Kathryn S. Panaretto

Prevalence of sexually transmitted infections in pregnant urban Aboriginal and Torres Strait Islander women in northern Australia

Objective:  To assess the prevalence of sexually transmitted infections (STI) in a cohort of pregnant urban Indigenous women and association of STI with preterm birth, low birthweight birth and perinatal mortality.

Effect of a computer-guided, quality improvement program for cardiovascular disease risk management in primary health care: the treatment of cardiovascular risk using electronic decision support cluster-randomized trial

Background— Despite effective treatments to reduce cardiovascular disease risk, their translation into practice is limited. Methods and Results— Using a parallel arm cluster-randomized controlled trial in 60 Australian primary healthcare centers, we tested whether a multifaceted quality improvement intervention comprising computerized decision support, audit/feedback tools, and staff training improved (1) guideline-indicated risk factor measurements and (2) guideline-indicated medications for those at high cardiovascular disease risk. Centers had to use a compatible software system, and eligible patients were regular attendees (Aboriginal and Torres Strait Islander people aged ≥35 years and others aged ≥45 years). Patient-level analyses were conducted using generalized estimating equations to account for clustering. Median follow-up for 38 725 patients (mean age, 61.0 years; 42% men) was 17.5 months. Mean monthly staff support was <1 hour/site. For the coprimary outcomes, the intervention was associated with improved overall risk factor measurements (62.8% versus 53.4% risk ratio; 1.25; 95% confidence interval, 1.04–1.50; P=0.02), but there was no significant differences in recommended prescriptions for the high-risk cohort (n=10 308; 56.8% versus 51.2%; P=0.12). There were significant treatment escalations (new prescriptions or increased numbers of medicines) for antiplatelet (4.3% versus 2.7%; P=0.01), and BP lowering (18.2% versus 11.0%; P=0.02) but not lipid-lowering medications. Conclusions— In Australian primary healthcare settings, a computer-guided quality improvement intervention, requiring minimal support, improved cardiovascular disease risk measurement but did not increase prescription rates in the high-risk group. Computerized quality improvement tools offer an important, albeit partial, solution to improving primary healthcare system capacity for cardiovascular disease risk management. Clinical Trial Registration— URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336630. Australian New Zealand Clinical Trials Registry No. 12611000478910.

Aboriginal community controlled health services: leading the way in primary care

The national Closing the Gap framework commits to reducing persisting disadvantage in the health of Aboriginal and Torres Strait Islander people in Australia, with cross‐government‐sector initiatives and investment. Central to efforts to build healthier communities is the Aboriginal community controlled health service (ACCHS) sector; its focus on prevention, early intervention and comprehensive care has reduced barriers to access and unintentional racism, progressively improving individual health outcomes for Aboriginal people. There is now a broad range of primary health care data that provides a sound evidence base for comparing the health outcomes for Indigenous people in ACCHSs with the outcomes achieved through mainstream services, and these data show: ➢models of comprehensive primary health care consistent with the patient‐centred medical home model; ➢coverage of the Aboriginal population higher than 60% outside major metropolitan centres; ➢consistently improving performance in key performance on best‐practice care indicators; and ➢superior performance to mainstream general practice. ACCHSs play a significant role in training the medical workforce and employing Aboriginal people. ACCHSs have risen to the challenge of delivering best‐practice care and there is a case for expanding ACCHSs into new areas. To achieve the best returns, the current mainstream Closing the Gap investment should be shifted to the community controlled health sector.

Assessing the accuracy of self-reported smoking status and impact of passive smoke exposure among pregnant Aboriginal and Torres Strait Islander women using cotinine biochemical validation

INTRODUCTION AND AIMS A significant level of misreport or error occurs during questionnaire-based assessment of smoking behaviour. Failure to measure environmental tobacco smoke, and participants inclination to under-report their smoking raise questions as to the accuracy of assessment. In order to establish an estimation of the possible error associated with such assessment, the accuracy of self-reported smoking status among a group of pregnant Aboriginal and Torres Strait Islander women was examined. DESIGN AND METHODS Women attending two Aboriginal Medical services in Far North Queensland for antenatal care were invited to participate. Women completed an interviewer assisted questionnaire relating to their smoking status and a 24 h diary of their exposure to nicotine and consumption of alcohol. Urine samples were analysed for cotinine using an Enzyme Linked Immunosorbent Assay. RESULTS Cotinine analysis indicated that 17% of women who reported that they were non-smokers were likely to have misreported this status, or be exposed to high levels of passive smoke. The only significant predictors of cotinine level were self-reported nicotine exposure (including passive smoke) and number of cigarettes smoked in the previous 24 h. Other individual and environmental variables had no significant influence on cotinine level using this analysis technique. DISCUSSION AND CONCLUSIONS The level of potential error in smoking assessment among this group was substantial. Exposure to environmental tobacco smoke might explain part of this error, but the reasons for misreport can only be speculated. This rate of misclassification should be taken into consideration in routine screening of antenatal women in primary health care.

A randomised controlled trial of a consumer-focused e-health strategy for cardiovascular risk management in primary care: the Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) study protocol

Introduction Fewer than half of all people at highest risk of a cardiovascular event are receiving and adhering to best practice recommendations to lower their risk. In this project, we examine the role of an e-health-assisted consumer-focused strategy as a means of overcoming these gaps between evidence and practice. Consumer Navigation of Electronic Cardiovascular Tools (CONNECT) aims to test whether a consumer-focused e-health strategy provided to Aboriginal and Torres Strait Islander and non-indigenous adults, recruited through primary care, at moderate-to-high risk of a cardiovascular disease event will improve risk factor control when compared with usual care. Methods and analysis Randomised controlled trial of 2000 participants with an average of 18 months of follow-up to evaluate the effectiveness of an integrated consumer-directed e-health portal on cardiovascular risk compared with usual care in patients with cardiovascular disease or who are at moderate-to-high cardiovascular disease risk. The trial will be augmented by formal economic and process evaluations to assess acceptability, equity and cost-effectiveness of the intervention. The intervention group will participate in a consumer-directed e-health strategy for cardiovascular risk management. The programme is electronically integrated with the primary care providers software and will include interactive smart phone and Internet platforms. The primary outcome is a composite endpoint of the proportion of people meeting the Australian guideline-recommended blood pressure (BP) and cholesterol targets. Secondary outcomes include change in mean BP and fasting cholesterol levels, proportion meeting BP and cholesterol targets separately, self-efficacy, health literacy, self-reported point prevalence abstinence in smoking, body mass index and waist circumference, self-reported physical activity and self-reported medication adherence. Ethics and dissemination Primary ethics approval was received from the University of Sydney Human Research Ethics Committee and the Aboriginal Health and Medical Research Council. Results will be disseminated via the usual scientific forums including peer-reviewed publications and presentations at international conferences Clinical Trials registration number ACTRN12613000715774.

The Treatment of cardiovascular Risk in Primary care using Electronic Decision suppOrt (TORPEDO) study-intervention development and protocol for a cluster randomised, controlled trial of an electronic decision support and quality improvement intervention in Australian primary healthcare

Background Large gaps exist in the implementation of guideline recommendations for cardiovascular disease (CVD) risk management. Electronic decision support (EDS) systems are promising interventions to close these gaps but few have undergone clinical trial evaluation in Australia. We have developed HealthTracker, a multifaceted EDS and quality improvement intervention to improve the management of CVD risk. Methods/design It is hypothesised that the use of HealthTracker over a 12-month period will result in: (1) an increased proportion of patients receiving guideline-indicated measurements of CVD risk factors and (2) an increased proportion of patients at high risk will receive guideline-indicated prescriptions for lowering their CVD risk. Sixty health services (40 general practices and 20 Aboriginal Community Controlled Health Services (ACCHSs) will be randomised in a 1:1 allocation to receive either the intervention package or continue with usual care, stratified by service type, size and participation in existing quality improvement initiatives. The intervention consists of point-of-care decision support; a risk communication interface; a clinical audit tool to assess performance on CVD-related indicators; a quality improvement component comprising peer-ranked data feedback and support to develop strategies to improve performance. The control arm will continue with usual care without access to these intervention components. Quantitative data will be derived from cross-sectional samples at baseline and end of study via automated data extraction. Detailed process and economic evaluations will also be conducted. Ethics and dissemination The general practice component of the study is approved by the University of Sydney Human Research Ethics Committee (HREC) and the ACCHS component is approved by the Aboriginal Health and Medical Research Council HREC. Formal agreements with each of the participating sites have been signed. In addition to the usual scientific forums, results will be disseminated via newsletters, study websites, face-to-face feedback forums and workshops. Trial registration The trial is registered with the Australian Clinical Trials Registry ACTRN 12611000478910.

Factors to consider in smoking interventions for Indigenous women

More than 18,000 Australians die annually from diseases caused by tobacco. Indigenous Australians suffer a greater smoking-related disease burden than the remainder of the general public and have a higher prevalence of tobacco use than other Australians. The overall decline in smoking rates is slowest in women of low educational status between the ages of 25 -44. This is of particular concern as these young women may be pregnant or raising young children. During pregnancy, the effects on the foetus from cigarette smoke include respiratory illness, low birthweight and Sudden Infant Death Syndrome. However, if the mother is able to give up smoking by her fourth month of pregnancy, her risk of delivering a low birthweight baby decreases to nearly that of a non-smoker. As part of the planning to develop an effective smoking cessation program for young Indigenous pregnant women, the Townsville Aboriginal and Islanders Health Services (TAIHS) surveyed a group of women to assess smoking habits, attitudes to smoking, nicotine dependence and readiness for change. This paper reports on this survey and the results found can be used to develop a tailored, smoking cessation program for Indigenous women.

Sudden infant death syndrome in Indigenous and non-Indigenous infants in north Queensland, 1990–1998

Objective: To compare the epidemiology of sudden infant death syndrome (SIDS) in Indigenous and non‐Indigenous infants in north Queensland, and to assess the quality of data recorded for SIDS deaths.

Sudden infant death syndrome risk factors in North Queensland: a survey of infant care practices in Indigenous and non-Indigenous women

Objective: To assess the prevalence of sudden infant death syndrome (SIDS) risk factors in the Indigenous and non‐Indigenous community of Townsville, a large remote urban centre in north Queensland, Australia.

Cervical smear participation and prevalence of sexually transmitted infections in women attending a community‐controlled Indigenous health service in North Queensland

Objective: To increase Pap smear participation and to assess the prevalence of sexually transmitted infection (STI) in urban Indigenous women in Townsville.