Towards enhanced cardiovascular disease prevention in Primary Health Care : pragmatic evaluation using embedded mixed methods

Abstract

Background Cardiovascular disease (CVD) and other lifestyle related chronic diseases are increasing at an alarming rate both in Australia and around the world. While Primary Health Care (PHC) has a key role in addressing CVD prevention, a large evidence to practice gap exists. The Expanded Chronic Care Model (ECCM) has emerged as a leading approach to chronic disease management. This model proposes a comprehensive approach to disease management that adds prevention and health promotion to direct clinical care. While elements of the ECCM have been implemented within Australia, a full comprehensive application and evaluation of the model has not been carried out. This research addresses this gap in knowledge. Using the ECCM as a basis, the role and capacity of the community-based lifestyle modification workforce to support PHC in the management of CVD and behaviour change for risk reduction were examined. The feasibility, effectiveness and sustainability of this augmented approach to care were examined along with broader implications related to reorientation of PHC towards prevention. Methods A mixed methods approach, embedded within an overarching case study in a single Australian jurisdiction (the Australian Capital Territory),was used to provide an integrated understanding of the real-world challenges of undertaking CVD management and prevention in contemporary PHC practice. The research design was guided by a number of interrelating theoretical and framing approaches governing different aspects of the research including: the transtheoretical model (stages of change); normalisation process theory; the expanded chronic care model and the complex adaptive system approach. A wide range of data was collected to examine the feasibility and effectiveness of the approach and to understand critical success factors for its implementation and sustainability. A one-group pre-post quasi experimental study was conducted to estimate health effects or assess process challenges and outcomes. Quantitative data from patient surveys and general practice clinical information systems were gathered and analysed. Process evaluation was conducted using surveys and clinical information systems data. Qualitative data were collected using semi-structured or focus group interviews with: intervention participants; patients not responding to the intervention invitation; general practice staff; lifestyle advisors (health coaches); allied health professionals; and community-based lifestyle modification programme providers. All data were analysed separately using descriptive and inferential statistics for the quantitative data and both thematic and single coding analyses for the qualitative data. Pattern matching was used to test the study findings against case study propositions. Results The intervention led to positive health and systems outcomes. There was a statistically significant reduction in population CVD absolute risk of 2.26%. Study programme participants were mostly satisfied with the service provided and all reported making positive changes to the health behaviours relevant to them. Patients who did not respond to the invitation to participate in the intervention reported varying levels of heart health education by general practitioners and practice nurses and only 44% had received a ‘heart and stroke check’ in the last two years. Interviews with these non-respondents highlighted that: existing relationship with a GP; apprehension to address CVD risk; and a low priority of addressing CVD risk influenced their choices not to participate. Further qualitative investigation revealed that more effort would be needed across multiple levels and stakeholders to implement such a complex intervention and embed evidence-based change into practice. Key barriers identified were: current funding mechanisms; the challenging nature of lifestyle modification; and the low value proposition of CVD prevention. The community-based sector, including allied health professionals and lifestyle modification programme providers, were highly motivated to contribute to CVD prevention but were underutilised and considered the level of funding available to be inadequate. The low value placed on and the ‘hard work’ of prevention was also noted. A need to improve cross-sector linkages were also highlighted. Overall, the case study propositions were confirmed, with the Expanded Chronic Care Model proving a useful framework to develop a whole-of-system approach to CVD prevention. An emergent theme from the research was that this chronic disease management system demonstrated many of the features of a complex adaptive system. These findings were synthesised into a complexity-informed Enhanced Chronic Care Model, providing both an explanation of the study outcomes and suggesting how best to progress ‘evidence to practice’ translation. Conclusion Reorientation of primary health care systems towards prevention continues to be highly resistant to change. The research undertaken here demonstrated that moving towards a CVD prevention-orientated PHC will need: 1. An improved value proposition for CVD prevention, 2. Better local health intelligence,3. Enhanced relationships between all stakeholders,4. A PHC workforce that has the skills to leverage added value to the system and 5. A more supportive policy environment.

Date of Award	2018
Original language	English
Supervisor	Rachel DAVEY (Supervisor), Tom Cochrane (Supervisor) & Lauren Williams (Supervisor)