G1.1. Develop a government/industry/NGO partnership to achieve population wide reductions in saturated fat and dietary salt intake in the Australian context.Support work commenced by the National Heart Foundation to develop a partnership between government, the food industry and peak bodies to achieve population wide reductions in saturated fat, trans fats, sugar and dietary salt intake and portion reductions where appropriate.
The National Heart Foundation has been working with the Australian Food and Grocery Council to establish a forum for discussion on how fat, sugar and salt reductions could be achieved in Australia. This work should be supported and progressed.
A diet high in saturated fats can contribute to developing a range of serious illnesses including cardiovascular disease. In addition to improving community awareness a key factor in reducing saturated fat intake is the development of partnerships with industry. These partnerships could involve reducing the amount of saturated fat in foods, increasing the range of healthy options and decreasing portion size. There is clear evidence to support this recommendation in UK studies and some US studies from 2006-2008 to support this.
The Australian Division of World Action on Salt and Health (AWASH) is actively working with key stakeholders to reduce Australian intake of salt, currently at 9.0g per day to 6g per day. 27
A salt reduction campaign in the UK has resulted in a significant improvement in reduced salt intake. The Foods Standards Agency (FSA) recently published figures which showed that the UK’s average daily salt consumption has fallen from 9.5g to 8.6g since 2000. 28 The UK government has set a salt intake target of 6 g per day, potentially preventing 20,200 premature deaths a year.
The reduction in salt consumption in the UK was achieved through the food industry voluntarily reformulating products, in addition to achieving behavioural changes in consumers. The evidence from the UK indicates that there are opportunities within in the Australian context for similar gains in fat and salt reductions.
This recommendation links closely with one of the key priorities of the National Preventative Health Taskforce, “Reshape industry supply and consumer demand towards healthier products”. The Taskforce could facilitate further work on government/NGO/industry partnerships with saturated fat and salt reduction targets a first priority.
G1.2. Support the work of the National Preventative Health Taskforce in developing national policy and strategy to improve nutrition and reduce alcohol and tobacco consumption, with a focus on reducing lifestyle related risks in socially and economically disadvantaged populations.Higher consumption of tobacco and alcohol and low-level consumption of fruit and vegetables are among the top seven preventable risk factors that influence the burden of disease. Modifiable risk factors make up 32% of the burden of disease in Australia. 29 The World Health Organisation (WHO) identifies the key lifestyle risk factors for CVD as increases in high energy, low nutrient diets, reduced physical activity and increased tobacco consumption. 30
The National Preventative Health Taskforce was established by the Federal Minister for Health in April 2008 to advise on preventative health action for Australia, in particular strategies to improve action on obesity, tobacco and alcohol. A National Health Preventative Strategy will be announced in June 2009 and will for the blueprint for preventative health reform.
The taskforce has released a discussion paper entitled “Australia the healthiest country by 2020 – a discussion paper”, which outlines a range of suggested policy and strategic directions to be taken to develop a strong preventative health framework for Australia.
The Taskforce has identified the increased risk of CVD in populations with higher social disadvantage. This is supported by international studies which also demonstrate increased risk of CVD in groups with higher socioeconomic disadvantage. 31 There are a number of reasons for this difference, including poorer access to good nutrition and higher smoking rates. Strategies to reduce smoking rates, lower consumption of alcohol and improve access to good food should include specific actions aimed at improving outcomes for populations with higher social disadvantage, including Indigenous Australians.
G2.1. Implement culturally oriented and effective CVD rehabilitation within Indigenous communities, within mainstream and Aboriginal specific health services.Utilise the outcomes of work undertaken by the NHMRC 32 and other Indigenous Health stakeholders, in particular the development of rehabilitation and secondary prevention guidelines, to support Aboriginal Community Controlled Health Services and mainstream health services develop appropriate rehabilitation programs. In particular utilise the guidelines for cultural competency within mainstream services. Establish performance indicators and enhanced funding agreements or consider the use of accreditation programs to achieve better practice.
Issues regarding access to CVD rehabilitation exist for Indigenous Australians living in urban, rural and remote settings. However, CVD outcomes for Indigenous Australians living in remote communities are worse. 33 The existence of groups, who are relatively worse off within a population group that has generally poorer outcomes, should be considered in the planning of action strategies for this recommendation and the next.
A lack of understanding of Aboriginal and Torres Strait Islander culture, concepts of health and history, and Western-dominated models of care can result in Indigenous Australians feeling disempowered and less likely to use health services (Bailey 2005). According to Anderson et al (2004), Aboriginal and Torres Strait Islander peoples may need a different approach when consulting a GP, because of differences in how Indigenous people respond to illness and how they interact with health care providers. 34
Difficulties in communicating with service providers may also affect treatment choices and treatment outcomes. Around 11% of Indigenous adults reported that they had difficulty understanding and/or being understood by service providers. Indigenous people living in remote areas were more likely than those in non-remote areas to report experiencing difficulty (19% compared with 8%) (ABS & AIHW 2005).
Cardiac rehabilitation is designed to minimise functional, psychological and social disability, while stroke rehabilitation aims to improve function and/ or prevent the deterioration of function and facilitate the highest possible level of independence.
The Framework notes that Indigenous Australians die from heart, stroke and vascular disease at twice the rate of other population groups 35 and are less likely to access Cardiac rehabilitation programs than non indigenous Australians.
Models of care that focus on self management and coordination through General Practice are probably not the most appropriate for Aboriginal & Torres Strait Islander people, instead flexible methods are needed.
Key elements of an effective Indigenous rehab program include:
- cultural competency within the organisation;
- involvement of Aboriginal Health Workers and family, community involvement;
- incorporation of elements within existing community activities;
- specialist education for staff; and
- specific planning for Aboriginal & Torres strait Islander people in the planning and delivering of mainstream services. 36
This recommendation and the following recommendation are heavily dependent on strategies to improve the number and capacity of the health workforce generally and in particular the workforce supporting services to the Indigenous community. Currently there are significant shortfalls in the health workforce, especially in remote areas.
G2.2. Support the implementation within jurisdictions of national strategies and guidelines to address low intervention rates for Indigenous people presenting to hospital with heart disease and stroke.COAG’s National Indigenous Reform Agenda (NIRA) provides an overarching summary of action being taken in the commitment to closing the gap in Indigenous disadvantage. COAG has also agreed to an Indigenous Health NP worth $1.6 million over four years. This proposal includes expanded primary health care and targeted prevention activities to reduce the burden of chronic disease.
Indigenous Australians have higher rates of illness and death from cardiovascular diseases. The average life expectancy for Indigenous Australians is 17yrs less than other Australians. They are more likely than other Australians to have a major coronary event and to die afterwards. Their health care needs are also more complex when they present to hospital. 37
Of major concern is the fact that Indigenous Australians are less likely to receive coronary procedures to treat their coronary heart disease when they do present to a hospital. The AIHW advises that in 2002 - 03 Indigenous Australians admitted to hospital with chronic heart disease were 40% less likely than other Australians to receive percutaneous coronary interventions (PCI) and 20% less likely to receive coronary artery bypass grafts (CABG) as other Australians. 38 The AIHW further advises that “Compared with other Australians, in 2002 – 2003 Indigenous Australians were 3.0 times as likely to suffer a coronary event such as a heart attack, 1.4 times as likely to die it without being admitted to hospital, and 2.3 times as likely to die from it if admitted hospital. 39 In hospital they were less likely to be investigated by angiography and receive coronary angioplasty, stenting or coronary bypass surgery. “ This information builds a driving argument for improving access and intervention rates.
The particular strategy arising out of this recommendation should include the development of clinical protocols and guidelines to support culturally appropriate better practice in the hospital environment. The application of targeted performance measures will support accountability. This strategy should contribute to and be informed by foundation elements relating to collection of clinical data to guide clinical practice and track clinical outcomes.
G2.3 Develop specific strategies to address poorer outcomes and lower intervention rates for people with higher levels of social and economic disadvantage.Many studies show that people or groups who are socially and economically disadvantaged have reduced life expectancy, premature mortality, increased disease incidence and prevalence, increased biological and behavioural risk factors for ill health, and lower overall health status. Results from the 2004- 05 National Health Survey (NHS) indicate that people with lower socioeconomic status are more likely to smoke, exercise less, be overweight and/or obese, and have fewer or no daily serves of fruit. These are risk factors for a number of long-term health conditions such as respiratory diseases, lung cancer and cardiovascular disease. 40
The AIHW advises that if everyone experienced the same hospitalisation rate as that in the least disadvantaged areas, around 16% of all CVD hospitalisations, and 38% of emergency CHD and 24% of stroke hospitalisations, would have been avoided in 2003–04. This translates to almost 45,400 CVD hospitalisations, which includes over 22,500 for CHD emergencies and just over 3,400 for stroke. 41
There is also evidence to indicate that intervention rates are lower for people from the more disadvantaged groups. The AIHW advises that, although CVD mortality and morbidity are higher in the more disadvantaged groups, coronary procedures are lower, particularly for coronary angioplasty. In addition drug-eluting stents are more likely to be used with less disadvantaged groups and base metal stents with more disadvantaged groups. 42 Although these observations are based on limited data, this indicates an area where further research and specific strategy development is required.
Strategies should be developed in consultation with the relevant cultural groups and link to best practice guidelines.
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G3.1. Test a range of linked strategies to improve the management of patients with cardiovascular disease, involving all health sectors (General Practice, public health services, NGO’s, other private providers) within identified communities.Within Australian jurisdictions there are a number of initiatives already in place to develop integrated models of care within a community and across general practice, publicly funded primary health care services and private providers. Examples include the HealthOne NSW strategy and GP Plus in South Australia. These models are based on international research that indicates improved outcomes for a range of conditions through the application of co-ordinated clinical care within integrated health services.
An example is the “medical home”, a concept that originated in the USA, in response to shortages in primary health care physicians and the increasing rates of chronic disease. The medical home is a model of care that is grounded in primary health care and offers a care co-ordination model, which ensures people with chronic illness access the appropriate levels and types of care for their conditions at all stages of their disease, including preventative and primary, secondary and tertiary care, within a framework of integrated interprofessional care management. The model delivers on improved quality of care and reductions in errors but it requires health professionals to make changes to their practices in order for it to work effectively. 43 44
This can be a challenge. For example, a 2006 survey indicates Australian GPs were less likely than primary health care doctors in the UK, Netherlands, Germany or New Zealand to use a multidisciplinary team approach to the management of chronic conditions. They were also less likely to identify their practice as well prepared to manage chronic conditions than their counterparts on the UK, Germany and the Netherlands. 45
A potential vehicle through this recommendation could be implemented is the Australian Primary Care Collaboratives initiative, which has, according to a number of stakeholders, become a viable and effective means by which general practice can apply evidence based models of care and measure their performance to improve practice. The Collaboratives would need to be broadened to include primary health care partners such as community health services and NGO’s.
Coronary Heart Disease (CHD) is the largest single cause of death in Australia and people who have had a heart attack are at high risk of experiencing a future heart attack 46. People who have experienced a stroke and their families are in need of ongoing specifically tailored rehabilitation, care and support. 47 Therefore it is important to ensure that people who have experienced a cardiac event or a stroke are effectively followed up within primary care
Improving the co-ordinated management of people with CVD in General Practice-led models will not only maximise quality of life but will also assist with reducing hospital readmissions and reducing the risk of further disability or death from a recurrent cardiovascular event. A specific CVD program would complement the risk assessment and management strategy, particularly if it focused on the following initiatives:
Coordinated multidisciplinary team care is widely considered to be essential in the effective treatment of people with chronic disease. It has been demonstrated to improve the quality of care and economic analysis indicates that well planned and comprehensive multidisciplinary strategies are cost effective.
- Developing or enhancing existing multidisciplinary teams to co-ordinate CVD care, especially in rural areas by utilising existing regional strategies (led by general practice or by jurisdictions) to integrate care across the system.
Specifically, in relation to heart failure it has been demonstrated that Chronic Care programs that engage multidisciplinary teams in the delivery of patient care result in a decrease in hospital readmissions for heart failure patients. 48
A key element in successful programs is the development of written and individualised shared management plans developed by the client and their Health professional and care provider. Other essential components include shared information systems, clinical review by a General Practitioner and appropriate ongoing follow up and support by the team.
Cardiac rehabilitation involves individual assessment, holistic goal setting, treatment, review, planning & follow up by an interdisciplinary team of health professionals with specialist knowledge of cardiac disease. Effective rehabilitation services help to support self management and independence and assist people with cardiac disease to achieve optimal function through encouraging lifestyle modification, addressing psychosocial risk factors and improving the use of medication. While cardiac rehabilitation is a well recognised as an effective secondary prevention measure, participation rates are low. It has been identified that this is due to both a lack of initial referral and failure of the person to attend once referred. 49 50 Key factors that contribute to this include; lack of rehabilitation programs particularly in rural and remote areas, transport difficulties, work commitments, lack of knowledge about risk factors and the value of rehabilitation to a person’s quality of life.
- Addressing low rates of participation in rehabilitation and on-going prevention programs for people who have suffered a stroke, heart attack or unstable angina.
Stroke rehabilitation is a comprehensive program which is developed to address the specific disabilities of each individual and focuses on improving functioning to the maximum possible. It addresses a range of functional disabilities including limb weakness, communication difficulties, swallowing, cognitive functioning, bladder and bowel function as well as the psychosocial impacts of the stroke. Stroke rehabilitation occurs initially in the acute setting but can then be provided in inpatient, outpatient or community settings. In both cases, it is best provided by multidisciplinary teams to address the complex care requirements. Evidence indicates increased patient satisfaction with rehabilitation within the community, where general practice and other primary health care provider have a critical role. There is evidence that rehabilitation can continue to improve outcomes several years after, so ongoing assessment and access to rehabilitation is important for people who have experienced a stroke. 51 There are clear clinical practice guidelines for care after a stroke.
Unfortunately people with the most need for services and potential to benefit from rehabilitation services are often unable to access them. It is essential that rehabilitation programs are easy for people to access as early as possible.
Strategies to address low participation rates need to include addressing the system factors such as the adoption of rehabilitation guidelines, discharge planning, communication between hospitals and primary care, rural and remote access and the treating physician’s attitude to cardiac or stroke rehabilitation. In addition a national audit of CVD rehabilitation programs and routine and inclusive referral procedures to an effective rehabilitation program are recommended.
CVD co-ordination and support roles might range from dedicated positions in specialist units to clearly defined and supported roles for new or existing staff in NGO’s, community-based organisations, community hospitals, primary health care centres, Divisions of General Practice or GP surgeries.
- Establishing a CVD co-ordination and support function within communities. This may be located within existing health services, NGOs or community-based organisations according to best or most suitable models.
People with CVD have complex care needs and must interact with many different services and individuals, at a time when they are probably least equipped to do so. Carers also need support and advice to continue in a highly stressful role. The health, social support and community care systems available to patients and their carers are complex and poorly co-ordinated. For individuals with complicated and multi-faceted care needs these systems can become virtually unnavigable.
Australian CVD co-ordination and support models need to be developed and evaluated for urban and rural settings as the environment and resources available in these two settings are very different. CVD coordination and support should at the least include assistance with coordination of ongoing care, liaison between various service providers and the provision of information about community and support services.
There are some excellent national examples available, for example Heart Support, which is a volunteer, notfor- profit organisation and provides support information and encouragement for people with a heart condition and their families, has branches in most states and territories 52. Heart Support supports selfmanagement and rehabilitation for people with a heart condition. Trained members, who have been heart patients themselves, provide support to other heart patients in their area.
The National Stroke Foundation is rolling out a research-based Self Management Program in Melbourne to assist stroke survivors get their lives back on track after stroke. 53 The program is run by a health professional and a trained volunteer and is co-facilitated by a stroke survivor or carer from the local community.
G4.1 Establish comprehensive stroke services covering acute, post-acute and rehabilitation care at every hospital admitting more than 200 acute stroke patients per year and in relevant smaller hospitals and strengthen networked access to Stroke Care Units for rural hospitals.Access to stroke care units or alternate models (for rural and remote communities) is a critical intervention point in the NSIF. Stroke units are already in place in many major hospitals throughout Australia; however research indicates that there is some variability in the capacity of some stroke care units to deliver evidence-based therapeutic interventions for stroke within required time frames; 54 this is supported by anecdotal information from jurisdictional representatives, which also indicates some variability between units.
Half the survivors of stroke are left with a level of disability that leaves them dependent on people for activities of daily living. 55 The benefits of care within a stroke unit are now well recognised and there is clear evidence of improved outcomes for stroke patients in stroke units 56. At present only 1 in 2 stroke patients receive stroke unit care, which is defined as “dedicated, coordinated care for stroke patients in hospital under a multidisciplinary team who specialise in stroke management in a stroke unit”. 57 The NSF advises if 80% of strokes were treated in stroke units, health gains could be improved by 7, 200 DALY’s.
The NHMRC advises that stroke patients who receive care in a stroke unit have better outcomes than those who do not. 58 This is supported by a Cochrane systematic review. Ideally stroke units include a dedicated inpatient ward and a service which combines acute, post-acute and rehabilitation services within the one unit, providing multidisciplinary care from a team of doctors, nurses and allied health. Specific features contributing to improved outcomes include access to diagnostic and scanning, continuity of care, ongoing education for multidisciplinary team members, clear clinical protocols which are followed by the team and early access to rehabilitation.
The NHMRC (NICS) further advises that “based on numbers needed to treat (NNT) , if all patients in Australia experiencing a stroke were treated in a stroke unit, 900more people would survive, 1,500 more people would regain their independence and a further 1,500 people would return home” 59
Currently not all hospitals with over 200 stroke presentations have dedicated stroke units. Variability in service scope and standards could be managed through the development of specific service standards and performance measures.
The current Australian Guidelines recommend all people should be admitted to a comprehensive stroke unit. 60 This recommendation is consistent with international recommendations and is based on high level evidence.
The NSF has developed a set of defining criteria and recommended services for the different levels of stroke services that should be made available in different size hospitals. 61 The NSF recommends comprehensive stroke units with advanced functions such as capacity to manage complex strokes and delivery of intravenous tissue plasminogen activator (tPA) in hospitals with greater than 200 stroke patients admitted per year (120 in rural areas). In hospitals with less than 100 stroke patients admitted per year (80 in rural areas) stroke units may not be viable and the recommendation is to transfer to a hospital with a stroke unit.
While there is some discussion regarding the value of alternate approaches, such as mobile stroke services, 62 in the absence of a dedicated stroke unit, this approach is not supported by the NSF or the current Australian guidelines.
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G4.2. Support public education campaigns to help people recognise the warning signs of CVD and seek emergency treatment.It is important that the community has ongoing access to information that is evidence based, consistent and culturally appropriate in order to increase awareness of appropriate responses to a CVD event.
Information needs to be widely distributed through a variety of communication mechanisms at levels that have been demonstrated to be effective. An analysis of results of a range of programs suggests that to be effective, programs need to be ongoing, culturally appropriate, focused and targeted to high risk groups. 63
A range of government and non government organisations currently provide information about risk factors and risk reduction to the general population. The National Stroke Foundation has developed the FAST campaign, which describes symptoms and delivers the following message:
Face - Can the person smile, has their mouth drooped?
Arms - Can the person raise both arms?
Speech - Can the person speak clearly and understand what you say?
Time - Act FAST and call 000 immediately.
If you answer yes to any of these questions, act FAST and call 000. Stroke is always a medical emergency. Remembering the signs of stroke and acting FAST could mean saving a life. 64
Public information about stroke should include information on the importance of seeking treatment after a transient ischaemic attack (TIA) as TIA is a high risk factor for a stroke in the near future.
Advice from the National Heart Foundation is that the most recent Warning Signs activity by Heart Foundation in Australia was a short-burst, PR led campaign during Heart Week 2007. The key platform was Chest Pain. Call 000 - every minute counts. The objective was to reduce the length of time Australians wait between onset of heart attack warning signs and calling triple zero for an ambulance. The key campaign messages were :
- Chest pain and other warning signs of heart attack are serious and life threatening
- Warning signs of heart attack vary
- Call triple zero ((000) and ask for an ambulance if you, or someone near you, is experiencing warning signs of a heart attack
- Immediate actions by patients, bystanders and health professions will save lives
The Heart Foundation is currently in the process of developing a longer term strategic communications campaign relating to warning signs of heart attacks, which is a key initiative of the foundation's 2008 - 2012 strategic plan.
G5.1 Support an adequately resourced education campaign to increase awareness of high blood pressure and the importance of Absolute Risk Assessment (ARA) in the community and encourage people to seek ARA from their GP.Prior to commencing action on this recommendation, DoHA should be confident that the service system is configured correctly and can cope with additional demand. Current concerns, regarding the availability of evidence-based and timely treatment indicate system capacity building should be an area of focus first.
It will be important to undertake research to determine the required investment required to achieve significant benefits from a public education campaign. Evidence seems to suggest that there is a minimum amount of exposure to media below which the effectiveness of campaigns drops off. Particular attention should be paid to the information needs of vulnerable and high risk groups to ensure public education is targeted and effective for those groups.
G6.1 Use standards defined under the National Palliative Care Strategy to review existing palliative care services in order to assess and improve their capacity to provide appropriate care and timely access to those with end stage CVD.While palliative care services exist across all jurisdictions, they are often structurally and philosophically based within the framework of cancer care. Palliation is a service need, particularly for people with chronic heart failure, yet this is often overlooked by both referrers and service providers. Linkages between CVD specialists and palliation specialists may not always be strong.
There are a number of existing strategies and programs to support appropriate palliative care, including:
- National Palliative Care strategy
- Rural Palliative Care Program
- Palliative Care for People Living at Home Initiative
- Palliative Care Research Program
27 AWASH, www.awash.org.au
28 Food Standards Agency, United Kingdom, http://www.food.gov.uk/news
29 National Preventative Health Taskforce, Australia, the healthiest country by 2020 – a discussion paper, Commonwealth Government of Australia, 2008
30 WHO, Global Strategy on Diet, Physical Activity and Health, Cardiovascular Disease Prevention and Control, www.who
31 Davey Smith G & Hart C, Life-Course Socioeconomic and Behavioral Influences on Cardiovascular Disease Mortality: The Collaborative Study , American Journal of Public Health, August 2002, Vol 92 (8) , pp1295-1298
32 NHMRC, Strengthening Cardiac Rehabilitation and secondary Prevention for Aboriginal and Torres Strait Islander Peoples; A guide for health professionals, Australian Government, 2005
33 Communication from Professor Wendy Hoy
34 ABS & AIHW: The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008,
35 National Health Priority Action Council (NHPAC) (2006), National Service Improvement Framework for Heart, Stroke and Vascular Disease, Australian Government Department of Health and Ageing, Canberra
36 Hayman, N, Wenitong,M, Zangger,J, Hall,E, Strengthening cardiac rehabilitation and secondary prevention for Aboriginal and Torres Strait Islander peoples, MJA, vol 184, No 10, May 2006
37 AIHW CVD series number 26 Aboriginal & Torres Strait Islander people with coronary heart disease report summary report , Sept 2006, Australian Government, Canberra
38 AIHW, Aboriginal and Torres Strait Islander People with Coronary Disease – summary report, Australian Government, 2006
39 Australian Institute of Health and Welfare, Australia’s Health 2008, Australian Government, Canberra: AIHW.
41 AIHW Bulletin 37, Socioeconomic Inequalities in Cardiovascular Disease in Australia – Current Picture and Trends Since 1992, August 2006, Canberra
43 Rosenthal TC, The Medical Home: Growing Evidence to Support a New Approach to Primary Care, The Journal of the American Board of Family Medicine 21 (5): 427-440 ,2008
44 . Berenson A, Hammons T, Gans D N et al., A House Is Not a Home: Keeping Patient at the Center of Practice Redesign, Health Affairs, September/October 2008 27(5):1219–30
45 Schoen C, Osborn R, Trang Huynh P et al. (2006 Nov 2). On the front lines of care: Primary care doctors’ office systems, experiences, and views in seven countries. Health Affairs; Web Exclusive: w555–w571. in Health Council of Canada Annual Report to Canadians, 2006
46 NHF, NSF, Submission on the 2009-10 Federal Budget A National Action Plan for Cardiovascular Disease, Nov 2008.
47 Lindley R, Community Care After Stroke, reprinted from Australian Family Physician, Vol 36, No 1, Nov 2007.accessed at www.racgp.org.au on 23/01/09
48 Mc Alister,F, Stewart,S Ferrua, S, McMurray, J, Multidisciplinary Strategies for the Management of Heart Failure Patients at High Risk for Admission, Journal of the American College of Cardiology, vol 44, No 4, 2004
49 Bunker, S, Goble, A, Cardiac Rehabilitation: under referral and underutilization, MJA, vol179, Oct 2003
50 Sochalaski, T, Jaarsma, T, Krumholz, H et l., What Works in Chronic Care Management: The Case of Heart Failure, Health Affairs, 2009
51 Pollack M & Disler P, Rehabilitation of patients after stroke, MJA, 2002, 177 (8), pp452 - 6
54 Anderson C, Clinical stroke guidelines – where to now?, MJA, 2008, 189 (1), pp4 – 5.
55 National Health Priority Action Council (NHPAC) (2006), National Service Improvement Framework for Heart, Stroke and Vascular Disease, Australian Government Department of Health and Ageing, Canberra
56 Optimising Care for Stroke Patients, NICS, Evidence – Practice Gaps Report, Vol 2, 2005
57 National Heart Foundation & National Stroke Foundation, Submission on the 2009-10 Federal Budget: A National Action Plan for Cardiovascular Disease, Nov 2008
58 NHMRC, NICS, Optimising Care for Stroke Patients, Experience – Practice Gaps Report, Vol 2, 2005
60 National Guideline Clearinghouse, Clinical Guidelines for Acute Stroke Management, www.guideline.gov
61 National Stroke Foundation, Acute Stroke Services Framework Summary 2008, www.strokefoundation.com.au
62 Van der Wait A, Gillgan A, Cadhilac D, Brodtmann A, Pearce D & Donnan G, Quality of stroke care within a hospital: effects of a mobile stroke service, MJA, 2005, 182 (4), pp 160 – 3.
63 Finn J, Bett J, Shilton T, Cunningham C, Thompson P, on behalf of the National Heart Foundation of Australia Chest Pain Every Minute Counts Working Group, Patient delay in responding to symptoms of possible heart attack: can we reduce time to care? MJA (2007); 187 (5): 293-298
64 Hunter New England Area Health Service, New South Wales Government, http://www.hnehealth.nsw.gov.au/news
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