New Australian research highlights gaps in treating cardiovascular risks
Heart attacks, strokes and other vascular diseases are a major driver of the life expectancy gap between Indigenous and non-Indigenous Australians. Indigenous Australians are 2.6 times more likely to die from them.
So a new study highlighting significant gaps in the identification and treatment of cardiovascular disease in Indigenous Australians has important national implications. In parallel with a separate study on risk assessment and treatment in mainstream general practice, it highlights the need for wide scale reform to ensure that people at the highest risk of having a stroke or heart attack are identified early and provided with optimal care.
Absolute risk management in cardiovascular disease recognizes that risk factors should not be regarded in isolation but need to be considered as a whole so that risk can be properly assessed and treatment can be targeted to those most likely to benefit.
"The recognition of absolute risk has been around for a while but we wanted to test how much it is being practised at the coal face" said Dr David Peiris, senior research fellow at The George Institute, a GP and an author on both studies.
Key Kanyini Findings
An audit of a random sample of 1165 health care records was conducted with seven Aboriginal Community Controlled Health Services and one state government Indigenous health service spread across NSW, Queensland and central Australia. This study, known as the Kanyini Audit, is the first leg of the Kanyini Vascular Collaboration, a national health services program established to improve vascular disease outcomes for Indigenous people. The collaboration includes The George Institute, the Baker IDI Heart and Diabetes Institute, Aboriginal communities, government and other organisations. (Kanyini is a term used by a number of language groups in central Australia which can be translated as "to have, to hold and to care".)
The Kanyini audit found substantial gaps in both screening and prescribing for Indigenous people at high risk of cardiovascular disease. 53% were not adequately screened for cardiovascular disease risk according to national guidelines.
Under-screening was significantly associated with younger age and less frequent attendance at health services though not with remoteness of location. "Quite a lot of people are getting quite haphazard screening. They might receive some things but not a comprehensive overview of their vascular health", said Dr Peiris. However in an encouraging finding, the use of Medicare Health Assessments was associated with significantly smaller screening gaps.
Of those with cardiovascular disease, 60% were prescribed a combination of blood pressure medicines, statins and anti-platelet agents, and of those high risk individuals without cardiovascular disease, 44% were prescribed blood pressure medicines and statins. Around one third of high risk people were classified by both National Heart Foundation guidelines and Pharmaceutical Benefits Scheme subsidy criteria as not qualifying for statin therapy.
Although these gaps are large, a key finding was that patient management was substantially better at Indigenous health care sites than in the parallel study conducted in mainstream general practices. In the mainstream GP study, only 46% of people with cardiovascular disease were prescribed appropriate therapy and only 20% of high risk individuals without cardiovascular disease were prescribed blood pressure medicines and statins.
A new way to diagnose cardiovascular risk
Dr Peiris emphasised that, although measuring vascular risk is essential, it "doesn’t necessarily confer better performance or better patient outcomes on their own. Making that link between measuring and doing something about it is needed", he said.
He said conflicting and multiple guidelines were a barrier to the uptake of absolute risk-based management. While new assessment guidelines were a step in the right direction, unified treatment guidelines were still some years away. GPs meanwhile were confronted with a confusing array of information when deciding on treatments.
To help bridge the gap, researchers at The George Institute have developed and tested an electronic decision support tool for health practitioners which analyses patient details and generates an absolute risk assessment and management plan. This will ensure easier adherence to guidelines. The Baker IDI Heart and Diabetes Institute is developing integrated models of care for vascular disease involving nurse-led specialist clinics. In addition, both institutes are testing a polypill which combines four proven risk reduction medicines into one low cost pill which is easy to prescribe, administer and take.
"There remains significant gain that can be achieved in reducing the enormous burden of heart disease in our community, simply by identifying and managing risk with the tools and therapies we already have at our disposal", said Dr Alex Brown, Chief Kanyini Investigator, the Baker IDI Heart and Diabetes Institute.