Speaking of Science: SOLVEing Coronary Heart Disease with Professor Julie Redfern

In recognition of World Heart Day, celebrated on Sunday 29 September 2024, NHMRC was joined by distinguished public health researcher, physiotherapist and NHMRC Leadership Fellow, Professor Julie Redfern to discuss the impact of her research under the SOLVE-CHD Synergy grant and how this work is transforming the way Australians are supported and cared for after cardiovascular events.

Listen to Professor Redfern ‘Speak of Science’, and answer questions on her research career, how we can improve the involvement of other allied health professionals, community members and consumers in research, and the advice she would give to early and mid-career researchers.

Recorded on Thursday 26 September 2024 from 11:00 – 12:00 AEST.

Video transcript

Professor Steve Wesselingh 0:00
That we're all meeting across the country. I'm on Kaurna land today, but I'm sure all of us are on a lot of different lands and we'd like to acknowledge them as the traditional custodians of the lands and the waters of the regions that we're on. I'd like to pay my respect to Elders past and present, and I'd also like to pay my respects to any Aboriginal or Torres Strait Islanders who are on the call today.

Before we start, I would just want to emphasise that there's an opportunity to ask questions and you can put those questions in the chat, and I'll be watching the chat and then ask those questions at the end. Also, past recordings of all of our previous Speaking of Science webinars are available on the NHMRC website so have a look at those and obviously today's will be recorded as well and uploaded in the coming days so you can watch it or you can recommend friends and colleagues to watch it.

Speaking of science has actually gone really well. We've had really good crowds coming to our webinars and, but I just want to emphasise that this is obviously yours and so if you have any thoughts about who we should bring onto Speaking of science, any thoughts about how to improve it, please talk to us. I'm sure we can improve it with your help, but today we're talking about cardiovascular disease, which is the world's number one killer. Combined conditions affecting the heart or blood vessels, such as heart attack, stroke and heart failure kill more than 20 million people globally. Julie, I hope I'm not stealing your first slide there.

This Sunday, the 29th of September, is World Heart Day, which was established in partnership with the World Health Organization to raise awareness and mobilise international action against cardiovascular disease. This is now celebrated annually and about 2 billion people are connected together to talk about cardiovascular disease prevention, detection and treatment. On a national scale, heart disease is the leading single cause of disease burden in Australia, causing about 11% of deaths and obviously that means that we should be doing lots of work on this. NHMRC should be funding lots of research and obviously there are some fantastic cardiovascular researchers out there and one of them is the fabulous Professor Julie Redfern. I'm really excited to hear from Julie today.

Julie is a distinguished public health research and physiotherapist as well as an NHMRC Leadership Fellow and received the NHMRC Elizabeth Blackburn Investigator Grant Award in the Health Services category. Among other projects and grant funding, she's the principal investigator on a really successful NHMR Synergy grant, SOLVE-CHD and we, Julie and I were just chatting about how well that grant is going. And she's had over 15 years’ experience in developing, testing and implementing scalable strategies to close evidence-practice gaps and improving health outcomes for people with chronic and cardiovascular diseases. In May of this year, Julie commenced a new role as Director of the Institute for Evidence Based Healthcare at Bond University. She's also being the recipient of the 2022 NSW Women of Excellence Award, an Australian Cardiovascular Alliance Mentor Award and a University of Sydney Vice Chancellor's Award for Leadership and Mentoring. Even more, she's had a NSW tall poppy and winner of the Cardiac Society of Australia and New Zealand and the Australian Cardiovascular Health and Rehabilitation Association Researcher Award. The list just goes on and on, Julie. I think I'll stop there because that could go on for too long. But really thank you very much for joining our webinar today. I'm really looking forward to your talk and looking forward to the discussion afterwards. Thanks very much.

Professor Julie Redfern 4:18
OK, thanks so much, Steve, and nice to see so many people online and pleased to share with you as Steve said, some of our work we've been doing really leading from our Synergy Grant. I'll share my screen, hopefully everything will work. Are we good?

Professor Steve Wesselingh 4:42
Yep, that was good on my screen. Excellent.

Professor Julie Redfern 4:45
As Steve said, I'll talk you through a few things we've been doing and a bit of A Cook's Tour and then we'll have some time and I'm very happy to take some questions and have some discussions. Really our work is about trying to transform care for people who survive a heart attack. I'm going to sort of talk you through where we've gone and how we've got there. I also would like to acknowledge the traditional custodians of the lands on which we meet today, pay my respects to elders past, present and emerging.

But as Steve said on the 29th of September is World Heart Day. I am a member of the World Heart Federation Science Committee and I'm quite passionate about supporting the World Heart Federation as well as our National Heart Foundation in Australia. As Steve's already said, we know cardiovascular disease is actually the world's number one killer. Not everybody is always aware of that. People with heart disease look the same potentially on one day to the next, and potentially even feel the same as well. So, it's quite different to some other health conditions, it's actually quite hidden even though it's the number one killer. We know that around 20 million people die of this condition every year, which is not ideal, of course and the World Heart Federation is working to bring this number down, way down, as they say. On the left, I've given you a small little image of some of my amazing team that's working on our Synergy Grant and others yesterday holding a bit of an event at the University of Sydney.

As we've sort of already alluded to, but just to refine a little bit more, cardiovascular disease, it actually effects around 60,000 Australians every year. That's a serious heart event being a heart attack or an admission to hospital and unfortunately 13% of those people pass away. But my area of work is really what do we do about the 51,000 odd people who actually survive? That's where I've been working really for the last 15 years because those people are at a tenfold risk of a future heart attack. We want to try and prevent these things, of course, and with more people surviving, which I'm going to come to in a minute, what happens then to all of these 51,000 people and how can we do as well as we can with those people, keep them as healthy and have the best quality of life they can for as long as possible? Unfortunately, cardiovascular disease, traditionally, people might have thought otherwise, but it doesn't actually resolve spontaneously. It's not like a broken leg, you get a plaster, wear it for six weeks, get an X-ray, get some other treatment and essentially your bone is healed. Cardiovascular disease is a chronic condition, and it does require long term risk management. Now we know a programme that's been around for a while, which I'll come to as well, it's cardiac rehabilitation, which is really the focus of our Synergy Grant and we know it's effective for those who attend, but about 40,000 Australian people miss out on such a programme every year and this is consistent all around the world and actually a bigger problem in some of the other low and middle income countries. But Australia is pretty well similar to the rest of the western world in this space. We need more systematic and improved long term care for everyone that needs it in this space and it's actually an area that's increasing as more people are surviving.

I'm just going to touch on a couple of very basic things. You don't need to think about any of the detail, but one of my early papers from my own PhD was looking at people who didn't attend the traditional cardiac rehabilitation programme and we found that those that don't go actually have the highest risk, and the poorest knowledge compared to those that attend. That is one of the primary reasons why my career has since focused on those people largely who don't currently participate and access such programmes. I did some other work which kind of feels interesting now looking back. It was published in 2009, I ran a trial as part of my own PhD [and] we called it the choice trial and interestingly enough, what we did is we let people with heart disease actually have real choice in how their health was going to be managed. We gave them some at the time, telehealth support and goal setting. We found, heaven bid, that giving people choice in their way, they manage their own health was actually helpful in reducing risk among those not attending the rehabilitation programme. This is something I've been building on and of course, back at that time, some of the digital technologies were only really just starting to come in. We've taken that and, and done some further work around those areas. But I think it's interesting looking back, of course, it feels obvious, but giving people choice in how they were doing things is actually a key point here.

Around all of this time, I was part of a large team in Australia and New Zealand that led what we call the Snapshot ACS study. Professor Derek Chew, Professor David Brieger and Professor John French were three of the leaders along with various others. I really was involved in what happens when it's time to leave hospital and after people get home. We looked at what happens in Australian hospitals for people with acute coronary syndrome, which is a heart attack or an acute period of angina needing hospitalisation, and we wanted to look at what actually happens when they're in hospital and about to leave. We found not that good as we would have liked. We found that 65% of people only were discharged with the recommended medicines they should be on. Less than half of them were referred to a cardiac rehabilitation programme. Less than half received any advice about quitting smoking, at least it was documented anyway. Around 1/3 had any level of mention of physical activity or dietary advice. Unfortunately, only 10% of people were screened for, for depression, which we know is linked to cardiovascular disease. We also sort of looked at, well, who got a bit of everything, so something about lifestyles, something about the medicines and a referral. We found only 1/4 of people admitted to Australian hospitals actually got that package, which is quite frightening to be honest. The data was collected in 2013 and 2014. But I would say while some things have changed, there's a lot of work to do because this is not good enough.

Just to sort of jump back to the cardiac rehabilitation before I move forward and talk to you about our Synergy Grant, we started to sort of look back in time, well, why have we got this problem? I think looking at the history kind of really laid it out for us. This a bit of interesting information, but also really provides the foundation of where we've gone. You might, or might not know, that back before 1950, people who had a heart attack were actually put on bed rest, they were not allowed to move largely often for a year and even to go to the bathroom. This was not something that was encouraged or people, people thought it was dangerous. Their heart wouldn't cope, they'd have another heart attack. After that time, people needed rehabilitation because they were very weak and could hardly walk around. Then there was some pioneering research in the 60s that discovered, oh, heaven forbid people can sit in a chair and actually do a bit of walking and actually be OK. This is interesting if you think about World Heart Day coming up now in this period of time, in this 70-80 odd years, we've seen a complete flip in this that we know people being active is actually helpful for preventing heart disease. In the 70s though, bypass surgery started to become more common, of course and we saw people in intensive care and people are still needing this sort of reconditioning of rehabilitation. We saw this proliferation of these group based cardiac rehabilitation programmes, which included exercise and education. They started inpatient and then progressed to sort of outpatient sessions, and they really proliferated across the Western world. But then at the same time, sort of since that period, we've seen enormous advances in bypass surgery for heart disease. We've seen the introduction of coronary intervention, which is keyhole surgery for helping to open up the vessels around the heart. Of course, we then see a reduction in the number of time in hospital and this sort of not such a need for rehabilitation, physical rehabilitation anymore, but different needs where we would need to manage people's risk factors. But unfortunately in Australia, and all around the world, we see that the majority of these cardiac rehabilitation programmes have sort of fallen through the cracks of progression and transformation and 70 to 80% of those programmes still do what was introduced back in the 1970s despite these enormous changes in medicine and surgery. It's really been an underdeveloped, under researched, under resourced area of healthcare, but also of research.

At the same time, more recently, we've had enormous societal change around the world in terms of language, culture, technology, and obviously the pandemic where we saw some shift in care. I think this diagram really lays the whole foundation of where we're trying to go and shows what we're trying to do. This is all about trying to help cardiac rehabilitation and the systems around post discharge care for people catch up with the rest of medicine really in this space.

Just to summarise sort of where we were at, I started to really have developed my own career and my own connections. We knew obviously there's a large evidence practice gap in the care for people, and a major health issue being cardiovascular disease. In Australia, clinical environment, the people working in rehabilitation are very multidisciplinary. I myself, allied health, a lot of nursing colleagues, medical colleagues, we'd come together and set up what would be the key performance indicators in this space to show we were doing well. But my own experience had also expanded enormously through my postdoctoral time. Luckily, I've been funded by the NHMRC, thank you, Steve, with various fellowships and other grants. But through that I'd worked at the George Institute, The University of Sydney, grown a lot of experience with data extraction, data linkage for health implementation science, health services research, but also in doing clinical trials. My own track record and experience was definitely at a different level at this time. Also we've developed significant collaborations, partnerships and grant success. But this area of sort of this cardiac rehabilitation, not so much driven by the medical fraternity, was really lacking in research and real sort of drive I guess and support to move forward.

But then along came the NHMRC change in the structure of your of the grant funding programme. I can't speak highly enough, certainly for the area that I work. The Synergy Grants came along, they're designed to support outstanding multidisciplinary teams to work together to answer major questions that can't be answered by a single investigator. I tend to add there, Steve, not only single investigator, but single project and the, the whole thing just spoke to me right from the start when I very first saw it. I thought this is an opportunity. We have the track record, we have the knowledge, we have the skills, we have the problem, and this is a way for us to move forward and hence the, the concept of our SOLVE CHD programme was born at that time.

I'm just going to tell you a little bit about what we've sort of been doing. I don't want to go into too much detail because it's a bit too heavy. But basically, the SOLVE CHD Synergy grant vision, as we saw it originally with my colleagues, was to optimise that after hospital care, reduce the burden of heart disease by integrating data, technology, partnerships and capacity building. I should say that at the time we were obviously we were successful in being awarded the Synergy Grant in the very first round. I did not know, I had no precedent to think about how do we construct this, how do we write this? A lot of people have asked me since what we did and I've actually helped a lot of other people, but I'm really proud to say that I am an allied health clinician researcher. Then at my CIB, Professor Tom Briffa is an exercise scientist, epidemiologist, also allied health. Then my CIC is Professor Robyn Gallagher who's a professor of nursing.

For me, this was sort of the first really big infrastructure funding in cardiac rehabilitation and secondary prevention space in Australia and led by 3 people who are nursing an allied health background along with various other amazing investigators. What are our goals? It's four-fold. Number 1 is to facilitate national systems to collect data, you develop reporting and enable quality improvement. To really actually do these things to improve the care that people are receiving, which I'll come to, support innovative research, identify and cultivate a whole new research capacity and community, which I'll come to as well, and then establish a network, bring everyone together and try and show that leadership. I'm just going to talk through a bit of those four areas, the kind of things we're doing.
Firstly, what about these facilitating systems to understand rehab. Unfortunately, this cardiac rehabilitation community is kind of dropped off, it's not in hospital, it doesn't sit directly necessarily in hospital funding and research and quality systems. It doesn't sit in primary care systems, it's somewhere in between, and this is a big problem and it's part of the problem with our Australian healthcare system and so, you know, we're really trying to kind of close that gap, of course.

When I was a child, makes me feel old, I don't think I'm that old, but my mum used to take me to the doctor and the doctor would bring out have a card like this or similar put on their desk. Doctor would see me, I would answer questions, they would write things on that card, they would staple it to the previous card back into the filing cabinet until the next time that it came in. Of course, when we now see a GP, this is very different. In most cases where we might go in, we might get a blood pressure measured, or something done. The GP now types into a computer, they can generate an electronic script for example, that we can then manage. But what that means is in the background, in the primary care practice, there's a lot of data being recorded about the people that they see and they're trying to treat.

Now we wanted to understand where cardiac rehabilitation community in Australia was at with this kind of thing and we kind of see this as a bit of our baseline data if you'd like for our Synergy Grant and we want to try and move this dial forward over the 5 or 6 years, hopefully more of the programme. Initially we did a national survey. We got 81% of programmes to complete it and we found in cardiac rehabilitation in Australia, 61% of programmes still write on pieces of paper and this is problematic because we can't use the information to join it together to understand and advocate for this space and try and influence policy, but also improve the care that we're giving to people in a proactive way. Cardiac rehabilitation has fallen behind.

Tom Briffa, CIB on our Synergy Grant, will say it's frozen in time. Often, if data is even collected, 83% of the time these clinicians are having to enter this into multiple systems where they're being told by different groups got to enter data, got to enter data, and they're entering the same information. This is an important part of how we need to think about things. I do want to flag I've just moved to Queensland, not for this reason, but Queensland's actually leading the way in this cardiac space, which is another conversation. But they actually have included these cardiac rehabilitation variables into their system, which is fantastic. That's just a picture of the cardiac rehabilitation is still sort of back in time, as Tom would allude to.
Now this obviously is the extreme, but I'm not a Formula One racing supporter, but our Australian driver is going very well at the moment. We know in pilots, by Formula One races, these kind of things are more and more driven by data, even sport and athletic performance. What about health? How can we better use this in health? And in cardiac rehabilitation, we're not even at the starting gate because we don't have the data to even start knowing in our country how many people are benefiting and how we can do better.

This brings us to one of the things that we're trying to implement. We're trying to collaborate with the National Heart Foundation to do this, where we've got a national group. We want to certify our clinicians around Australia, which currently there is no official certification. We want to collect data, we want to use that data to improve the quality of what we're doing all around the country and then we want to be able to certify programmes. We've set ourselves a target of 50% of programmes being certified and have a bit of a traffic light to kind of drive up quality, which has already been implemented in the UK and the US. But Australia, there's nothing of this nature in this space.

This is sort of the first layer of what we're trying to do to get this kind of unified vision, unified data collection and then be able to advocate in this space.

That's a few things we're doing there. Moving on, what's some of our innovative research though? In our Synergy Grant, we are doing innovative research as well as our systems work, which is advocacy and policy. We're trying to look at a few innovative different ways that we can improve the area.

These are some of the projects we've had funded and I myself, as the CIA of this Synergy Grant, can't be more thankful to be honest to the NHMRC. It's a $5,000,000 grant. But as you'll see in the next few slides that I'll present, we've been able to leverage that original work to manage the core infrastructure and the central vision and some of the transformative work, and also some pilot work and things like that, to leverage and get a lot of other studies funded. Every study we originally proposed has now been funded by other grants, which is absolutely fantastic. We did the National Data Capture that I spoke to, we've done Gamification, I'm going to talk a bit about the QUEL, which is using data to see if it improves outcomes. We've got a Heart Foundation Strategic Grant, we've got a team in the UK, which I'm going to speak to and a whole bunch of other things, peer support and you'll see I like to have coordinated logos. These are some of the projects that we're working on. There are more, but we've now kind of got this whole group of projects and team.

Just to tell you a few, you don't need to think about any of the detail, but the first one is funded by an NHMRC partnership grant known as QUEL. I am the CIA on that grant, but I think it's interesting to highlight a couple of things. It's a cluster trial, which means you're randomised by the site. In this case, it's by a primary care practice. Some primary care practices get the intervention, and some don't, or half and half and what we do is we use data linkage and those electronic systems to understand and collect the data for 15,000 people. We then delivered some support to help those practices do quality improvement work using the data and then we want to see if that kept people out of hospital, reduced heart attacks and helped with prescriptions and risk factors and things like that. Now, the problem with the study is that the intervention took place in primary care right in the middle of the COVID pandemic and we are just analysing the data, but I'm not very confident because obviously all of the health systems became focused towards preventing and managing COVID-19 anyway. That remains to be seen.

But in all our projects, we do big process evaluations to understand the clinician and the patient's perspectives about everything. We've actually with this study, and I'm not sure anyone's done it before and happy to be corrected, we've linked 15,000 patients. All of the data from when they see their GP together with their hospital government readmission data for the participating states, plus the MBS and PBS information collected federally as well as who has passed away. We've got all of this now in this data set that is currently being analysed.

I don't need to go into this one because this one is our quicker project where we've taken all of that concept and we're doing it in 40 cardiac rehabilitation sites. This is where we want to see if having data and using it actually improves outcomes for the patients and the systems. This project is being led by my colleagues, Professor Robyn Gallagher, Doctor Dion Candelaria, and they're doing a fantastic job. We've got 40 sites recruited and we were able to get an MRFF Grant through the Cardiovascular Scheme to do that. That's ongoing.

I just wanted to touch on one other one. I'm not going to go into the science of it, even though we're speaking science, because this is about peer support. What about people helping other people? What about people that have had heart disease being able to give support and advice to other people? This is already happening in some places in person and, and more recently with the launch of My Heart, My Life by our National Heart Foundation. But this is a study to actually determine in a randomised controlled trial if it actually helps people. That heart to heart project is ongoing, also funded by the MRFF and also NSW Health.

I just want to flag another study because this is being led by our colleagues in the UK, Professor David Wood is one of our chief investigators, so we do have a project being based over there. We've piloted an interactive app for patients to work alongside cardiac rehabilitation. My plan and my hope, we've got a grant in submission over there in the UK, if that's successful, we'll try and apply for one of the international clinical trial grant schemes here in Australia to run an Australian arm of that trial. That one sort of we've helped pilot it and develop it and now we're in the next phase of getting ready to fund the trialling of it.

Moving forward, what about the research capacity, the community engagement? This is an area that's been, it's very multidisciplinary, very lacking in high level kind of research capacity and this has been a real passion of mine to really uplift this space, particularly amongst all these amazing multidisciplinary researchers, but also bring in implementation science, community engagement, consumers and develop health services research leaders.

These are some of the people that are working with us. Obviously, I can't go into all of them, but these are some of the amazing people. I think some of them are online. You can sign up, you can go to our website, solvechd.org.au and join our network if you want to know more about what we're doing or also you can email me at any time. Happy to link up and help anyone where I can.

Just to show you, I think this is how one can take a $5,000,000 Synergy Grant and turn it into something transformative. We've actually been successful in now getting 5 in NHMRC Investigator Grants through the team, including my own, a Heart Foundation postdoc, we've supported PhDs with scholarships, we've got a Partnership Grant for MRFF, various others. We've also supported 52 cardiac rehabilitation clinicians to get scholarships to be trained and certified. We also support clinicians and various academics and other groups to attend the ACRA conference, which is the Australian Cardiac Rehabilitation Association, who we've been collaborating with very heavily and very successfully. We've got a consumer group that we engage with and do lots of different things in terms of engagement, but we're sort of expanding internationally. It's really for me now honing a shared vision and a leadership and a collaboration and I'm really proud because I think we're actually have achieved that.

What about a national network that brings everyone together? Well, as I said, we’ve already achieved that pretty significantly. We're still working on it. But it's interesting, it's about the vision and getting a vision that's very simple and tangible and that's a little bit of space we're working in now. It's complicated to do health services research. But only a couple of weeks ago we went over to London, and we led an international forum in this space and we're really showing our leadership as Australians. We collaborated with the International Council over there but bringing together all of these groups led by really our Synergy Grant team, SOLVE CHD, and now the World Heart Federation. I'm currently in discussions with them, I am on their science committee, but it looks like we're going to be able to develop a whole programme within the World Heart Federation to try and tackle this diverse and huge problem. But I will say, as I've said to everyone at the forum, my personal and our Solve Synergy grant is really about Australia transforming things in Australia. But obviously we want to contribute to the global climate as well.

There's a bit of a photo of some of our Synergy Grant team at the top and then at the bottom is the attendees is at our recent global forum. I think just showing the kind of engagement, and the kind of people that have been doing all sorts of different things. But thank you to every person and to every patient who's been involved and helped us sort of move this space forward. It's very, it's very challenging, I should say.

Just to bring you back to why we're here today, it's World Heart Day as Steve said at the start, on the 29th of September. We've got the world's number 1 killer, and we do need to try and do better at bringing this down. I think that was pretty much all I had to say. But I'm very proud to see the vision actually come into reality and I can't be more thankful to the NHNMRC for supporting myself and allowing this area that previously had been underfunded and really under researched actually come to light and be leading the way. I think that's all from me. I'll stop sharing over to you, Steve.

Professor Steve Wesselingh 32:24
Thank you very much. That was fantastic and I do like the thanks for the NHMRC. Always appreciate those because we get other comments about NHMRC as I'm sure you're aware. That was terrific.

I'll encourage people to put some questions on chat and I'll be looking at the chat and be able to ask those questions if they come up. I actually already have one which I'll go into in a second. But I guess my first question was, I'm a big fan of clinical quality registries and I think there are examples around the country like the joint registry, like ROSA and others which have national clinical quality data. It just does surprise me that we don't have a clinical quality registry for cardiac disease and cardiac rehab that's national.

Professor Julie Redfern 33:22
Yeah, I mean, we absolutely don't. We've linked up with the National Cardiac Registry, that's for sure. It's such a complex space. The stroke team have done a really good job of having one and this is something, is it a registry or do we want to embed things within the electronic record?

A lot of the registries, so say in cardiac care when someone has an angioplasty or the balloon put in their artery to open it up, that's done as an inpatient and that data is collected and recorded in a computer. It's very easy to set, well not easy. That's not the right that we need to say, but you know, the data is actually there that can be collated. Now the problem we've got in cardiac rehabilitation is the clinicians are keen and willing, but actually the variables aren't in the systems to enter it. They tend to just type in a progress note. Just typing in words and you can't use that in a registry. We're trying to do that.

It is complicated. I think building variables into the EMR is a way forward. Queensland have done it and done it very, very well. Now they've got all this data and they're like, Julie, what do we now do? I think to the, to the point of the quality registry, I have been involved in a number as well, we've got a few trials going, as I alluded to QUEL and QUICR, where we actually want to see if using them drives improvement and better outcomes for patients and systems. I'm really excited about those 2 projects to take the registries and get the evidence as to whether we can actually use them to improve the care. That's kind of exciting, but Queensland are leading the way. Yes, we need to do more, and we want to do something national.

Professor Steve Wesselingh 35:12
Thanks for that.

The question on the line goes to one of the questions that I had in my mind as well, which is we've always been really keen on multidisciplinary research and obviously the Synergy Grants were designed with that in mind. But we've also been very keen on getting more allied health and more nursing and you alluded to that early in your talk. Recently I was talking to the Council of Deans of Nursing about how we could improve our funding of nurses. But it's a difficult area and you'd be aware of some of the issues, but the career path of someone in allied health and someone in nursing is quite different to someone medically or in biomedical science. Just interested in your thoughts about how we could improve the number of allied health and nursing people that NHMRC support?

Professor Julie Redfern 36:07
Yeah, fantastic question and I'm very passionate about it actually very proud allied health professional and love working with all of my colleagues. I have people from dietitians to various different nurses, and psychology backgrounds as well pharmacy. Interestingly, I have been recently successful in being awarded the MRFF Grant to evaluate the impact of the Clinician Researcher Scheme targeting nursing and allied health. I'm definitely focusing there and trying to understand how the capacity building's going associated with that particular scheme. But yes, it's a challenging area. I'm really proud that I am an allied health professional leading this, and really striving to build capacity in this space.

It's tough to uplift people and help people understand that underneath you need to be doing high quality research in order to be successful in this highly competitive environment. I was lucky enough to be well mentored, try and sort of pass that down. But you know, someone was only talking to me yesterday about something and I'm like, OK, we need to lift the quality and the robustness of the research that's actually being done, which will help you because they've got the fantastic ideas. I don't really know. I've done talks to allied health professionals and nursing as a clinician researcher. I want to help people have confidence as well, so we don't feel like we’re kind of second tier. That's absolutely not the case. I agree with you about the career paths. That is a huge problem. When you're a physiotherapist or a nurse in a hospital you're busy with your clinical care. There's not really a focus on supporting these types of professionals to do research. Actually, it's very much about clinical care.

When I was a physiotherapist, at the end of the day, you sort of type some statistics in what you were doing all day and the expectation is that you're doing the clinical care all day, every day. You need to be a researcher to get that time. I'm not sure how we change that as a concept, but I think we need to do better. I'm not sure that that would ever really happen much in nursing environments in the clinical world and it's clinicians are so important to this space.

Professor Steve Wesselingh 38:37
Thanks for that.

Wee-Ming has asked a question about consumer and community involvement, which is something that is a priority for NHMRC and for lots of people around the country. How has that contributed to your grants and also how do you do that? Because we we're promoting it, but a lot of people do say to us, how do I do that? How do I get community involvement? Just interested in your thoughts around that.

Professor Julie Redfern 39:05
Yeah, I mean, look, it's very important and very interesting and something that, unknowingly to me back before it was a well-recognised thing and maybe because I was a clinician, I was already thinking about the consumer. You might remember one of my early slides where I spoke about this Choice Programme. Now I sort of think about it now, I was very passionate even at the start of my PhD about giving people choice in how their own care was going to be provided to them or they were going to engage in it because that was a way to get better engagement.

I think I had a focus on that all the way through and since then, I sort of got more introduction to it back in my time at the George Institute when we were co-designing interventions, more digital health interventions, and we got a consultancy company to help us co-design. That exposed me to real co-design and that real involvement in the development of the interventions and the studies. I sort of had already been involved in it and then we've just always involved the consumers in the interventions and testing how we're going to evaluate things and what's important to them.

We did go on, I can say that my amazing postdoc who took some of our CBD work to breast cancer, went on and ran a trial in power SMS and we won for that trial the Act of the Australian Clinical Trial Alliance Consumer Involvement Award of the Year. In that trial, as we've done more and more, the consumers are authors, they're investigators, they're part of the co-design process, they're part of the evaluation process, everything really. But it takes time, Steve, and it's not easy., I think that's individual trials, but then the whole programme, we've got consumers being involved. We've had consumers help us, we've just done open calls, you can come, and our consumers will help give advice on grant applications. How to do it better? I think it's just kind of embedding it throughout resourcing the consumers for their participation. 
I'm just setting up at Bond now, in my new role, a consumer advisory group. We'll be advertising casual positions for them in that role, so they'll take proper positions as casual employees. I think we just need to keep listening and keep learning and keep collaborating. I mean, we all are people that live with different conditions and different disease and different experiences and diversity, which is actually what I thought you were going to say, diversity has been a focus as well, which I know is a focus of the of this Synergy Grants. It's not only multidisciplinary, but it's that diversity as well. All of the above, not easy.

Professor Steve Wesselingh 41:59
Fantastic. Thank you. Lots of questions appearing on the chat here.

One was, with these really big grants, the Synergy Grants and your volume of work there was just enormous, what's the biggest challenge in sort of managing all of that? I think Kate asked that question.

Professor Julie Redfern 42:21
Yeah, I mean, good, good question. Luckily for me, I took myself to the George Institute for Global Health in my early postdoc years because I wanted to challenge myself and I learned a lot there about clinical trials.

I think if there's anyone from the George online, I'm thankful to that long period of time that I was there for. But the George Institute at the time had a programme grant. Even though I was an ECR move and progressively an MCR, I was very exposed to the overall management and engagement with a pr- NHMRC programme grant at the time. I'd sort of seen how it works and how to get that engagement and how to get value out of that investment. That's why the Synergy Grant, I kind of felt like I had even that knowledge and kind of confidence, I guess. I went to Professor John Chalmers when this was successful to ask his advice. How do we manage it all?

I think there's one probably secret, and I think she's probably online, and in this particular Synergy grant, it's our amazing coordinator, Julia Ning. Having somebody who is positive, engaging, supportive, who works with us, who comes along with our vision, a professional staff, who really kind of is the glue, I think to all of the pieces. I think having that role, and having an amazing person in that role is transformative.

I think also for me is sort of the leader, having people to support me as the leader when challenges come up, but also trying to keep a simple vision and everybody kind of as much online with that vision as we can, but then allowing different people to grow and become their own people and run their own programmes as well. I like to mentor with people having their own sort of leadership and their own say in what they're doing. I think the glue is our professional leader.

Professor Steve Wesselingh 44:21
Thank you for that.
Interesting, you mentioned John Chalmers. He was actually a mentor of mine about four years ago at Flinders. John has influenced health and medical switch a lot across Australia, so just mention that.

There's a couple of questions about clinicians and rehab training, but it looks as though people are actually answering some of those in the chat, which is great.

Professor Julie Redfern 44:43
My team might be online.
Professor Steve Wesselingh 44:44 
— which is terrific, but I guess they just go to the fact that, and Julie's asked a question about what consumers would expect or ask of their clinician after a cardiac event, are you confident that consumers who do have a cardiac event are able both to ask their clinician and the clinicians have a pretty good view of, of rehab in Australia?

Professor Julie Redfern 45:07
Now I'm going to say probably no and probably no. There is a bit of a thing, I'll bring up one, one topic and that's women. I'll talk about the provider side; we know that women are less likely to be referred to these programmes. We know that women are less likely to be prescribed the medicines and they have other treatments that that they should and for various reasons. But other groups like First Nations people are disadvantaged, as are people in rural areas. I think we're quite confident that they’re potentially unknowingly subconscious biases that go on, and maybe it's not in the forefront of everyone's mind. Oh, this person doesn't need rehab. Now, 1 of the things we've sort of been trying to dispel, 2 things we've been trying to dispel. One with the National Heart Foundation, that heart disease is not something that is necessarily cured after you have a stent put in or whatever. It's something you need to continue to think about for the rest of your life. We've produced a video that's on YouTube about that Managing Heart Disease for Life. Now I've forgotten the other thing, of course. Anyway, Health Foundation, we're thinking about managing heart disease for life, which is important. But the other message is I think people understanding and being proactive and confident with their doctors to be confident and speak out. But a lot of the time the doctors are not aware.

I know what it was. The other thing is the rehabilitation. If you think about the timeline, it started because people were inactive. That's where it all started and then they needed physical sort of strengthening and reconditioning. Now people don't necessarily need strengthening and reconditioning. They need to be physically active if we can help reduce the risk. But sometimes there's perceptions that the traditional programme is focused on exercise, which it is still focused on exercise, it tends to be focused on group exercise. Some people will think they don't need to do the exercise., they play golf, go for a swim, do yoga, whatever it might be. But then they're missing all the other rich benefits of the other risk factors, the medications, the hearing pharmacists and psychologists. We're trying to get away from this concept of the focus on the physical activity component, even though that is obviously a key component In terms of the patients and the consumers and the people, not always, no.

I mean, people don't necessarily understand. We've done a whole programme. I didn't touch on it, didn't have time. Myself and Professor Clara Chow, also with an Investigator Grant, have done a lot of work in text messaging-like support for people. That's been fascinating to understand and get the feedback from people. What did they know? What did they want? People do largely know what the risk factors are for heart disease, but it's how do we help them embrace doing something about it. Alot of the people out there, a lot of the consumers don't know about rehabilitation and the providers equally, we're trying to work with the Heart Foundation on that space at the moment.

Professor Steve Wesselingh 48:31
Thanks for that. Justin's asked a 2-pronged question. One was, and this is an issue right across the board, about early and mid-career researchers and what they should be applying for what? What advice would you give them in terms of applications for funding and how that would then improve their success going forward?

But then he's got another question, which I think is also an important one and I'll keep that. OK, let you answer that one first.

Professor Julie Redfern 49:06
The EMCRs, are my secret passion and joy and I was an ECR myself of course. I have done a lot of work with the early mid-career researchers and quite try to be quite generous with helping this group. I myself didn't get my first CIA of a project funding from the NHMRC till I was 10 years post-doctoral. I had fellowships pretty much all the way through, but it took me 10 years at the time. I'd been a CI, I started off with just the smaller grants as a mid CI or second CI, the CIB on a Heart Foundation, a project grant, for example, and a HCF Research Foundation. But I really led the projects and then that kind of stepped up to me being able to be the CIA on one of those types of smaller things, $100,000, $50,000. Then I tried 3 times before I got my Partnership Grant and was able to get it and I've sort of gone from strength to strength there. I think applying for smaller things, but at the same time I mentioned that Snapshot Project, which was a big national project, and I really came in there and met a lot of people, learnt, built a lot of collaborations by just being in the middle of that group, and then leading a sub-piece which was the prevention part of it. Being generous, putting your hand up to do things, learning from people, giving yourself opportunities, taking opportunities. But I have also taken quite a lot of different leadership roles, panels I participate on, learned a lot.
Find good people. But underneath, Steve, I always tell people, especially with the focus on impact, you must be doing research that's robust, high quality and impactful because you can't package up, an empty box. You can make it look good, but I think underneath as a researcher, you've got to be doing robust, high quality and impactful research. It’s a tough one to answer here.

I've been there too. I've been in tears when my own EMCRs are successful with fellowships like an Investigator Grant, then the same day in tears with another one that is unsuccessful, and I know it's really hard and just trying to support and keep everyone positive. I think having that resilience and helping develop those softer skills as an early career researcher, and even as a senior researcher really helps so you can take feedback on. When I wrote this Synergy Grant, I got very intense feedback from different people and very tough. I was in tears myself; I can't do it. I couldn't believe in myself that we could do it, but that made me push harder and I really worked hard, and I think you get a better end product. So, embrace the feedback as well.

Professor Steve Wesselingh 52:12
Terrific answer. That's terrific.

The second part of Justin's question was about the Synergy Grants themselves. This is a very NHMRC type question, but we are very interested. We assess track record through publication leadership and research impact. Did that affect who you selected as your chief investigators?

Professor Julie Redfern 52:37
Yes, it did. I mean, for sure, yes, I wanted to get people who were leaders, but I also wanted early career researchers, mid-career researchers. But in the Synergy Grant it was the very first round so I think it's quite different now potentially. But I wanted with myself not leading a big infrastructure programme like this before. I mean, I had my own fellowships and projects. I really wanted some very strong programmatic leaders kind of as investigators to mentor me, support me and my other investigators and help me.

I mean, yes, we looked at publications. You know, it had taken a while as I kind of tried to allude to, to be ready to be capable of applying for something like this and delivering it. I needed a lot of skills to be able to lead something like this. But yeah, there's EMCRs, there's male, there's female, there's all sorts of different people. But all of those factors coming in as one would expect to determine the final team, and then there's AIs. Then of course, we’ve then collaborated with a lot more people since then.

There's something I wanted to touch on for you, Steve, but for the rest of the people, and it kind of speaks at that point to that question. The interplay between publications and impact is an interesting one and I think with Investigator Grants as well, because at the moment, I would say I'm quite focused on impact. I'm trying to make a transformative difference around the country in the way we do this care and the way clinicians are certified and various other things. But what that means is I'm not necessarily generating too many big clinical trials that are going to get in the New England Journal. It's kind of like I can see for me, if I was to do one now, I could get a high impact score, high leadership score, but maybe my papers aren't as good as somebody else. I think impact and publications are a little bit potentially in conflict or I could focus on the papers, and I wouldn't do the impact. That's just an interesting thought that kind of speaks to that point a little bit as well.

Professor Steve Wesselingh 54:49
Yeah, no, I think and there's a lot of discussion nationally and internationally on bibliometrics and how best to measure them. I think, I mean, I would argue that our move to 10 pubs has been really significant because you can concentrate on a smallish number of high-quality publications. It still doesn't totally answer your point that, you know, you could be spending a lot of time on having impact and therefore not having that time to write your New England Journal paper. I'm hopeful that when people look at the pubs, they look at what the pubs are saying and doing rather than necessarily only where they're published.

We work internationally with DORA and CORA and other international organisations that are asking exactly the same questions about individuals, but also about universities and MRI's which also get measured in a lot of different ways. I think the Bibliometrics is a real challenge and it's a challenge also because of artificially raised citations and other things which we know are happening internationally, not necessarily in Australia, but certainly that's another issue that we're watching very carefully. Really important points to bring up.

I actually had a question a little bit in my own area, but you mentioned that one of your trials was in the middle of COVID and that you're now looking at the data. I just wonder whether that's actually a really interesting opportunity rather than a challenge and actually look at the impact of COVID on the health system and on that area and there might be some really interesting insights.

Professor Julie Redfern 56:40
Correct. Look, I mean, I completely agree and obviously we've run this very different type of a trial, kind of like a virtual clinical trial, if you like, which was intended from the start. We have got a lot of information about the actual way we did the study, which was fantastic. But also, yes, we've got this huge cohort with all this amazing, linked data now in one place and absolutely we'll be able to look at that. Luckily, we were a bit interested in flu vaccination and cardiovascular disease. It's a bit of an offshoot. My postdoc Karisun was working on this space. We added in a bit more about vaccines, actually before you know any of this happened, we were thinking more about flu vaccines and so we actually do have probably more than what we may otherwise have had about vaccines. But yes, we'll know all of this sort of information about COVID and I can see obviously we do our primary analysis first, which is blinded, we don't know the outcome just yet, but then we'll be able to answer exactly. We use these kind of data sets now to answer really important questions, especially for these ones that were kind of in place before so you've got the pre and the post.

Professor Steve Wesselingh 57:52
Yeah, sounds like you need to add an infectious diseases position to the disciplinary team there.

Professor Julie Redfern 57:57
Yeah, well, flu vaccine is very important for people with cardiovascular disease actually, and quite a simple strategy. It's an interesting one, because it's in primary care guidelines. It previously wasn't in some of the cardiology guidelines. I'm pleased to say it will be in the new version that's about to go out for community consultation. Flu vaccinations are also important for preventing cardiovascular disease.

Professor Steve Wesselingh 58:24
Fantastic. I think we've sort of run out of time now and I would have loved to talk about infectious diseases for longer and our clinical guidelines, which obviously NHMRC play a big role in as well. Really pleased that that's happening. But no, we have run out of time. I'd just like to thank you, Julie, for a fabulous talk and great discussion afterwards. I can see your research is just going to go so well in the future and hopefully you continue to get in NHMRC support for that. Thank you for your acknowledgement of NHMRC.

I'd just like to say to the audience, thank you for being on board today, a terrific audience and lots of good questions and really encourage you to join us again in a month's time for our next Speaking of Science. I think this has been a really successful endeavour and we get great speakers, like Julie, and great questions and great discussion. Thank you all and hope you enjoy the rest of your afternoon. Thank you.

Professor Julie Redfern 59:30
Thanks, everyone. Thanks, Steve.

End of transcript.