Samantha J. Togni

A pragmatic randomized trial of a polypill-based strategy to improve use of indicated preventive treatments in people at high cardiovascular disease risk

Background Most individuals at high cardiovascular disease (CVD) risk worldwide do not receive any or optimal preventive drugs. We aimed to determine whether fixed dose combinations of generic drugs (‘polypills’) would promote use of such medications. Methods We conducted a randomized, open-label trial involving 623 participants from Australian general practices. Participants had established CVD or an estimated five-year CVD risk of ≥15%, with indications for antiplatelet, statin and ≥2 blood pressure lowering drugs (‘combination treatment’). Participants randomized to the ‘polypill-based strategy’ received a polypill containing aspirin 75 mg, simvastatin 40 mg, lisinopril 10 mg and either atenolol 50 mg or hydrochlorothiazide 12.5 mg. Participants randomized to ‘usual care’ continued with separate medications and doses as prescribed by their doctor. Primary outcomes were self-reported combination treatment use, systolic blood pressure and total cholesterol. Results After a median of 18 months, the polypill-based strategy was associated with greater use of combination treatment (70% vs. 47%; relative risk 1.49, (95% confidence interval (CI) 1.30 to 1.72) p < 0.0001; number needed to treat = 4.4 (3.3 to 6.6)) without differences in systolic blood pressure (−1.5 mmHg (95% CI −4.0 to 1.0) p = 0.24) or total cholesterol (0.08 mmol/l (95% CI −0.06 to 0.22) p = 0.26). At study end, 17% and 67% of participants in polypill and usual care groups, respectively, were taking atorvastatin or rosuvastatin. Conclusion Provision of a polypill improved self-reported use of indicated preventive treatments. The lack of differences in blood pressure and cholesterol may reflect limited study power, although for cholesterol, improved statin use in the polypill group counter-balanced use of more potent statins with usual care.

Liquor licensing and community action in regional and remote Australia: a review of recent initiatives

Objective : To review the effectiveness of community‐based initiatives involving restrictions on alcohol availability in remote and regional locations in Australia, and to assess their implications for other communities or towns contemplating similar measures.

Preventive medical care in remote Aboriginal communities in the Northern Territory: a follow-up study of the impact of clinical guidelines, computerised recall and reminder systems, and audit and feedback

BackgroundInterventions to improve delivery of preventive medical services have been shown to be effective in North America and the UK. However, there are few studies of the extent to which the impact of such interventions has been sustained, or of the impact of such interventions in disadvantaged populations or remote settings. This paper describes the trends in delivery of preventive medical services following a multifaceted intervention in remote community health centres in the Northern Territory of Australia.MethodsThe intervention comprised the development and dissemination of best practice guidelines supported by an electronic client register, recall and reminder systems and associated staff training, and audit and feedback. Clinical records in seven community health centres were audited at regular intervals against best practice guidelines over a period of three years, with feedback of audit findings to health centre staff and management.ResultsLevels of service delivery varied between services and between communities. There was an initial improvement in service levels for most services following the intervention, but improvements were in general not fully sustained over the three year period.ConclusionsImprovements in service delivery are consistent with the international experience, although baseline and follow-up levels are in many cases higher than reported for comparable studies in North America and the UK. Sustainability of improvements may be achieved by institutionalisation of relevant work practices and enhanced health centre capacity.

Aboriginal participation in health service delivery : coordinated care trials in the Northern Territory of Australia

Australian Aborigines have much higher rates of illness and life expectancy, up to 20 years lower than the Australian population as a whole. Community based primary healthcare to Aborigines in the Northern Territory of Australia has, historically, been under-resourced, in part due to distinctive characteristics of the Australian healthcare funding system which has disadvantaged rural and remote regions. From 1998, the Northern Territory was the site of two Coordinated Care Trials (CCTs) which sought to achieve three main objectives: to significantly increase funding available to health services; to implement a system of clinical best practice; and to improve Aboriginal participation in health service delivery through the establishment of Aboriginal community health boards to act as funds managers and providers of health services to the trial populations. The paper outlines general CCT outcomes according to the findings of the commissioned evaluation studies and examines the possibilities and constraints encountered in improving Aboriginal participation in complex health service developments.

Facilitating engagement through strong relationships between primary healthcare and Aboriginal and Torres Strait Islander peoples

Objective: Given the high prevalence of chronic disease, it is of concern that access to and sustained engagement with primary healthcare services by Aboriginal and Torres Strait Islander Australians is often far lower than would be expected. This study sought to explore ways in which relationships can support sustained engagement with healthcare services.

The Grog Mob: lessons from an evaluation of a multi-disciplinary alcohol intervention for Aboriginal clients

Objectives: To evaluate a 12‐month trial of an evidence‐based non‐residential treatment program for Indigenous clients with alcohol problems, offering three streams of care: pharmacotherapy, psychological and social support.

Economic and quality of care evaluation of dialysis service models in remote Australia: protocol for a mixed methods study

BackgroundAustralia’s Northern Territory (NT) has the country’s highest incidence and prevalence of kidney disease. Indigenous people from remote areas suffer the heaviest disease burden. Concerns regarding cost and sustainability limit the provision of dialysis treatments in remote areas and most Indigenous people requiring dialysis relocate to urban areas. However, this dislocation of people from their family, community and support networks may prove more costly when the broader health, societal and economic consequences for the individual, family and whole of government are considered.MethodsThe Dialysis Models of Care Study is a large cross organisation mixed methods study. It includes a retrospective (2000–2014) longitudinal data linkage study of two NT cohorts: Renal Cohort 1- comprising approximately 2000 adults who received dialysis and Renal Cohort 2- comprising approximately 400 children of those adults. Linkage of administrative data sets from the Australian and New Zealand Dialysis and Transplant Registry, NT Departments of Health, Housing and Education by a specialist third party (SA/NT Datalink) will enable extraction of activity, financial and outcome data. Interviews with patients, clinicians and service providers, using a snowball technique, will canvass relevant issues and assist in determining the full costs and impacts of the five most used dialysis Models of Care.DiscussionThe study uses a mixed methods approach to investigate the quantitative and qualitative dimensions of the full costs and outcomes associated with the choice of particular dialysis models of care for any given patient. The study includes a large data linkage component that for the first time links health, housing and education data to fully analyse and evaluate the impact on patients, their families and the broader community, resulting from the relocation of people for treatment. The study will generate a large amount of activity, financial and qualitative data that will investigate health costs less directly related to dialysis treatment, costs to government such as housing and/or education and the health, social and economic outcomes experienced by patients. This approach fills an evidence gap critical to health service planners.