Risk-guided disease management in coronary artery disease (Risk-Guided CAD)
Principal researchers: Associate Professor Melinda Carrington
Associate researchers: Professor Tom Marwick, Dr Quan Huynh, Associate Professor Jo-anne Manski-Nankervis, Professor Brian Oldenburg, Dr Dominika Kwasnicka, Associate Professor Erin Howden, Professor Garry Jennings, Professor David Thompson and Dr Deepak Haikerwal
Research/clinical nursing team: Ms Asmita Dalal, Ms Carla Duarte, Ms Glynis Cacavas, Ms Lilly Zhu and Mr Justin Braver
Risk-Guided CAD is a collaborative project between the Baker Heart and Diabetes Institute, Heartwest, The University of Melbourne and Queens University (Belfast).
Coronary artery disease (CAD) is a major cause of ill health in Australia and is an expensive disease group to treat owing to costly hospital readmissions. Many of these readmissions can be prevented with improved management. Predicting higher-risk patients with the greatest likelihood of recurrent hospital admission permits targeting of disease management/cardiac rehabilitation programs. which are known to improve long-term cardiovascular outcomes and quality of life. However current approaches to traditional models have tended to be insufficient. m-Health integrated with nurse management offers a valuable addition to patient care and for enhancing health service delivery.
We developed and tested the effectiveness of a novel disease management program (“Risk-Guided DMP”) in reducing hospital readmissions among patients with CAD who were identified as being at higher risk of readmission by using a simple and validated risk tool.
Risk-Guided DMP involves a nurse care co-ordinator who delivers a structured intervention entailing: 1) risk factor management; 2) tailored physical activity program; 3) mHealth via a mobile app and telehealth monitoring; and; 4) care planning and GP liaison.
This study brings together leaders in health care, implementation research and health economics with consumers/patients and industry groups in health care. A successful outcome will reduce mortality risks, improve quality of life and care and reshape the current practice of secondary prevention in Australia, as highlighted by the COVID-19 pandemic that different strategies can be used to deliver management and support.