Improving delivery of secondary prophylaxis for rheumatic heart disease in a high-burden setting

Outcome of a stepped-wedge, community, randomized trial

Anna P. Ralph, Jessica L. De Dassel, Adrienne Kirby, Clancy Read, Alison G. Mitchell, Graeme P. Maguire, Bart J. Currie, Ross S. Bailie, Vanessa Johnston, Jonathan R. Carapetis

Research output: Contribution to journalArticleResearchpeer-review

7 Citations (Scopus)

Abstract

Background—Health system strengthening is needed to improve delivery of secondary prophylaxis against rheumatic heart disease. Methods and Results—We undertook a stepped-wedge, randomized trial in northern Australia. Five pairs of Indigenous community clinics entered the study at 3-month steps. Study phases comprised a 12 month baseline phase, 3 month transition phase, 12 month intensive phase and a 3- to 12-monthmaintenance phase. Clinics received a multicomponent intervention supporting activities to improve penicillin delivery, aligned with the chronic care model, with continuous quality-improvement feedback on adherence. The primary outcome was the proportion receiving ≥80% of scheduled penicillin injections. Secondary outcomes included “days at risk” of acute rheumatic fever recurrence related to late penicillin and acute rheumatic fever recurrence rates. Overall, 304 patients requiring prophylaxis were eligible. The proportion receiving ≥80% of scheduled injections during baseline was 141 of 304 (46%)—higher than anticipated. No effect attributable to the study was evident: in the intensive phase, 126 of 304 (41%) received ≥80% of scheduled injections (odds ratio compared with baseline: 0.78; 95% confidence interval, 0.54–1.11). There was modest improvement in the maintenance phase among high-adhering patients (43% received ≥90% of injections versus 30% [baseline] and 28% [intensive], P<0.001). Also, the proportion of days at risk in the whole cohort decreased in the maintenance phase (0.28 versus 0.32 [baseline] and 0.34 [intensive], P=0.001). Acute rheumatic fever recurrence rates did not differ between study sites during the intensive phase and the whole jurisdiction (3.0 versus 3.5 recurrences per 100 patient-years, P=0.65). Conclusions—This strategy did not improve adherence to rheumatic heart disease secondary prophylaxis within the study time frame. Longer term primary care strengthening strategies are needed. Clinical Trial Registration—URL: www.anzctr.org.au. Unique identifier: ACTRN12613000223730.

Original languageEnglish
Article numbere009308
Number of pages15
JournalJournal of the American Heart Association
Volume7
Issue number14
DOIs
Publication statusPublished - 17 Jul 2018
Externally publishedYes

Keywords

  • Acute rheumatic fever
  • Adherence
  • Cluster randomized trial
  • Quality improvement
  • Rheumatic heart disease
  • Systems of care

Cite this

Ralph, Anna P. ; De Dassel, Jessica L. ; Kirby, Adrienne ; Read, Clancy ; Mitchell, Alison G. ; Maguire, Graeme P. ; Currie, Bart J. ; Bailie, Ross S. ; Johnston, Vanessa ; Carapetis, Jonathan R. / Improving delivery of secondary prophylaxis for rheumatic heart disease in a high-burden setting : Outcome of a stepped-wedge, community, randomized trial. In: Journal of the American Heart Association. 2018 ; Vol. 7, No. 14.
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title = "Improving delivery of secondary prophylaxis for rheumatic heart disease in a high-burden setting: Outcome of a stepped-wedge, community, randomized trial",
abstract = "Background—Health system strengthening is needed to improve delivery of secondary prophylaxis against rheumatic heart disease. Methods and Results—We undertook a stepped-wedge, randomized trial in northern Australia. Five pairs of Indigenous community clinics entered the study at 3-month steps. Study phases comprised a 12 month baseline phase, 3 month transition phase, 12 month intensive phase and a 3- to 12-monthmaintenance phase. Clinics received a multicomponent intervention supporting activities to improve penicillin delivery, aligned with the chronic care model, with continuous quality-improvement feedback on adherence. The primary outcome was the proportion receiving ≥80{\%} of scheduled penicillin injections. Secondary outcomes included “days at risk” of acute rheumatic fever recurrence related to late penicillin and acute rheumatic fever recurrence rates. Overall, 304 patients requiring prophylaxis were eligible. The proportion receiving ≥80{\%} of scheduled injections during baseline was 141 of 304 (46{\%})—higher than anticipated. No effect attributable to the study was evident: in the intensive phase, 126 of 304 (41{\%}) received ≥80{\%} of scheduled injections (odds ratio compared with baseline: 0.78; 95{\%} confidence interval, 0.54–1.11). There was modest improvement in the maintenance phase among high-adhering patients (43{\%} received ≥90{\%} of injections versus 30{\%} [baseline] and 28{\%} [intensive], P<0.001). Also, the proportion of days at risk in the whole cohort decreased in the maintenance phase (0.28 versus 0.32 [baseline] and 0.34 [intensive], P=0.001). Acute rheumatic fever recurrence rates did not differ between study sites during the intensive phase and the whole jurisdiction (3.0 versus 3.5 recurrences per 100 patient-years, P=0.65). Conclusions—This strategy did not improve adherence to rheumatic heart disease secondary prophylaxis within the study time frame. Longer term primary care strengthening strategies are needed. Clinical Trial Registration—URL: www.anzctr.org.au. Unique identifier: ACTRN12613000223730.",
keywords = "Acute rheumatic fever, Adherence, Cluster randomized trial, Quality improvement, Rheumatic heart disease, Systems of care",
author = "Ralph, {Anna P.} and {De Dassel}, {Jessica L.} and Adrienne Kirby and Clancy Read and Mitchell, {Alison G.} and Maguire, {Graeme P.} and Currie, {Bart J.} and Bailie, {Ross S.} and Vanessa Johnston and Carapetis, {Jonathan R.}",
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Improving delivery of secondary prophylaxis for rheumatic heart disease in a high-burden setting : Outcome of a stepped-wedge, community, randomized trial. / Ralph, Anna P.; De Dassel, Jessica L.; Kirby, Adrienne; Read, Clancy; Mitchell, Alison G.; Maguire, Graeme P.; Currie, Bart J.; Bailie, Ross S.; Johnston, Vanessa; Carapetis, Jonathan R.

In: Journal of the American Heart Association, Vol. 7, No. 14, e009308, 17.07.2018.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Improving delivery of secondary prophylaxis for rheumatic heart disease in a high-burden setting

T2 - Outcome of a stepped-wedge, community, randomized trial

AU - Ralph, Anna P.

AU - De Dassel, Jessica L.

AU - Kirby, Adrienne

AU - Read, Clancy

AU - Mitchell, Alison G.

AU - Maguire, Graeme P.

AU - Currie, Bart J.

AU - Bailie, Ross S.

AU - Johnston, Vanessa

AU - Carapetis, Jonathan R.

PY - 2018/7/17

Y1 - 2018/7/17

N2 - Background—Health system strengthening is needed to improve delivery of secondary prophylaxis against rheumatic heart disease. Methods and Results—We undertook a stepped-wedge, randomized trial in northern Australia. Five pairs of Indigenous community clinics entered the study at 3-month steps. Study phases comprised a 12 month baseline phase, 3 month transition phase, 12 month intensive phase and a 3- to 12-monthmaintenance phase. Clinics received a multicomponent intervention supporting activities to improve penicillin delivery, aligned with the chronic care model, with continuous quality-improvement feedback on adherence. The primary outcome was the proportion receiving ≥80% of scheduled penicillin injections. Secondary outcomes included “days at risk” of acute rheumatic fever recurrence related to late penicillin and acute rheumatic fever recurrence rates. Overall, 304 patients requiring prophylaxis were eligible. The proportion receiving ≥80% of scheduled injections during baseline was 141 of 304 (46%)—higher than anticipated. No effect attributable to the study was evident: in the intensive phase, 126 of 304 (41%) received ≥80% of scheduled injections (odds ratio compared with baseline: 0.78; 95% confidence interval, 0.54–1.11). There was modest improvement in the maintenance phase among high-adhering patients (43% received ≥90% of injections versus 30% [baseline] and 28% [intensive], P<0.001). Also, the proportion of days at risk in the whole cohort decreased in the maintenance phase (0.28 versus 0.32 [baseline] and 0.34 [intensive], P=0.001). Acute rheumatic fever recurrence rates did not differ between study sites during the intensive phase and the whole jurisdiction (3.0 versus 3.5 recurrences per 100 patient-years, P=0.65). Conclusions—This strategy did not improve adherence to rheumatic heart disease secondary prophylaxis within the study time frame. Longer term primary care strengthening strategies are needed. Clinical Trial Registration—URL: www.anzctr.org.au. Unique identifier: ACTRN12613000223730.

AB - Background—Health system strengthening is needed to improve delivery of secondary prophylaxis against rheumatic heart disease. Methods and Results—We undertook a stepped-wedge, randomized trial in northern Australia. Five pairs of Indigenous community clinics entered the study at 3-month steps. Study phases comprised a 12 month baseline phase, 3 month transition phase, 12 month intensive phase and a 3- to 12-monthmaintenance phase. Clinics received a multicomponent intervention supporting activities to improve penicillin delivery, aligned with the chronic care model, with continuous quality-improvement feedback on adherence. The primary outcome was the proportion receiving ≥80% of scheduled penicillin injections. Secondary outcomes included “days at risk” of acute rheumatic fever recurrence related to late penicillin and acute rheumatic fever recurrence rates. Overall, 304 patients requiring prophylaxis were eligible. The proportion receiving ≥80% of scheduled injections during baseline was 141 of 304 (46%)—higher than anticipated. No effect attributable to the study was evident: in the intensive phase, 126 of 304 (41%) received ≥80% of scheduled injections (odds ratio compared with baseline: 0.78; 95% confidence interval, 0.54–1.11). There was modest improvement in the maintenance phase among high-adhering patients (43% received ≥90% of injections versus 30% [baseline] and 28% [intensive], P<0.001). Also, the proportion of days at risk in the whole cohort decreased in the maintenance phase (0.28 versus 0.32 [baseline] and 0.34 [intensive], P=0.001). Acute rheumatic fever recurrence rates did not differ between study sites during the intensive phase and the whole jurisdiction (3.0 versus 3.5 recurrences per 100 patient-years, P=0.65). Conclusions—This strategy did not improve adherence to rheumatic heart disease secondary prophylaxis within the study time frame. Longer term primary care strengthening strategies are needed. Clinical Trial Registration—URL: www.anzctr.org.au. Unique identifier: ACTRN12613000223730.

KW - Acute rheumatic fever

KW - Adherence

KW - Cluster randomized trial

KW - Quality improvement

KW - Rheumatic heart disease

KW - Systems of care

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U2 - 10.1161/JAHA.118.009308

DO - 10.1161/JAHA.118.009308

M3 - Article

VL - 7

JO - American Heart Association. Journal. Cardiovascular and Cerebrovascular Disease

JF - American Heart Association. Journal. Cardiovascular and Cerebrovascular Disease

SN - 2047-9980

IS - 14

M1 - e009308

ER -