Exploring the potential to remain “Young @ Heart”: Initial findings of a multi-centre, randomised study of nurse-led, home-based intervention in a hybrid health care system

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Abstract

Background

Disease management programs have been shown to improve health outcomes in high risk individuals in many but not all health care systems.

Methods

Young @ Heart is a multi-centre, randomised controlled study of a nurse-led, home-based intervention (HBI) program vs. usual care (UC) in privately insured patients in Australia aged ≥ 45 years following an acute cardiac admission. Intensity of HBI is tailored to an individual's clinical stability, management and risk profile. The primary endpoint is the rate of all-cause stay during a mean of 2.5 years follow-up.

Results

A target of 602 adults (72% men) were randomised to HBI (n = 306) or UC (n = 296); their initial profiles being well matched. At baseline, 71% were overweight (body mass index 29.7 ± 3.9 kg/m2) and 66% had an elevated blood pressure (153 ± 18/89 ± 7 mm Hg). Over half had a history of smoking and 39% had a sub-optimal total cholesterol level > 4 mmol/L. Overall, 62% (376 cases) were treated for coronary artery disease (27% with multi-vessel disease and 39% underwent cardiac revascularisation). A further 20% (120 cases) were treated for a cardiac arrhythmia (predominantly atrial fibrillation) and 19% type 2 diabetes mellitus. At 7–14 days post-discharge, 293 (96%) HBI patients received a home visit triggering urgent clinical review and/or enhanced clinical management in many patients.

Conclusions

The Young @ Heart intervention is a well accepted and potentially effective intervention to reduce recurrent hospital stay in privately insured cardiac patients in Australia.

Introduction

Cardiovascular disease (CVD) and its most common manifestation, heart disease, affects more Australian adults than any other disease type. Nationally, it is responsible for the greatest burden of any disease group. In 2004–05, management of CVD was estimated to cost $5.94 billion (11% of total allocated health care expenditure) [1]. A major portion of this expenditure can be attributed to a growing number of older individuals with chronic heart disease. As such, while there are many effective treatments and expert guidelines to prevent disease progression [2], [3], [4], the burden imposed by a broad range of chronic heart disease states remains high world-wide [5], [6], [7]. This is potentially due to significant gaps in the overall application of gold-standard secondary prevention to at-risk patients and to a lack of flexible health care models to overcome individual factors such as treatment non-adherence, poor knowledge, poor health literacy and sub-optimal self-care behaviours [8], [9]. Not only pharmacological treatments, such as anti-platelet therapy, angiotensin converting enzyme (ACE) inhibitors and β-blockers, but non-pharmacological strategies to promote regular exercise, weight reduction and/or healthier dietary patterns need to be more consistently applied for optimal secondary prevention [10], [11], [12], [13], [14].

As described previously [15], we are in the process of refining our approach to optimising the management of essentially “high risk” individuals with established heart disease to prevent progressive cardiac dysfunction and a premature death. Our ultimate goal is to bridge the gap between proven short-term secondary prevention programs (i.e. cardiac rehabilitation for survivors of acute coronary syndrome) [2], [13] and specialist chronic heart failure (CHF) programs [16], by developing evidence-based programs that span the full spectrum of chronic heart disease. With this broad goal in mind, we have previously shown that a nurse-led, multidisciplinary, personalised (home-based) disease management program targeting patients with a wide range of chronic disease states is associated with both short [17] and longer-term [18], [19] reductions in recurrent hospital stay relative to usual care (UC).

The successful application of any structured disease management program, however, is potentially dependent on the nature of the health care system. For example, disease management operating within Sweden's universal single-payer health care system [20], [21] is likely to be very different to the highly complex and privatised health care system in the USA [22]. Certainly, the soaring cost of care for chronic illness and a need to “contain” health care expenditure have led to the widespread proliferation of disease management programs undertaken by private health management organisations such as Kaiser Permanente [23]. In the USA 97% of private health plans had disease management programs for diabetes, 86% for asthma, 83% for heart failure, and 70% for ischemic heart disease [24].

Australia's health care system operates under “hybrid” conditions. There is both public, free, universal access to hospital treatment alongside subsidised out-of-hospital medical treatment, as well as an alternative to utilise fee-for-service private health care facilities used by individuals covered by private health insurance plans. The latter are typically encouraged through tax incentives to adopt health insurance. Latest statistics from the Private Health Insurance Administration Council suggest that 44% of Australia's approximate 22 million people have private health care insurance [25]. Such individuals tend to use more healthcare resources with a greater frequency (e.g. primary care consultations and elective hospital procedures) [26]. Significantly, despite a range of disease management programs subsidised by private health insurance for individuals with chronic illness in Australia, there are few data beyond the USA to support their application in respect to reduced health care utilisation.

The Young @ Heart Study aims to examine the benefits of a disease management approach in an otherwise uncoordinated private sector setting, tailored to private health insured patients by virtue that the program was funded by Bupa Australia for its members, although independently delivered and managed by two large private hospitals. It tests the hypothesis that a specialist nurse-led, multidisciplinary, home-based intervention (HBI) program for high risk individuals with chronic heart disease, designed to implement gold-standard pharmacological and non-pharmacological therapy specifically directed at maximal cardio-renal and neurological protection, will reduce the rate (and cost) of all-cause hospital stay during an average of 2.5 years follow-up by a minimum of 20% relative to UC.

Section snippets

Study setting

All elective and emergency patients who were privately insured by Bupa Australia and admitted to the 286-bed St Andrew's War Memorial Hospital or 430-bed Wesley Hospital in Brisbane, Australia between June 2008 and December 2009 were screened for study eligibility.

Study cohort

Fig. 1 outlines the flow of patient recruitment for the Young @ Heart Study. Patients diagnosed with a chronic form of heart disease and aged ≥ 45 years were eligible to participate. Overall, 69% of patients were deemed ineligible

Demographic and clinical profile

Table 1 shows the demographic and clinical profile of the study cohort according to group allocation. All baseline characteristics were well balanced between the two arms except the HBI group had more patients who lived alone (p < 0.05). The majority of patients were men; women being on average 5 years older (p < 0.001). More than one in two patients had a smoking history (5% current smokers and 48% ex-smokers) and one in six was found to have thoughts/feelings indicative of depression. Although mean

Discussion

The Young @ Heart Study responds to the challenge to limit an “epidemic” of chronic heart disease in Australia's aging population. It aims to evaluate an individually-tailored, nurse-led, multidisciplinary home-based intervention to implement gold-standard therapeutics in patients with chronic heart disease. Whilst there have been broadly equivalent original studies and systematic reviews reporting safe and improved health outcomes in both Australia [17], [19] and North America [40], [41], the

Conflict of interest/disclosure

Young @ Heart nursing and recruitment staff are supported by Bupa Australia. SG is a medical advisor for Bupa Australia.

Acknowledgements

The authors gratefully acknowledge our dedicated research team including Linda Preston, Amanda Benvenuto, Margaret Eaton, Virginia Gehrke, Amanda Brown, Aaron Conway, Lisa Cowen and Jeff Cousins for patient recruitment, data collection and study administration. Wesley Hospital and St Andrew's War Memorial Hospital are sincerely thanked for allowing the Young @ Heart Study to be conducted in their cardiology wards. MC and SS are supported by the National Health and Medical Research Council of

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    Sources of support: The Young @ Heart Study was independently designed and analysed by Baker IDI Heart and Diabetes Institute and administered by UnitingCare Health in collaboration with the Wesley Hospital and St Andrew's War Memorial Hospital. Young @ Heart was generously supported by MBF Australia and an evaluation of the program is supported by the MBF Foundation. SS and MC are supported by the National Health and Medical Research Council of Australia.

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