Exploration of inequities in prevention and outcomes of cardiovascular disease in Australia

The prevention and treatment of cardiovascular disease (CVD), in particular, acute coronary syndrome (ACS), constitute a major economic and social burden globally and nationally. Furthermore, CVD continues to be the leading cause of death and affects patients as well as the healthcare system markedly. Despite the guidelines and policies available to reduce this burden, previous studies suggest that evidence-practice gaps in CVD care and management still exists; therefore, a greater understanding of inequities in healthcare and access to services is needed in order to close these gaps in CVD management. The World Health Organization (WHO) has reported that, across the globe, there are numerous social factors that are associated with health inequities. These inequities reportedly affect outcomes and impose problems for the individuals as well as the healthcare system. In Australia, inequity in the delivery of care has been documented in various chronic disease areas. Populations for whom inequity has been documented include women, those with lower socioeconomic status (SES) and limited English proficiency. Overall, there are a few studies, especially in Australia, describing how these subpopulations are managed in regard to the prevention and the treatment of CVD in primary healthcare, hospital and post-discharge. Therefore, the specific aims of this thesis are to [1] determine the effect of gender on the primary prevention of CVD, the receipt of CVD risk factor assessment and prescription of guideline-recommended medications in Australian primary healthcare; [2] determine the effect of socioeconomic status on ACS patients on the receipt of in-hospital care and clinical outcomes, including major adverse cardiovascular events or death; [3] determine if English proficiency of ACS patients admitted to Australian hospitals has an effect on the receipt of in-hospital care and major adverse cardiovascular events and death in hospital and from admission to follow-up; [4] identify the factors that contribute to household economic hardship following an ACS presentation, on the assumption that this may contribute to the lack of adherence to the appropriate care at post-discharge. For this thesis, two systematic reviews will be performed and the specific aims will be addressed by analysing three Australian datasets. First, the TORPEDO study (N=53,085) which extracted 53,085 patient data at baseline from 40 general practices and 20 Aboriginal community controlled health services. Second, the CONCORDANCE registry which is an ongoing registry which collected over 10,000 patients with suspected or confirmed ACS since 2009 from 42 public hospitals nationwide. Third, the SNAPSHOT ACS which was an observational audit that collected data on 4,387 patients with suspected or confirmed diagnosis of ACS admitted to 286 Australian and NZ hospitals between 14-27 May 2012. For Aim 1, a systematic review was performed to find the pooled effect of gender difference in the assessment of CVD risk factors. Further, TORPEDO data were used to compare the likelihood of primary prevention of CVD by evaluating the risk factor assessment, and further, for those at high-risk of CVD, prescription of medications at primary healthcare services between women and men. For Aim 2, the receipt of individual guideline-recommended medications in patients with ACS compared between the low and the high individual or area-level SES groups was explored through a systematic review. Moreover, CONCORDANCE dataset was used to compare in-hospital care (the receipt of coronary angiogram, revascularisation, a combination of the guideline-recommended medications and referral to cardiac rehabilitation) and clinical outcomes (major adverse cardiovascular event (MACE) and death) between four socioeconomic groups determined by their area of residence. For Aim 3, SNAPSHOT ACS data were used to compare limited English proficient and English proficient patients in regards to their in-hospital care, including the length of stay and the receipt of coronary angiogram, revascularisation, guideline-recommended medications, referral to cardiac rehabilitation smoking cessation advice, dietary advice and physical activity advice, and clinical outcomes, including MACE (myocardial infarction/heart failure/stroke) and death. For Aim 4, SNAPSHOT ACS health economic data were used to examine the factors associated with greater likelihood of experiencing economic hardship following their acute presentation. In terms of results, there was inequitable care for primary prevention of CVD but comparable care and clinical outcomes were observed during the acute presentation to Australian hospitals. For Aim 1, although the pooled international results showed no gender disparity in the assessment of CVD risk, in Australian primary healthcare, women were disadvantaged in receiving weaker primary prevention of CVD than men. In Australia, women had 12% lower odds of being assessed for CVD risk factors (odds ratio (95% confidence interval): 0.88 (0.81, 0.96)). Among patients with CVD or at high CVD risk, women aged 35-54 years were less likely to be prescribed the recommended medications for CVD management (0.63 (0.52, 0.77)), whereas women aged ≥65 years were more likely to be prescribed the medications (1.34 (1.17, 1.54)) compared to their male counterparts. For Aim 2 and Aim 3, the pooled international studies presented the difference in the prescription of guideline-recommended discharge medications, including beta blocker, statin and angiotensin-converting enzyme (ACE), between the lowest and the highest SES groups to patients with ACS in hospital. In Australian hospitals, equitable care was provided to patients with ACS despite their SES or English proficiency during an acute presentation. The likelihood of receiving coronary angiogram, revascularisation, four or more of the five guideline-recommended medication and referral to cardiac rehabilitation were similar across the SES groups. The group with the lowest SES status were found to have higher odds of MACE, driven by the odds of heart failure, however, no significant difference in the odds of short-term and long-term death was found between the groups. Similarly, patients’ proficiency in English did not affect the length of stay, and receipt of coronary angiogram, revascularisation, guideline-recommended medications, referral to cardiac rehabilitation and advice on smoking cessation, diet and physical activity. Further, the likelihood of short-term and long-term MACE and/or death were comparable. For Aim 4, post-discharge, more than 50% of patients who survived ACS reported having experienced economic hardship. Those who were more likely to experience household economic hardship included patients who were younger (18-59 vs ≥80 years: 1.89 (0.77, 4.63)), with no private health insurance (2.04 (1.37, 3.03)), with pensioner concession card (1.80 (1.03, 3.18)) and in low socioeconomic group (lowest vs. highest: 1.77 (0.91, 3.45)). Gender was not associated with experiencing hardship. Overall, this thesis suggests that, in Australia, inequities exist in primary healthcare regarding the prevention and care of CVD between genders, where women are disadvantaged compared to men, but equitable acute care is provided to patients who have presented to a hospital due to ACS, regardless of their SES or English proficiency. Post discharge, patients with low SES are more likely to experience economic hardship which may lead to further inequity in long-term secondary prevention. Although it is an encouraging affirmation that ACS patient care in hospital is not affected by patients’ SES or English proficiency, system-wide solutions are needed to resolve the issue of inequity in primary prevention of CVD and reduce the economic burden of managing ACS to, therefore, reduce the risk of a secondary event

The household economic burden for acute coronary syndrome survivors in Australia

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background: Studies of chronic diseases are associated with a financial burden on households. We aimed to determine if survivors of acute coronary syndrome (ACS) experience household economic burden and to quantify any potential burden by examining level of economic hardship and factors associated with hardship. Methods: Australian patients admitted to hospital with ACS during 2-week period in May 2012, enrolled in SNAPSHOT ACS audit and who were alive at 18 months after index admission were followed-up via telephone/paper survey. Regression models were used to explore factors related to out-of-pocket expenses and economic hardship. Results: Of 1833 eligible patients at baseline, 180 died within 18 months, and 702 patients completed the survey. Mean out-of-pocket expenditure (n = 614) in Australian dollars was A$258.06 (median: A$126.50) per month. The average spending for medical services was A$120.18 (SD: A$310.35) and medications was A$66.25 (SD: A$80.78). In total, 350 (51 %) of patients reported experiencing economic hardship, 78 (12 %) were unable to pay for medical services and 81 (12 %) could not pay for medication. Younger age (18–59 vs ≥80 years (OR): 1.89), no private health insurance (OR: 2.04), pensioner concession card (OR: 1.80), residing in more disadvantaged area (group 1 vs 5 (OR): 1.77), history of CVD (OR: 1.47) and higher out-of-pocket expenses (group 4 vs 1 (OR): 4.57) were more likely to experience hardship. Conclusion: Subgroups of ACS patients are experiencing considerable economic burden in Australia. These findings provide important considerations for future policy development in terms of the cost of recommended management for patients

Mobile phone text messaging for medication adherence in secondary prevention of cardiovascular disease.

BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of death globally, accounting for almost 18 million deaths annually. People with CVDs have a five times greater chance of suffering a recurrent cardiovascular event than people without known CVDs. Although drug interventions have been shown to be cost-effective in reducing the risk of recurrent cardiovascular events, adherence to medication remains suboptimal. As a scalable and cost-effective approach, mobile phone text messaging presents an opportunity to convey health information, deliver electronic reminders, and encourage behaviour change. However, it is uncertain whether text messaging can improve medication adherence and clinical outcomes. This is an update of a Cochrane review published in 2017. OBJECTIVES: To evaluate the benefits and harms of mobile phone text messaging for improving medication adherence in people with CVDs compared to usual care. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers. We also checked the reference lists of all primary included studies and relevant systematic reviews and meta-analyses. The date of the latest search was 30 August 2023. SELECTION CRITERIA: We included randomised controlled trials (RCTs) with participants with established arterial occlusive events. We included trials investigating interventions using short message service (SMS) or multimedia messaging service (MMS) with the aim of improving adherence to medication for the secondary prevention of cardiovascular events. The comparator was usual care. We excluded cluster-RCTs and quasi-RCTs. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were medication adherence, fatal cardiovascular events, non-fatal cardiovascular events, and combined CVD event. Secondary outcomes were low-density lipoprotein cholesterol for the effect of statins, blood pressure for antihypertensive drugs, heart rate for the effect of beta-blockers, urinary 11-dehydrothromboxane B2 for the antiplatelet effects of aspirin, adverse effects, and patient-reported experience. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS: We included 18 RCTs involving a total of 8136 participants with CVDs. We identified 11 new studies in the review update and seven studies in the previous version of the review. Participants had various CVDs including acute coronary syndrome, coronary heart disease, stroke, myocardial infarction, and angina. All studies were conducted in middle- and high-income countries, with no studies conducted in low-income countries. The mean age of participants was 53 to 64 years. Participants were recruited from hospitals or cardiac rehabilitation facilities. Follow-up ranged from one to 12 months. There was variation in the characteristics of text messages amongst studies (e.g. delivery method, frequency, theoretical grounding, content used, personalisation, and directionality). The content of text messages varied across studies, but generally included medication reminders and healthy lifestyle information such as diet, physical activity, and weight loss. Text messages offered advice, motivation, social support, and health education to promote behaviour changes and regular medication-taking. We assessed risk of bias for all studies as high, as all studies had at least one domain at unclear or high risk of bias. Medication adherence Due to different evaluation score systems and inconsistent definitions applied for the measurement of medication adherence, we did not conduct meta-analysis for medication adherence. Ten out of 18 studies showed a beneficial effect of mobile phone text messaging for medication adherence compared to usual care, whereas the other eight studies showed either a reduction or no difference in medication adherence with text messaging compared to usual care. Overall, the evidence is very uncertain about the effects of mobile phone text messaging for medication adherence when compared to usual care. Fatal cardiovascular events Text messaging may have little to no effect on fatal cardiovascular events compared to usual care (odds ratio 0.83, 95% confidence interval (CI) 0.47 to 1.45; 4 studies, 1654 participants; low-certainty evidence). Non-fatal cardiovascular events We found very low-certainty evidence that text messaging may have little to no effect on non-fatal cardiovascular events. Two studies reported non-fatal cardiovascular events, neither of which found evidence of a difference between groups. Combined CVD events We found very low-certainty evidence that text messaging may have little to no effect on combined CVD events. Only one study reported combined CVD events, and did not find evidence of a difference between groups. Low-density lipoprotein cholesterol Text messaging may have little to no effect on low-density lipoprotein cholesterol compared to usual care (mean difference (MD) -1.79 mg/dL, 95% CI -4.71 to 1.12; 8 studies, 4983 participants; very low-certainty evidence). Blood pressure Text messaging may have little to no effect on systolic blood pressure (MD -0.93 mmHg, 95% CI -3.55 to 1.69; 8 studies, 5173 participants; very low-certainty evidence) and diastolic blood pressure (MD -1.00 mmHg, 95% CI -2.49 to 0.50; 5 studies, 3137 participants; very low-certainty evidence) when compared to usual care. Heart rate Text messaging may have little to no effect on heart rate compared to usual care (MD -0.46 beats per minute, 95% CI -1.74 to 0.82; 4 studies, 2946 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: Due to limited evidence, we are uncertain if text messaging reduces medication adherence, fatal and non-fatal cardiovascular events, and combined cardiovascular events in people with cardiovascular diseases when compared to usual care. Furthermore, text messaging may result in little or no effect on low-density lipoprotein cholesterol, blood pressure, and heart rate compared to usual care. The included studies were of low methodological quality, and no studies assessed the effects of text messaging in low-income countries or beyond the 12-month follow-up. Long-term and high-quality randomised trials are needed, particularly in low-income countries

eHealth Literacy: Predictors in a Population With Moderate-to-High Cardiovascular Risk

Background: Electronic health (eHealth) literacy is a growing area of research parallel to the ongoing development of eHealth interventions. There is, however, little and conflicting information regarding the factors that influence eHealth literacy, notably in chronic disease. We are similarly ill-informed about the relationship between eHealth and health literacy, 2 related yet distinct health-related literacies.Objective: The aim of our study was to investigate the demographic, socioeconomic, technology use, and health literacy predictors of eHealth literacy in a population with moderate-to-high cardiovascular risk.Methods: Demographic and socioeconomic data were collected from 453 participants of the CONNECT (Consumer Navigation of Electronic Cardiovascular Tools) study, which included age, gender, education, income, cardiovascular-related polypharmacy, private health care, main electronic device use, and time spent on the Internet. Participants also completed an eHealth Literacy Scale (eHEALS) and a Health Literacy Questionnaire (HLQ). Univariate analyses were performed to compare patient demographic and socioeconomic characteristics between the low (eHEAL

The underutilisation of dual antiplatelet therapy in acute coronary syndrome

Background Despite guideline recommendation of dual antiplatelet therapy (DAPT) in treating ACS, DAPT is underutilized. Our objective was to determine independent predictors of DAPT non-prescription in ACS and describe pattern of DAPT prescription over time. Methods Patients presenting to 41 Australian hospitals with an ACS diagnosis between 2009 and 2016 were stratified according to discharge prescription with DAPT and single antiplatelet therapy (SAPT) or no antiplatelet therapy. Multiple stepwise logistic regression, accounting for within hospital clustering, was used to determine the independent predictors of DAPT non-prescription, defined as discharge with SAPT alone or no antiplatelet agent. Results 8939 patients survived to discharge with an ACS diagnosis. Of these, 6294 (70.4%) patients were discharged on DAPT, 2154 (24.1%) on SAPT and 491 (5.5%) on no antiplatelet agent. Independent predictors of DAPT non-prescription in the overall cohort were: in-hospital CABG (OR 0.09, 95%CI 0.05–0.14), discharge with warfarin (0.10 (0.07–0.14)), in hospital major bleeding (0.48 (0.34–0.67), diagnosis of unstable angina (0.35, (0.27–0.45)), non-ST-elevation myocardial infarction (0.67 (0.57–0.78)) [both vs. ST-segment elevation myocardial infarction], in hospital atrial arrhythmia (0.72 (0.60–0.86)), history of hypertension (0.83 (0.73–0.94)) and GRACE high risk (0.83 (0.71–0.98)). There was an increase in prescription of DAPT and a shift towards ticagrelor over clopidogrel for ACS from 2013 to 2016 (p\ua

Prognostic benefit of catheter ablation of atrial fibrillation in heart failure: An updated meta‐analysis of randomized controlled trials

Abstract Background The prognostic role of catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) remains uncertain, with guideline recommendations largely based on a single trial. We conducted a meta‐analysis of randomized controlled trials (RCTs) assessing the prognostic impact of AF ablation in patients with HF. Methods Electronic databases were searched for RCTs comparing ‘AF ablation’ versus ‘other care’ (medical therapy and/or atrioventricular node ablation with pacing) in patients with HF. Primary endpoints were ≥1‐year mortality, HF hospitalization and change in left ventricular ejection fraction (LVEF). Meta‐analyses were performed using random‐effects modelling. Results Nine RCTs (n = 1462) met inclusion criteria. Compared to ‘other care’, AF ablation significantly reduced ≥1‐year mortality (relative risk [RR] 0.65; 95% confidence intervals [CI], 0.49–0.87) and HF hospitalization (RR 0.64; 95% CI, 0.51–0.81). AF ablation demonstrated significantly greater improvement in LVEF (mean difference [MD] 5.4; 95% CI, 4.4–6.4), 6‐min walk test distance (MD 21.5 meters; 95% CI, 4.6–38.4) and quality of life as measured by Minnesota Living with Heart Failure Questionnaire score (MD 7.2; 95% CI, 2.8–11.7). Meta‐regression analyses showed the beneficial impact of AF ablation on LVEF was significantly blunted by higher prevalence of ischaemic cardiomyopathy. Conclusions Our meta‐analysis demonstrates AF ablation is superior to ‘other care’ in improving mortality, HF hospitalization, LVEF and quality of life in patients with HF. However, the highly selected study populations in included RCTs and effect modification mediated by etiology of HF suggests these benefits do not uniformly apply across the HF population

The effect of socioeconomic disadvantage on prescription of guideline-recommended medications for patients with acute coronary syndrome: systematic review and meta-analysis

Abstract Background There are varying data on whether socioeconomic status (SES) affects the treatment in patients with acute coronary syndrome (ACS). Our aim was to obtain a reliable estimate of the effect of SES on discharge prescription of medications following an ACS through systematic review and meta-analysis. Methods Medline, EMBASE and Global Health were searched systematically on 6th April 2016. Studies were eligible if the participants had ACS and reported the rate/odds of guideline-recommended ACS medications prescription (aspirin, antiplatelet, beta blocker, angiotensin co-enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB) and statin) at discharge stratified by SES. A meta-analysis was performed to pool the estimates, comparing the prescription ratio (PR) between the lowest and the highest SES groups. Results Of 252 articles found from the search, seven met the eligibility criteria and it included 41,462 (20,986 from the lowest SES group) patients. We found that the individual/neighbourhood level SES did not affect the prescription of aspirin (PR (95% CI): 0.97 (0.91, 1.03)), but for beta blocker and statin, the lowest SES group were disadvantaged (0.84 (0.73, 0.94), 0.80 (0.62, 0.98), respectively). In contrast, ACEi were prescribed more often to the lowest individual/neighbourhood level SES group than the highest (1.13 (1.05, 1.22)). Although the risk of bias was low, there was considerable heterogeneity between the studies. Conclusions Despite the recommendations to close the treatment gap, the rate of prescription of guideline-recommended medications in managing ACS is significantly different between patients with the lowest and the highest groups. A solution is needed to provide equitable care across the SES groups. PROSPERO Registry Systematic review registration no.: CRD42016048503. Registered 28 September 2016

Understanding Preferences for Lifestyle-Focused Visual Text Messages in Patients With Cardiovascular and Chronic Respiratory Disease: Discrete Choice Experiment

BackgroundSupporting healthy lifestyle changes is a key aim of cardiovascular and pulmonary rehabilitation programs. SMS text messaging programs have demonstrated effectiveness in cardiovascular disease risk reduction, weight loss, increasing physical activity, and smoking cessation. The optimization of SMS text messaging programs may deliver greater population benefits as mobile phone use becomes ubiquitous. Visual messaging (ie, image-based messages) has the potential to communicate health messages via digital technology and result in enhanced engagement. ObjectiveThis study aims to determine and understand patient preferences for lifestyle-focused visual text messages that support cardiovascular and pulmonary rehabilitation. MethodsA discrete choice experiment was conducted in a 4-stage iterative process to elicit patient preferences for visual message features. Attribute and level development yielded 3 attributes (purpose, image type, and web address), and 16 choice sets were subsequently constructed according to a full factorial design. Patients participating in cardiovascular and pulmonary rehabilitation were surveyed (on the web) for their preferences regarding the visual message choice sets. Respondents were asked to choose among 16 pairs of visual messages regarding key lifestyle behaviors, namely, physical activity and nutrition. The data were analyzed using a conditional logit model. ResultsThere was a total of 1728 observations from 54 unique respondents. Two factors that were associated with patient preference were gain-framed purpose compared with no purpose (odds ratio [OR] 1.93, 95% CI 1.40-2.65) and real images compared with cartoon images (OR 1.26, 95% CI 1.04-1.54). A loss-framed purpose was less preferred than no purpose (OR 0.55, 95% CI 0.42-0.74). Overall, patients preferred positive images that were colorful and engaged with text that supported the image and had a preference for images of real people rather than cartoons. ConclusionsA discrete choice experiment is a scientific method for eliciting patient preferences for a visual messaging intervention that is designed to support changes in lifestyle behaviors. SMS text messaging programs that use visual aids may result in greater patient satisfaction by using a gain frame, using real images, and avoiding a loss frame. Further research is needed to explore the feasibility of implementation and the health and behavioral outcomes associated with such visual messaging programs

Time trends in stroke risk management among high-risk patients with non-valvular atrial fibrillation in Australia between 2011-2019

Background: Atrial fibrillation (AF) is associated with stroke. Major changes to AF management recommendations in 2016–2018 advised that: 1. Stroke risk be estimated using the CHA2DS2-VA score; 2. Antiplatelet agents (APAs) do not effectively mitigate stroke risk; 3. Anticoagulation is prioritised above bleeding risk among highrisk patients; and 4. Non-vitamin K oral anticoagulants (NOACs) are used as first-line anticoagulants. Aim: To examine trends in stroke risk management among high-risk patients with non-valvular AF in Australia between 2011–2019. Method: De-identified data of patients were obtained from 164 separate general practices. Data included information on patient demographics, diagnoses, health risk factors and recent prescriptions. Patients with a diagnosis of non-valvular AF were identified and stroke risk was calculated by CHA2DS2-VA score. High risk patients (i.e. CHA2DS2-VA ≥ 2) were categorised as being managed by oral anticoagulants (OACs, i.e., warfarin or NOACs), APAs only, or neither (i.e., no OACs or APAs) and time trends in prescribing were examined. Multivariate analyses examined the characteristics of patients receiving the guideline recommended OAC management. Results: Data were available for 337,964 patients; 8696 (2.6 %) had AF. Most patients with AF (85.8 %, n = 7116) had high stroke risk. The proportion of high-risk patients managed on OACs increased from 56.7 % in 2011 to 73.7 % in 2019, while the proportion prescribed APAs declined from 31.1 % to 14.0 %. Those receiving neither treatment remained steady (around 12 %). Overall, 26.3 % of patients were inadequately anticoagulated at the end of the study period. There were no age or gender differences in receiving the guideline-recommended therapy, and patients with comorbidities associated with increased stroke risk were more likely to receive OAC therapy. Conclusions: Stroke risk management among patients with AF has improved between 2011–2019, however there is still scope for further gains as many high-risk patients remain inadequately anticoagulated. Better stroke risk assessment by clinicians coupled with addressing practitioner concerns about bleeding risk may improve management of high-risk patients