Background and Aims

In response to the growing burden of chronic disease, governments are investing substantially in innovative models of primary care, involving structured self-management support. Currently, large scale population-based evaluations of these policies are lacking. We aim to compare differences in survival following stroke or transient ischaemic attack, based on receipt or non-receipt of incentivised primary care management.

Methods

A target trial approach, with the study-design emulating a randomised controlled trial within a linked-data cohort, was used. Person-level linkages included data from: the Australian Stroke Clinical Registry (January 2012-June 2015) to define the cohort; Australian Medicare claims to identify relevant primary care items in the 6-18 months post-stroke (exposure period); government-held hospital, pharmaceutical and aged care datasets to define covariates; and National Death Registry to define outcomes during the 19-30 months post-stroke (outcome period). A landmark approach including those alive at the start of the outcome period was used. Multivariable survival analysis, adjusted using propensity score methods (PSM) was applied.

Results

Among 9,337 included AuSCR registrants (42% female, median age 70 years, 28% TIA), 45% received incentivised care during the exposure period and 95% were linked across all datasets. Following PSM, excellent balance was achieved between groups across 35 variables. Receipt compared to non-receipt of incentivised primary care was associated with a 28% reduced hazard of death (adjusted Hazard Ratio: 0.70, 95% CI 0.57, 0.87, p<0.001).

Conclusions

We provide an evaluation of the effectiveness of incentivised primary care within “real world” healthcare provision. Further work is underway to examine causal mechanisms.

Background and Aims

Australian primary care physicians receive financial incentives for providing chronic disease management (CDM) plans. It is unclear if these CDM plans improve medication adherence following stroke or transient ischaemic attack (TIA).

Aims: To determine whether use of a CDM plan post-stroke/TIA improves preventive medication adherence.

Methods

Retrospective cohort study of Victorian and Queensland survivors of stroke/TIA from the Australian Stroke Clinical Registry (Jan 2012-Jun 2016). We linked our cohort with administrative claims data and undertook analyses to emulate a randomised controlled trial. Use of CDM plans during the exposure period (6-18 months post-admission) was assessed using Medicare claims. The proportion of days covered (PDC) by each medication (antihypertensive, lipid-lowering, non-aspirin antithrombotic) during outcome assessment (19-30 months post-admission) was determined based on dispensing records from the Pharmaceutical Benefits Scheme. The average treatment effect of CDM plans on being adherent (PDC ≥80% was determined using propensity-score adjusted logistic regression.

Results

Among 14,465 survivors of stroke/TIA (median age 70 years; 42% female), 44% received a CDM plan during the exposure period (median age 73 years; 45% female). During the 1-year outcome period, the median PDC was 80% for antihypertensive, 81% for lipid-lowering, and 62% for non-aspirin antithrombotic medications. In propensity-score adjusted analyses, treatment with CDM plan was associated with being adherent to antihypertensive (odds ratio [OR]: 1.13; 95% CI: 1.05-1.22), lipid-lowering (OR: 1.21; 95% CI: 1.13-1.30), and non-aspirin antithrombotic medications (OR: 1.14; 95% CI: 1.06-1.23).

Conclusions

Use of CDM plans is associated with improved long-term adherence to secondary prevention medications following stroke/TIA.

Background and Aims

It is unclear if survivors of stroke or transient ischaemic attack (TIA) understand information provided by their doctor about prescribed secondary prevention medications. We investigated whether survivors understand their doctors’ explanation of their medications and the association with medication adherence and perceived risk factor control.

Methods

Cross-sectional survey, co-designed with consumers, was administered among survivors of stroke/TIA from the Australian Stroke Clinical Registry at two years post-admission (Victoria and Queensland, 2016). Participants reported whether they understood the explanation from their doctor about each prescribed secondary prevention medication (antihypertensive, antithrombotic or lipid-lowering). Multivariable logistic regression was used to assess associations between understanding of doctors’ explanations and self-reported medication adherence and risk factor control.

Results

Overall 632/1455 eligible survivors completed the survey (median age 69 years; 37% female). Most participants reported using medications (76% antihypertensive; 84% antithrombotic; 76% lipid-lowering). The majority of medication users understood their doctor’s explanation (75% antihypertensive; 66% antithrombotic; 74% lipid-lowering). Compared to participants who did not understand, those who did were more likely to report 30-day adherence for antihypertensive (adjusted odds ratios [aOR]: 2.04; 95% CI: 1.24-3.34), antithrombotic (aOR: 2.13; 95% CI: 1.38-3.28) and lipid-lowering medications (aOR: 1.85; 95% CI: 1.15-2.97). Understanding information about medications was also associated with self-reported control of blood pressure (aOR: 12.27; 95% CI: 6.76-22.25) and cholesterol (aOR: 9.72; 95% CI: 5.53-17.10).

Conclusions

Understanding of information about medications may promote medication adherence and risk factor control after stroke. More efforts are needed to improve patient education of medications after stroke.

Background and Aims

General practitioners use chronic disease management plans (CDMPs) to manage the healthcare of people with chronic diseases who require a structured approach. We aimed to determine whether treatment with CDM plans reduces all-cause readmission costs in patients with stroke or TIA.

Methods

Secondary data linkage analyses were conducted using the cohort of the cluster-randomised trial (STAND FIRM). Participants aged ≥18 years admitted for stroke or TIA were recruited from four hospitals in Melbourne. Person-level data from the trial were linked to datasets on CDM plan use and hospitalisations. Costs of readmissions from index discharge to two years were estimated using information from the 2015 National Hospital Costs Data Collection in AUD. The cost of same-day and multiday readmissions were estimated applying the average cost of same day separations and average cost per day for overnight separations, respectively. Median regression was used to compare readmission costs between those who used CDMPs for two years and those who did not.

Results

Among 563 participants recruited (median age 70 years, 64% male), 323 used CDMPs and 422 had at least one all-cause readmission within two years after hospital discharge. The median length of stay was three days (interquartile range 2-11 days). The median cost of readmissions was $4,358 (interquartile range $2,638-$19,268). The between-group difference was not significant (adjusted for age, sex and comorbidity profile ß=$-1,004, 95% CI $-4,399; $2,391, p value 0.56).

Conclusions

Treatment with CDMPs was not significantly associated with reduced readmission costs in patients with stroke or TIA.