F1. Use the National Health and Research Medical Council (National Institute of Clinical Studies) to manage the development and review of new and existing national clinical practice guidelines for CVD.Clinical guidelines are a critical component in the translation of evidence into practice and improving the quality of healthcare. In order to ensure evidence based, consistent and safe approach to CVD, it is critically important to utilise clinical practice guidelines. Providing accessible guides to best practice will assist clinicians and policy makers to make the most appropriate health care decisions.
There is a range of guidelines currently available in Australia for the acute care of people with cardiovascular disease. It was identified by stakeholders during the consultation process that not only was there was a definite need for further clinical guideline development and the ongoing maintenance of guidelines but there was also a need for incentives to comply with guidelines.
Stakeholders advise that clinician involvement in the development and review of clinical practice guidelines is critical to their successful adoption and implementation.
The NHMRC (NICS) currently provides support for evidence-based practice through:
- working in partnership with clinical groups and health care organisations to help improve evidence uptake in areas where there are important evidence-practice gaps;
- providing access to resources and evidence for health professionals, managers, researchers and policy makers; and
- providing opportunities for health professionals to increase knowledge and skills in improving evidence uptake9
In addition NHMRC is currently transitioning to a model whereby NICS will be responsible for the process of developing clinical practice guidelines funded by DoHA. This new model is planned to commence on the 1st July 2009.
A strategic approach by DoHA to the development of CVD guidelines will need to be taken to incorporate their development and review into NICS business plan.
F2. Work strategically with the National Institute of Clinical Studies within National Health and Research Medical Council to improve uptake of nationally standardised clinical guidelines across general practice, acute and community care.The adoption of clinical guidelines into practice is often slow and is dependent on successful implementation strategies. The NHMRC through NICS aims to facilitate the translation of best available evidence into clinical practice and is currently undertaking a survey of Australian clinical practice guidelines and developing a portal and register to improve access to evidence-based clinical practice guidelines. In addition NHMRC (NICS) offers fellowships to future clinical leaders who have identified practice areas where there is evidence available but it is not being applied. Fellowships provide financial support, education, mentoring and access to expertise that would not otherwise be readily available.
Generally there is currently limited uptake and implementation of clinical guidelines across the acute and primary health care sector. This has been identified by stakeholders during the consultation process and in the literature review. It is not that clinicians are averse to utilising current evidence and clinical guidelines to ensure the best care for their patients. The issue lies with the volume, length and currency of individual guidelines and the time taken to gain familiarity with multiple guidelines.
It is important to establish easy to access information sources for clinical guidelines and pathways that clinicians can use in their everyday work. One of the issues for clinicians is the sheer volume of evidence available; clinical information systems should be able to improve access to the right clinical information at the right time. Guidelines are often best incorporated into electronic decision support tools associated with electronic patient information systems. This action should link with work being undertaken to develop electronic clinical records that span the entire health service system.
A priority under this recommendation could be improving uptake of best practice guidelines for assessment and treatment of transient ischaemic attack (TIA) in public and private health facilities and NGO’s (Hospital emergency departments, small hospitals, community health services, aged care services, General Practice).
TIA is closely associated with recurrent stroke, yet this condition is not always treated as seriously as is warranted. Early treatment after TIA (within 48 hours) can significantly reduce the risk of recurrent stroke. International evidence indicates that even when appropriate and timely acute care is provided for TIA, secondary prevention is often poor in both the inpatient and outpatient setting. 10
A person who is experiencing TIA or has recently experienced TIA may present in a variety of settings, including but not limited to general practice, primary health care, the local pharmacy or within an aged care facility. Guidelines apply in all these settings.
Implementation of best practice clinical guidelines for TIA will require strategies which take into account the urban, rural and remote environments. Strategies might include testing innovative models of care for treatment of TIA across the primary health care and hospital settings.
In relation to the overall uptake of guidelines in General Practice, there is an opportunity to harness the energy created in participating general practices through the Australian Primary Care Collaboratives, AGPN, the Divisions of General Practice and the RACGP.
F3. Support the work of the Australian Commission for Safety and Quality in Health Care (ACSQHC) to validate its draft Operating Principles and Technical Standards for Australian Clinical Quality Registries.ACSQHC has developed draft Operating Principles and Technical Standards for registries in collaboration with the NHMRC Centre for Research Excellence in Patient Safety and the National E-Health Transition Authority. It subsequently called for tenders for pilot studies to test and validate the draft principles and standards.
Two of the six registries selected for the validation study are the Australian Cardiac Procedures Registry and the Australian Stroke Clinical Registry.
The Australian Cardiac Procedures Registry is conducted by the Australian Society of Cardiothoracic Surgeons and Centre for Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University.
The aim of this registry is to enhance and develop the merger of two existing clinical registries in cardiac surgery and percutaneous cardiac intervention (PCI) into a scalable national cardiac procedures registry that will improve the reliability of information acquisition across all contributing locations, and to develop an additional module that will extend the registry information collection to include implantable devices such as pacemakers and implanted defibrillators. The development of such modules will enhance the cardiac registry functionality to provide a common platform to enhance its national utility.
The draft Operating Standards and Technical Standards will be tested and evaluated through the development of this nationally scalable registry.
The Australian Stroke Clinical Registry will be conducted by the National Stroke Research Institute, the George Institute for International Health, the National Stroke Foundation and Stroke Society of Australasia.
This will be a new clinical Registry, spanning all aspects of the development and implementation process (from governance establishment, dataset selection, ethics, clinical uptake and operation).
The development of this registry will include the migration of existing data into a Registry compliant with the Principles as the NSRI proposal includes the migration of a minimum 1000 records from past stroke audits into the new Australian Stroke Clinical Registry – such that the impacts of this can be assessed and reported.
Implementation across multiple State jurisdictions. The NSRI project will provide the Commission with an opportunity to assess how the Principles and Standards support or impact implementation differently between States and Territories.
The full Registry lifecycle within the 13 month period of the pilot. The NSRI project will successfully allow testing and validation of the principles and standards during Registry design, build, implementation and steady state operations.
The benefits derived from the establishment of a national cardiac procedures registry and national stroke registry include; supporting the application of clinical guidelines, allowing clinicians to compare clinical outcomes and contributing to better planning of services and improved efficiency of the healthcare system.11 They also assist in patients decisions about treatment options through the provision of better
Registries contribute to the evidence base for better practice through the collection and review of real life data on outcomes from clinical procedures. This information within registries complements gold standard evidence gathering such as Random Controlled Trials (RCTs).
There are numerous international examples where Registries have contributed to the body of knowledge around clinical procedures or devices. Registries can be particularly valuable where RCTs are inappropriate or numbers of presentations are too low to comprise a significant sample12. In these cases, access to real life data about treatments and outcomes can be of great value to clinicians and patients.13 Data from registries is assisting in evaluation of specific treatments, for example a multicentre registry in the USA has provided data to assess the prognosis from a specific intervention14 or compare outcomes between different devices.15
In the Australian context, it will be particularly important to collect data on interventions and outcomes for Indigenous Australians. There is currently insufficient data on current services and outcomes for Indigenous people. Strategies to improve this will need to include identification of Aboriginal and Torres Strait Islander origin when collecting patient data and engagement with ACCHOs in research and data collection.16
Stakeholder consultation and cardiac research indicates clinical registries have the highest degree of compliance and use when they are perceived to be owned by the relevant clinicians, therefore it will be important to ensure clinician engagement in the development of the registries.
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F4. Develop an implementation plan for general practice to support the implementation of Absolute Risk Assessments (ARA) to identify people at risk of heart disease, stroke, diabetes, and kidney disease and then address their risk factors through a program involving on-going management.Stakeholder consultations and current literature have identified the importance of promoting the routine assessment of absolute risk within the primary health care sector.17 Evidence supports early identification of risk in order to put in place appropriate cost effective prevention and management strategies and this is currently being reflected in the treatment guidelines in both Britain and the US. The School of Public Health and Community Medicine at the University of NSW is currently undertaking a study to assess the impact of absolute risk assessment in general practice on prescribing and adherence to guidelines. The Cochrane Collaboration, funded by the National Heart Foundation, identified and analysed available evidence on ARA to guide practice and this work is being used as the basis for CVD risk assessment guidelines recently endorsed by the NHMRC and expected to be released in March 2009 18. The guidelines use an AR approach and will be released with an Australian version of the NZ paper based tool, and an online calculator.
Risk assessment tools have been available for more than a decade but are still not routinely used. Stakeholders advise that ARA requires a significant shift in practice for most GPs as well as some structural changes. Successfully undertaking an ARA with a patient requires a collaborative approach to interactions and significant negotiation with the patient around possible lifestyle changes. This is a complex interaction that does not fit well within a standard short consultation. Advice from key general practice stakeholders is that achieving implementation of ARA across general practice and other primary health care providers will require a sustained long term strategy (5 years or more) with a number of underpinning elements, including:
- effective use of existing MBS items and consideration of additional items to cover those not currently covered by existing MBS items, particularly those under 40; this should be coupled with processes to make use of MBS items simpler for general practice;
- access to MBS items for risk assessment and early intervention by other practitioners such as exercise physiologists, nurses and allied health professionals;
- continued evaluation of suitable risk assessment tools for the Australian context, including for younger Australians (under 45), with new evidence being Incorporated into the ARA tools;
- integration of the various existing guidelines for the management of CVD based on an absolute risk assessment approach;
- the engagement of Divisions of General Practice to support general practice in making the necessary changes;
- education and support for clinicians, including role pays and practice sessions;
- shifts in the roles of practice staff, including practice nurses and practice managers;
- access to appropriate software;
- implementation support; and
- workforce strategies to enhance the availability of appropriate services for GP referral, for example exercise physiologists.
It will be important to integrate the strategy within existing chronic care management and funding initiatives such as the Australian Primary Health Care Collaboratives, the Well Persons Health Check and appropriate MBS items.
Building on the success of the existing Australian Primary Care Collaborative initiative has been suggested as the logical way to systematically engage General Practice through their local Division of General Practice. However, the successes of the collaborative methodology thus far have been greatest where changes are small and build on existing structures.
A new methodological approach may need to be devised to support this much larger and complex change. The National Primary Health Care strategy may provide guidance in this matter, particularly in relation to increasing the attention paid to chronic disease in current health education curricula, supporting teambased models of care, investigating new workforce models and improving clinical information to support integrated care. 19
F5. Hospitals to be required to undertake and report the results of biennial audits of CVD services, in particular heart attack and stroke, in acute and post-acute care.Work undertaken in Queensland has achieved some significant improvements in the treatment of acute cardiac events, using a collaborative methodology. However, the authors note that there are still opportunities for further improvements, particularly in relation to the timeliness of thrombolysis, provision of in-hospital cardiac counselling, referral to cardiac rehabilitation, and use of non-invasive stress testing to identify reversible ischaemia in patients with ACS, along with objective assessment of left ventricular function and more aggressive use of second-line vasodilators, β-blockers and warfarin in patients with CHF.20
There is evidence from the UK that regular independent audits of services assist them to improve performance. Auditing of services will link with strategies to improve implementation of clinical guidelines; it will assist with monitoring the quality and performance of stroke units and highlight clinical issues for services to act on. Audits can focus on structures, processes and outcomes of care.
The National Stroke Foundation commenced the National Stroke Audit Program in 2007. The Foundation seeks to extend the current audit of acute services to cover post-acute services as well. The approach needs to continue to be supportive and with a primary aim of assisting services to improve.
Jurisdictions might choose how they undertake audits, with standardised indicators in place through accreditation programs or performance agreements to support audit processes. A set of agreed indicators should be developed to ensure consistency in auditing. These might be taken from existing audit processes and refined in conjunction with key clinical stakeholders. Indicators must be able to be collected easily; examples might include the % of people with stroke admitted to a stroke unit; the % of people provided with appropriate treatment following a TIA; number of people referred to cardiac rehabilitation.
NICS is currently working with a Stroke Reference Group to develop and trial a care bundle to support evidence-based care for stroke presentation in the hospital emergency department 21. Care bundles are effectively used as part of the Collaboratives methodology as defined by the Institute for Health Improvement; stroke audits could be undertaken against the components of care bundles where they exist.
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F6. Investigate the benefits of including CVD risk factors in a national health survey and investigate the benefits and costs of including biomedical risk assessments such as blood and urine collection and analysis.The Australian Government is initiating a National Nutrition and Physical Activity Survey Program, which will collect self-reported and objective population level data on nutrition, physical activity and physical measurements through an ongoing series of national surveys covering adults, children and Indigenous Australians. It is anticipated that the first survey of the Program will collect data from a representative sample of Australian adults aged 17 years and over with results available from 2012/13. The last survey to collect detailed data on food intake from a representative sample of Australian adults was the 1995 National Nutrition Survey.
The National Preventative Health Taskforce recommends the establishment of a national surveillance system, focusing on biomedical, environmental and behavioural risk factors. It suggests the expansion of the National Nutrition and Physical Activity Survey to include biomedical risk factors 22. Biomedical surveys are used in a number of countries and have been undertaken within the Australian context 23. They can be used to monitor and compare disease risk factors at the population level; information which builds up a bank of information against which long term population health strategies can be measured.
The sampling criteria for collection of biomedical indicators from Indigenous Australians need to accommodate the wide variations in health profiles between different communities and different levels of remoteness.24 This requirement should not reduce the emphasis on measuring risk in Indigenous populations as the risk factors are generally higher within groups with higher levels of socioeconomic disadvantage including many Indigenous Australians.
There is a range of economic, logistical and ethical issues associated with the implementation of a biomedical survey and these issues would need to be fully considered prior to the inclusion of biomedical factors in a national survey. The NHMRC Statement 1999 provides direction on issues such as consent for collection of human tissue samples however such issues as collection, storage and use of samples need to be comprehensively addressed.
There are international experiences that Australia can draw on. For example, the Health Survey for England 2003 25 took saliva and urine samples from a sub-group of survey participants, in addition to undertaking interviews.
F7. Include specific CVD indicators, including ARA, in datasets for national and jurisdictional performance accountability frameworks.As an outcome of the recent COAG, the Commonwealth and the jurisdictions have agreed to a range of outcomes from the Australian health system, including the following:
- children are born and remain healthy;
- Australians manage the key risk factors that contribute to ill health;
- Australians have access to the support, care and education they need to make healthy choices;
- the primary health care needs of all Australians are met effectively through timely and quality care in the community;
- people with complex care needs can access comprehensive, integrated and coordinated services;
- Australians receive high-quality hospital and hospital related care;
- older Australians receive high-quality, affordable health and aged care services that are appropriate to their needs and enable choice and seamless, timely transitions within and across sectors;
- Australians have positive health and aged care experiences which take account of individual circumstances and care needs;
- Australia’s health system promotes social inclusion and reduces disadvantage, especially for Indigenous Australians; and
- Australians have a sustainable health system.
- preventable disease and injuries;
- timely access to GPs, dental and other primary health care professionals;
- life expectancy, including the gap between Indigenous and non-Indigenous Australians;
- waiting times for services; and
- net growth in the health workforce.26
9 NICS Fact Sheet, NHMRC, Australian Government, Canberra, www.nhmrc.gov.au
10 Scholte Op-Reimer W J, Dippel D W, Franke C L, van Oostenbrugge R J, de Jong G,Hoeks S, Simoons M L, Quality of hospital or outpatient care after stroke or transient ischemic attack: insights from a stroke survey in the Netherlands, Stroke, 2006 July, 37 (7), pp1844 – 9,
11 Tonkin A, Why Australia Needs a Cardiac Procedures Database, Heart, Lung and Circulation, 2001:10
12 Basso C, Wichter B, Danieli G, Corrado D, Czarnowska E, Fonataine G. McKenna W, Nava, A, Protonotarius N, Antoniades L, Wlodarska K, D’alessi F, Thiene G, Arrythmogenic right ventricular cardiomyopathy: clinical registry and database, evaluation of therapies, pathology registry, DNA banking, European Heart Journal 2004 25(6):531-534;
13 Kpodonu J, Tshibaka C, Massad M, The Importance of Clinical Registries for Pulmonary Epithelioid Hemangioendothelioma, Chest, May 2005, Vol 127 (5), pp 1870 - 1
14 Shaw L, Utility of Normal Perfusion Studies: results from a Multicenter Clinical Registry, Medscape, 2002
15 Chong E; Shen L; Soon C; Ong H; Poh K; Teo S; Lee R; Low A; Tan H, Two Years Clinical Registry Follow Up of Endothelial progenitor Cell Capture Stent versus Sirolimus-Eluting Bioabsorbable Polymer-Coated Stent versus Bare Metal Stents in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction, Circulation. 2008; 118:S_1043
16 Communications from Professor Wendy Hoy and Dr Alex Brown.
17 Tonkin A, Lim S, Schirmer H, Cardiovascular Risk Factors – When Should we treat?, MJA 2003 178 (3): 101-102
18 Source: email communication from the NSF 13/02/09
19 Towards a National Primary Health Care strategy – A Discussion Paper from the Australian Government, 2008, Australian Government, Canberra
20 Scott I, Darwin I, Harvey K, Duke A, Buckmaster N, Atherton J, Harden and Ward M, for the CHI Cardiac Collaborative, Multisite quality improvement collaboration to optimise cardiac care in Queensland public hospitals, MJA , 2004, 180 (8), pp392 – 397.
21 NICS Update, November – December 2008
22 National Health Preventative Taskforce, Australia: the healthiest country by 2020 A discussion paper, Commonwealth of Australia, 2008
23 Hetzel D. (2003) A National Biomedical Risk Factor Survey for Australia: Issues for consideration. AHMS Working Paper Series No. 1. Public Health Information Development Unit, Adelaide.
24 Communication from Professor Wendy Hoy
25 NHS, Health Survey for England 2003, Vol 3, Methodology and Documentation
26 Council of Australian Governments Meeting Communique, 29 November 2008, Canberra
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