Transcript Developing a Chronic Disease Model of Care for Coronary Artery Disease and Depression in Rural Settings Dr Steve Bunker Prof James Dunbar Dr Prasuna Reddy Greater.

Developing a Chronic Disease Model of
Care for Coronary Artery Disease and
Depression in Rural Settings
Dr Steve Bunker
Prof James Dunbar
Dr Prasuna Reddy
Greater Green Triangle
University Department of Rural Health
The Greater Green Triangle Region
Why
depression?
Background
•
In 2003, the National Heart Foundation of
Australia (NHFA) published the results of an
evidence-based review which concluded that
depression is an independent predictor for
adverse cardiac outcomes. (Bunker S. et al. Med J Aust
2003;178:272-6)
•
These findings have since been incorporated
by the NHFA into clinical practice guidelines
for preventing cardiovascular events in
people with coronary heart disease. (Reducing
Risk in Heart Disease. National Heart Foundation of Australia &
Cardiac Society of Australia and New Zealand, 2004.
Depression and relative risk of
developing CHD
Age
HT Stage 2
Smoking
Diabetes
LDL>160
HDL<35
Depressed Mood
Clinical Depression
0
Low Risk
1
2
3
4
High Risk
5
Survival free of cardiac
mortality, cumulative %
Depression following myocardial
infarction
Days after MI Discharge
The INTERHEART Study
Risk factor
Odds ratio PAR%
Abnormal lipids
3.25
49.2
Cigarette smoking
2.87
35.7
Psychosocial stressors
2.67
32.5
Diabetes
2.37
9.9
High blood pressure
1.91
17.9
Abdominal obesity
1.62
20.1
Yusuf, S., et al. The Lancet 3rd Sept 2004
Musselman, D. et al. (1998). The Relationship of Depression to Cardiovascular Disease.
Epidemiology, Biology and Treatment. Archives of General Psychiatry 55: 580-592.
Cardiovascular will remain the leading
cause of disease burden
The ten leading causes of disease burden in developed countries 1990–2020
1990 disease or injury1 Rank order
2020 disease or injury2
Ischaemic heart disease
Cerebrovascular disease
1
2
Ischaemic heart disease
Road traffic accidents
3
Unipolar depression
Trachea bronchus & lung cancers
4
Trachea bronchus & lung cancers
Self-inflicted injuries
5
Road traffic accidents
Perinatal conditions
6
Alcohol use
Lower respiratory infections
7
Osteoarthritis
Congenital anomalies
8
Dementia and other CNS disorders
Colon and rectal cancers
9
Chronic obstructive pulmonary disease
Stomach cancer
10
Cerebrovascular disease
Self-inflicted Injuries
1. Murray and Lopez. Global Burden of Disease Study. 1996. 2. Murray and Lopez. Global Burden of Disease Study. 1997
Note: Disease burden is measured in disability-adjusted life years (DALYs), a measure that combines the impact on health of
years lost due to premature death and years lived with a disability. One DALY is equivalent to one lost year of healthy life
Aim
• The aim of this study, funded by the National Heart
Foundation of Australia, is to implement the
evidence-based guidelines into routine clinical
practice.
• A model of care, incorporating a clinical pathway,
will be developed to identify depressive symptoms in
acute coronary syndrome (ACS) patients at the time
of hospital discharge and eight weeks later when
assessed in the primary care setting.
Methodology
1.
2.
3.
4.
5.
6.
7.
Identification of current activities in Australia and overseas in
relation to the development and implementation of clinical
pathways for depression and CHD and other co-morbid
chronic illness.
Gaining management commitment from participating
organisations.
Creating a Clinical Pathways Team, scoping the Pathway and
developing Process Maps.
Health Provider Interviews.
Discovery Interviews with patients and carers at discharge
and 8 weeks. Interviews with GPs of patients at 8 weeks.
Identifying best practice model of care for specific patient
groups.
Pilot implementation of model of care and evaluation of
guidelines.
Study Sites
South Australia:
• Mount Gambier Hospital
• Limestone Coast Division of General Practice
Victoria:
• Wimmera Health Care Group
• West Vic Division of General Practice
Target Numbers
• 30 patients (+ carers, GPs) in Mount Gambier
• 30 patients (+ carers, GPs) in Wimmera
Process Mapping the Patient Journey
Steps
• Admission interview with patient and
carer
• Interviews with health staff
• Eight week interview with patient and
carer
• GP interview at eight weeks
• Process mapping day
Participants
• 57 patients (22 Women & 35 Men)
• 57 carers (mainly spouses and adult
children)
• 18 Health Professionals
• 18 General Practitioners
GP suggestions to identify acute coronary syndrome
patients with psychological issues such as depression
•
•
•
•
•
•
Continuity of care (not just a tool to pick up)
Ask them specific questions (including family
history)
Rating scale tool (must be concise as there is
not time)
Political issues: not enough funding for rural
mental health
Public awareness, education
Time is a problem (may need to tell the
receptionist to get a longer consultation)
Conclusions
• Depression is hard to identify by interview
• Symptoms seldom volunteered by patient
• Patients, carers and health care providers
generally attribute the symptoms of
depression to the heart disease itself
• Rate of identified depression well below
rates reported from studies of hospitalised
patients using routine screening
Recommendations
When should patients be screened?
(a) Prior to discharge
(b) 8 weeks from the event and
(c) 3 to 6 months from the event
What screening tool should be used?
HADS and PHQ 9
Who should do the screening?
(a) Cardiac rehab nurse
(b) GP or Practice nurse
Where should patients be screened?
(a) Hospital
(b) Cardiac rehab
(c) Primary care
Previous history of depression needs to be assessed
Pilot Implementation
Evidence-based best practice model of care for
people with co-morbid depression and
coronary heart disease:
Pilot implementation plan for Mt Gambier and
District Health Service and Limestone Coast
Division of General Practice (Hawkins
Medical Centre)
Chronic Disease Management:
Depression and CHD
NHFA Guideline
Practice Protocol
Database
Audit of CHD
Population
Register of patients
Periodic
Recall
Database
Assessment
by Protocol
Proposed intervention
(modified from Rozanski*)
Stepped
Interventions
Degree Of Psychosocial
Distress
Step 3
Step 2
Step 1
MILD
SEVERE
MODERATE
Examples
Add mental health care
specialist, and nurse
manager
Add BOMH, nurse
manager, and adherence
promotion (eg telephone
follow-up)
GP and nurse
follow
up
*Rozanski, et al. Psychosocial Risk Factors in Cardiac Practice. J Am Coll Cardiol 2005;45:637–51