Health systems model for chronic disease secondary prevention in rural and remote areas - Chronic disease: Road to health.

Objectives Cardiac rehabilitation (CR) provides evidence-based secondary prevention for people with heart disease (HD) (clients). Despite HD being the leading cause of mortality and morbidity, CR is under-utilised in Australia. This research investigated healthcare systems required to improve access to CR in rural and remote areas of North Queensland (NQ). Methods A qualitatively dominant case study series to review management systems for CR in rural and remote areas of NQ was undertaken. Data collection was via semi-structured interviews in four tertiary hospitals and four rural or remote communities. An audit of discharge planning and CR referral, plus a review of community-based health services, was completed. An iterative and co-design process including consultation with healthcare staff and community members culminated in a systems-based model for improving access to CR in rural and remote areas. Results Poorly organised CR systems, poor client/staff understanding of discharge planning and low referral rates for secondary prevention, resulted in the majority of clients not accessing secondary prevention, despite resources being available. Revised health systems and management processes were recommended for the proposed Heart: Road to health model, and given common chronic diseases risk factors it was recommended to be broadened into Chronic disease: Road to health . Conclusion A Chronic disease: Road to health model could provide effective and efficient secondary prevention for people with chronic diseases in rural and remote areas. It is proposed that this approach could reduce gaps and duplication in current healthcare services and provide flexible, client-centred, holistic, culturally responsive services, and improve client outcomes.

Australian Aboriginal and Torres Strait Islander Health Information: Progress, Pitfalls, and Prospects.

Despite significant developments in Aboriginal and Torres Strait Islander Health information over the last 25 years, many challenges remain. There are still uncertainties about the accuracy of estimates of the summary measure of life expectancy, and methods to estimate changes in life expectancy over time are unreliable because of changing patterns of identification. Far too little use is made of the wealth of information that is available, and formal systems for systematically using that information are often vestigial to non-existent. Available information has focussed largely on traditional biomedical topics and too little on access to, expenditure on, and availability of services required to improve health outcomes, and on the underpinning issues of social and emotional wellbeing. It is of concern that statistical artefacts may have been misrepresented as indicating real progress in key health indices. Challenges and opportunities for the future include improving the accuracy of estimation of life expectancy, provision of community level data, information on the availability and effectiveness of health services, measurement of the underpinning issues of racism, culture and social and emotional wellbeing (SEWB), enhancing the interoperability of data systems, and capacity building and mechanisms for Indigenous data governance. There is little point in having information unless it is used, and formal mechanisms for making full use of information in a proper policy/planning cycle are urgently required.

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.

Building better systems of care for Aboriginal and Torres Strait Islander people: findings from the Kanyini health systems assessment.

BACKGROUND: Australian federal and jurisdictional governments are implementing ambitious policy initiatives intended to improve health care access and outcomes for Aboriginal and Torres Strait Islander people. In this qualitative study we explored Aboriginal Medical Service (AMS) staff views on factors needed to improve chronic care systems and assessed their relevance to the new policy environment. METHODS: Two theories informed the study: (1) 'candidacy', which explores "the ways in which people's eligibility for care is jointly negotiated between individuals and health services"; and (2) kanyini or 'holding', a Central Australian philosophy which describes the principle and obligations of nurturing and protecting others. A structured health systems assessment, locally adapted from Chronic Care Model domains, was administered via group interviews with 37 health staff in six AMSs and one government Indigenous-led health service. Data were thematically analysed. RESULTS: Staff emphasised AMS health care was different to private general practices. Consistent with kanyini, community governance and leadership, community representation among staff, and commitment to community development were important organisational features to retain and nurture both staff and patients. This was undermined, however, by constant fear of government funding for AMSs being withheld. Staff resourcing, information systems and high-level leadership were perceived to be key drivers of health care quality. On-site specialist services, managed by AMS staff, were considered an enabling strategy to increase specialist access. Candidacy theory suggests the above factors influence whether a service is 'tractable' and 'navigable' to its users. Staff also described entrenched patient discrimination in hospitals and the need to expend considerable effort to reinstate care. This suggests that Aboriginal and Torres Strait Islander people are still constructed as 'non-ideal users' and are denied from being 'held' by hospital staff. CONCLUSIONS: Some new policy initiatives (workforce capacity strengthening, improving chronic care delivery systems and increasing specialist access) have potential to address barriers highlighted in this study. Few of these initiatives, however, capitalise on the unique mechanisms by which AMSs 'hold' their users and enhance their candidacy to health care. Kanyini and candidacy are promising and complementary theories for conceptualising health care access and provide a potential framework for improving systems of care.

Rationale and design of the Kanyini guidelines adherence with the polypill (Kanyini-GAP) study: a randomised controlled trial of a polypill-based strategy amongst indigenous and non indigenous people at high cardiovascular risk.

BACKGROUND: The Kanyini Guidelines Adherence with the Polypill (Kanyini-GAP) Study aims to examine whether a polypill-based strategy (using a single capsule containing aspirin, a statin and two blood pressure-lowering agents) amongst Indigenous and non-Indigenous people at high risk of experiencing a cardiovascular event will improve adherence to guideline-indicated therapies, and lower blood pressure and cholesterol levels. METHODS/DESIGN: The study is an open, randomised, controlled, multi-centre trial involving 1000 participants at high risk of cardiovascular events recruited from mainstream general practices and Aboriginal Medical Services, followed for an average of 18 months. The participants will be randomised to one of two versions of the polypill, the version chosen by the treating health professional according to clinical features of the patient, or to usual care. The primary study outcomes will be changes, from baseline measures, in serum cholesterol and systolic blood pressure and self-reported current use of aspirin, a statin and at least two blood pressure lowering agents. Secondary study outcomes include cardiovascular events, renal outcomes, self-reported barriers to indicated therapy, prescription of indicated therapy, occurrence of serious adverse events and changes in quality-of-life. The trial will be supplemented by formal economic and process evaluations. DISCUSSION: The Kanyini-GAP trial will provide new evidence as to whether or not a polypill-based strategy improves adherence to effective cardiovascular medications amongst individuals in whom these treatments are indicated. TRIAL REGISTRATION: This trial is registered with the Australian New Zealand Clinical Trial Registry ACTRN126080005833347.

Our hearts and minds--what would it take for Australia to become the healthiest country in the world?

OBJECTIVE: To highlight recent reductions in mortality rates in Australia and identify conditions and population groups with the greatest potential for further reduction in mortality rates. DESIGN: International benchmarking and intranational comparisons of mortality rates were used to identify areas with the greatest potential for improvement. RESULTS: Latest data from Organisation for Economic Cooperation and Development (OECD) countries confirm that, while Japan's death rates remain the lowest in the world, Australia's are decreasing rapidly and we now rival Switzerland for second overall ranking. When the contributions of specific conditions are compared, the areas with the greatest potential for reductions are circulatory diseases (especially ischaemic heart disease); suicide; injury and violence; smoking-related conditions; and cancers amenable to prevention/early detection. Intranational comparisons show considerable scope for reduction in inequalities, especially those between Aboriginal and Torres Strait Islander peoples and other Australians, between males and females, and between low and high socioeconomic groups. These conditions and inequalities are highly interrelated, as differentials in health status are often mediated through broader societal inequalities. CONCLUSIONS: Australia should aim to become the country with the lowest mortality rate in the world. This could realistically be achieved by benchmarking performance nationally and internationally, applying current knowledge and available interventions, matching policies with funding, and implementing systemic national programs and activities to promote health and prevent "illth".

Diagnosis and management costs of suspicious skin lesions from a population-based melanoma screening programme.

BACKGROUND: Recently, massive increases in health-care costs for the diagnosis and management of skin lesions have been observed (2000-05). The aim of this study was to describe the health system costs attributed to the diagnosis and management of suspicious skin lesions detected during a trial of a population melanoma screening programme (1998-2001). SETTING: Queensland, Australia. METHODS: Data from the trial and Medicare Australia were used to categorize and cost all suspicious skin lesions arising from the trial, which included general practitioner consultations, diagnosis/management and pathology. Comparisons were made with other screened and unscreened populations. RESULTS: Overall, 2982 lesions were treated within the trial producing a mean cost of Aus$118 per lesion. Excisions for benign lesions contributed the greatest proportion of total costs (45%). The total cost burden was approximately 10% higher for men than women, and 63% of overall costs were for persons aged >or=50 years. For diagnosis and management procedures, the estimated average cost per 1000 individuals was Aus$23,560 for men aged >or=50 years from the skin cancer screening trial, compared with Aus$26,967 for BreastScreen Australia and Aus$3042 for the National Cervical Screening Program. CONCLUSIONS: The proportion of costs for benign skin lesions and biopsies arising from the screening programme were no higher than in the two-year period outside the trial. While comparisons are difficult, it appears that diagnostic and management costs for skin cancer as a result of screening may be comparable with those for BreastScreen Australia, if screening is targeted at men aged >or=50 years.

Comparability of skin screening histories obtained by telephone interviews and mailed questionnaires: a randomized crossover study.

The comparability of information collected through telephone interviews and information collected through mailed questionnaires has not been well studied. As part of the first phase of a randomized controlled trial of population screening for melanoma in Queensland, Australia, the authors compared histories of skin examination reported in telephone interviews and self-administered mailed questionnaires. A total of 1,270 subjects each completed a telephone interview and a mailed questionnaire 1 month apart in 1999; 564 subjects received the interview first, and 706 received the mailed questionnaire first. Agreement between the two methods was 91.2% and 88.6% for whole-body skin examination by a physician in the last 12 months and the last 3 years, respectively, and 81.9% for whole-body skin self-examination in the last 12 months. Agreement was lower for "any" skin self-examination. Agreement between the two methods was similar regardless of whether the interview or the questionnaire was administered first. Missing data were less frequent for interviews (0.5%) than for mailed questionnaires (3.8%). Costs were estimated at A$9.55 (US$6.21) per completed interview and A$3.01 (US$1.96) per questionnaire. The similarity of results obtained using telephone interviews and mailed questionnaires, coupled with the substantially higher cost of telephone interviews, suggests that self-administered mailed questionnaires are an appropriate method of assessing this health behavior.

Indigenous health: chronically inadequate responses to damning statistics.

In the 10 years 1990-2000, despite improvements in some conditions, there has been little or no overall progress in the health of the Aboriginal and Torres Strait Islander populations of Australia. This is in stark contrast to the gains made in Indigenous health in other countries. The issue is one of lack of commitment to and implementation of already existing policies. We need to (i) fully and adequately fund the Primary Health Care Access Program to provide the out-of-hospital services for prevention and early treatment required to break the cycle of ill-health; (ii) implement a National Training Plan to train the necessary health workforce; and (iii) introduce a National Infrastructure Plan to rectify the continuing deficiencies in water supply, sanitation, education and other basic services.