Abstract: Globally, cardiovascular disease (CVD) accounts for millions of preventable deaths each year. Based on 2014–15 data, more than 11 million Australians (47%) have at least one chronic condition, with people living in rural and remote areas, and Indigenous Australians, having significantly increased chronic disease prevalence and risk. Access to health care in rural and remote areas is poor compared to metropolitan areas. This includes insufficient service provision for the needs of the population and the requirement of many rural and remote patients to travel long distances to access health care such as hospitals, general practitioners and emergency departments. As provision of primary health care is mainly located in urban and regional centres, it is of no surprise that secondary prevention services such as cardiac services, including cardiac rehabilitation (CR) programs, health services with cardiac capacity, and programs aimed at prevention, are mainly located in metropolitan and inner regional areas. This is concerning, as a leading reason for Royal Flying Doctor Service (RFDS) aeromedical retrievals is diseases of the circulatory system, with acute myocardial infarction (heart attack) being the leading diagnosis. Furthermore, many of the retrieval locations are in remote and very remote areas, with many of these locations having low primary care services per population. This is important, as rural and remote populations have higher levels of mortality and morbidity, related to delayed acute treatment (i.e. heart attack treatment delays), and limited access to chronic disease management. Furthermore, rural and remote populations have increased prevalence of smoking, overweight and obesity, mental health acuity, and alcohol and drug misuse, than people living in major cities. The RFDS currently provides extensive telehealth and primary healthcare support to patients in rural and remote communities across Australia including providing guidance on risk factors for CVD and evidence-based recommendations for treatment, although there are limited programs focusing on the rehabilitation of CVD patients. Participating in a CR program is a first critical step in a person’s recovery from their heart attack or heart event. Not only do these programs improve quality of life and risk factors, but people are 40% less likely to be readmitted to hospital and 25% less likely to die from another heart event if they have participated in CR. The reported barriers to participation in metropolitan and traditional hospital-based CR programs have included patient, provider, health system and societal-level barriers such as: older age, lower education level, a lack of perceived benefit, work or time constraints, transport difficulties, lack of referral, limited availability of programs and lack of patient financial reimbursement, as well as limited social or family support. In addition to these barriers, rural and remote patients face additional obstacles to participating in CR, including extensive travel time to access the few services that exist. To help overcome some of these barriers, there has been increasing availability of, and evidence for, alternative modes of delivery of CR, including phone-based, home-based and online CR. As such, there is an opportunity for rural and remote healthcare providers, such as the RFDS, to consider furthering the provision of innovative service developments to overcome these barriers to participation and address the significant treatment gap. For the RFDS, such an approach could consider telerehabilitation interventions in addition to the formulation and testing of an RFDS travelling CR service. Through geographical mapping, similar to the RFDS service planning operating tool (SPOT), this service could identify and visit communities in most need, via a locally-tailored program. Services, such as a travelling CR service, could potentially address the limitations of traditional CR program delivery, by removing attendance access barriers for rural and remote patients and providing continuity of care for CR.Regardless of the type of CR service the RFDS may develop or choose to implement in the future, it would ideally incorporate the Australian Cardiovascular Health and Rehabilitation Association (ACRA)’s CR guidelines of providing “equity and access to services”, utilise patient-centred telehealth and technology, and support and provide community-based CR. Further, the context of rural and remote healthcare provision must be carefully considered in service design. It is likely that the provision of co-designed, culturally appropriate CR services in rural and remote areas, that are understood, valued and supported by health professionals, would provide a much-needed service that would be highly utilised. The intended outcomes are likely to include improved quality of life, positive lifestyle modifications, and reductions in future CVD patient admissions to hospital and cardiac-related deaths.
Gardiner, Fergus, Bishop, Lara, Foreman, Rachelle, Potter, Jane, Gale, Lauren, Laverty, Martin, 2019, Cardiovascular disease prevention and rehabilitation in rural and remote populations, Report, viewed 18 February 2020, https://www.nintione.com.au/?p=16419.