Barbara Schmidt

Sustaining better diabetes care in remote indigenous Australian communities

Abstract Problem:Inhabitants of Torres Strait Islands have the highest prevalence of diabetes in Australia and many preventable complications. In 1999, a one year randomised cluster trial showed improved diabetes care processes and reduced admissions to hospital when local indigenous health workers used registers, recall and reminder systems, and basic diabetes care plans, supported by a specialist outreach service. This study looked at whether those improvements were sustained two years after the end of the trial. Design: Three year follow up clinical audit of 21 primary healthcare centres, and review of admissions to hospital in the previous 12 months. Background and setting: Remote indigenous communities in far north east Australia, population about 9600, including 921 people with diabetes. Key measures for improvement Number of people on registers, care processes (regular measures of weight, blood pressure, haemoglobin A 1c, urinary protein concentration, and concentrations of serum lipids and creatinine), appropriate clinical interventions (drug treatment and vaccinations), and intermediate patient outcome measures (weight, blood pressure, and glycaemic control). Admissions to hospital. Strategies for change: Audit and feedback to clinicians and managers; provision of clinical guidelines and a clear management structure; workshops and training. Effects of change: The number of people on registers increased from 555 in 1999 to 921 in 2002. Most care processes and clinical interventions improved. The proportion of people with good glycaemic control (haemoglobin A 1c ≤ 7%) increased from 18% to 25% in line with increased use of insulin (from 7% to 16%). The proportion of those with well controlled hypertension (< 140/90) increased from 40% to 64%. The proportion admitted to hospital with a diabetes related condition fell from 25% to 20%. Mean weight increased from 87 kg to 91 kg. Lessons learnt: In remote settings, appropriate management structures and clinical support for people with diabetes can lead to improvements in care processes, control of blood pressure, and preventable complications that result in admission to hospital. Control of weight and glycaemia are more difficult and requires more active community engagement. Priorities now include increasing the availability and affordability of good food, achieving weight loss, and increasing appropriate use of hypoglycaemic agents, including insulin.

Getting better at chronic care in remote communities: study protocol for a pragmatic cluster randomised controlled of community based management

BackgroundPrevalence and incidence of diabetes and other common comorbid conditions (hypertension, coronary heart disease, renal disease and chronic lung disease) are extremely high among Indigenous Australians. Recent measures to improve quality of preventive care in Indigenous community settings, while apparently successful at increasing screening and routine check-up rates, have shown only modest or little improvements in appropriate care such as the introduction of insulin and other scaled-up drug regimens in line with evidence-based guidelines, together with support for risk factor reduction. A new strategy is required to ensure high quality integrated family-centred care is available locally, with continuity and cultural safety, by community-based care coordinators with appropriate system supports.Methods/designThe trial design is open parallel cluster randomised controlled trial. The objective of this pragmatic trial is to test the effectiveness of a model of health service delivery that facilitates integrated community-based, intensive chronic condition management, compared with usual care, in rural and remote Indigenous primary health care services in north Queensland. Participants are Indigenous adults (aged 18–65 years) with poorly controlled diabetes (HbA1c>=8.5) and at least one other chronic condition. The intervention is to employ an Indigenous Health Worker to case manage the care of a maximum caseload of 30 participants. The Indigenous Health Workers receive intensive clinical training initially, and throughout the study, to ensure they are competent to coordinate care for people with chronic conditions. The Indigenous Health Workers, supported by the local primary health care (PHC) team and an Indigenous Clinical Support Team, will manage care, including coordinating access to multidisciplinary team care based on best practice standards. Allocation by cluster to the intervention and control groups is by simple randomisation after participant enrolment. Participants in the control group will receive usual care, and will be wait-listed to receive a revised model of the intervention informed by the data analysis. The primary outcome is reduction in HbA1c measured at 18 months. Implementation fidelity will be monitored and a qualitative investigation (methods to be determined) will aim to identify elements of the model which may influence health outcomes for Indigenous people with chronic conditions.DiscussionThis pragmatic trial will test a culturally-sound family-centred model of care with supported case management by IHWs to improve outcomes for people with complex chronic care needs. This trial is now in the intervention phase.Trial registrationAustralian New Zealand Clinical Trials Registry ACTR12610000812099

Community health workers as chronic care coordinators: evaluation of an Australian Indigenous primary health care program

Objectives: To explore how a client‐centred Chronic Care model was implemented by Indigenous Health Workers (IHWs) at participating sites in a trial of IHW‐led case management. To understand the experiences of engaging with the model from the perspective of the IHWs, health team members and clients.

Implementing a chronic disease strategy in two remote indigenous Australian settings: a multi-method pilot evaluation

OBJECTIVE To test an evaluation framework designed to evaluate implementation of the North Queensland Indigenous communities between August and December 2005. SETTING Both communities are located in Cape York, North Queensland. Community A has an estimated population of around 600 people; Community B has an enumerated population of 750, although health centre records indicate a higher number. PARTICIPANTS Process evaluation involved health centre staff in both communities; clinical audits used random samples from the adult population (each sample n = 30); ethnographic fieldwork was conducted with resident population. MAIN OUTCOME MEASURES Health centre scores and qualitative findings using a System Assessment Tool; clinical audits--extent to which scheduled services recorded; selected primary health performance indicators; qualitative ethnographic findings. RESULTS On almost all indicators, implementation of NQICDS had progressed further in Community A than in Community B; however, some common issues emerged, especially lack of linkages between health centres and other groups, and lack of support for client self-management. CONCLUSIONS The evaluation framework is an effective and acceptable framework for monitoring implementation of the NQICDS at the primary health centre level.

Economic evaluation of Indigenous health worker management of poorly controlled type 2 diabetes in north Queensland

Objective: To conduct an economic evaluation of intensive management by Indigenous health workers (IHWs) of Indigenous adults with poorly controlled type 2 diabetes in rural and remote north Queensland.

Assessing the link between implementation fidelity and health outcomes for a trial of intensive case management by community health workers: a mixed methods study protocol

BackgroundBetter systems of care are required to address chronic disease in Indigenous people to ensure they can access all their care needs. Health research has produced evidence about effective models of care and chronic disease strategies to address Indigenous health, however the transfer of research findings into routine clinical practice has proven challenging. Complex interventions, such as those related to chronic disease, have many components that are often poorly implemented and hence rarely achieve implementation fidelity. Implementation fidelity is “the degree to which programs are implemented as intended by the program developer”. Knowing if an intervention was implemented as planned is fundamental to knowing what has contributed to the success of an intervention.MethodsThe aim of this study is to adapt the implementation fidelity framework developed by Keith et al. and apply it to the intervention implemented in phase 1 of the Getting Better at Chronic Care in North Queensland study. The objectives are to quantify the level of implementation fidelity achieved during phase 1 of the study, measure the association between implementation fidelity and health outcomes and to explore the features of the primary health care system that contributed to improved health outcomes. A convergent parallel mixed methods study design will be used to develop a process for assessing implementation fidelity. Information collected via a questionnaire and routine data generated during phase 1 of the study will be used to explain the context for the intervention in each site and develop an implementation fidelity score for each component of the intervention. A weighting will be applied to each component of the intervention to calculate the overall implementation score for each participating community. Statistical analysis will assess the level of association between implementation fidelity scores and health outcomes.DiscussionHealth services research seeks to find solutions to social and technical problems to improve health outcomes. The development of a tool and methodology for assessing implementation fidelity in the Indigenous primary health care context will help address some of the barriers to the translation of research into practice.Trial registrationACTRN12610000812099: 29.9.2010