Study alerts GPs to be proactive in activating CDM care plans

A retrospective analysis of 1.93 million adult Australian patient records over five years has uncovered multiple opportunities for GPs to improve care and reduce hospital admissions, morbidity and mortality.¹

The ‘Study of Heart failure in the Australian Primary carE setting (SHAPE)^*’, published in the Australian Journal of General Practice (AJGP), is said to be the first real-world long-term research into the management of heart failure in Australia.

“Heart failure should be a higher priority as the condition often has a bad prognosis but can be managed well — especially with the care plans available in Australia which encourage patients to play a role in managing their condition². Despite this, the SHAPE study shows our system is not being utilised to its full potential,” said Professor Andrew Sindone, a cardiologist, heart failure specialist and SHAPE study co-author.

“I would encourage GPs and specialists to be more proactive in activating government-funded chronic disease management (CDM) care plans^± to ensure heart failure patients receive the best treatment and outcomes possible,” he added.

CDM care plans are recognised as a quality improvement (QI) activity which GPs can undertake within their practices and receive incentives via their local Primary Health Network (PHN) and the Australian Government Department of Health (DoH).³

Professor Ralph Audehm, GP and SHAPE study lead-author, Melbourne, said, “Our data shows GPs are visited by each of their heart failure patients on average 14 times per year, which reinforces the crucial role we have in providing timely access to the planned and shared care that our patients need.”

The study uncovered a number of opportunities, including:¹

1. Assessment and recognition of silent symptoms and comorbidities^§ that may require multidisciplinary (shared) care
   • As less than half of patients are referred to a cardiologist by their GP within one month following diagnosis, only 11.4% are referred to an endocrinologist and 5.2% to a renal physician.
2. Activation and review of government funded CDM care plans to empower patients²
   • As only 50% had a CDM in place, only a third (35.3%) had their CDM plan reviewed at least once, and less than 3% had it reviewed annually.
3. Awareness and management of comorbid anxiety and depression
   • As just 37.1% of heart failure patients with anxiety or depression had a GP Mental Health Treatment Plan (GP-MHTP) in place, and only 15.5% had it reviewed.
      

Depression is a common and significant issue for people with heart failure which can be under-recognised and often complicated further by overlapping symptoms¹. The SHAPE study alerts GPs to how they can be more proactive in noticing and managing depression, which is a key strategy for improving the general wellbeing and self-management of their heart failure patients.

This latest data forms parts of series of SHAPE study publications and provides a much anticipated and concerning picture of the management of heart failure in Australia, and the under-utilisation of the healthcare services available.

The authors conclude how increased efforts from GPs to plan and coordinate holistic multidisciplinary team-based care can help meet the needs of their patients, reduce hospital admissions by up to 20% and prolong lives.¹ More information about the SHAPE study can be accessed online here.

References

• _{* The Study of Heart failure in the Australian Primary carE setting (SHAPE) analysed the records of 1.93 million adult Australian patients from 43 general practices from 1 July 2013 to 30 June 2018.¹}
• _{± There are two types of Medicare-funded care plans that can be prepared by a General Practitioner (GP) for Chronic Disease Management (CDM), including GP Management Plans (GPMP) and Team Care Arrangements (TCAs). In addition, GPs can also initiate GP Mental Health Treatment Plans (GP-MHTP) which are part of the Government funded Better Access Initiative.^4,5}
• _{§ The most common comorbidities for people with heart failure included hypertension, COPD, asthma, depression, anxiety, ischaemic heart disease, diabetes, osteoporosis, renal impairment and atrial fibrillation.¹}

^{1. Audehm RG et al, Health care services utilisation by patients with heart failure in Australia – findings from the SHAPE study, The Australian Journal of General Practice; 2022}

^{2. NSW Health, Integrated care for patients with chronic conditions. Available online: https://www.health.nsw.gov.au/integratedcare/Pages/chronic-conditions.aspx (accessed August 2022)}

^{3. Chan Y-K et al. Current and projected burden of heart failure in the Australian adult population: a substantive but still ill-defined major health issue, BMC Health Services Research (2016) 16:501.}

^{4. The Australian Government Department of Health, Chronic Disease Management Patient Information. Available online: https://www1.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdisease-pdf-infosheet (accessed July 2022).}

^{5. The Australian Government Department of Health, Better Access Initiative. Available online: https://www.health.gov.au/initiatives-and-programs/better-access-initiative (accessed July 2022).}

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