Ross S. Bailie

Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability

Study objective: To examine the role of specialist outreach in supporting primary health care and overcoming the barriers to health care faced by the indigenous population in remote areas of Australia, and to examine issues affecting its sustainability. Design: A process evaluation of a specialist outreach service, using health service utilisation data and interviews with health professionals and patients. Setting: The Top End of Australias Northern Territory, where Darwin is the capital city and the major base for hospital and specialist services. In the rural and remote areas outside Darwin there are many small, predominantly indigenous communities, which are greatly disadvantaged by a severe burden of disease and limited access to medical care. Participants: Seventeen remote health practitioners, five specialists undertaking outreach, five regional health administrators, and three patients from remote communities. Main results: The barriers faced by many remote indigenous people in accessing specialist and hospital care are substantial. Outreach delivery of specialist services has overcome some of the barriers relating to distance, communication, and cultural inappropriateness of services and has enabled an over fourfold increase in the number of consultations with people from remote communities. Key issues affecting sustainability include: an adequate specialist base; an unmet demand from primary care; integration with, accountability to and capacity building for a multidisciplinary framework centred in primary care; good communication; visits that are regular and predictable; funding and coordination that recognises responsibilities to both hospitals and the primary care sector; and regular evaluation. Conclusions: In a setting where there is a disadvantaged population with inadequate access to medical care, specialist outreach from a regional centre can provide a more equitable means of service delivery than hospital based services alone. A sustainable outreach service that is organised appropriately, responsive to local community needs, and has an adequate regional specialist base can effectively integrate with and support primary health care processes. Poorly planned and conducted outreach, however, can draw resources away and detract from primary health care.

Ambient biomass smoke and cardio-respiratory hospital admissions in Darwin, Australia

BackgroundIncreasing severe vegetation fires worldwide has been attributed to both global environmental change and land management practices. However there is little evidence concerning the population health effects of outdoor air pollution derived from biomass fires. Frequent seasonal bushfires near Darwin, Australia provide an opportunity to examine this issue. We examined the relationship between atmospheric particle loadings <10 microns in diameter (PM10), and emergency hospital admissions for cardio-respiratory conditions over the three fire seasons of 2000, 2004 and 2005. In addition we examined the differential impacts on Indigenous Australians, a high risk population subgroup.MethodsWe conducted a case-crossover analysis of emergency hospital admissions with principal ICD10 diagnosis codes J00–J99 and I00–I99. Conditional logistic regression models were used to calculate odds ratios for admission with 10 μg/m3 rises in PM10. These were adjusted for weekly influenza rates, same day mean temperature and humidity, the mean temperature and humidity of the previous three days, days with rainfall > 5 mm, public holidays and holiday periods.ResultsPM10 ranged from 6.4 – 70.0 μg/m3 (mean 19.1). 2466 admissions were examined of which 23% were for Indigenous people. There was a positive relationship between PM10 and admissions for all respiratory conditions (OR 1.08 95%CI 0.98–1.18) with a larger magnitude in the Indigenous subpopulation (OR1.17 95% CI 0.98–1.40). While there was no relationship between PM10 and cardiovascular admissions overall, there was a positive association with ischaemic heart disease in Indigenous people, greatest at a lag of 3 days (OR 1.71 95%CI 1.14–2.55).ConclusionPM10 derived from vegetation fires was predominantly associated with respiratory rather than cardiovascular admissions. This outcome is consistent with the few available studies of ambient biomass smoke pollution. Indigenous people appear to be at higher risk of cardio-respiratory hospital admissions associated with exposure to PM10.

Effect of health promotion and fluoride varnish on dental caries among Australian Aboriginal children: results from a community-randomized controlled trial

Objectives We tested a dental health program in remote Aboriginal communities of Australias Northern Territory, hypothesizing that it would reduce dental caries in preschool children. Methods In this 2-year, prospective, cluster-randomized, concurrent controlled, open trial of the dental health program compared to no such program, 30 communities were allocated at random to intervention and control groups. All residents aged 18–47 months were invited to participate. Twice per year for 2 years in the 15 intervention communities, fluoride varnish was applied to childrens teeth, water consumption and daily tooth cleaning with toothpaste were advocated, dental health was promoted in community settings, and primary health care workers were trained in preventive dental care. Data from dental examinations at baseline and after 2 years were used to compute net dental caries increment per child (d3mfs). A multi-level statistical model compared d3mfs between intervention and control groups with adjustment for the clustered randomization design; four other models used additional variables for adjustment. Results At baseline, 666 children were examined; 543 of them (82%) were re-examined 2 years later. The adjusted d3mfs increment was significantly lower in the intervention group compared to the control group by an average of 3.0 surfaces per child (95% CI = 1.2, 4.9), a prevented fraction of 31%. Adjustment for additional variables yielded caries reductions ranging from 2.3 to 3.5 surfaces per child and prevented fractions of 24–36%. Conclusions These results corroborate findings from other studies where fluoride varnish was efficacious in preventing dental caries in young children.

Skin infection, housing and social circumstances in children living in remote Indigenous communities: testing conceptual and methodological approaches

BackgroundPoor housing conditions in remote Indigenous communities in Australia are a major underlying factor in poor child health, including high rates of skin infections. The aim of this study is to test approaches to data collection, analysis and feedback for a follow-up study of the impact of housing conditions on child health.MethodsParticipation was negotiated in three communities with community councils and individual participants. Data were collected by survey of dwelling condition, interviews, and audit health centre records of children aged under seven years. Community feedback comprised immediate report of items requiring urgent repair followed by a summary descriptive report. Multivariate models were developed to calculate adjusted incidence rate ratios (IRR) for skin infections and their association with aspects of household infrastructure.ResultsThere was a high level of participation in all communities. Health centre records were inadequate for audit in one community. The records of 138 children were available for development of multivariate analytic models. Rates of skin infection in dwellings that lacked functioning facilities for removing faeces or which had concrete floors may be up to twice as high as for other dwellings, and the latter association appears to be exacerbated by crowding. Younger children living in older dwellings may also be at approximately two-fold higher risk. A number of socioeconomic and socio-demographic variables also appear to be directly associated with high rates of skin infections.ConclusionThe methods used in the pilot study were generally feasible, and the analytic approach provides meaningful results. The study provides some evidence that new and modern housing is contributing to a reduction in skin infections in Aboriginal children in remote communities, particularly when this housing leads to a reduction in crowding and the effective removal of human waste.

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.

Liver function test abnormalities in users of aqueous kava extracts

Abstract Introduction. Hepatic toxicity from manufactured herbal remedies that contain kava lactones has been reported in Europe, North America, and Australia. There is no evidence for serious liver damage in kava‐using populations in Pacific Island societies or in Indigenous Australians who have used aqueous kava extracts. This article presents evidence that liver function changes in users of aqueous kava extracts appear to be reversible. Data from one Arnhem Land community [Northern Territory (NT), Australia] with 340 indigenous people older than 15 years of age in 2000 are used. Methods. This study was a cross‐sectional study with 98 participants, 36 of whom had never used kava. Among 62 kava users, 23 had discontinued kava at least 1 year before the study. Continuing users had not used kava for 1 to 2 months (n = 10) or 1 to 2 weeks previously (n = 15). Some (n = 14) had used kava within the previous 24 hr. Liver function tests were compared across these groups, taking into account differences due to age, sex, alcohol, and other substance use. Results. The average quantity of kava powder consumed was 118 g/week, and median duration of use was 12 years (range, 1–18 years). Kava usage levels were less than one‐half of those found in previous studies. More recent kava use was independently associated with higher levels of liver enzymes gamma‐glutamyl transferase (GGT) (p < 0.001) and alkaline phosphatase (ALP) (p < 0.001), but not with alanine aminotransferase or bilirubin, which were not elevated. In those who were not heavy alcohol users, only those who used kava within the previous 24 hr showed GGT levels higher than nonusers (p < 0.001), whereas higher ALP levels occurred only in those who last used kava 1 to 2 weeks (p = 0.015) and 24 hr previously (p = 0.005). Discussion. Liver function changes in users of aqueous kava extracts at these moderate levels of consumption appear to be reversible and begin to return to baseline after 1 to 2 weeks abstinence from kava. No evidence for irreversible liver damage has been found.

Ten principles relevant to health research among Indigenous Australian populations

riting in the Journal about Indigenous health in 2011, Sir Michael Marmot suggested that the challenge was to conduct research, and to ultimately apply findings from that research, to enable Indigenous Australians to lead more flourishing lives that they would have reason to value. 1 As committed Indigenous health researchers in Australia, we reflect Marmot’s ideal — to provide the answers to key questions relating to health that might enable Indigenous Australians to live the lives that they would choose to live. As a group, we have over 120 collective years’ experience in Indigenous health research. Over this time, particularly in recent years as ethical guidelines have come into play, there have been many examples of research done well. However, as the pool of researchers is constantly replenished, we hold persisting concerns that some emerging researchers may not be well versed in the principles of best practice regarding research among Indigenous Australian populations. Implementing any research methodology among Indigenous Australian groups will work best when the following 10 principles are met. These principles are reflected in the many documents related to working and researching with Indigenous Australians; for example, the National Health and Medical Research Council (NHMRC) ethical guidelines for research among Aboriginal and Torres Strait Islander people. 2 In this article, we set out these principles in one short, accessible document. Essential principles

Estimating chronic disease prevalence among the remote Aboriginal population of the Northern Territory using multiple data sources.

Objective: To determine the prevalence rates of hypertension, diabetes, ischaemic heart disease (IHD), renal disease and chronic obstructive pulmonary disease (COPD), and their co‐occurrence among the remote Aboriginal population of the Northern Territory (NT) in 2005.

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.

Specialist outreach to isolated and disadvantaged communities: a population-based study

BACKGROUND Visiting-specialist clinics (specialist outreach) have the potential to overcome some of the substantial access barriers faced by disadvantaged rural, remote, and Indigenous communities, but the effectiveness of outreach clinics has not been assessed outside urban and non-disadvantaged settings. We aimed to assess the effects of outreach clinics on access, referral patterns, and care outcomes in remote communities in Australia. METHODS We undertook a population-based observational study of regular surgical, ophthalmological, gynaecological, and ear, nose, and throat outreach visits, compared with hospital clinics alone, on access, referral practices, and outcomes for the populations of three remote Indigenous communities in northern Australia for 11 years. We assessed all new non-emergency potential specialist surgical cases who presented initially between Jan 1, 1990, and Jan 1, 2001. The effects of outreach clinics on the proportion of patients referred, the time from referral to initial specialist consultation, and the rates of community-based and hospital-based procedures were analysed using logic regression and Cox proportional hazard models. FINDINGS 2339 new surgical problems presented in 2368 people between 1990 and 2001. Outreach improved the rate of referral completion (adjusted hazard ratio 1.41, 95% CI 1.07-1.86) and the risk of timely completion according to the urgency of referral (adjusted relative risk 1.30, 1.05-1.53). Outreach had no significant effect on initiation of elective referrals, but there were 156 opportunistic presentations on outreach clinic days. Specialist investigations and procedures in community clinics removed the need for many patients to travel to hospital, and outreach consultations were associated with a reduced rate of procedures that needed hospital admission (adjusted hazard ratio 0.67, 0.43-1.03). INTERPRETATION Specialist outreach visits to remote disadvantaged Indigenous communities in Australia improve access to specialist consultations and procedures without increasing elective referrals or demands for hospital inpatient services.