I am
heartfoundation.org.au|Helpline 13 11 12

Risk-guided Intervention to Reduce Heart Failure Readmission

Dr Quan Huynh, Institution: Baker Heart and Diabetes Institute

2019 Vanguard Grant

Years funded: 2020-2021


Around 500,000 Australians are affected by heart failure (HF). As HF patients form a large proportion of hospital readmissions, reducing HF readmission rates would benefit both hospital expenditure and quality of care. Our planned study arises from four preparatory observations. First, we demonstrated significant regional variations in HF readmission in Australia. These were linked to the availability of nurse-led disease management programs (DMP) and were independent of disease severity and comorbidity. Second, we developed and validated a HF risk score based on our observations that psychosocial determinants, such as living alone, cognitive decline and carer stress, are important drivers of HF readmission.

Unlike existing scores (which predict death), our HF risk score effectively predicts the chance of readmission with the best discrimination to date. Third, we developed a nurse-led “DMP-Plus” multidisciplinary intervention through a recently completed randomised controlled trial – which effectively reduced HF readmission and was best at reducing HF readmissions in patients with the highest risk.

Finally, we have recently collaborated to develop a smartphone app, as a digital health coach, to educate and prompt appropriate behaviours in HF patients. In this proposed study, we plan to apply the risk-guided DMP-Plus intervention in two geographically and socially diverse hospitals. We will investigate the effectiveness of DMP-Plus in high-risk HF patients, and test the additional potential of the digital health coach to reduce readmission rates. Given the high numbers of people experiencing HF, calibrating DMP to those most likely to benefit will have wide-reaching implications for medical service delivery both nationally and internationally.

You might also be interested in

Research Directory

Research Directory

A program of research to improve ACCESS to cardiovascular care

A program of research to improve ACCESS to cardiovascular care

Professor Robyn Clark, Institution: Flinders University...

Altering the rehabilitation environment to improve stroke survivor activity (AREISSA)

Altering the rehabilitation environment to improve stroke survivor activity (AREISSA)

Assistant Professor Neil Spratt, Institution: The University of Newcastle...

Constructing Aboriginal health: a review of cardiovascular research, 1933-2014

Constructing Aboriginal health: a review of cardiovascular research, 1933-2014

Ms Joanne Luke, Institution: University of Melbourne...

Exercise and brain volume loss after stroke

Exercise and brain volume loss after stroke

Professor Amy Brodtmann, Institution: Florey Institute of Neuroscience and Mental Health...

Growing healthy hearts - how passive smoke exposure and elevated blood pressure early in life impacts adult cardiovascular health

Growing healthy hearts - how passive smoke exposure and elevated blood pressure early in life impacts adult cardiovascular health

Growing healthy hearts - how passive smoke exposure and elevated blood pressure early in life impacts adult cardiovascular health

Dr Costan Magnussen, Institution: University of Tasmania...

Lipid disorders in patients at high cardiovascular disease risk

Lipid disorders in patients at high cardiovascular disease risk

Dr Esther Ooi, Institution: University of Western Australia...

Promoting active, healthy lifestyles among women at key life stages

Promoting active, healthy lifestyles among women at key life stages

Associate Professor Verity Cleland, Institution: University of Tasmania...

Reducing population salt consumption in Victoria

Reducing population salt consumption in Victoria

Reducing population salt consumption in Victoria

Professor Bruce Neal, Institution: University of New South Wales...

Starting early – Increasing young children’s physical activity

Starting early – Increasing young children’s physical activity

Associate Professor Hayley Christian, Institution: University of Western Australia...

Heart Age Calculator

Heart Age Calculator

Heart Age Calculator

Could you be at risk of heart disease? Get your estimated heart age now....

Heart Health Check Toolkit

Heart Health Check Toolkit

Environment, climate change and heart health

Environment, climate change and heart health

Environment, climate change and heart health

Information on how air pollution, heatwaves and bushfires can impact heart health, and what you can do to look after yourself. ...

Chicken and avocado banh mi

Chicken and avocado banh mi

Chicken and avocado banh mi

15 minutes + 30 minutes chilling
Serves 4

Aboriginal heart health

Aboriginal heart health

Aboriginal heart health

Visit the St Vincents Hospital NSW and Heart Foundation Aboriginal heart health website for more information...

Physical activity after a heart attack

Physical activity after a heart attack

Physical activity after a heart attack

Discover what you need to know about being active after a heart attack....

Nutrition Resources for Practice and Patient Care

Nutrition Resources for Practice and Patient Care

Nutrition Resources for Practice and Patient Care

Nutrition Resources for Patients

Nutrition Resources for Patients

Nutrition Resources for Patients

Resources to help people follow a heart healthy eating pattern in their daily lives. ...

Wholegrains and heart health

Wholegrains and heart health

Wholegrains and heart health

All you need to know about wholegrains to put you on the right track...

Getting active at school

Getting active at school

Getting active at school

Physical activity resources for school staff....

Donate to the Heart Foundation

Donate to the Heart Foundation

Donate to the Heart Foundation

Every dollar that you donate will help fund research, support and programs that help save lives....

Easy chicken nasi goreng

Easy chicken nasi goreng

Easy chicken nasi goreng

10 minutes
Serves 4

For professionals: Heart failure tools and resources

For professionals: Heart failure tools and resources

Resources for healthcare professionals on the management of patients with heart failure ...

WEBINAR | Absolute CVD risk assessment practical update

WEBINAR | Absolute CVD risk assessment practical update

A multidisciplinary panel of experts discuss the practical application of absolute CVD risk assessment through Heart Health Checks....

What is a heart attack?

What is a heart attack?

What is a heart attack?

The most common cause of a heart attack is coronary heart disease....

Asian tofu rice salad

Asian tofu rice salad

Asian tofu rice salad

10 minutes
Serves 2

COVID-19 info & FAQs

COVID-19 info & FAQs

COVID-19 info & FAQs

Information and FAQs about COVID-19 and heart disease....

Supporting Your Emotional Wellbeing: An Online Forum for Young Heart Patients

Supporting Your Emotional Wellbeing: An Online Forum for Young Heart Patients

Supporting Your Emotional Wellbeing: An Online Forum for Young Heart Patients

Join Kate in making a difference to future generations

Join Kate in making a difference to future generations

Join Kate in making a difference to future generations

Kate wanted to find a way she could make a difference to future generations...

What is a healthy body weight?

What is a healthy body weight?

What is a healthy body weight?

Find out what a healthy body weight is and the steps you can take to achieve it. ...

Action Plans

Action Plans

Action Plans

Recovery is a long journey, so having a plan makes a huge difference. Using an action plan gives you a step-by-step guide to improving your lifestyle....

Vegetarian lasagne

Vegetarian lasagne

Vegetarian lasagne

1 hour
Serves 6

Heart failure clinical resources

Heart failure clinical resources

Resources and clinical information for health professionals...

Clinical Guidelines

Clinical Guidelines

Clinical Guidelines

Full list of clinical guidlines and references for CVD, heart failure, ACS, hypertension, atrial fibrillation, SCAD and RHD...

Dessert recipes

Dessert recipes

Dessert recipes

Find heart healthy dessert recipes....

Driving Best Practice CVD Prevention in a Post-COVID World

Driving Best Practice CVD Prevention in a Post-COVID World

Driving Best Practice CVD Prevention in a Post-COVID World

Sodium and salt converter

Sodium and salt converter

Convert the sodium listed on food products into grams of salt or vice versa. ...

Peter is breathing easy again after heart valve surgery

Peter is breathing easy again after heart valve surgery

Peter is breathing easy again after heart valve surgery

Peter has lived with a rare heart condition since he was 14, but hadn’t given it too much thought until his 30s....

Western Australian Cardiovascular Research Alliance

Western Australian Cardiovascular Research Alliance

Western Australian Cardiovascular Research Alliance

WACRA are the peak leadership body in Western Australian advancing research into heart, stroke and vascular disease to accelerate translation and improve health outcomes....

Pregnancy and heart disease

Pregnancy and heart disease

Information and resources for health professionals....