Risk-guided Disease Management in Coronary Artery Disease
Australia101 participantsStarted 2021-07-17
Plain-language summary
Coronary artery disease (CAD) is the number one killer of Australians with a high risk for a recurrent event(s) and hospital readmission. Many of these readmissions can be prevented with better management to control the problem of CAD. A disease management program, led by nurses who interact with other health professionals/providers, can help with education and counselling, taking medications correctly and making healthy lifestyle changes for higher risk patients. Newer models of disease management programs make use of mobile devices (such as an "app") and telehealth (by phone or video call) to monitor and manage health which could facilitate CAD management. Therefore, the aim of this study is to test this type of disease management program (DMP) compared to standard care for reducing hospital readmissions or death in people with CAD who are at high risk of being readmitted. The Investigators envisage that a novel Risk-Guided DMP will be favorable to patients and associated with high-level participation. The Investigators hypothesize that high-risk patients randomized to Risk-Guided CAD will have reduced hospital readmissions or death compared with those randomized to usual care.
Who can participate
Age range30 Years – 74 Years
SexALL
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Inclusion criteria
✓. Aged between 30 to 74 years; AND
✓. Hospitalised with CAD or other eligible cardiac procedure or condition including acute myocardial infarction (STEMI or NSTEMI), unstable angina, coronary artery bypass grafting or percutaneous coronary intervention; AND
✓. Defined as higher risk (score \>= 5) by PEGASUS-TIMI 54 criteria; AND
✓. Eligible for Medicare.
Exclusion criteria
✕. Inability to provide written informed consent; OR
✕. Non-English speaking; OR
✕. Inability to attend clinic visits; OR
✕. Inability to engage with an app due to low technical literacy or lacking access to a smart phone or wi-fi; OR
✕. Hospitalised with a primary diagnosis of heart failure; OR
✕. eGFR \<30 ml/min/1.73m2 (CKD stage 4 or stage 5); OR