In a Progress Report prepared for the Department of Health and Ageing in December 2008, a number of early and emerging themes were identified. These helped to inform the development of recommendations for the Final Report. Themes are described below.
National Leadership in CVDThis is an area where the Australian Government has direct influence.
It appears the uptake of the National Service Improvement Framework for Heart, Stroke and Vascular Disease as a means of shaping service planning and delivery for CVD has been limited. The level of penetration of the Framework appears to have been light, with contacts in several peak bodies interviewed not aware of and not using the Framework at all.
Jurisdictional representatives were all aware of the framework and had utilised the information within it to varying degrees however it was not seen as an action document. A common comment was that the Framework was released without resources attached and without a mandatory requirement to deliver on the critical intervention points, which allowed other priorities to overtake it.
The need for national leadership in CVD and/or co-ordination of particular elements of the identification and management continuum was quite strongly expressed by a number of key stakeholders. This is of particular concern to the NHF and the NSF; both organisations strongly support the establishment of a National Action Plan for CVD, similar to the National Action Plans for Mental Health. A number of jurisdictions also described the need for some form of national leadership for CVD in Australia.
National leadership is considered particularly important in the areas of clinical guidelines, standards, health monitoring, health information and measuring performance.
Themes by setting
Primary Health Care and General PracticeThis is an area where the Australian Government has direct influence.
The role of GPs and the wider primary health care sector in early identification, ongoing management and end of life care is significant. Primary care, in particular, has been highlighted as an area of great opportunity. Emerging priorities and possible solutions that could be addressed within primary health care and general practice include:
- support for greater uptake of absolute risk assessment for CVD in general practice;
- broadening of criteria for some MBS items to include CVD specific activities; and
- incentives to increase use of clinical guidelines.
Hospitals and emergency departmentsThis is an area for joint strategy between the Australian Government and jurisdictions.
In the area of acute care, the options for stroke and heart disease can be quite different. The considerations of jurisdictions and peak bodies were closely aligned with regards to key themes for acute or critical care. These included:
- improving compliance with current guidelines for management of presentations to Emergency Departments with symptoms related to cardiac or stroke;
- improving care for people with stroke (for example in stroke units);
- improving after-care for people with cardiac events; and
- reducing the time between symptom onset and appropriate treatment (for example ECGs in ambulance).
Themes by action
Risk AssessmentThis is an area where the Australian Government has significant influence (in Primary Care).
CVD risk assessments, particularly absolute risk assessment, have been identified by most stakeholders as a critical enabling factor in early identification of vascular diseases. An absolute risk assessment, measures the probability of a person developing a CV event over a particular time, usually 5 or 10 years. Once a risk is identified, it can be actively managed with a set of interventions tailored to the individual’s risk profile. These interventions might include lifestyle changes, pharmacotherapy and/or clinical treatments.
The logical setting for most risk assessment is the primary care setting; however there has been limited uptake of absolute risk assessment as a clinical tool in general practice or other community health settings. Research has identified that improving the use of absolute risk assessment as a routine clinical tool in general practice may need action on a number of fronts, which might include:
- improving access to electronic decision support tools which support the use of a CVD absolute risk assessment;
- increasing patient awareness of the value of an absolute risk assessment; and
- identifying existing/new incentive payments for undertaking CVD absolute risk assessments.
Clinical GuidelinesThis is an area where the Australian Government and jurisdictions can act.
Clinical guidelines are in place to cover many areas of CVD. While most focus on the clinical treatment of different forms of CVD, there is a particularly comprehensive set of guidelines for stroke, which cover the psychosocial and community support as well as clinical treatment.
Implementation of clinical guidelines has been identified as an issue by a number of stakeholders. Apart from the issue of establishing a process for developing standardised and evidence-based guidelines, there are also issues related to low levels of compliance with guidelines and ease of access to current guidelines in the clinical setting.
Clinical guidelines are applicable across all health delivery settings and at all stages of CVD management – from risk reduction, through early detection, care and support, acute care, long term care and advanced care.
Reports from stakeholders, including jurisdictions, indicate that compliance with current evidence-based guidelines for CVD is patchy in all settings.
Themes by measurement
Key Performance MeasuresThis is an area where the Australian Government and jurisdictions can act.
A consistently emerging theme from peak bodies is the need for national KPI's that will measure performance and incentivise both jurisdictions and General Practice to deliver on identified actions to improve CVD outcomes. These can then be measured by data and audit. The National Health And Hospitals Reform Commission has identified a range o performance measures, some of which are applicable to CVD.
Population MonitoringThis is an area where the Australian Government has direct influence.
A number of jurisdictions and peak bodies have identified the lack of a national population monitoring process (for example a biomedical survey) that focuses on indicators of risk, such as obesity, which objectively measures our national progress through repeat biennial surveying.
Similarly action to investigate the feasibility and the benefits of a healthy food partnership with industry to drive food reformulation and reduce saturated fats, trans-fats and salt in the food supply, increase fruit and vegetables and promote portion control has been strongly promoted by the National Heart Foundation.
DataThis is an area where the Australian Government and jurisdictions can act.
Many of the emerging priorities identified in this Review rely on high quality information. Data has been an emerging theme in most interactions with stakeholders and is clearly identified in current reform reports for the Australian Government.
Good information is required for access to clinical guidelines, for learning from the results of clinical interventions (for example through the establishment of clinical registers), for monitoring health status and for measuring system performance.
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