC), but without a national core curriculum, there can be considerable variation in the content of such courses. The core curriculum is developed to be adapted locally, allowing the addition of nationally relevant competencies, for example, culturally appropriate care of Aboriginal and Torres Strait Islander individuals. Two existing specialist resources could be utilised to deliver a tailored cardiovascular core curriculum; the Heart Education Assessment and Rehabilitation Toolkit (HEART) online (www.heartonline.org.au) and HeartOne (www.heartone.com.au). Both resources could be further enhanced by incorporating the core curriculum. The release of the European core curriculum should be viewed as a call to action for Australia to develop a core curriculum for cardiovascular nurses.

Evidence-based care in a population with chronic kidney disease and acute coronary syndrome. Findings from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE).

BACKGROUND: Acute coronary syndrome (ACS) guidelines recommend that patients with chronic kidney disease (CKD) be offered the same therapies as other high-risk ACS patients with normal renal function. Our objective was to describe the gaps in evidence-based care offered to patients with ACS and concomitant CKD. METHODS: Patients presenting to 41 Australian hospitals with suspected ACS were stratified by presence of CKD (glomerular filtration rate <60 mL/min). Receipt of evidence-based care including, coronary angiography (CA), evidence-based discharge medications (EBMs), and cardiac rehabilitation (CR) referral, were compared between patients with and without CKD. Hospital and clinical factors that predicted receipt of care were determined using multilevel multivariable stepwise logistic regression models. RESULTS: Of the 4,778 patients admitted with suspected ACS, 1,227 had CKD. On univariate analyses, patients with CKD were less likely to undergo CA (59.1% vs 85.0%, P < .0001) or receive EBM (69.4% vs 78.7%, P < .0001), or were offered CR (49.5% vs 68.0%, P < .0001). After adjusting for patient characteristics and clustering by hospital, CKD remained an independent predictor of not undergoing CA only (odds ratio 0.48, 95% CI 0.37-0.61). Within the CKD cohort, presenting to a hospital with a catheterization laboratory was the strongest predictor of undergoing CA (odds ratio 3.07, 95% CI 1.91-4.93). CONCLUSION: The presence of CKD independently predicts failure to undergo CA but not failure to receive EBM or CR, which is predicted by comorbidities. Among the CKD population, performance of CA is largely determined by admission to a catheterization capable hospital. Targeting these patients through standardization of care across institutions offers opportunities to improve outcomes in this high-risk population.

Australian Cardiovascular Health and Rehabilitation Association (ACRA) core components of cardiovascular disease secondary prevention and cardiac rehabilitation 2014.

BACKGROUND: Research on Australian cardiovascular disease secondary prevention and cardiac rehabilitation to guide practice needs updating to reflect current context of practice. It is timely therefore to review the core components that underpin effective services that deliver maximum benefits for participants. METHODS: The Australian Cardiovascular Health and Rehabilitation Association (ACRA) convened an inter-agency, multidisciplinary, nationally representative expert panel of Australia's leading cardiac rehabilitation clinicians, researchers and health advocates who reviewed the research evidence. RESULTS: Five core components for quality delivery and outcomes of services were identified and are recommended: 1) Equity and access to services, 2) Assessment and short-term monitoring, 3) Recovery and longer term maintenance, 4) Lifestyle/behavioural modification and medication adherence, and 5) Evaluation and quality improvement. CONCLUSIONS: ACRA seeks to provide guidance on the latest evidence in cardiovascular disease secondary prevention and cardiac rehabilitation. Clinicians should use these core components to guide effective service delivery and promote high quality evidence based care. Directors of hospitals and health services should use these core components to aid decision-making about the development and maintenance of these services.

Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand.

OBJECTIVE: To evaluate the proportion of patients hospitalised with acute coronary syndrome (ACS) in Australia and New Zealand who received optimal inpatient preventive care and to identify factors associated with preventive care. METHODS: All patients hospitalised bi-nationally with ACS were identified between 14-27 May 2012. Optimal in-hospital preventive care was defined as having received lifestyle advice, referral to rehabilitation, and prescription of secondary prevention pharmacotherapies. Multilevel multivariable logistic regression was used to determine factors associated with receipt of optimal preventive care. RESULTS: For the 2299 ACS survivors, mean (SD) age was 69 (13) years, 46% were referred to rehabilitation, 65% were discharged on sufficient preventive medications, and 27% received optimal preventive care. Diagnosis of ST elevation myocardial infarction (OR: 2.64 [95% CI: 1.88-3.71]; p<0.001) and non-ST elevation myocardial infarction (OR: 1.99 [95% CI: 1.52-2.61]; p<0.001) compared with a diagnosis of unstable angina, having a percutaneous coronary intervention (PCI) (OR: 4.71 [95% CI: 3.67-6.11]; p<0.001) or coronary bypass (OR: 2.10 [95% CI: 1.21-3.60]; p=0.011) during the admission or history of hypertension (OR:1.36 [95% CI: 1.06-1.75]; p=0.017) were associated with greater exposure to preventive care. Age over 70 years (OR:0.53 [95% CI: 0.35-0.79]; p=0.002) or admission to a private hospital (OR:0.59 [95% CI: 0.42-0.84]; p=0.003) were associated with lower exposure to preventive care. CONCLUSIONS: Only one-quarter of ACS patients received optimal secondary prevention in-hospital. Patients with UA, who did not have PCI, were over 70 years or were admitted to a private hospital, were less likely to receive optimal care.