Abstract: Background Chronic Heart Failure (CHF) is defined as a complex clinical syndrome that is frequently, but not exclusively, characterised by objective evidence of an underlying structural abnormality or cardiac dysfunction. CHF affects up to 3% of the adult population and this rate is consistent throughout the developed world. In spite of the proven efficacy of treatments, there is a common theme of low implementation rates for recommended therapeutic guidelines. In Australia, where access to specialist CHF management is limited, the burden of care, for the 40% of CHF patients living outside capital cities falls predominantly onto community- based general practitioners (GPs). Unfortunately, there are diminishing numbers of GPs in rural and remote regions and this has created an apparent dual deficit in terms of equitable access to primary and specialist care for the CHF population living in these areas. Aims The purpose of this research was to determ ine, in a series of themed studies, the population distribution, management and potential information technology solutions for CHF in rural and remote Australia. Method Appropriate methods were utilised for each study and included epidemiological studies, a quantitative analysis of a large practice audit, geo-mapping, a systematic review, a case study review and a qualitative analysis of participant feedback and clinical notes. Results Using results from the Australian Bureau of Statistics population census of 2001, it was estimated that approximately 335,000 Australians (58% male) had symptomatic heart failure associated with bot h left ventricular systolic dysfunction (LVSD) and diastolic dysfunction and an additional 214,000 had asymptomatic LVSD. Of the total symptomatic population, 140,000 (40%) lived in rural and remote areas with a higher prevalence of CHF in rural Australia (19.8%) than in capital cities (16.9%) within the population over 45years. In 2004/05 only 5,000 of the total CH F patients discharged from hospital received specialist management. Ninety-six per cent of all CHF specialist services were located in Capital cities. The 4% that were located outside capital cities serviced a total of 80 patients. The mean distance from any Australian population centre to the nearest CHF management program was 332 km (median 163 km, range 0.15 – 3246 km). In rural areas where the burden of CHF management falls upon the GP, the mean distance to GP services was 37 km (median 20 km, range 0 km – 656 km). A practice audit of rural versus urban CHF management revealed that, CHF diagnosis using echocardiography was lower in rural and remote areas compared to urban (52% vs. 67.3%, p<0.001) areas. Rates of specialist referral were also significantly lower in rural and remote areas (69.6% vs. 59.1%, p<0.001) as were prescribing rates of angiotensin converting enzyme inhibitors (ACEI) (60.1% vs. 51.4%, p<0.001). There was no geographical variation in prescribing rates of beta- blockers across areas (11.8% vs. 12.6%, p< 0.32). Overall, only 3% of all Australians received gold-standard evidence based practice (Diagnosis by echocardiogram + ACEI + Beta Blocker) and there was statistically less prescription of recommended pharmacotherapy in rural areas. In rural Australia, the distances to CHF management programs or, where these are not available, to GP care, preclude CHF models of care such as home visiting. As a consequence, consideration needs to be given to alternate solutions of care, including GP-based multidisciplinary team approaches and/or the use of information technology to bridge the ga p between very remote communities and centres of care. Telemonitoring and structured telephone support have shown great potential in supporting CHF patients in their homes by reducing CHF hospitalisation rates by 22% (95% CI, 11% to 32%) and all-cause mortality by 21% (95% CI, 8% to 31%); However, the requirement of multistate licensure for all Australian health professionals to practice nationally has been identified as a barrier to telemonitoring practise. In spite of the bureaucratic hurdles, the Chronic Heart Failure Assistance by Telephone (CHAT) study has shown that elderly CHF patients can adapt quickly, find the use of telemonitoring an acceptable part of their healthcare routine, and are able to maintain good adherence for least 12 months. Conclusion The burden of CHF was significant in rural and remote Australia, due to a higher prevalence of the disease and issues in accessing appropriate healthcare. Overall this research has shown how disenfranchised these patients are and why we need solutions. With the likelihood of more cases of CHF within our ageing population and the release of the new 2006 Australian therapeutic guidelines, there is a clear need to better understand and support the rural health workforce, to promote best practice in accurately diagnosing and managing CHF and ultimately improving health outcomes at the individual and population levels.
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|Number of pages||332|
|Publication status||Published - 2007|