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Transition between hospital and community care for patients with coronary heart disease: New South Wales and Victoria 2012–2015

Primary health care Hospitals Community health Cardiovascular diseases Heart disease New South Wales Victoria
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People with chronic conditions often require complex health care. For patients discharged from hospital with chronic conditions, regular follow-up visits to their primary health-care providers can be important for their long-term health. People with coronary heart disease (CHD, including heart attack or angina) are at higher risk of recurrent heart attacks and other cardiovascular diseases such as heart failure and atrial fibrillation. Effective and appropriate health care after an acute hospitalisation for CHD has been shown to improve a patient’s health outcomes.

In one of the first studies of its kind within Australia, the AIHW examined the health services used by people with CHD after their discharge from hospital. More than 37,300 CHD patients who were discharged from hospital between April 2012 and June 2013 were followed in the data for 2 years to see if visiting a general practitioner (GP) or a cardiologist, or claiming Medicare Benefits Schedule (MBS) items for specific health services, affected their chances of being re-admitted to hospital or dying.

The study analysed linked de-identified hospitalisation data from New South Wales and Victoria to MBS data and National Death Index data. By analysing linked multiple data sets, the study provides insights into hospital and community-based health care that cannot be explored using single data collections. It also provides a deeper understanding of the ways people interact with the health system, and may help to inform policies to improve health-care delivery for people with chronic conditions.

The study has shown that the vast majority of CHD patients visited their GP within 30 days of being discharged from hospital and that they had, on average, 1 or 2 visits per month during the two year timeframe. Timely and regular contact with a GP were associated with lower risk of having an emergency re-admission to hospital for cardiovascular disease (CVD).

Future research could explore how a person’s use of primary health-care services affects their pharmaceutical treatment, and focus on identifying approaches to improve regular primary health care use.

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