Tarun Weeramanthri

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.

Epidemiological study of severe febrile reactions in young children in Western Australia caused by a 2010 trivalent inactivated influenza vaccine

Background The 2010 influenza vaccination program for children aged 6 months to 4 years in Western Australia (WA) was suspended following reports of severe febrile reactions, including febrile convulsions, following vaccination with trivalent inactivated influenza vaccine (TIV). Methods To investigate the association between severe febrile reactions and TIV, three studies were conducted: (i) rates of febrile convulsions within 72 h of receiving TIV in 2010 were estimated by vaccine formulation and batch; (ii) numbers of children presenting to hospital emergency departments with febrile convulsions from 2008 to 2010 were compared; and (iii) a retrospective cohort study of 360 children was conducted to compare the reactogenicity of available TIV formulations. Findings In 2010, an estimated maximum of 18 816 doses of TIV were administered and 63 febrile convulsions were recorded, giving an estimated rate of 3.3 (95% CI 2.6 to 4.2) per 1000 doses of TIV administered. The odds of a TIV-associated febrile convulsion was highly elevated in 2010 (p<0.001) and was associated with the vaccine formulations of one manufacturer—Fluvax and Fluvax Junior (CSL Biotherapies). The risk of both febrile convulsions (p<0.0001) and other febrile reactions (p<0.0001) was significantly greater for Fluvax formulations compared to the major alternate brand. The risk of febrile events was not associated with prior receipt of TIV or monovalent 2009 H1N1 pandemic vaccine. The biological cause of the febrile reactions is currently unknown. Interpretation One brand of influenza vaccine was responsible for the increase in febrile reactions, including febrile convulsions. Until the biological reason for this is determined and remediation undertaken, childhood influenza vaccination programs should not include Fluvax-type formulations and enhanced surveillance for febrile reactions in children receiving TIV should be undertaken.

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 – Diabetes and related conditions in urban Indigenous people in the Darwin, Australia region: aims, methods and participation in the DRUID Study

BackgroundDiabetes mellitus is a serious and increasing health problem in Australia and is a designated national health priority. Diabetes and related conditions represent an even greater health burden among Indigenous Australians (Aborigines and Torres Strait Islanders), but there are critical gaps in knowledge relating to the incidence and prevalence, aetiology, and prevention of diabetes in this group, including a lack of information on the burden of disease among Indigenous people in urban areas. The DRUID Study (Diabetes and Related conditions in Urban Indigenous people in the Darwin region) was designed to address this knowledge gap.Methods/designThe study was conducted in a specified geographic area in and around Darwin, Australia. Eligible participants underwent a health examination, including collection of blood and urine samples, clinical and anthropometric measurements, and administration of questionnaires, with an additional assessment for people with diabetes. The study was designed to incorporate local Indigenous leadership, facilitate community engagement, and provide employment and training opportunities for local Indigenous people. A variety of recruitment methods were used. A total of 1,004 eligible people gave consent and provided at least one measurement. When compared with census data for the Indigenous population living in the study area, there was a marked under-representation of males, but no substantial differences in age, place of residence, Indigenous group, or household income. Early participants were more likely than later participants to have previously diagnosed diabetes.DiscussionDespite lower than anticipated recruitment, this is, to our knowledge, the largest study ever conducted on the health of Indigenous Australians living in urban areas, a group which comprises the majority of Australias Indigenous population but about whose health and wellbeing relatively little is known. The study is well-placed to provide new information that can be used by policy makers and service providers to improve the delivery of services and programs that affect the health of Indigenous people. It also represents a valuable opportunity to establish an urban Indigenous cohort study, provided participants can be followed successfully over time.

Diabetes and cardiovascular risk factors in urban Indigenous adults: Results from the DRUID study

INTRODUCTION Little is known about the burden of diabetes and related conditions among urban Indigenous Australians. The DRUID study was established to address this important information gap. SUBJECTS Eligible participants were Aboriginal and Torres Strait Islander adult volunteers aged 15 years and over who had lived in a defined region in and around Darwin, NT for at least 6 months. MATERIALS AND METHODS Participants underwent a health examination based on the AusDiab protocol, including blood and urine collection, clinical and anthropometric measurements and questionnaires, in 2003-2005. RESULTS Among 861 participants included in the analysis (approximately 14% of the target population), diabetes and other cardiovascular risk factors were common and increased with age. Almost one-third of those aged >or=35 years (31.7%) and over half of those >or=55 years (52.4%) had diabetes. Of 48 participants with newly diagnosed diabetes, half would not have been diagnosed without OGTT. Cardiovascular risk factors were common even among young people without diabetes-45% had >or=2 risk factors and only 18% had none. CONCLUSIONS This study indicates a very high burden of current disease and high risk of future disease, even among young people. Both primary prevention and better management of known risk factors and existing disease are urgently required.

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.

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.

Socioeconomic status and diabetes among urban Indigenous Australians aged 15-64 years in the DRUID study

Background. Diabetes is associated with lower socioeconomic status (SES) in developed countries, but the reverse is true in developing countries. Little is known about the relationship between SES and diabetes among Indigenous populations in developed countries. Design. We examined the relationship between measures of SES and the prevalence of diabetes in the DRUID Study, a cross-sectional study of urban Indigenous Australian volunteers in the Darwin region. Results. Among 777 participants aged 15–64 years included in the analysis, 17.1% had diabetes, ranging from 2.0% among those aged 15–24 years to 50.8% of those aged 55–64 years. After adjusting for age and sex, diabetes was significantly more common among those of lower SES, whether measured by housing tenure, household income, or employment status. For example, compared with those living in a household that was owned/being purchased by its occupants, the relative odds of diabetes was 2.66 (95% confidence interval 1.71–4.15) for those living in rented/other accommodation. The inverse relationship between SES and diabetes was present even among those who had not previously been diagnosed with diabetes. The relationship between disadvantage and diabetes was not mediated to any great degree by obesity. Conclusions. The relationship between SES and diabetes among Indigenous Australians in this study is consistent with the patterns observed in developed countries, rather than those in some developing countries.