Recent research has identified important opportunities for improving outcomes for people after a heart attack, with a call for efforts to focus in particular on addressing the disparities experienced by people in outer regional and remote areas, and other high-risk groups.
“Our findings emphasise the importance of strengthening the continuity of care after hospital discharge, especially within the first year following the heart attack,” writes public health and health economics researcher Sangita Shakya.
Sangita Shakya writes:
Recovery from a heart attack doesn’t stop when you leave the hospital. In fact, that is when the most important stage of your recovery begins.
Our research shows that good follow up from your general practitioner can be lifesaving, reducing the chance of death and re-hospitalisation in the first year, and highlighting the importance of quality ongoing care for people once they are back at home.
Coronary heart disease remains the leading cause of morbidity and mortality globally and in Australia, with more than 200 hospital admissions attributable to it each day.
The number of Australians living with coronary heart disease is projected to increase substantially by 2045, driven largely by population growth and ageing. People who also have type-2 diabetes have even greater risks of complications, re-hospitalisations, and premature death, with nearly double the mortality rate in people with type-2 diabetes and reduced life expectancy by 12 years.
Our recent Australian research suggests the more often a patient visits their GP within the first year of a coronary heart disease episode, the better the outcome.
This highlights the importance of ongoing follow-up and long-term management of patients, as well as improving our understanding of how they engage with primary and secondary care.
Across the healthcare continuum
We examined healthcare pathways of more than 2,000 patients with coronary heart disease and type-2 diabetes in Western Australia using 10 years (2010-2022) of linked longitudinal datasets comprising MedicineInsight GP, hospital, emergency department (ED), and mortality records.
Patients with both coronary heart disease and type-2 diabetes are a clinically high-risk multimorbid group requiring more intensive primary and secondary care and cardiometabolic management than patients only having coronary heart disease.
We centred our study on the index coronary heart disease event at the emergency department, which represents the critical turning point in a patient’s healthcare journey. We then followed patients across primary and secondary care, examined their GP visits, prescriptions of guideline-recommended medications, hospitalisations and mortality within the 1 year before and after the coronary event.
This broader view is important because it moves beyond what happens during a hospital admission and gives us a more complete picture of patients’ healthcare journey after a heart attack.
When we looked at the whole healthcare system, rather than siloed data, our research found that greater GP visits after the heart attack were associated with better outcomes. Greater GP visits after the coronary heart disease event were associated with a six percent reduction in odds of coronary heart disease -related recurrent rehospitalisation and a 13 percent lower risk of death within the first year.
This highlights the importance of the critical intervention period of the first year after the coronary heart disease event for secondary prevention and ongoing disease management.
Follow up matters
The GP follow up plays a coordinating role for secondary prevention and provides opportunities for risk factor management, medication review, identifying deterioration early, support in lifestyle management, and long-term patient engagement with other health professionals.
This suggests that the focus needs to be on quantity, quality, continuity and coordination of the care the patients receive.
However, as our study was an observational study, we cannot determine which aspect of the GP visits resulted in the better health outcome.
Our findings on the medication prescription also underscore the importance of both quantity and quality of the care. The study identified a gap in prescribing four guideline-recommended CHD medications, revealing a disconnect between guidelines and actual implementation.
Only around three-quarters of patients were prescribed at least one of four guideline-recommended coronary heart disease medications, and fewer than one in five had been prescribed all four.
These findings need to be interpreted cautiously, as our data did not capture the hospital-supplied medicines when the patient was discharged, which may underestimate the prescribing rate. Further, the individual patient’s clinical circumstances, such as contraindications, may influence the prescription of the medications.
Nevertheless, taken together, the findings reinforce the importance of both frequency and quality of care.
What needs to change?
In our study, we found evidence of geographic inequities, with people with coronary heart disease and type-2 diabetes living in outer regional areas having a 31-35 percent higher risk of recurrent rehospitalisation.
We also found a 57-68 percent higher risk of death among people living in remote areas compared to those living in major cities or metropolitan areas.
Similarly, those with additional morbidity of heart failure were 58 percent higher and with additional chronic kidney disease were two-fold higher risk than those only having coronary heart disease and type-2 diabetes.
This suggests a tailored program is needed for those at higher risk to make the follow up care more accessible, coordinated and tailored to different levels of need of patients.
Our findings emphasise the importance of strengthening the continuity of care after hospital discharge, especially within the first year following the heart attack.
Calls to action include:
- Hospitals and health services should ensure timely communication with GPs about patients’ medication, treatment and ongoing care needs.
- GPs represent the critical leverage point in the delivery of secondary prevention and long-term management; thus, they should take post-discharge follow up as an opportunity to optimise care management for the patient.
- Policymakers and health program planners should support an integrated model of care which is accessible, particularly for people living in regional and remote areas and those having multiple chronic conditions.
In the end, along with more GP visits, the goal should be timely, high-quality, and coordinated care after patients are discharged from hospital.
Author details
Sangita Shakya is a public health and health economics researcher with a research focus on non-communicable disease, particularly coronary heart disease and type-2 diabetes. She is a PhD candidate in Health Economics at Deakin University and holds a Master of Public Health, specialising in health economics from the University of Melbourne. Her research integrates epidemiology, health services research, and health economics, using linked health datasets to examine healthcare utilisation, costs and health outcomes. Her expertise also includes economic evaluation and cost-effectiveness modelling to inform health policy and chronic disease care.
See Croakey’s archive of articles on safety and quality of healthcare
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