ORCID Profile
0000-0002-5755-4018
Current Organisation
Government of South Australia
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Publisher: Elsevier BV
Date: 02-2021
Publisher: Elsevier BV
Date: 05-2016
DOI: 10.1016/J.JACC.2016.03.472
Abstract: Although proof-of-concept for mobile health (mHealth) life-style programs targeting physical inactivity and overweight/obesity has been established in randomized trials, the feasibility and effect of a globally distributed, large-scale, mass-participation mHealth implementation has not been investigated. The purpose of this study was to determine the effect of Stepathlon, an international, low-cost, mass-participation mHealth intervention, on physical activity, sitting, and weight. We prospectively collected cohort data from participants completing Stepathlon, an annual 100-day global event in 2012, 2013, and 2014. Participants were organized in worksite-based teams, issued pedometers, and encouraged to increase daily steps and physical activity as part of the team-based race. The program was conducted via an interactive multiplatform application available on mobile devices and the Internet. Analysis was performed according to a pre-specified plan. A total of 69,219 subjects participated (481 employers, 1,481 cities, 64 countries, all populated continents, age 36 ± 9 years, 23.9% female, 8.0% high-income countries, and 92.0% lower-middle income countries). After Stepathlon completion, participants recorded improved step count (+3,519 steps/day 95% confidence interval [CI]: 3,484 to 3,553 steps/day p < 0.0001), exercise days (+0.89 days 95% CI: 0.87 to 0.92 days p < 0.0001), sitting duration (-0.74 h 95% CI: -0.78 to -0.71 h p < 0.0001) and weight (-1.45 kg 95% CI: -1.53 to -1.38 kg p < 0.0001). Improvements occurred in women and men, in all geographic regions, and in both high and lower-middle income countries, and the results were reproduced in 2012, 2013, and 2014 cohorts. Predictors of weight loss included step increase, sitting duration decrease, and increase in exercise days (all p < 0.0001). Distributed mHealth implementation of a low-cost life-style intervention is associated with short-term, reproducible, large-scale improvements in physical activity, sitting, and weight. (Effect of the Stepathlon Pedometer Program on Physical Activity, Weight and Well-Being ACTRN12615001310550).
Publisher: Radcliffe Media Media Ltd
Date: 28-03-2023
Abstract: Background: Functional testing for acute chest pain assessment is a common practice that has not been re-examined in the era of high-sensitivity cardiac troponin. This population poses a significant analytical dilemma for physicians to achieve accurate diagnosis, balanced against the inherent risks of hospital admission and invasive downstream testing. This single-centre study evaluated outcomes in patients who underwent chest pain assessment, whose initial diagnosis was not consistent with a MI, comparing subsequent functional testing versus no functional testing. Methods: An inverse probability propensity-matched analysis of patients who underwent chest pain assessment in the emergency department and not initially referred for coronary angiography was performed to examine whether functional testing was associated with a lower rate of death or MI at 30 days. Results: In total, 3,101 patients were included. Functional testing was performed in 986 patients, while 2,115 did not undergo functional testing. The quality of propensity matching for covariates was high. The overall event rate of all-cause mortality and MI was low, totalling at five events. There was no significant difference between those who underwent functional testing versus those who did not undergo functional testing. Conclusion: Functional testing is not likely to be associated with a reduced risk of death or MI within 30 days, and provides limited further diagnostic benefit in the acute timeframe in the context of high-sensitivity cardiac troponin testing.
Publisher: Elsevier BV
Date: 02-2019
DOI: 10.1016/J.AHJ.2018.09.016
Abstract: Elevated troponin level findings among patients presenting with suspected acute coronary syndrome (ACS) or another intercurrent illness undeniably identifies patients at increased risk of mortality. Whilst enhancing our capacity to discriminate risk, the use of high-sensitivity troponin assays frequently identifies patients with myocardial injury (i.e. troponin rise without acute signs of myocardial ischemia) or type 2 myocardial infarction (T2MI oxygen supply-demand imbalance). This leads to the clinically challenging task of distinguishing type 1 myocardial infarction (T1MI coronary plaque rupture) from myocardial injury and T2MI in the context of concurrent acute illness. Diagnostic discernment in this context is crucial because MI classification has implications for further investigation and care. Early invasive management is of well-established benefit among patients with T1MI. However, the appropriateness of this investigation in the heterogeneous context of T2MI, where there is high competing mortality risk, remains unknown. Although coronary angiography in T2MI is advocated by some, there is insufficient evidence in existing literature to support this opinion as highlighted by current national guidelines. The objective is to evaluate the clinical and economic impact of early invasive management with coronary angiography in T2MI in terms of all-cause mortality and cost effectiveness. This prospective, pragmatic, multicenter, randomized trial among patients with suspected supply demand ischemia leading to troponin elevation (n=1,800 T2MI [1,500], chronic myocardial injury [300]) compares the impact of invasive angiography (or computed tomography angiography as per local preference) within 5 days of randomization versus conservative management (with or without functional testing at clinician discretion) on all-cause mortality by 2 years. Randomized treatment allocation will be stratified by baseline estimated risk of mortality using the Acute Physiology, Age, and Chronic Health Evaluation (APACHE) III risk score. Cost-effectiveness will be evaluated by follow-up on clinical events, quality of life, and resource utilization over 24 months. Ascertaining the most appropriate first-line investigative strategy for these commonly encountered high-risk T2MI patients in a randomized comparative study will be pivotal in informing evidence-based guidelines that lead to better patient and health care outcomes.
Publisher: BMJ
Date: 17-07-2014
Publisher: Oxford University Press (OUP)
Date: 02-08-2016
Abstract: Despite being recommended in acute coronary syndrome (ACS) guidelines, the use of invasive management within specific risk groups continues to be debated. This study examines the change in the use of invasive management in ACS by patient risk and the associated change in mortality within Australia over the last 17 years. Pooled cohorts derived from five ACS registries (ACACIA, CONCORDANCE, GRACE, Snapshot-ACS, and Predict) spanned from 1999 to 2015. After excluding patients without a final diagnosis of ACS (n = 4460), enrolled outside Australia (n = 1477) and without an enrolling year (n = 4), 15 912 patients were analysed. Data was stratified across three time periods (1999–2004, 2005–2009, and 2010–2015) using clinical risk characteristics (age, ACS diagnosis, biomarker elevation, and GRACE score) to monitor change in practice. Over the 17-year period, the use of invasive management increased (4073/6863 (59.3%) cases [1999–2009] vs. 6670/8706 (76.6%) cases [2010–2015]). Invasive management accounted for improvements in mortality in intermediate- and high-risk groups (intermediate risk: 14% (95% CI 1–66%) [1999–2009] vs. 49% (95% CI 2–59%) [2010–2015] high risk: 24% (95% CI 6–42%) [1999–2009] vs. 48% (95% CI 19–76%) [2010–2015]). Patients receiving no angiography compared with interventional management had worse outcomes (1999–2004 1.55 HR [95% CI 1.36–1.80], P & 0.0001 vs. 2010–2015 1.90 HR [95% CI 1.45–2.51], P & 0.0001). Clinical practice in ACS has changed over the last 17 years with positive outcomes seen with invasive management among high-risk patients. Unfortunately, a considerable burden of mortality remains in patients managed medically, highlighting a need for more focused strategies that improve care and outcomes in this group.
Publisher: Wiley
Date: 02-06-2017
Abstract: Many meta-analyses have provided synthesised likelihood ratio data to aid clinical decision-making. However, much less has been published on how to safely combine clinical information in practice. We aimed to explore the benefits and risks of pooling clinical information during the ED assessment of suspected acute coronary syndrome. Clinical information on 1776 patients was collected within a randomised trial conducted across five South Australian EDs between July 2011 and March 2013. Bayes theorem was used to calculate patient-specific post-test probabilities using age- and gender-specific pre-test probabilities and likelihood ratios corresponding to the presence or absence of 18 clinical factors. Model performance was assessed as the presence of adverse cardiac outcomes among patients theoretically discharged at a post-test probability less than 1%. Bayes theorem-based models containing high-sensitivity troponin T (hs-troponin) outperformed models excluding hs-troponin, as well as models utilising TIMI and GRACE scores. In models containing hs-troponin, a plateau in improving discharge safety was observed after the inclusion of four clinical factors. Models with fewer clinical factors better approximated the true event rate, tended to be safer and resulted in a smaller standard deviation in post-test probability estimates. We showed that there is a definable point where additional information becomes uninformative and may actually lead to less certainty. This evidence supports the concept that clinical decision-making in the assessment of suspected acute coronary syndrome should be focused on obtaining the least amount of information that provides the highest benefit for informing the decisions of admission or discharge.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2013
DOI: 10.1161/CIRCOUTCOMES.111.000072
Abstract: Acute coronary syndrome registries report the use of incomplete guideline therapies, especially among the highest risk patients. Whether this treatment gap results from misperceptions of risk by physicians is uncertain. The Perceived Risk of Ischemic and Bleeding Events in Acute Coronary Syndrome Patients (PREDICT) study was a prospective acute coronary syndrome registry in Australia, China, India, and Russia, involving 58 hospitals between May 2009 and February 2011. In-hospital care and events up to 6 months were assessed. At least 2 clinicians involved in patient care estimated the untreated risk and change in risk with each therapy. Physician risk assessment and objective risk measures (eg, Global Registry of Acute Coronary Events [GRACE] score) for death, death/myocardial infarction, and bleeding events were compared using the c statistic and integrated discrimination improvement. In total, 1542 patients and 4230 patient-specific physician estimates were obtained. Of responding clinicians, 81.9% were cardiovascular specialists (years of practice: mean [SD], 11.5 [7.7] years). The median physician-perceived risk of 6-month death was 25% (interquartile range, 14%–35%). The GRACE score was superior to physician estimation (c statistic: GRACE score, 0.812 [95% confidence interval, 0.772–0.851] versus physician, 0.652 [95% confidence interval, 0.596–0.708] P .0001). The GRACE score added to clinician intuition improved discrimination (integrated discrimination improvement, 0.0632 [SE, 0.012] P .0001). Invasive management correlated with physician-estimated risk but not with GRACE risk. Among patients not at high risk by physician estimation, increased risk by GRACE score was associated with higher mortality (3.7% versus 0.8% P .001). Objective risk assessment provides superior risk discrimination when compared with physician-estimated risk. Whether systematic use of objective risk stratification improves clinical outcomes should be studied in appropriately designed clinical trials.
Publisher: BMJ
Date: 02-2019
DOI: 10.1136/BMJOPEN-2018-026595
Abstract: Percutaneous coronary interventions (PCIs) and coronary angiography are two of the treatments administered to acute coronary syndrome (ACS) patients. However, whether and how patients’ health-related quality of life (HRQoL) influences treatment decisions and subsequent risk benefit analyses is unclear. In this study, we will review the available evidence on the impact of patients’ HRQoL on physicians’ prescribing or treatment decisions and on the estimation of mortality and bleeding risk in ACS patients. We will undertake a systematic review of all quantitative and qualitative studies. The search will include studies that describe the impact of HRQoL on prescribing PCIs or angiography, and impact of HRQoL on perceived risks in terms of mortality and bleeding events. We will conduct an initial search on Google scholar and MEDLINE to build the searching terms followed by a full search strategy using all identified keywords and index terms across the five databases, namely MEDLINE, PubMed, CINAHL, SCOPUS and Web of Sciences. We will use the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for protocol guidelines to present the protocol. Only English language articles will be included for the review. We will use a standardised Joanna Briggs Institute data extraction tool to synthesise the information extracted from the selected studies into themes with summary findings presented in a table. We will not require a formal ethical approval as we will not be collecting primary data. Review findings will be disseminated through a peer-reviewed publication, workshops, conference presentations and a media release. CRD42018108438.
Publisher: Elsevier BV
Date: 02-2016
DOI: 10.1016/J.IJCARD.2015.11.132
Abstract: Low-range troponin elevations without clear coronary manifestations remain a major diagnostic challenge. We sought to determine if troponin velocity could allow for early identification of patients without an obvious cardiac diagnosis and who are at increased risk for cardiac-specific events. All patients presenting to South Australian public hospitals between 1 September 2011 and 30 September 2012, with at least two troponin measurements during the first 6h after ED presentation were included. Diagnoses were classified as 'coronary', 'non-coronary cardiac', and 'non-cardiac' using the International Classification of Diseases 10 codes. The relationship between troponin velocity and cardiac-specific mortality and combined cardiac outcome (death and myocardial infarction) was assessed using Fine and Gray competing risk models in patients with an initial troponin <52 ng/L. Sensitivity analyses were performed using different initial and maximum troponin cut-off values. In total, 7300 patients were identified. A troponin velocity of 2.5 ng/L/h or greater in the non-cardiac (n=2793) patient group was significantly associated with an increased risk for 12-month cardiac mortality (sub-hazard ratio [SHR] 2.90, 95% CI 1.33-6.34) and combined cardiac outcome (SHR 2.08, 95% CI 1.01-4.27). This association was consistent for coronary (n=3835) and non-coronary cardiac (n=672) patient groups, and remained after sensitivity analyses. The significant association observed across all patient groups suggests that troponin velocity could be used for early risk stratification of patients with low-range troponin elevations without clear cardiac symptoms. These results may help guide future clinical trials aimed at assessing the utility of cardiac-targeted interventions in this challenging patient population.
Publisher: Elsevier BV
Date: 10-2018
DOI: 10.1016/J.IJCARD.2018.07.078
Abstract: The aim of this study was to characterise the interaction between ACS- and non-ACS-risk on the benefits of invasive management in patients presenting with acute coronary syndrome (ACS). Consecutive patients admitted to a tertiary hospital's Cardiac Care Unit in the months of July-December, 2003-2011 with troponin elevation (>30 ng/L) were included. "ACS-specific-risk" was estimated using the GRACE score and "non-ACS-risk" was estimated using the Charlson-Comorbidity-Index (CCI). Inverse-probability-of-treatment weighting was used to adjust for baseline differences between patients who did or did not receive invasive management. A multivariable flexible parametric model was used to characterise the time-varying hazard. In total, 3057 patients were included with a median follow-up of 9.0 years. Based on CCI, 1783 patients were classified as 'low-non-ACS risk' (CCI ≤ 1 invasive management 81% 12-month mortality 5%), 820 as 'medium-non-ACS risk' (CCI 2-3 invasive management 68% 12-month mortality 13%), and 468 as 'high-non-ACS risk' (CCI ≥ 4 invasive management 47% 12-month mortality 29%). After adjustment, invasive management was associated with a significant reduction in one-year overall-mortality in the 'low-risk' and 'medium-risk' groups (HR = 0.38, 95%CI:0.26-0.56 HR = 0.46, 95%CI:0.32-0.67) but not in the 'high-risk' group (HR = 1.02, 95%CI:0.67-1.56). The absolute benefit of invasive management was greatest with higher baseline ACS-risk, with a non-linear interaction between ACS- and non-ACS-risk. There is a complex interaction between ACS- and non-ACS-risk on the benefit of invasive management. These results highlight the need to develop robust methods to objectively quantify risk attributable to non-ACS comorbidities in order to make informed decisions regarding the use of invasive management in in iduals with numerous comorbidities.
Publisher: Elsevier BV
Date: 07-2017
Publisher: Elsevier BV
Date: 2016
DOI: 10.1016/J.HLC.2015.05.023
Abstract: Ensuring optimal evidence translation is challenging when health-service design has not kept pace with developments in care. Differences in patient outcomes were evident when specific cardiac conditions were discordant with the subspecialty of the cardiologists managing their care. We prospectively explored the clinical and health service implications of a "condition-based" redesign in cardiac care delivery, rather than acuity-based, within a tertiary hospital. Prospective evaluation of a disease-specific streaming model of care compared to propensity-matched historical controls, among cardiac patients admitted to a tertiary hospital cardiology unit was undertaken. The outcome measures of 30-day death, and readmission for myocardial infarction, cardiac arrhythmia, and heart failure were explored. In total, 2018 patients admitted subsequent to the implementation of the streaming model were compared with 1830 patients admitted prior. The median age was 68.9 years, and 39.5% were female. There was no significant difference in the overall proportion of patients admitted with an acute coronary syndrome, arrthythmia or heart failure, nor their Charlson index before and after streaming. Subsequent to the implementation, there was a reduction in the use of angiography (pre: 35.4% vs. post: 31.2%, p=0.007) and echocardiography (pre: 59.4% vs. post: 55.6%, p=0.007). A reduction in length of length-of-stay was observed in the entire cohort (pre: 2.7 (range: 1.2-5.0) days vs. post: 2.3 (range 1.0-4.5) days, p=0.0003). By 30 days, the propensity-adjusted hazard ratio for major adverse cardiac events and death or any cardiovascular admission was 0.76 (95% C.I. 0.59-0.97, p=0.026). Cardiac service redesign that streams cardiac patients by presenting diagnosis into teams designed to treat that condition may provide capacity and productivity gains for health services striving to improve outcome and efficiency.
Publisher: Springer Science and Business Media LLC
Date: 28-02-2016
DOI: 10.1007/S40258-015-0160-Y
Abstract: Variation in adherence to clinical guidelines, and in the organisation and delivery of health care significantly impact patient outcomes and health service costs. Despite mounting evidence of variation in clinical practice, the funds allocated to improve the quality of existing services remain small, relative to the resources allocated to new technologies. Quality improvement is a complex intervention, with a lack of focus on outcomes, and greater uncertainty around its effects. These factors have contributed to a relatively narrow, mainstream view of quality improvement as focussing on safety, with efforts to improve adherence to best practice limited to high profile clinical areas. This paper presents an analysis of linked, routinely collected data to identify variation in patient outcomes and processes of care across hospitals for patients presenting with low-risk chest pain. Such analyses provide a low cost, broadly applicable approach to identifying potentially important areas of variation in clinical practice, to inform the prioritisation of more detailed analyses to validate, and further investigate the causes of variation.
Publisher: Wiley
Date: 05-2015
DOI: 10.1111/IMJ.12739
Abstract: We aimed to assess differences in patient management, and outcomes, of Australian and New Zealand patients admitted with a suspected or confirmed acute coronary syndrome (ACS). We used comprehensive data from the binational Australia and New Zealand ACS 'SNAPSHOT' audit, acquired on in idual patients admitted between 00.00 h on 14 May 2012 to 24.00 h on 27 May 2012. There were 4387 patient admissions, 3381 (77%) in Australia and 1006 (23%) in New Zealand Australian patients were slightly younger (67 vs 69 years, P = 0.0044). Of the 2356 patients with confirmed ACS, Australian patients were at a lower cardiovascular risk with a lower median Global Registry Acute Coronary Events score (147 vs 154 P = 0.0008), but as likely to receive an invasive coronary angiogram (58% vs 54%, P = 0.082), or revascularisation with percutaneous coronary intervention (32% vs 31%, P = 0.92) or coronary artery bypass graft surgery (7.0% vs 5.6%, P = 0.32). Of the 1937 non-segment elevation myocardial infarction/unstable angina pectoris (NSTEMI/UAP) patients, Australian patients had a shorter time to angiography (46 h vs 67 h, P < 0.0001). However, at discharge, Australian NSTEMI/UAP survivors were less likely to receive aspirin (84% vs 89%, P = 0.0079, a second anti-platelet agent (57% vs 63%, P = 0.050) or a beta blocker (67% vs 77%, P = 0.0002). In-hospital death rates were not different (2.7% vs 3.2%, P = 0.55) between Australia and New Zealand. Overall more similarities were seen, than differences, in the management of suspected or confirmed ACS patients between Australia and New Zealand. However, in several management areas, both countries could improve the service delivery to this high-risk patient group.
Publisher: Elsevier BV
Date: 02-2014
DOI: 10.1016/J.IJCARD.2013.12.010
Abstract: As there are limited data evaluating "clinical intuition" in risk prediction among acute coronary syndromes (ACS) patients. We evaluated the relationship between perceived and "scored" risk in ACS patients, and their association with care and outcome. Within a prospective multi-center international ACS study from 58 hospitals in Australia, China, India and Russia enrolling patients between May 2009 and February 2011, at least 2 physicians involved in each patient's care estimated the patient's untreated risk, and the change in risk with invasive management. The association between clinical factors and physician perceived risk was assessed with multilevel mixed-effects regression models. Risk underestimation was defined as when physician-predicted risk was lower than GRACE score calculated risk and was used to compare clinical care and 6 month mortality. In total, 1542 patients and 4230 patient-specific physicians' estimates were obtained. By 6 months 48/1542 (3.1%) of patients had died compared with an estimated rate of 2.5% with full treatment. Advanced age, hypotension, tachycardia and ST changes on ECG were associated with increased perceived risk, while female gender was associated with lower perceived risk. Clinician risk underestimation was associated with less guideline therapy and higher 6-month mortality (not underestimated: 10/967 (1.0%) vs. one physician underestimated: 25/429 (5.8%) vs. all physician's underestimated: 13/146 (8.9%), any underestimation vs. no underestimation adjusted OR: 6.0 [95% CI: 2.3-15.5, p<0.001]). Clinical risk prediction using established risk characteristics is not consistently observed in clinical practice. Studies evaluating the implementation and outcomes associated with objective risk prediction are warranted.
Publisher: Oxford University Press (OUP)
Date: 11-12-2014
Abstract: Myonecrosis provoked by illness unrelated to unstable coronary plaque is common, but uncertainty about a cause-effect relationship with future events challenges the appropriateness of initiating therapies known to be effective in cardiac conditions. We examined the causal relationship between troponin elevation in non-coronary diagnoses and late cardiac events using the Bradford Hills criteria for causality. Patients presenting acutely to South Australian public hospitals receiving at least one troponin between September 2011-September 2012 were included. Diagnoses were classified as coronary, non-coronary cardiac and non-cardiac using the International Classification of Diseases, version 10 Australian Modified, codes. The relationship between peak in-hospital troponin, using a high-sensitivity troponin T assay and adjudicated cardiac and non-cardiac mortality, and subsequent myocardial infarction (MI) was assessed using competing-risk flexible parametric survival models. Troponin results were available for 38,161 patients of whom, 12,645 (33.6%), 3237 (8.5%), and 22,079 (57.9%) patients were discharged with coronary, non-coronary cardiac and non-cardiac diagnoses, respectively. Troponin >14 ng/l was observed in 43.6%. The relationship between troponin and cardiac mortality was stronger among the non-coronary diagnosis group (troponin 1000 ng/l: coronary hazard ratio: 5.1 (95% confidence interval (CI) 4.0-6.6) vs non-coronary hazard ratio: 16.3 (95% CI 12.6-22.4)). The temporal hazard for cardiac death was marked within 30 days in both groups. Among non-coronary diagnoses, the hazard for recurrent MI was higher but did not vary with time. Consistency with causal criteria between secondary myonecrosis and cardiac events suggest the potential benefit for extending cardiac specific interventions to this population if supported in trials appropriately designed to address competing risks. Troponin elevation precipitated by non-coronary events is common and demonstrates an associations with late mortality that are analogous to spontaneous MI resulting from unstable coronary plaque. These observations help inform the design of randomized clinical trials exploring the benefits and risk of therapies with established benefits in other cardiac conditions. Such studies will need to appropriately account for competing risks in this population of patients.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2016
DOI: 10.1161/CIRCOUTCOMES.115.002488
Abstract: High-sensitivity troponin T (hs-TnT) assays promise greater discrimination of evolving myocardial infarction, but the impact of unguided implementation on the effectiveness of care is uncertain. We evaluated the impact of hs-TnT reporting on care and outcome among chest pain patients presenting to 5 emergency departments within a multicenter randomized trial. Patients were allocated to hs-TnT reporting (hs-report) or standard reporting (std-report Roche Elecys). The primary end point was death and new or recurrent acute coronary syndrome by 12 months. A total of 1937 patients without ST-segment elevation were enrolled between July 2011 and March 2013. The median age was 61 (interquartile range, 48–74) years, and 46.3% were women. During the index hospitalization, 1466 patients (75.7%) had maximal troponin ng/L within 24 hours. Randomization to hs-report format did not alter the admission rate (hs-report: 57.7% versus std-report: 58.0% P =0.069). There was no difference in angiography (hs-report: 11.9% versus std-report: 10.9% P =0.479). The hs-reporting did not reduce 12-month death or new/recurrent acute coronary syndrome in the overall population (hs-report: 9.7% versus std-report: 7.2% [hazard ratio, 0.83 (0.57–1.22) P =0.362]). However, among those with troponin levels ng/L, a modest reduction in the primary end point was observed (hs-report: 2.6% versus std-report: 4.4%, [hazard ratio, 0.58 95% confidence interval, 0.34–0.1.00 P =0.050). High-sensitivity troponin reporting alone is associated with only modest changes in practice. Clinical effectiveness in the adoption of high-sensitivity troponin may require close coupling with protocols that guide interpretation and care. URL: www.ANZCTR.org.au . Unique identifier: ACTRN12611000879965.
Publisher: Elsevier BV
Date: 03-2018
Publisher: Mark Allen Group
Date: 02-10-2018
DOI: 10.12968/BJCA.2018.13.10.498
Abstract: Patients with chest pain represent a large portion of emergency department (ED) presentations around the world. Accurate risk assessment to rule out acute coronary syndrome (ACS) is required. To measure accuracy and characteristics of ED doctors and nurses when assessing patients for suspected ACS and the associations with outcome. A sub-analysis of a large randomised trial that compared high-sensitivity troponin to conventional troponin was carried out. Both nurses and doctors conducted ACS risk assessments on 1857 patients and concordance comparisons were undertaken. There was no difference between the accuracy of ED nurses and doctors (c-statistic: 0.67 vs 0.68 respectively P=0.35). Both clinician types made similar ACS risk assessments. Nurses with specialist qualifications and consultant doctors were the most accurate, at 65.4% and 74.2%, respectively. Nurses and doctors in the ED made similar ACS risk assessments but both were sub-optimal. Standard clinical pathways to assist ED doctors and nurses improve their ACS impression accuracy could be beneficial.
Publisher: CSIRO Publishing
Date: 2017
DOI: 10.1071/AH15101
Abstract: Objective Unwarranted variation in clinical practice is a target for quality improvement in health care, but there is no consensus on how to identify such variation or to assess the potential value of initiatives to improve quality in these areas. This study illustrates the use of a triple test, namely the comparative analysis of processes of care, costs and outcomes, to identify and assess the burden of unwarranted variation in clinical practice. Methods Routinely collected hospital and mortality data were linked for patients presenting with symptoms suggestive of acute coronary syndromes at the emergency departments of four public hospitals in South Australia. Multiple regression models analysed variation in re-admissions and mortality at 30 days and 12 months, patient costs and multiple process indicators. Results After casemix adjustment, an outlier hospital with statistically significantly poorer outcomes and higher costs was identified. Key process indicators included admission patterns, use of invasive diagnostic procedures and length of stay. Performance varied according to patients’ presenting characteristics and time of presentation. Conclusions The joint analysis of processes, outcomes and costs as alternative measures of performance inform the importance of reducing variation in clinical practice, as well as identifying specific targets for quality improvement along clinical pathways. Such analyses could be undertaken across a wide range of clinical areas to inform the potential value and prioritisation of quality improvement initiatives. What is known about the topic? Variation in clinical practice is a long-standing issue that has been analysed from many different perspectives. It is neither possible nor desirable to address all forms of variation in clinical practice: the focus should be on identifying important unwarranted variation to inform actions to reduce variation and improve quality. What does this paper add? This paper proposes the comparative analysis of processes of care, costs and outcomes for patients with similar diagnoses presenting at alternative hospitals, using linked, routinely collected data. This triple test of performance indicators extracts maximum value from routine data to identify priority areas for quality improvement to reduce important and unwarranted variations in clinical practice. What are the implications for practitioners? The proposed analyses need to be applied to other clinical areas to demonstrate the general application of the methods. The outputs can then be validated through the application of quality improvement initiatives in clinical areas with identified important and unwarranted variation. Validated frameworks for the comparative analysis of clinical practice provide an efficient approach to valuing and prioritising actions to improve health service quality.
Publisher: Elsevier BV
Date: 08-2017
DOI: 10.1016/J.AHJ.2017.05.004
Abstract: Protocols incorporating high-sensitivity troponin to guide decision making in the disposition of patients with suspected acute coronary syndromes (ACS) in the emergency department have received a lot of attention. Traditionally, patients with chest pain have required long periods of observation in emergency department before being deemed safe for discharge. In an era of limited health service resources, a protocol that could discharge patients safely within an hour of presentation is extremely attractive. Unfortunately, despite incorporation into some guidelines, these protocols have not been subjected to randomized comparisons evaluating safety, effectiveness, and cost-effectiveness. This study is designed to provide the evidence required to allow key decision makers to implement these protocols: specifically, to provide evidence that a decision rule based on 0- and 1-hour high-sensitivity troponin T (hs-TnT) is safe, provides noninferior outcomes in all patients with suspected ACS, and that implementation of a rapid troponin protocol leads to efficient care. This prospective pragmatic trial (n=5,400, 5 hospitals) randomly allocates patients with suspected ACS to either a 0/1-hour hs-TnT protocol as advocated in clinical guidelines, versus usual care of standard troponin reporting evaluated at 3 and 6hours. The primary effectiveness composite end points of this study are all-cause death and new/recurrent ACS within 30days. To evaluate cost-effectiveness, follow-up will determine clinical events, quality of life, and resource utilization within 12 months. Demonstrating that a 0/1-hour hs-TnT protocol improves the effectiveness and efficiency of care within a robust comparative study will fill an evidence gap that currently limits the translation of more precise hs-TnT testing into better patient and health service outcomes.
Publisher: Wiley
Date: 10-2012
DOI: 10.1111/J.1445-5994.2011.02583.X
Abstract: We sought to assess a broad array of possible precipitants of acute coronary syndromes (ACS) and evaluate their association with detectable inflammatory activation. Within a case-crossover design, using a standardised questionnaire, interviews among 348 ST-elevation myocardial infarction (44%) or high-risk non-ST-elevation ACS patients (56%), explored potential precipitants, including: infection (INF)-temperature >38°C and/or respiratory tract, urinary or skin infection inflammation (INFL)-exacerbation of inflammatory conditions exercise (EX)-moderate to heavy exercise fast food (FF)-consumption of a meal purchased from a fast food company. Risk and control periods were: weekly over 8 weeks for INF and INFL 24 hourly over 4 days for FF and 4 hourly over 48 h for EX. C-reactive protein (CRP) levels were assessed at admission. These precipitants were identified in 203/348 (58.3%) patients. An increased temporal risk was observed for: INF (0-7 days vs 7-8 weeks odds ratio (OR): 7.5, confidence interval (CI): 1.7-67.6, P = 0.002) INFL (0-7 days vs 7-8 weeks OR: 14.0, CI: 2.13-591.9, P = 0.001) EX (0-4 h vs 24-28 h OR: 2.2, CI: 1.3-3.5, P = 0.001) and FF (0-24 h vs 72-96 h OR: 5.67, CI: 1.6-30.2, P = 0.003). CRP levels were significantly elevated among patients reporting infective and inflammatory potential precipitants, but not among those reporting fast food consumption and unaccustomed moderate-heavy exercise. Infection, inflammatory conditions, moderate-heavy exercise and potentially fast food consumption appear to precipitate high-risk ACS. Increased inflammation as measured by CRP was not consistently detected despite the identification of an ACS precipitant. Strategies that target improved overall health may also lead to fewer ACS events through a reduction in triggers.
Publisher: MDPI AG
Date: 21-09-2020
Abstract: There is little up-to-date evidence about changes in quality of life following treatment for acute coronary syndrome (ACS) patients. The main aim of this review was to assess the changes in QoL in ACS patients after treatment. We undertook a systematic review and meta-analysis of quantitative studies. The search included studies that described the change of QoL of ACS patients after receiving treatment options such as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical therapy (MT). We synthesized findings using content analysis and pooled the estimates using meta-analysis. We used the PRISMA guidelines to select and appraise the studies and report the findings. Twenty-nine (29) articles were included in the review. We found a significant improvement of QoL in ACS patients after receiving treatment. Particularly, the meta-analytic association found that the mean QoL of patients diagnosed with ACS was higher after receiving treatment compared to baseline (overall pooled mean difference = 31.88 95% CI = 31.64–52.11, I2 = 98) with patients on PCI having slightly lower QoL gains (pooled mean difference = 30.22 95% CI = 29.9–30.53, I2 = 0%) compared to those on CABG (pooled mean difference = 34.01 95% CI = 33.66–34.37, I2 = 0%). The review confirmed that QoL of ACS patients improved after receiving treatment therapies although varied by the treatment options and patients’ preferences. This suggests the need to perform further study on the QoL, patient preferences and physicians’ decision to prescription of treatment options.
Publisher: AMPCo
Date: 08-2016
DOI: 10.5694/MJA15.01410
Abstract: Variation in the provision of coronary angiography is associated with health care inefficiency and inequity. We explored geographic, socio-economic, health service and disease indicators associated with variation in angiography rates across Australia. Australian census and National Health Survey data were used to determine socio-economic, health workforce and service indicators. Hospital separations and coronary deaths during 2011 were identified in the National Hospital Morbidity and Mortality databases. All 61 Medicare Locals responsible for primary care were included, and age- and sex-standardised rates of acute coronary syndrome (ACS) incidence, coronary angiography, revascularisation and mortality were tested for correlations, and adjusted by Bayesian regression. There were 3.7-fold and 2.3-fold differences between in idual Medicare Locals in the lowest and highest ACS and coronary artery disease mortality rates respectively, whereas angiography rates varied 5.3-fold. ACS and death rates within Medicare Locals were correlated (partial correlation coefficient [CC], 0.52 P < 0.001). There was modest correlation between ACS and angiography rates (CC, 0.31 P = 0.018). The proportion of patients undergoing angiography who proceeded to revascularisation was inversely correlated with the total angiogram rate (CC, -0.71 P < 0.001). Socio-economic disadvantage and remoteness were correlated with disease burden, ACS incidence and mortality, but not with angiography rate. In the adjusted analysis, the strongest association with local angiography rates was with admissions to private hospitals (71 additional angiograms [95% CI, 47-93] for every 1000 admissions). Variation in rates of coronary angiography, not related to clinical need, occurs across Australia. A greater focus on clinical care standards and better distribution of health services will be required if these variations are to be attenuated.
No related grants have been discovered for Matthew Horsfall.