Limited evidence to assess the impact of primary health care system or service level attributes on health outcomes of Indigenous people with type 2 diabetes: a systematic review.

BACKGROUND: To describe reported studies of the impact on HbA1C levels, diabetes-related hospitalisations, and other primary care health endpoints of initiatives aimed at improving the management of diabetes in Indigenous adult populations of Australia, Canada, New Zealand and the United States. METHOD: Systematic literature review using data sources of MEDLINE, Embase, the Cochrane Library, CINHAL and PsycInfo from January 1985 to March 2012. Inclusion criteria were a clearly described primary care intervention, model of care or service, delivered to Indigenous adults with type 2 diabetes reporting a program impact on at least one quantitative diabetes-related health outcome, and where results were reported separately for Indigenous persons. Joanna Briggs Institute critical appraisal tools were used to assess the study quality. PRISMA guidelines were used for reporting. RESULTS: The search strategy retrieved 2714 articles. Of these, 13 studies met the review inclusion criteria. Three levels of primary care initiatives were identified: 1) addition of a single service component to the existing service, 2) system-level improvement processes to enhance the quality of diabetes care, 3) change in primary health funding to support better access to care. Initiatives included in the review were diverse and included comprehensive multi-disciplinary diabetes care, specific workforce development, systematic foot care and intensive individual hypertension management. Twelve studies reported HbA1C, of those one also reported hospitalisations and one reported the incidence of lower limb amputation. The methodological quality of the four comparable cohort and seven observational studies was good, and moderate for the two randomised control trials. CONCLUSIONS: The current literature provides an inadequate evidence base for making important policy and practice decisions in relation to primary care initiatives for Indigenous persons with type 2 diabetes. This reflects a very small number of published studies, the general reliance on intermediate health outcomes and the predominance of observational studies. Additional studies of the impacts of primary care need to consider carefully research design and the reporting of hospital outcomes or other primary end points. This is an important question for policy makers and further high quality research is needed to contribute to an evidence-base to inform decision making.

A systematic review of evidence on the association between hospitalisation for chronic disease related ambulatory care sensitive conditions and primary health care resourcing.

BACKGROUND: Primary health care is recognised as an integral part of a country's health care system. Measuring hospitalisations, that could potentially be avoided with high quality and accessible primary care, is one indicator of how well primary care services are performing. This review was interested in the association between chronic disease related hospitalisations and primary health care resourcing. METHODS: Studies were included if peer reviewed, written in English, published between 2002 and 2012, modelled hospitalisation as a function of PHC resourcing and identified hospitalisations for type 2 diabetes as a study outcome measure. Access and use of PHC services were used as a proxy for PHC resourcing. Studies in populations with a predominant user pay system were excluded to eliminate patient financial barriers to PHC access and utilisation. Articles were systematically excluded based on the inclusion criteria, to arrive at the final set of studies for review. RESULTS: The search strategy identified 1778 potential articles using EconLit, Medline and Google Scholar databases. Ten articles met the inclusion criteria and were subject to review. PHC resources were quantified by workforce (either medical or nursing) numbers, number of primary care episodes, service availability (e.g. operating hours), primary care practice size (e.g. single or group practitioner practice--a larger practice has more care disciplines onsite), or financial incentive to improve quality of diabetes care. The association between medical workforce numbers and ACSC hospitalisations was mixed. Four of six studies found that less patients per doctor was significantly associated with a decrease in ambulatory care sensitive hospitalisations, one study found the opposite and one study did not find a significant association between the two. When results were categorised by PHC access (e.g. GPs/capita, range of services) and use (e.g. n out-patient visits), better access to quality PHC resulted in fewer ACSC hospitalisations. This finding remained when only studies that adjusted for health status were categorised. Financial incentives to improve the quality of diabetes care were associated with less ACSC hospitalisations, reported in one study. CONCLUSION: Seven of 12 measures of the relationship between PHC resourcing and ACSC hospitalisations had a significant inverse association. As a collective body of evidence the studies provide inconclusive support that more PHC resourcing is associated with reduced hospitalisation for ACSC. Characteristics of improved or increased PHC access showed inverse significant associations with fewer ACSC hospitalisations after adjustment for health status. The varied measures of hospitalisation, PHC resourcing, and health status may contribute to inconsistent findings among studies and make it difficult to interpret findings.

A simple diabetes vascular severity staging instrument and its application to a Torres Strait Islander and Aboriginal adult cohort of north Australia.

BACKGROUND: To develop an instrument that predicts diabetes-related vascular disease severity using routinely collected data on Australian Aboriginal and Torres Strait Islander adults with type 2 diabetes, in the absence of diabetes duration. METHODS: A complex diabetes severity classification system was simplified and adapted for use with an Australian Aboriginal and Torres Strait Islander adult population with type 2 diabetes in north Queensland. Detailed vascular health risks and morbidities were mapped to routinely collected measures. Individual-level health screening, hospital separation and mortality data were linked and used to plot mean monthly in-patient hospital cost and percent mortality by disease severity as defined by the newly developed instrument, to test construct validity. RESULTS: The revised instrument consists of four combined diabetes-related microvascular and macrovascular stages that range from least severe (stage 1) to severe irreversible vascular impairment (stage 4). When applied to data of an Aboriginal and Torres Strait Islander Australian population the instrument showed good construct validity, predicting higher hospital cost and mortality as vascular disease severity increased. CONCLUSIONS: This instrument discriminates between levels of diabetes-related vascular disease severity, displays good construct validity by predicting increased hospital cost and mortality with worsening severity and can be populated with routinely collected data. It may assist with future health service research and its use could be extended to practice settings for health care planning for diabetes management programs and monitoring vascular disease progression.

Sugar-sweetened beverage consumption, correlates and interventions among Australian Aboriginal and Torres Strait Islander communities: a scoping review protocol.

INTRODUCTION: Aboriginal and Torres Strait Islander communities of Australia experience poorer health outcomes in the areas of overweight and obesity, diabetes and cardiovascular disease. Contributing to this burden of disease in the Australian community generally and in Aboriginal and Torres Strait Islander communities, is the consumption of sugar-sweetened beverages (SSBs). We have described a protocol for a review to systematically scope articles that document use of SSBs and interventions to reduce their consumption with Aboriginal and Torres Strait Islander people. These results will inform future work that investigates interventions aimed at reducing harm associated with SSB consumption. METHODS AND ANALYSIS: This scoping review draws on a methodology that uses a six-step approach to search databases including PubMed, SCOPUS, CINAHL, Informit (including Informit: Indigenous Peoples), Joanna Briggs Institute EBP Database and Mura, between January 1980 and February 2017. Two reviewers will be engaged to search for and screen studies independently, using formulated selection criteria, for inclusion in our review. We will include primary research studies, systematic reviews including meta-analysis or meta-synthesis, reports and unpublished grey literature. Results will be entered into a table identifying study details and characteristics, summarised using a Preferred Reporting Items for Systematic Reviews and Meta-Analysis chart and then critically analysed. ETHICS AND DISSEMINATION: This review will not require ethics committee review. Results will be disseminated at appropriate scientific meetings, as well as through the Aboriginal and Torres Strait Islander community.