Developing a Chronic Disease Model of Care for Coronary Artery Disease and

Depression in Rural Settings

Dr Steve BunkerProf James DunbarDr 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.

0 1 2 3 4 5

Low Risk High Risk

Age

HT Stage 2

Smoking

Diabetes

LDL>160

HDL<35

Depressed Mood

Clinical Depression

Depression and relative risk of developing CHD

Days after MI Discharge

Su

rviv

al f

ree

of

card

iac

mo

rtal

ity,

cu

mu

lati

ve %

Depression following myocardial infarction

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

The INTERHEART Study

Musselman, D. et al. (1998). The Relationship of Depression to Cardiovascular Disease. Epidemiology, Biology and Treatment. Archives of General Psychiatry 55: 580-592.

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

The ten leading causes of disease burden in developed countries 1990–2020

Self-inflicted Injuries 10Stomach cancer

Chronic obstructive pulmonary disease9Colon and rectal

cancers

Dementia and other CNS disorders8Congenital anomalies

Osteoarthritis7Lower respiratory infections

Alcohol use6Perinatal conditions

Road traffic accidents5Self-inflicted injuries

Trachea bronchus & lung cancers4Trachea bronchus & lung cancers

Unipolar depression3Road traffic accidents

Cerebrovascular disease2Cerebrovascular disease

Ischaemic heart disease1Ischaemic heart disease

2020 disease or injury2 Rank order1990 disease or injury1

Cardiovascular will remain the leading cause of disease burden

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. 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.

2. Gaining management commitment from participating organisations.

3. Creating a Clinical Pathways Team, scoping the Pathway and developing Process Maps.

4. Health Provider Interviews.

5. Discovery Interviews with patients and carers at discharge and 8 weeks. Interviews with GPs of patients at 8 weeks.

6. Identifying best practice model of care for specific patient groups.

7. 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

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)

Pilot Implementation

Chronic Disease Management: Depression and CHD

Practice ProtocolNHFA Guideline

Database

Register of patients

Periodic Recall

Assessment by Protocol

Database

Audit of CHD Population

Proposed intervention (modified from Rozanski*)

SEVERE

MODERATE

MILD

Stepped Interventions

Degree Of Psychosocial Distress

Step 3

Step 2

Step 1

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