Damin Si

Delivery of maternal health care in Indigenous primary care services: baseline data for an ongoing quality improvement initiative

BackgroundAustralias Aboriginal and Torres Strait Islander (Indigenous) populations have disproportionately high rates of adverse perinatal outcomes relative to other Australians. Poorer access to good quality maternal health care is a key driver of this disparity. The aim of this study was to describe patterns of delivery of maternity care and service gaps in primary care services in Australian Indigenous communities.MethodsWe undertook a cross-sectional baseline audit for a quality improvement intervention. Medical records of 535 women from 34 Indigenous community health centres in five regions (Top End of Northern Territory 13, Central Australia 2, Far West New South Wales 6, Western Australia 9, and North Queensland 4) were audited. The main outcome measures included: adherence to recommended protocols and procedures in the antenatal and postnatal periods including: clinical, laboratory and ultrasound investigations; screening for gestational diabetes and Group B Streptococcus; brief intervention/advice on health-related behaviours and risks; and follow up of identified health problems.ResultsThe proportion of women presenting for their first antenatal visit in the first trimester ranged from 34% to 49% between regions; consequently, documentation of care early in pregnancy was poor. Overall, documentation of routine antenatal investigations and brief interventions/advice regarding health behaviours varied, and generally indicated that these services were underutilised. For example, 46% of known smokers received smoking cessation advice/counselling; 52% of all women received antenatal education and 51% had investigation for gestational diabetes. Overall, there was relatively good documentation of follow up of identified problems related to hypertension or diabetes, with over 70% of identified women being referred to a GP/Obstetrician.ConclusionParticipating services had both strengths and weaknesses in the delivery of maternal health care. Increasing access to evidence-based screening and health information (most notably around smoking cessation) were consistently identified as opportunities for improvement across services.

Improving organisational systems for diabetes care in Australian Indigenous communities

BackgroundIndigenous Australians experience disproportionately high prevalence of, and morbidity and mortality from diabetes. There is an urgent need to understand how Indigenous primary care systems are organised to deliver diabetes services to those most in need, to monitor the quality of diabetes care received by Indigenous people, and to improve systems for better diabetes care.MethodsThe intervention featured two annual cycles of assessment, feedback workshops, action planning, and implementation of system changes in 12 Indigenous community health centres. Assessment included a structured review of health service systems and audit of clinical records. Main process of care measures included adherence to guideline-scheduled services and medication adjustment. Main patient outcome measures were HbA1c, blood pressure and total cholesterol levels.ResultsThere was good engagement of health centre staff, with significant improvements in system development over the study period. Adherence to guideline-scheduled processes improved, including increases in 6 monthly testing of HbA1c from 41% to 74% (Risk ratio 1.93, 95% CI 1.71–2.10), 3 monthly checking of blood pressure from 63% to 76% (1.27, 1.13–1.37), annual testing of total cholesterol from 56% to 74% (1.36, 1.20–1.49), biennial eye checking by a ophthalmologist from 34% to 54% (1.68, 1.39–1.95), and 3 monthly feet checking from 20% to 58% (3.01, 2.52–3.47). Medication adjustment rates following identification of elevated HbA1c and blood pressure were low, increasing from 10% to 24%, and from 13% to 21% respectively at year 1 audit. However, improvements in medication adjustment were not maintained at the year 2 follow-up. Mean HbA1c value improved from 9.3 to 8.9% (mean difference -0.4%, 95% CI -0.7;-0.1), but there was no improvement in blood pressure or cholesterol control.ConclusionThis quality improvement (QI) intervention has proved to be highly acceptable in the Indigenous Australian primary care setting and has been associated with significant improvements in systems and processes of care and some intermediate outcomes. However, improvements appear to be limited by inadequate attention to abnormal clinical findings and medication management. Greater improvement in intermediate outcomes may be achieved by specifically addressing system barriers to therapy intensification through more effective engagement of medical staff in QI activities and/or greater use of nurse-practitioners.

Assessing health centre systems for guiding improvement in diabetes care

BackgroundAboriginal people in Australia experience the highest prevalence of diabetes in the country, an excess of preventable complications and early death. There is increasing evidence demonstrating the importance of healthcare systems for improvement of chronic illness care. The aims of this study were to assess the status of systems for chronic illness care in Aboriginal community health centres, and to explore whether more developed systems were associated with better quality of diabetes care.MethodsThis cross-sectional study was conducted in 12 Aboriginal community health centres in the Northern Territory of Australia. Assessment of Chronic Illness Care scale was adapted to measure system development in health centres, and administered by interview with health centre staff and managers. Based on a random sample of 295 clinical records from attending clients with diagnosed type 2 diabetes, processes of diabetes care were measured by rating of health service delivery against best-practice guidelines. Intermediate outcomes included the control of HbA1c, blood pressure, and total cholesterol.ResultsHealth centre systems were in the low to mid-range of development and had distinct areas of strength and weakness. Four of the six system components were independently associated with quality of diabetes care: an increase of 1 unit of score for organisational influence, community linkages, and clinical information systems, respectively, was associated with 4.3%, 3.8%, and 4.5% improvement in adherence to process standards; likewise, organisational influence, delivery system design and clinical information systems were related to control of HbA1c, blood pressure, and total cholesterol.ConclusionThe state of development of health centre systems is reflected in quality of care outcome measures for patients. The health centre systems assessment tool should be useful in assessing and guiding development of systems for improvement of diabetes care in similar settings in Australia and internationally.

Study protocol: national research partnership to improve primary health care performance and outcomes for Indigenous peoples

BackgroundStrengthening primary health care is critical to reducing health inequity between Indigenous and non-Indigenous Australians. The Audit and Best practice for Chronic Disease Extension (ABCDE) project has facilitated the implementation of modern Continuous Quality Improvement (CQI) approaches in Indigenous community health care centres across Australia. The project demonstrated improvements in health centre systems, delivery of primary care services and in patient intermediate outcomes. It has also highlighted substantial variation in quality of care. Through a partnership between academic researchers, service providers and policy makers, we are now implementing a study which aims to 1) explore the factors associated with variation in clinical performance; 2) examine specific strategies that have been effective in improving primary care clinical performance; and 3) work with health service staff, management and policy makers to enhance the effective implementation of successful strategies.Methods/DesignThe study will be conducted in Indigenous community health centres from at least six States/Territories (Northern Territory, Western Australia, New South Wales, South Australia, Queensland and Victoria) over a five year period. A research hub will be established in each region to support collection and reporting of quantitative and qualitative clinical and health centre system performance data, to investigate factors affecting variation in quality of care and to facilitate effective translation of research evidence into policy and practice. The project is supported by a web-based information system, providing automated analysis and reporting of clinical care performance to health centre staff and management.DiscussionBy linking researchers directly to users of research (service providers, managers and policy makers), the partnership is well placed to generate new knowledge on effective strategies for improving the quality of primary health care and fostering effective and efficient exchange and use of data and information among service providers and policy makers to achieve evidence-based resource allocation, service planning, system development, and improvements of service delivery and Indigenous health outcomes.

Evaluating the effectiveness of a multifaceted, multilevel continuous quality improvement program in primary health care: developing a realist theory of change

BackgroundVariation in effectiveness of continuous quality improvement (CQI) interventions between services is commonly reported, but with little explanation of how contextual and other factors may interact to produce this variation. Therefore, there is scant information available on which policy makers can draw to inform effective implementation in different settings. In this paper, we explore how patterns of change in delivery of services may have been achieved in a diverse range of health centers participating in a wide-scale program to achieve improvements in quality of care for Indigenous Australians.MethodsWe elicited key informants’ interpretations of factors explaining patterns of change in delivery of guideline-scheduled services over three or more years of a wide-scale CQI project, and inductively analyzed these interpretations to propose fine-grained realist hypotheses about what works for whom and in what circumstances. Data were derived from annual clinical audits from 36 health centers operating in diverse settings, quarterly project monitoring reports, and workshops with 12 key informants who had key roles in project implementation. We abstracted potential context-mechanism-outcome configurations from the data, and based on these, identified potential program-strengthening strategies.ResultsSeveral context-specific, mechanism-based explanations for effectiveness of this CQI project were identified. These were collective valuing of clinical data for improvement purposes; collective efficacy; and organizational change towards a population health orientation. Health centers with strong central management of CQI, and those in which CQI efforts were more dependent on local health center initiative and were adapted to resonate with local priorities were both favorable contexts for collective valuing of clinical data. Where health centers had prior positive experiences of collaboration, effects appeared to be achieved at least partly through the mechanism of collective efficacy. Strong community linkages, staff ability to identify with patients, and staff having the skills and support to take broad ranging action, were favorable contexts for the mechanism of increased population health orientation.ConclusionsOur study provides evidence to support strategies for program strengthening described in the literature, and extends the understanding of mechanisms through which strategies may be effective in achieving particular outcomes in different contexts.

Comparison of diabetes management in five countries for general and indigenous populations: an internet-based review

BackgroundThe diabetes epidemic is associated with huge human and economic costs, with some groups, such as indigenous populations in industrialised countries, being at especially high risk. Monitoring and improving diabetes care at a population level are important to reduce diabetes-related morbidity and mortality. A set of diabetes indicators has been developed collaboratively among the Organisation for Economic Co-operation and Development (OECD) countries to monitor performance of diabetes care. The aim of this review was to provide an overview of diabetes management in five selected OECD countries (Australia, Canada, New Zealand, the US and the UK), based on data available for general and indigenous populations where appropriate.MethodsWe searched websites of health departments and leading national organisations related to diabetes care in each of the five countries to identify publicly released reports relevant to diabetes care. We collected data relevant to 6 OECD diabetes indicators on processes of diabetes care (annual HbA1c testing, lipid testing, renal function screening and eye examination) and proximal outcomes (HbA1c and lipid control).ResultsData were drawn from 29 websites, with 14 reports and 13 associated data sources included in this review. Australia, New Zealand, the US and the UK had national data available to construct most of the 6 OECD diabetes indicators, but Canadian data were limited to two indicators. New Zealand and the US had national level diabetes care data for indigenous populations, showing relatively poorer care among these groups when compared with general populations. The US and UK performed well across the four process indicators when compared with Australia and New Zealand. For example, annual HbA1c testing and lipid testing were delivered to 70-80% of patients in the US and UK; the corresponding figures for Australia and New Zealand were 50-60%. Regarding proximal outcomes, HbA1c control for patients in Australia and New Zealand tended to be relatively better than patients in the US and UK.ConclusionsSubstantial efforts have been made in the five countries to develop routine data collection systems to monitor performance of diabetes management. Available performance data identify considerable gaps in clinical care of diabetes across countries. Policy makers and health service providers across countries can learn from each other to improve data collection and delivery of diabetes care at the population level.

Study protocol: Audit and Best Practice for Chronic Disease Extension (ABCDE) Project

BackgroundA growing body of international literature points to the importance of a system approach to improve the quality of care in primary health care settings. Continuous Quality Improvement (CQI) concepts and techniques provide a theoretically coherent and practical way for primary care organisations to identify, address, and overcome the barriers to improvements. The Audit and Best Practice for Chronic Disease (ABCD) study, a CQI-based quality improvement project conducted in Australias Northern Territory, has demonstrated significant improvements in primary care service systems, in the quality of clinical service delivery and in patient outcomes related to chronic illness care. The aims of the extension phase of this study are to examine factors that influence uptake and sustainability of this type of CQI activity in a variety of Indigenous primary health care organisations in Australia, and to assess the impact of collaborative CQI approaches on prevention and management of chronic illness and health outcomes in Indigenous communities.Methods/designThe study will be conducted in 40–50 Indigenous community health centres from 4 States/Territories (Northern Territory, Western Australia, New South Wales and Queensland) over a five year period. The project will adopt a participatory, quality improvement approach that features annual cycles of: 1) organisational system assessment and audits of clinical records; 2) feedback to and interpretation of results with participating health centre staff; 3) action planning and goal setting by health centre staff to achieve system changes; and 4) implementation of strategies for change. System assessment will be carried out using a System Assessment Tool and in-depth interviews of key informants. Clinical audit tools include two essential tools that focus on diabetes care audit and preventive service audit, and several optional tools focusing on audits of hypertension, heart disease, renal disease, primary mental health care and health promotion.The project will be carried out in a form of collaborative characterised by a sequence of annual learning cycles with action periods for CQI activities between each learning cycle.Key outcome measures include uptake and integration of CQI activities into routine service activity, state of system development, delivery of evidence-based services, intermediate patient outcomes (e.g. blood pressure and glucose control), and health outcomes (complications, hospitalisations and mortality).ConclusionThe ABCD Extension project will contribute directly to the evidence base on effectiveness of collaborative CQI approaches on prevention and management of chronic disease in Australias Indigenous communities, and to inform the operational and policy environments that are required to incorporate CQI activities into routine practice.

Incidence of type 2 diabetes in Aboriginal Australians: an 11-year prospective cohort study

BackgroundDiabetes is an important contributor to the health inequity between Aboriginal and non-Aboriginal Australians. This study aims to estimate incidence rates of diabetes and to assess its associations with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) among Aboriginal participants in a remote community.MethodsSix hundred and eighty six (686) Aboriginal Australians aged 20 to 74 years free from diabetes at baseline were followed for a median of 11 years. During the follow-up period, new diabetes cases were identified through hospital records. Cox proportional hazards models were used to assess relationships of the incidence rates of diabetes with IFG, IGT and body mass index (BMI).ResultsOne hundred and twenty four (124) new diabetes cases were diagnosed during the follow up period. Incidence rates increased with increasing age, from 2.2 per 1000 person-years for those younger than 25 years to 39.9 per 1000 person-years for those 45-54 years. By age of 60 years, cumulative incidence rates were 49% for Aboriginal men and 70% for Aboriginal women. The rate ratio for developing diabetes in the presence of either IFG or IGT at baseline was 2.2 (95% CI: 1.5, 3.3), adjusting for age, sex and BMI. Rate ratios for developing diabetes were 2.2 (95% CI: 1.4, 3.5) for people who were overweight and 4.7 (95% CI: 3.0, 7.4) for people who were obese at baseline, with adjustment of age, sex and the presence of IFG/IGT.ConclusionsDiabetes incidence rates are high in Aboriginal people. The lifetime risk of developing diabetes among Aboriginal men is one in two, and among Aboriginal women is two in three. Baseline IFG, IGT and obesity are important predictors of diabetes.

Assessing quality of diabetes care and its variation in Aboriginal community health centres in Australia

Examining variation in diabetes care across regions/organizations provides insight into underlying factors related to quality of care. The aims of this study were to assess quality of diabetes care and its variation among Aboriginal community health centres in Australia, and to estimate partitioning of variation attributable to health centre and individual patient characteristics.

Reorienting primary health care for addressing chronic conditions in remote Australia and the South Pacific: Review of evidence and lessons from an innovative quality improvement process

This paper reviews what is known about the challenges of implementing quality improvement programs and draws on data from a systematic continuous quality improvement (CQI) project in remote communities in Australia and Fiji, known as Audit and Best practice for Chronic Disease, to synthesise lessons and discuss the potential for broader application in low and middle income countries, including Pacific Island countries and territories. Although a number of systematic reviews have indicated that quality improvement programs can be effective in changing professional practice and improving the quality of care and patient outcomes, little is known about the key ingredients for change or how services use and implement different strategies to achieve improvements. We identify key features of an innovative CQI model and factors related to implementation that support improvement in diabetes service delivery and intermediate outcomes. Requirements for supporting CQI are identified and the potential for wider application discussed. It is argued that the participatory action research approach supports innovation and broad-based change and the evidence it has produced extends the current knowledge base and facilitates the translation of knowledge into action, for both policy and practice.