Evidence to service gap: cardiac rehabilitation and secondary prevention in rural and remote Western Australia

Abstract Background Cardiovascular disease (CVD), a leading cause of morbidity and mortality, has similar incidence in metropolitan and rural areas but poorer cardiovascular outcomes for residents living in rural and remote Australia. Cardiac Rehabilitation (CR) is an evidence-based intervention that helps reduce subsequent cardiovascular events and rehospitalisation. Unfortunately CR attendance rates are as low as 10–30% with rural/remote populations under-represented. This in-depth assessment investigated the provision of CR and secondary prevention services in Western Australia (WA) with a focus on rural and remote populations. Methods CR and Aboriginal Community Controlled Health Services were identified through the Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Structured interviews with CR coordinators included questions specific to program delivery, content, referral and attendance. Results Of the 38 CR services identified, 23 (61%) were located in rural (n = 11, 29%) and remote (n = 12, 32%) regions. Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) found 77% of rural/remote services were hospital-based, with no service providing a comprehensive home-based or alternative method of program delivery. The majority of rural (60%) and remote (80%) services provided CR through chronic condition exercise programs compared with 17% of metropolitan services; only 27% of rural/remote programs provided education classes. Rural/remote coordinators were overwhelmingly physiotherapists, and only 50% of rural and 33% of remote programs had face-to-face access to multidisciplinary support. Patient referral and attendance rates differed greatly across WA and referrals to rural/remote services generally numbered less than 5 per month. Program evaluation was reported by 33% of rural/remote coordinators. Conclusion Geography, population density and service availability limits patient access to CR services in rural/remote WA. Current inadequacies in delivering comprehensive centre-based CR in rural/remote settings impedes management of cardiovascular risk and opportunities for event reduction. Health pathways that ensure referral and continuity of care are needed, with emerging technology-based CR support to supplement centre-based CR services requiring assessment. Implementing systematic data collection across services to establish benchmarks and enable service monitoring and evaluation is needed

Smartphones in the secondary prevention of cardiovascular disease: a systematic review

Abstract Background Cardiac Rehabilitation (CR) and secondary prevention are effective components of evidence-based management for cardiac patients, resulting in improved clinical and behavioural outcomes. Mobile health (mHealth) is a rapidly growing health delivery method that has the potential to enhance CR and heart failure management. We undertook a systematic review to assess the evidence around mHealth interventions for CR and heart failure management for service and patient outcomes, cost effectiveness with a view to how mHealth could be utilized for rural, remote and Indigenous cardiac patients. Methods A comprehensive search of databases using key terms was conducted for the years 2000 to August 2016 to identify randomised and non-randomised trials utilizing smartphone functionality and a model of care that included CR and heart failure management. Included studies were assessed for quality and risk of bias and data extraction was undertaken by two independent reviewers. Results Nine studies described a mix of mHealth interventions for CR (5 studies) and heart failure (4 studies) in the following categories: feasibility, utility and uptake studies; and randomised controlled trials. Studies showed that mHealth delivery for CR and heart failure management is feasible with high rates of participant engagement, acceptance, usage, and adherence. Moreover, mHealth delivery of CR was as effective as traditional centre-based CR (TCR) with significant improvement in quality of life. Hospital utilization for heart failure patients showed inconsistent reductions. There was limited inclusion of rural participants. Conclusion Mobile health delivery has the potential to improve access to CR and heart failure management for patients unable to attend TCR programs. Feasibility testing of culturally appropriate mHealth delivery for CR and heart failure management is required in rural and remote settings with subsequent implementation and evaluation into local health care services

Additional file 1: of Smartphones in the secondary prevention of cardiovascular disease: a systematic review

Search Strategies. This supplementary document details four database search strategies: Three for all databases searched except Medline and the fourth is for MEDLINE. (DOC 34 kb

Somatic mutations in three LUAD candidate driver genes (<i>POU4F2</i>, <i>ZKSCAN1</i>, and <i>ASEF</i>) in EAGLE, TCGA and Broad Institute studies.

<p>The protein sequences from these three genes are schematically described using grey bars along with their respective structural and functional domains in color-coded blocks. Each mallet represents an independent nonsilent mutation with potential functional relevance in the three studies (the complete list of mutations is reported in <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1002162#pmed.1002162.s007" target="_blank">S1 Table</a>). Numbers below each sequence representation mark the total length of the transcript, the domain ranges, and the locations of mutations.</p

Distribution of demographic and clinical variables of 101 lung adenocarcinoma patients.

<p>Distribution of demographic and clinical variables of 101 lung adenocarcinoma patients.</p

Mutual exclusivity of driver genes detected in 825 patients combining TCGA, Broad Institute, and EAGLE WES of lung adenocarcinoma.

<p><b>(A)</b> A MEGS with six genes covering 60.3% of patients. Samples without nonsynonymous mutations in these six genes are not shown. Samples labelled as blue carry a nonsynonymous mutation in the gene region, while samples labelled as gray do not carry a synonymous mutation in the gene region. <b>(B)</b> A MEGS with four genes covering 33.3% of patients. Samples without nonsynonymous mutations in these four genes are not shown.</p

Somatic mutations of lung adenocarcinoma in EAGLE data.

<p><b>(A)</b> Distribution of point somatic mutations across nine mutation types. <b>(B)</b> The top panel shows the number of nonsilent mutations detected by whole-exome analysis for 101 EAGLE samples. Tumor samples were arranged from left to right by the number of nonsilent mutations. The middle panel shows the mutations for previously reported significantly mutated genes based on the TCGA data, reported in the TumorPortal website. The next panel shows the mutations for the three new driver genes. The bottom panels show smoking status. The right panel shows the frequency of nonsilent mutations in EAGLE data for each driver gene. Each column represents one patient.</p

Association between genomic features and clinical outcomes.

<p><b>(A)</b> The mutational status of TP53 and KRAS and the time of developing distant metastasis. <i>p</i>-values were two-sided. Red: mutated; blue: not mutated. <b>(B)</b> The association between the fraction of nine point mutation types and overall transversions and the time of developing distant metastasis after initial diagnosis. Relative risks and their 95% confidence intervals were estimated based on a Cox regression model adjusted for age, sex, and disease stage. <i>p</i>-values were two-sided. <b>(C)</b> Cancer-free survival was not associated with the mutational status of TP53 or KRAS. <i>p</i>-values were two-sided. Red: mutated; blue: not mutated.</p