Improved medical therapies and an increased use of coronary revascularisation have been associated with a decline in the acute mortality associated with acute coronary syndromes. However, the burden of chronic coronary heart disease (CHD) and other forms of cardiovascular disease remains high, with CHD and stroke as the two leading single causes of death in Australia.
Clinical research is rich in evidence documenting the robust benefits of lifestyle and phannacologic interventions for people with CHD.2"" However, both international and local studies demonstrate that the application of these therapies is incomplete, and persistence of therapy is suboptimal.6'7 Therefore, a key strategic approach to improve the health and wellbeing of Australians living with CHD is to target the evidence-management gap by providing national supports and incentives to optimise the delivery of proven therapies and the achievement of treatment goals among these complex patients. Such an approach may be of particular benefit to populations which carry a greater CHD burden; specifically Aboriginal and Torres Strait Islander populations (who in 2000-02 died from CHD at 2.6 times the rate of other Australians8) and rural and regional populations, where rates of death from cardiovascular disease appear to be higher than in urban areas, and access to specialised medical services is more difficult.
This type of initiative has been successfully implemented in diabetes, asthma and mental health management, immunisation and cervical cancer screening. To date, there has been no equivalent level of recognition for CHD care that is accessible to all general practices, although the Australian Primary Care Collaboratives is a positive initiative that has enhanced CHD care in several participating practices (see http;//www. apcc.org. ait, accessed 2009).
Important considerations in the development of any national program for CHD will be the potential impact on morbidity and mortality, combined with the likely cost-burden faced by the Australian taxpayer. To address these questions we sought to design and economically model a general practice-based chronic disease management program for patients with CHD.
An exploratory economic appraisal was undertaken, comparing the additional 'net cost' of the proposal (i.e. gross cost of the intervention minus anticipated cost offsets), with the attributable health benefits measured as quality adjusted life years. Costs and outcomes were assessed from a 'health sector perspective', but with a primary focus on 'government as third party funder'. The analysis was undertaken using 2006 as the reference year, with a 3% discount rate applied to costs and health gains received in future years.
Key design features of the 'General Practice-based CHD initiative' include the establishment of practice-specific patient registers of CHD patients with recall mechanisms and provision of 'cycles' of assessment and care as outlined in Fig. 1. Specific interventions would focus on the initiation and maintenance of lifestyle changes, the quality use of guideline-advocated therapies, promotion of self-care and consideration of psychosocial needs. This multi-faceted approach is described in Table 1.
Following an initial assessment, review consultations occur every 3 months, with a reassessment at 1 2 months. This initiative would be supported by existing reimbursements for each of the consultations, as well as the introduction of financial incentives for maintenance of a data system addressing quality of care indicators and achievement of clinical outcomes.
Key contributors to the cost-effectiveness of such a program are: (i) the local burden of CHD morbidity and mortality; (ii) the health benefits achieved by the program; (iii) the uptake of the program; (iv) the costs of implementation; and (v) the likely cost offsets associated with the health benefits. …