Amanda K. Buttery

BackgroundDespite early success in COVID-19 vaccine rollout, several East Asian countries have seen declining uptake of annual COVID-19 vaccination among adults since 2022. Through a comparative lens, we examine vaccine confidence, trusted information sources, and mRNA vaccine acceptance in four super-ageing societies. MethodsWe analysed nationally representative Global Listening Project survey data from Japan, South Korea, Taiwan, and Hong Kong (2023; n=1,000 participants per region) and a Tokyo deep-dive survey (2024; n=5,050). We compared institutional trust, trusted voices, vaccine safety and perceptions, and mRNA awareness and mRNA vaccine acceptance across demographic groups. We pair descriptive results with contemporary vaccination policy contexts. FindingsA high-uptake/low-confidence paradox emerged around COVID-19 vaccination uptake, exceeding 80% across settings, while confidence in vaccine safety ranged from 51% in Japan to 68% in Taiwan. Consistent gender and generational divides exist: men and older adults’ express higher confidence than women and younger groups. Family members, doctors, and local governments were widely trusted while national governments less so. Older adults relied on television, and younger groups turned to social media for trusted information. Knowledge of mRNA vaccines was limited, even among healthcare professionals. Acceptance of a new mRNA vaccine was highest in Taiwan (78%) and lowest in Japan (56%), with men more accepting than women. InterpretationsTailored communication that leverages local trust networks, addresses cultural, gender-specific concerns and accounts for the influential role of family members and doctors, is essential to build vaccine confidence in routine vaccine programs as well as for pandemic preparedness. Policies should reinforce recommendations and reminder systems (e.g., SMS recall), while simultaneously addressing cost and access barriers for older adults. Integrating gender- and age-specific trust-building measures into immunisation policy and crisis planning is needed.

Background: Implementation of clinical guidelines into routine practice remains highly variable. Strategies to increase guideline uptake include developing digital tools and mobile apps for use in clinical practice. The National Heart Foundation of Australia in collaboration with the Cardiac Society of Australia and New Zealand published 3 key cardiac clinical guidelines, including the Australian clinical guidelines for the (1) prevention and detection of atrial fibrillation, (2) detection and management of heart failure, and (3) management of acute coronary syndromes. To improve access and uptake for health care providers, we developed the Smart Heart Guideline App. Objective: This study aims to evaluate the acceptability, implementation, and usability of an Australian-specific cardiac guidelines mobile app. Methods: We used an iterative multiple methods development and implementation approach. First, we conducted a cross-sectional web-based survey with end users (n=504 health professionals) in 2017 to determine the acceptability of an Australian-specific cardiac clinical guidelines mobile app. Second, the Smart Heart Guidelines app was created using a design, user testing, and revision process. The app includes interactive algorithms and flowcharts to inform diagnosis and management at the point of care. The freely available app was launched in October 2019 on iOS and Android operating systems and promoted and implemented using multiple methods. Third, data from 2 annual national cross-sectional general practitioner (GP) surveys in 2019 and 2020 were evaluated to understand the awareness and use of the clinical guidelines and the app. Fourth, data from the app stores were analyzed between October 1, 2019, and June 30, 2021, to evaluate usage. Results: Most health professionals surveyed (447/504, 89%) reported accessing resources electronically, and most (318/504, 63%) reported that they would use an Australian-specific cardiac guidelines app. GPs surveyed in 2019 were aware of the heart failure (159/312, 51%) and atrial fibrillation (140/312, 45%) guidelines, and in 2020, a total of 34 of 189 (18%) reported that they were aware of the app. The app was downloaded 11,313 times (7483, 66% from the Apple App Store; 3830, 34% from Google Play) during the first 20-month period. Most downloads (6300/7483, 84%) were a result of searching for the app in the stores. Monthly download rates varied. App Store data showed that people used the app twice (on average 2.06 times) during the 20 months. Many (3256/3830, 85%) Android users deleted the app. Conclusions: Health professionals supported the development of the Smart Heart Guidelines app. Although initial downloads were promising, the frequency of using the app was low and deletion rates were high. Further evaluation of users’ experience of the most and least useful components of the app is needed.

Aim: Reports of sex-specific differences in mortality after coronary artery bypass graft surgery (CABGS) are contradictory. The review aim was to determine whether CABGS is differentially efficacious than alternative procedures by sex, on short- and longer-term mortality. Methods and results: EMBASE, CINAHL, Medline, and the Cochrane Library were searched. Inclusion criteria: English language, randomized controlled trials from 2010, comparing isolated CABGS to alternative revascularization. Analyses were included Mantel–Haenszel fixed-effects modelling, risk of bias (Cochrane RoB2), and quality assessment (CONSORT). PROSPERO Registration ID: CRD42020181673. The search yielded 4459 citations, and full-text review of 29 articles revealed nine studies for inclusion with variable time to follow-up. Risk of mortality for women was similar in pooled analyses [risk ratio (RR) 0.94, 95% confidence interval (CI) 0.84–1.05, P = 0.26] but higher in sensitivity analyses excluding ‘high risk’ patients (RR 1.22, 95% CI 1.01–1.48, P = 0.04). At 30 days and 10 years, in contrast to men, women had an 18% (RR 0.82, 95% CI 0.66–1.02, P = 0.08) and 19% (RR 0.81, 95% CI 0.69–0.95, P = 0.01) mortality risk reduction. At 1–2 years women had a 7% (RR 1.07, 95% CI 0.69–1.64, P = 0.77), and at 2–5 years a 25% increase in risk of mortality compared with men (RR 1.25, 95% CI 1.03–1.53, P = 0.03). Women were increasingly under-represented over time comprising 41% (30 days) to 16.7% (10 years) of the pooled population. Conclusion: Meta-analysis revealed inconsistent sex-specific differences in mortality after CABGS. Trials with sex-specific stratification are required to ensure appropriate sex-differentiated treatments for revascularization.

BACKGROUND Implementation of clinical guidelines into routine practice remains highly variable. Strategies to increase guideline uptake include developing digital tools and mobile applications (apps) for real-time use in clinical practice. The National Heart Foundation of Australia publish three key cardiac clinical guidelines in collaboration with the Cardiac Society of Australia and New Zealand including: 1) the Australian clinical guidelines for the prevention and detection of atrial fibrillation; 2) the Australian clinical guidelines for the detection and management of heart failure ; and 3) the Australian clinical guidelines for the management of acute coronary syndromes. To improve access and uptake for healthcare providers we developed the Smart Heart Guideline App OBJECTIVE To understand the need for, develop and evaluate the uptake of an Australian-specific mobile app to improve access and uptake of three national cardiac clinical guidelines. METHODS We used an iterative mixed methods approach, an established method in mobile app development and evaluation. First, we conducted an online survey of end-users in 2017 to determine the need and acceptability of an Australian-specific mobile app to access cardiac clinical guidelines. Second, we engaged a software developer to create the Smart Heart Guidelines App using a process of design, testing and revision, which included user testing. The app was registered with the regulatory body in Australia, the Therapeutic Goods Administration, and made freely available from October 2019 on iOS and Android operating systems and promoted using multiple methods. Third, data from the app stores was analyzed between 1 October 2019 – 1 October 2020 to evaluate the app’s uptake and performance. Fourth, data from two annual national General Practitioner (GP) surveys in 2019 and 2020 were analyzed to assess awareness and use of the clinical guidelines and the app. RESULTS Most health professionals surveyed (89%; n=447/504) reported accessing resources electronically and most (70%) reported they would use an Australian-specific cardiac guidelines app. The app was downloaded 11 313 times (66%; n=7483 from Apple App Store; 34%; n=3,830 from Google Play) during the first 20-month period. Most downloads (84%; n=6300) were a result of searching for the app in the stores. Apple App Store data indicated over 59900 impressions (the number of times the app appeared in a search) and 9000 product page views (number of times a user viewed the apps product page). Monthly downloads rates varied. Many (85%) Android users deleted the app. CONCLUSIONS Health professionals supported the development of the Smart Heart Guidelines App. The number of app store searches and total downloads indicate initial promotion of the app was effective. Further evaluation of users’ experience is needed.

Comprehensive cardiac rehabilitation programmes include multifactorial components to optimise cardiovascular risk reduction, promote healthy behaviours and an active lifestyle, reduce disability and improve health and wellbeing. There is compelling evidence that older people with certain cardiovascular conditions, such as heart failure, can benefit both physically and mentally from cardiac rehabilitation. This chapter discusses the evolution of cardiac rehabilitation, frailty assessment in cardiac rehabilitation and guideline recommendations in the context of ageing populations. Contemporary cardiac rehabilitation service models are presented along with potential solutions to meeting older people’s preferences and improving access to effective treatment for those with frailty. Innovations in catheter-based surgical interventions mean that more people with frailty are undergoing cardiovascular surgery than ever before. Although traditionally, cardiac rehabilitation has been associated with secondary prevention after cardiac diagnoses, events and interventions, new models of preconditioning rehabilitation or ‘prehab’ are being offered to frail older people before surgery to improve functional outcomes and reduce hospital stay. Individual tailoring of cardiac rehabilitation programme components is a cornerstone of high-quality care. Importantly, participation in core components, such as exercise and nutritional interventions, can impact on both cardiac vascular disease and frailty, providing the potential to change the trajectory of both conditions.