Impact of an integrated community-based model of care for older people with complex conditions on hospital emergency presentations and admissions: a step-wedged cluster randomized trial.

BACKGROUND: Health systems must reorient towards preventative and co-ordinated care to reduce hospital demand and achieve positive and fiscally responsible outcomes for older persons with complex needs. Integrated care models can improve outcomes by aligning primary practice with the specialist health and social services required to manage complex needs. This paper describes the impact of a community-facing program that integrates care at the primary-secondary interface on the rate of Emergency Department (ED) presentation and hospital admissions among older people with complex needs. METHODS: The Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) study is a multicentre randomised controlled trial with a stepped wedge cluster design. General practitioners (GPs; n = 14) in primary practice within the Cairns region are considered 'clusters' each comprising a mixed number of participants. 80 community-dwelling persons over 70 years of age if non-Indigenous and over 50 years of age if Indigenous were included at baseline with no new participants added during the study. Clusters were randomly assigned to one of three steps that represent the time at which they would commence the OPEN ARCH intervention, and the subsequent intervention duration (3, 6, or 9 months). Each participant was its own control. GPs and participants were not blinded. The primary outcomes were ED presentations and hospital admissions. Data were collected from Queensland Health Casemix data and analysed with multilevel mixed-effects Poisson regression modelling to estimate the effectiveness of the OPEN ARCH intervention. Data were analysed at the cluster and participant levels. RESULTS: Five clusters were randomised to steps 1 and 2, and 4 clusters randomised to step 3. All clusters (n = 14) completed the trial accounting for 80 participants. An effect size of 9% in service use (95% CI) was expected. The OPEN ARCH intervention was found to not make a statistically significant difference to ED presentations or admissions. However, a stabilising of ED presentations and a trend toward lower hospitalisation rates over time was observed. CONCLUSIONS: While this study detected no statistically significant change in ED presentations or hospital admissions, a plateauing of ED presentation and admission rates is a clinically significant finding for older persons with complex needs. Multi-sectoral integrated programs of care require an adequate preparation period and sufficient duration of intervention for effectiveness to be measured. TRIAL REGISTRATION: The OPEN ARCH study received ethical approval from the Far North Queensland Human Research Ethics Committee, HREC/17/QCH/104-1174 and is registered on the Australian and New Zealand Trials Registry, ACTRN12617000198325p .

Cross-sectional association of seafood consumption, polyunsaturated fatty acids and depressive symptoms in two Torres Strait communities.

Background Dietary intake of long-chain omega 3 (n-3) polyunsaturated fatty acids (LCPUFA) represents a putative modifiable risk factor for depression, and a high ratio of omega 6 (n-6) to n-3 LCPUFA is frequently observed in patients with major depressive disorder. Recent reports suggest that the availability of fish and seafood may be associated with lower depression rates. The aim of this study was to investigate associations of fish consumption and LCPUFA levels with depressive symptoms.Methods Participants for this cross-sectional study (n=206) were recruited at a community screening programme in two Torres Strait Islander communities (Mer and Waiben). Depressive symptoms were assessed with the adapted Patient Health Questionnaire-9 (aPHQ-9) and diet with a structured questionnaire. LCPUFA concentrations were measured with a capillary dried blood spot system (PUFAcoat). Logistic and quantile regression modelling was used to test the relationship between seafood consumption, membrane LCPUFAs and depression scores.Results A higher blood n-6/3 LCPUFA ratio was associated with moderate/severe depression scores across both study sites (OR=1.59 (95%CI 1.09-2.34), P = .017). Seafood consumption was higher and the proportion of participants with aPHQ-9 scores above the cut-off for depression was lower on Mer (n = 100) compared with Waiben (n = 106). Higher seafood consumption was associated with lower depression scores on Waiben (B = -0.57 (95%CI -0.98 - -0.16), P = .006) but not on Mer.Conclusions Our findings support an association of n-3 LCPUFA from natural sources with depressive symptoms. The availability of fresh seafood in the local diet may represent a protective factor for depression in this setting.

Primary Prevention of Cardiovascular Disease in Minority Indigenous Populations: A Systematic Review.

INTRODUCTION: Cardiovascular disease (CVD) is the commonest cause of death across the globe; incidence and prevalence rates are increasing. Together, CVD and diabetes mellitus are responsible for a quarter of the health gap observed between Aboriginal Australians and Torres Strait Islanders, and non-Indigenous Australians. Numerous programs have been proposed and implemented to Close the Gap; ideally, these should be evidence-based. OBJECTIVE: The aim of this review is to evaluate primary prevention measures and programs that aim to reduce CVD risk in minority Indigenous populations around the world. METHODS: A search of PubMed, the Cochrane Library and the Elsevier Scopus Database was initially conducted using the terms "cardiovascular disease", "population groups", "primary prevention", "health services, indigenous", "indigenous health", "risk assessment" and "risk management". Results were then assessed per inclusion/exclusion criteria. A second reviewer independently evaluated the publications and review process to ensure agreement. RESULTS: The initial search produced 37 publications; 19 met the inclusion criteria and were incorporated into a comparative table. Most were descriptive, mixed-methods, audit or intervention studies. Heterogeneity of study design prevented statistical analysis. CONCLUSION: Addressing CVD risk in minority Indigenous populations is a multifactorial challenge; there is substantial room for improvement in routine risk assessment and management. Holistic approaches need to embrace local cultural perceptions of health and wellbeing. Validated risk reduction tools, individualised management plans, polypills and computer based decision support tools are promising to improve outcomes for those at risk.

Development and Use of Prediction Models for Classification of Cardiovascular Risk of Remote Indigenous Australians.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death for Indigenous Australians. There is widespread belief that current tools have deficiencies for assessing CVD risk in this high-risk population. We sought to develop a 5-year CVD risk score using a wide range of known risk factors to further improve CVD risk prediction in this population. METHODS: We used clinical and demographic information on Indigenous people aged between 30 and 74 years without a history of CVD events who participated in the Well Person's Health Check (WPHC), a community-based survey. Baseline assessments were conducted between 1998 and 2000, and data were linked to administrative hospitalisation and death records for identification of CVD events. We used Cox proportional hazard models to estimate the 5-year CVD risk, and the Harrell's c-statistic and the modified Hosmer-Lemeshow (mH-L) χ2 statistic to assess the model discrimination and calibration, respectively. RESULTS: The study sample consisted of 1,583 individuals (48.1% male; mean age 45.0 year). The risk score consisted of sex, age, systolic blood pressure, diabetes mellitus, waist circumference, triglycerides, and albumin creatinine ratio. The bias-corrected c-statistic was 0.72 and the bias-corrected mH-L χ2 statistic was 12.01 (p-value, 0.212), indicating good discrimination and calibration, respectively. Using our risk score, the CVD risk of the Indigenous Australians could be stratified to a greater degree compared to a recalibrated Framingham risk score. CONCLUSIONS: A seven-factor risk score could satisfactorily stratify 5-year risk of CVD in an Indigenous Australian cohort. These findings inform future research targeting CVD risk in Indigenous Australians.

Hair cortisol, allostatic load, and depressive symptoms in Australian Aboriginal and Torres Strait Islander people.

Chronic stress and adversity are associated with poor mental health and are thought to contribute to the existing mental health gap between Aboriginal and Torres Strait Islander people and other Australians. Hair cortisol and allostatic load (AL) are indices of sustained stress and may be mediators of the effects of stress on health. The aim of this study was to examine the relationship between hair cortisol, AL, and depressive symptoms. This cross-sectional study comprised 329 Aboriginal and Torres Strait Islander adolescents and adults recruited at two health screening programs operating in three communities in north Queensland. We measured hair cortisol and calculated an AL index from 10 biomarkers. We assessed depressive symptoms with a version of the Patient Health Questionnaire-9 adapted for Aboriginal and Torres Strait Islander people (aPHQ-9). We found differences in cortisol and AL between the screening programs and communities, which were not explained by depressive symptoms. Overall aPHQ-9 scores were unrelated to hair cortisol (p = .25 and p = .94) and AL (p = .30 and p = .88) when age, gender and smoking were taken into account. However, anhedonia (p = .007) and insomnia (p = .006) sub-scores were each significantly associated with AL in one study site. Our present data did not demonstrate overall associations of stress biomarkers and multisystem dysregulation with depressive symptoms, which suggests that the relationship between cumulative stress and depression may be better explained by other factors in this population. The specific association between anhedonia and insomnia with AL indicates that chronic multisystem dysregulation plays a role in these features of depression in this population. Lay summary Our study investigated the relationship between symptoms of depression and two biological pathways thought to mediate depression risk - the stress hormone cortisol and allostatic load (AL) - in an Australian Aboriginal and Torres Strait Islander population. Overall, cortisol and AL were unrelated to depression. However, AL was selectively associated with anhedonia (lack of motivation or drive) and sleep disturbances. These results suggest that metabolic dysregulation measured as AL may be relevant to the depression risk in this population.

Low proportions of folic acid deficiency after introduction of mandatory folic acid fortification in remote areas of northern Queensland, Australia: a secondary health data analysis.

Background: Australia implemented mandatory folic acid fortification of bread-making flour in 2009. Objective: To assess the impact of folic acid fortification in remote vs. regional urban areas and Indigenous vs. non-Indigenous populations in northern Queensland. Methods: Routinely collected data on folic acid measurements in remote areas and two regional urban centres in northern Queensland between 2004 and 2015 were analysed (n = 13,929) dichotomously (folic deficient vs. non-deficient). Results: Overall prevalence of folic acid deficiency was 3.2% (235/7282) in urban centres compared with 7.2% (480/6647) in remote areas (p < 0.001), and 9.3% (393/4240) in the Indigenous population compared with 3.2% (273/8451) in the non-Indigenous population (p < 0.001). Prevalence of folic acid deficiency dropped from 12.2% (n = 481) in 2004-2008 to 1.5% (n = 126) in 2010-2015 (p < 0.001). This translates into a relative risk reduction (RRR) of 88%. RRR was 79% (7.2% vs. 1.5%) in urban centres, 91% (17.3% vs. 1.5%) in remote areas, 92% (20.5% vs. 1.6%) in the Indigenous population and 80% (7.4% vs. 1.5%) in the non-Indigenous population (p < 0.001 for all). Conclusions: Substantial declines of folic acid deficiency to low and comparable proportions in former high-risk populations indicate that mandatory folic acid fortification of flour has had a population-wide benefit in northern Queensland.

Safety and tolerability of experimental hookworm infection in humans with metabolic disease: study protocol for a phase 1b randomised controlled clinical trial.

BACKGROUND: Abdominal obesity and presence of the metabolic syndrome (MetS) significantly increase the risk of developing diseases such as Type 2 diabetes mellitus (T2DM) with escalating emergence of MetS and T2DM constituting a significant public health crisis worldwide. Lower prevalence of inflammatory and metabolic diseases such as T2DM in countries with higher incidences of helminth infections suggested a potential role for these parasites in the prevention and management of certain diseases. Recent studies confirmed the potential protective nature of helminth infection against MetS and T2DM via immunomodulation or, potentially, alteration of the intestinal microbiota. This Phase 1b safety and tolerability trial aims to assess the effect of inoculation with helminths on physical and metabolic parameters, immune responses, and the microbiome in otherwise healthy women and men. METHODS: Participants eligible for inclusion are adults aged 18-50 with central obesity and a minimum of one additional feature of MetS recruited from the local community with a recruitment target of 54. In a randomised, double-blind, placebo-controlled design, three groups will receive either 20 or 40 stage three larvae of the human hookworm Necator americanus or a placebo. Eligible participants will provide blood and faecal samples at their baseline and 6-monthly assessment visits for a total of 24 months with an optional extension to 36 months. During each scheduled visit, participants will also undergo a full physical examination and complete diet (PREDIMED), physical activity, and patient health (PHQ-9) questionnaires. Outcome measurements include tolerability and safety of infection with Necator americanus, changes in metabolic and immunological parameters, and changes in the composition of the faecal microbiome. DISCUSSION: Rising cost of healthcare associated with obesity-induced metabolic diseases urgently calls for new approaches in disease prevention. Findings from this trial will provide valuable information regarding the potential mechanisms by which hookworms, potentially via alterations in the microbiota, may positively influence metabolic health. TRIAL REGISTRATION: The protocol was registered on ANZCTR.org.au on 05 June 2017 with identifier ACTRN12617000818336. Alternatively, a Google search using the above trial registration number will yield a direct link to the trial protocol within the ANZCTR website.

Folic acid deficiency declined substantially after introduction of the mandatory fortification programme in Queensland, Australia: a secondary health data analysis.

OBJECTIVE: To investigate the prevalence of folic acid deficiency in Queensland-wide data of routine laboratory measurements, especially in high-risk sub-populations. DESIGN: Secondary health data analysis. SETTING: Analysis of routine folic acid tests conducted by Pathology Queensland (AUSLAB). PARTICIPANTS: Female and male persons aged 0-117 years with routine folic acid testing between 1 January 2004 and 31 December 2015. If repeat tests on the same person were conducted, only the initial test was analysed (n 291 908). RESULTS: Overall the prevalence of folic acid deficiency declined from 7·5 % before (2004-2008) to 1·1 % after mandatory folic acid fortification (2010-2015; P < 0·001) reflecting a relative reduction of 85 %. Levels of erythrocyte folate increased significantly from a median (interquartile range) of 820 (580-1180) nmol/l in 2008 before fortification to 1020 (780-1350) nmol/l in 2010 (P < 0·001) after fortification. The prevalence of folic acid deficiency in the Indigenous population (14 792 samples) declined by 93 % (17·4 v. 1·3 %; P < 0·001); and by 84 % in non-Indigenous residents (7·0 v. 1·1 %; P < 0·001). In a logistic regression model the observed decrease of folic acid deficiency between 2008 and 2010 was found independent of gender, age and ethnicity (ORcrude = 0·20; 95 % CI 0·18, 0·23; P < 0·001; ORadjusted = 0·21; 95 % CI 0·18, 0·23; P < 0·001). CONCLUSIONS: While voluntary folic acid fortification, introduced in 1995, failed especially in high-risk subgroups, the 2009 mandatory folic acid fortification programme coincided with a substantial decrease of folic acid deficiency in the entire population.

Diagnosis and management of type 2 diabetes in youth in North Queensland and the Northern Territory: A health professional survey.

OBJECTIVE: To describe clinician practice regarding diagnosis, management and perceived barriers to the optimal management of youth-onset type 2 diabetes mellitus in North Queensland and the Northern Territory and to compare self-reported practice to guideline recommendations. DESIGN: A mailed questionnaire distributed between July and October 2017. SETTING: Clinicians practising in three tertiary hospitals and two primary care organisations in North Queensland and the Northern Territory. PARTICIPANTS: Of the 72 participants, 42 (58%) who responded were endocrinologists, diabetes educators, GPs and paediatricians. RESULTS: Of the 42 clinicians, 23 referred to the guidelines. A diabetes educator, GP, endocrinologist and dietitian were the most commonly included clinicians in the multidisciplinary team. Half of the clinicians' screen the children if additional risk factors are present. The HbA1c is the most common test used for screening and diagnosis. At diagnosis, the clinicians' recommended lifestyle change in 86% of the patients, treatment with metformin in 48%, and, when indicated, treatment with insulin in up to 45%. All clinicians believe that non-adherence is a major factor limiting optimal care. Most commonly cited barriers to optimal care were poor patient or family health literacy and limited patient or family understanding of the condition. CONCLUSION: This study demonstrates several aspects of diagnosis and management of type 2 diabetes mellitus in youth that deviate from the guidelines. Patients need improved access to social workers, psychologists and Indigenous health workers. Other key areas to address are evaluation of risk-based screening, supporting appropriate and early use of insulin and the management of youth with type 2 diabetes mellitus inclusive of their family through contextualised health care delivery.

Diabetes and smoking as predictors of cancer in Indigenous adults from rural and remote communities of North Queensland - A 15-year follow up study.

Indigenous Australians generally have a poor health status and an elevated cancer mortality that has increased in recent decades. A cohort of 2,273 Aboriginal and Torres Strait Islander (TSI) adults (18+ years) from 26 remote communities in far North Queensland, who were initially free of cancer, were followed-up for an average of 15 years. The associations of baseline anthropometric, biochemical and behavioural factors with cancer incidence were investigated using competing risk survival analysis. The age-standardised incidence (all cancers) was 5.2 cases/1,000 person-years (pys) (95% CI 4.1-6.6). Liver/bile duct and lung were the most common cancer sites. Overall cancer incidence was significantly higher in TSIs than Aboriginal people. The baseline prevalence of diabetes was 15.6% in Aboriginal and 25.6% in TSI people. The smoking rate of 59.8% for Aboriginal people was higher than the rate of 45.2% for TSIs. At follow-up, the adjusted sub hazard ratios (SHRs) of diabetes for all cancers combined were 1.8 (95% CI, 1.3-2.6), and for digestive system cancers, 2.3 (95% CI, 1.2-4.4). Smokers had a 60% higher risk (SHR 1.6, 95% CI: 1.1-2.0) for all cancers combined and a fourfold risk (SHR 3.7, 95% CI 1.7-8.0) for lung cancers when compared to non-smokers, regardless of age, sex and ethnicity. The most common cancers encountered by this Indigenous cohort and their consequences are potentially preventable in Indigenous Australians by effective management of highly prevalent modifiable risks in primary service settings, screening participation and arranging for good access to treatment services.

Screening for depression in young Indigenous people: building on a unique community initiative.

Gurriny Yealamucka Health Service Aboriginal Corporation (GYHSAC) is an Indigenous community-controlled health organisation providing comprehensive primary care to the people of Yarrabah in far north Queensland, Australia. GYHSAC conducts an annual Young Person's Health Check (YPC) for people aged 15-25 years based on the Medical Benefits Schedule Item 715. However, the YPC is constantly evolving to meet the needs of the community, and in 2016, in response to concerns about psychological risk among Indigenous youth, GYHSAC teamed up with James Cook University to trial an adapted PHQ-9 depression screening tool (aPHQ-9) as part of the YPC. This study describes the 2016 YPC event, reports the prevalence of depressive symptoms, examines local issues related to the use of the screening tool and proposes recommendations for future health screening. Experienced health professionals conducted the aPHQ-9 assessment in a private area of the clinic. One-in-five young people were found to have moderate-severe symptoms or self-harm ideation in the previous 2 weeks; they were referred to the mental health service. The aPHQ-9 screening process was found to be straightforward and well accepted by staff and youth. Importantly, it provided valuable 'space' to facilitate communication on sensitive issues and was a conduit for speedy referral and follow up by trained staff. Based on our experience, we recommend dedicated depression screening in future routine community health checks for young people and adults.

How effective are family-based and institutional nutrition interventions in improving children's diet and health? A systematic review.

BACKGROUND: Effective strategies to improve dietary intake in young children are a priority to reduce the high prevalence of chronic non-communicable diseases in adulthood. This study aimed to assess the impact of family-based and school/preschool nutrition programs on the health of children aged 12 or younger, including the sustainability of these impacts and the relevance to socio-economic inequalities. METHODS: A systematic review of literature published from 1980 to December 2014 was undertaken. Randomised controlled trials involving families with children aged up to 12 years in high income countries were included. The primary outcomes were dietary intake and health status. Results were presented in a narrative synthesis due to the heterogeneity of the interventions and outcomes. RESULTS: The systematic search and assessment identified 39 eligible studies. 82% of these studies were set in school/preschools. Only one school study assessed the impact of involving parents systematically. The family-based programs which provided simple positive dietary advice to parents and regular follow-up reduced fat intake significantly. School and family-based studies, if designed and implemented well, increased F&V intake, particularly fruit. Effective school-based programs have incorporated role-models including peers, teachers and heroic figures, rewards and increased access to healthy foods. School nutrition programs in disadvantaged communities were as effective as programs in other communities. CONCLUSIONS: Family and school nutrition programs can improve dietary intake, however evidence of the long-term sustainability of these impacts is limited. The modest overall impact of even these successful programs suggest complementary nutrition interventions are needed to build a supportive environment for healthy eating generally.

Alcohol management plans in Aboriginal and Torres Strait Islander (Indigenous) Australian communities in Queensland: community residents have experienced favourable impacts but also suffered unfavourable ones.

BACKGROUND: In Australia, 'Alcohol Management Plans' (AMPs) provide the policy infrastructure for State and Commonwealth Governments to address problematic alcohol use among Aboriginal and Torres Strait Islanders. We report community residents' experiences of AMPs in 10 of Queensland's 15 remote Indigenous communities. METHODS: This cross-sectional study used a two-stage sampling strategy: N = 1211; 588 (48%) males, 623 (52%) females aged ≥18 years in 10 communities. Seven propositions about 'favourable' impacts and seven about 'unfavourable' impacts were developed from semi-structured interviews. For each proposition, one-sample tests of proportions examined participant agreement and multivariable binary logistic regressions assessed influences of gender, age (18-24, 25-44, 45-64, ≥65 years), residence (≥6 years), current drinking and Indigenous status. Confirmatory factor analyses estimated scale reliability (ρ), item loadings and covariances. RESULTS: Slim majorities agreed that: AMPs reduced violence (53%, p = 0.024); community a better place to live (54%, 0.012); and children were safer (56%, p < 0.001). More agreed that: school attendance improved (66%, p < 0.001); and awareness of alcohol's harms increased (71%, p < 0.001). Participants were equivocal about improved personal safety (53%, p = 0.097) and reduced violence against women (49%, p = 0.362). The seven 'favourable' items reliably summarized participants' experiences of reduced violence and improved community amenity (ρ = 0.90). Stronger agreement was found for six 'unfavourable' items: alcohol availability not reduced (58%, p < 0.001); drinking not reduced (56%, p < 0.001)); cannabis use increased (69%, p < 0.001); more binge drinking (73%, p < 0.001); discrimination experienced (77%, p < 0.001); increased fines, convictions and criminal records for breaching restrictions (90%, p < 0.001). Participants were equivocal (51% agreed, p = 0.365) that police could enforce restrictions effectively. 'Unfavourable' items were not reliably reflected in one group (ρ = 0.48) but in: i) alcohol availability and consumption not reduced and ii) criminalization and discrimination. In logistic regressions, longer-term (≥ 6 years) residents more likely agreed that violence against women had reduced and that personal safety had improved but also that criminalization and binge drinking had increased. Younger people disagreed that their community was a better place to live and strongly agreed about discrimination. Current drinkers' views differed little from the sample overall. CONCLUSIONS: The present Government review provides an opportunity to reinforce 'favourable' outcomes while targeting: illicit alcohol, treatment and diversion services and reconciliation of criminalization and discrimination issues.

Assessing the link between implementation fidelity and health outcomes for a trial of intensive case management by community health workers: a mixed methods study protocol.

BACKGROUND: Better systems of care are required to address chronic disease in Indigenous people to ensure they can access all their care needs. Health research has produced evidence about effective models of care and chronic disease strategies to address Indigenous health, however the transfer of research findings into routine clinical practice has proven challenging. Complex interventions, such as those related to chronic disease, have many components that are often poorly implemented and hence rarely achieve implementation fidelity. Implementation fidelity is "the degree to which programs are implemented as intended by the program developer". Knowing if an intervention was implemented as planned is fundamental to knowing what has contributed to the success of an intervention. METHODS: The aim of this study is to adapt the implementation fidelity framework developed by Keith et al. and apply it to the intervention implemented in phase 1 of the Getting Better at Chronic Care in North Queensland study. The objectives are to quantify the level of implementation fidelity achieved during phase 1 of the study, measure the association between implementation fidelity and health outcomes and to explore the features of the primary health care system that contributed to improved health outcomes. A convergent parallel mixed methods study design will be used to develop a process for assessing implementation fidelity. Information collected via a questionnaire and routine data generated during phase 1 of the study will be used to explain the context for the intervention in each site and develop an implementation fidelity score for each component of the intervention. A weighting will be applied to each component of the intervention to calculate the overall implementation score for each participating community. Statistical analysis will assess the level of association between implementation fidelity scores and health outcomes. DISCUSSION: Health services research seeks to find solutions to social and technical problems to improve health outcomes. The development of a tool and methodology for assessing implementation fidelity in the Indigenous primary health care context will help address some of the barriers to the translation of research into practice. TRIAL REGISTRATION: ACTRN12610000812099 : 29.9.2010.

Depression and diabetes in the remote Torres Strait Islands.

Issue addressed Diabetes is associated with significant depression, which can result in poorer clinical outcomes, including increased mortality. Little is known about the prevalence of depression among Torres Strait Islander adults with diabetes. Methods Self-reported depression was measured using the Patient Health Questionnaire (PHQ)-9 translated into Torres Strait Creole, and associations with socioeconomic, behavioural and clinical indicators in Torres Strait Islander adults with diabetes in five remote Torres Strait Islands were examined. Results Seventy-three men and 115 women completed interviews. The median PHQ-9 score was 5.5 (IQR 0-7); 42% of respondents scored 0-4 (none-minimal), 46% scored 5-9 (mild) and 12% scored 10+ (moderate-severe). Mean HbA1c was 8.3% (67.4mmol). HbA1c was not related to PHQ-9 scores (ß=0.20, P=0.323), however exercise in hours (ß=-0.34, P<0.001) and screen time in hours (ß=0.11, P<0.001) were significant predictors of depression after adjusting for other study variables. Conclusions This sample of remote living Torres Strait Islanders reported relatively low rates of depression compared with national samples, and depression was not related to glycaemic control. Exercise and screen time were the strongest predictors of depression based on PHQ-9 scores. This represents an opportunity for health promotion. So what? These findings provide an indication of the health impact of physical activity in rural and remote communities. Local health and education services, councils and sporting bodies should work collaboratively to promote sustainable physical activity programs.

Review of patient-reported experience within Patient-Centered Medical Homes: insights for Australian Health Care Homes.

Understanding patient experience is necessary to advance the patient-centred approach to health service delivery. Australia's primary healthcare model, the 'Health Care Home', is based on the 'Patient-Centered Medical Home' (PCMH) model developed in the United States. Both these models aim to improve patient experience; however, the majority of existing PCMH model evaluations have focussed on funding, management and quality assurance measures. This review investigated the scope of evidence reported by adult patients using a PCMH. Using a systematic framework, the review identified 39 studies, sourced from 33 individual datasets, which used both quantitative and qualitative approaches. Patient experience was reported for model attributes, including the patient-physician and patient-practice relationships; care-coordination; access to care; and, patient engagement, goal setting and shared decision-making. Results were mixed, with the patient experience improving under the PCMH model for some attributes, and some studies indicating no difference in patient experience following PCMH implementation. The scope and quality of existing evidence does not demonstrate improvement in adult patient experience when using the PCMH. Better measures to evaluate patient experience in the Australian Health Care Home model are required.

Are general practice characteristics predictors of good glycaemic control in patients with diabetes? A cross-sectional study.

OBJECTIVES: To determine whether certain characteristics of general practices are associated with good glycaemic control in patients with diabetes and with completing an annual cycle of care (ACC). RESEARCH DESIGN AND METHODS: Our cross-sectional analysis used baseline data from the Australian Diabetes Care Project conducted between 2011 and 2014. Practice characteristics were self-reported. Characteristics of the patients that were assessed included glycaemic control (HbA1c level ≤ 53 mmol/mol), age, sex, duration of diabetes, socio-economic disadvantage (SEIFA) score, the complexity of the patient's condition, and whether the patient had completed an ACC for diabetes in the past 18 months. Clustered logistic regression was used to establish predictors of glycaemic control and a completed ACC. RESULTS: Data were available from 147 general practices and 5455 patients with established type 1 or type 2 diabetes in three Australian states. After adjustment for other patient characteristics, only the patient completing an ACC was statistically significant as a predictor of glycaemic control (P = 0.011). In a multivariate model, the practice having a chronic disease-focused practice nurse (P = 0.036) and running educational events for patients with diabetes (P = 0.004) were statistically significant predictors of the patient having complete an ACC. CONCLUSIONS: Patient characteristics are moderately good predictors of whether the patient is in glycaemic control, whereas practice characteristics appear to predict only the likelihood of patients completing an ACC. The ACC is an established indicator of good diabetes management. This is the first study to report a positive association between having completed an ACC and the patient being in glycaemic control.

Economic evaluation of Indigenous health worker management of poorly controlled type 2 diabetes in north Queensland.

OBJECTIVE: To conduct an economic evaluation of intensive management by Indigenous health workers (IHWs) of Indigenous adults with poorly controlled type 2 diabetes in rural and remote north Queensland. DESIGN: Cost-consequence analysis alongside a cluster randomised controlled trial of an intervention delivered between 1 March 2012 and 5 September 2013. SETTING: Twelve primary health care services in rural and remote north Queensland communities with predominantly Indigenous populations. PARTICIPANTS: Indigenous adults with poorly controlled type 2 diabetes (HbA1c ≥ 69 mmol/mol) and at least one comorbidity (87 people in six IHW-supported communities (IHW-S); 106 in six usual care (UC) communities). MAIN OUTCOME MEASURES: Per person cost of the intervention; differential changes in mean HbA1c levels, percentage with extremely poor HbA1c level control, quality of life, disease progression, and number of hospitalisations. RESULTS: The mean cost of the 18-month intervention trial was $10 060 per person ($6706 per year). The intervention was associated with a non-significantly greater reduction in mean HbA1c levels in the IHW-S group (-10.1 mmol/mol v -5.4 mmol/mol in the UC group; P = 0.17), a significant reduction in the proportion with extremely poor diabetes control (HbA1c ≥ 102 mmol/mol; P = 0.002), and a sub-significant differential reduction in hospitalisation rates for type 2 diabetes as primary diagnosis (-0.09 admissions/person/year; P = 0.06), with a net reduction in mean annual hospital costs of $646/person (P = 0.07). Quality of life utility scores declined in both groups (between-group difference, P = 0.62). Rates of disease progression were high in both groups (between-group difference, P = 0.73). CONCLUSION: Relative to the high cost of the intervention, the IHW-S model as implemented is probably a poor investment. Incremental cost-effectiveness might be improved by a higher caseload per IHW, a longer evaluation time frame, and improved service integration. Further approaches to improving chronic disease outcomes in this very unwell population need to be explored, including holistic approaches that address the complex psychosocial, pathophysiological and environmental problems of highly disadvantaged populations. TRIAL REGISTRATION: ANZCTR12610000812099.

Clinical outcomes associated with albuminuria in central Australia: a cohort study.

BACKGROUND: Chronic kidney disease (CKD) and end-stage-kidney disease (ESKD) continue to be under-diagnosed and a major burden for Aboriginal communities in central Australia. The aim of this study was to examine the risk of poor clinical outcomes associated with elevated albumin-to-creatinine ratio (ACR) among Aboriginal people in central Australia. METHODS: Cox proportional hazards models were used to estimate the risk of end stage kidney disease (ESKD), dialysis, CVD (cardiovascular disease) and mortality associated with participants' baseline albuminuria reading from a 10-year cohort study of Aboriginal people (n = 623) from three communities in central Australia. Predictors of progression of albuminuria were also examined in the context of the Kidney Health Australia (KHA) Risk Matrix. RESULTS: A baseline ACR level of ≥3.5 mg/mmol was associated with an almost 10-fold increased risk of ESKD (95%CI 2.07-43.8) and a 15-fold risk of dialysis (95%CI 1.89-121). Albuminuria ≥3.5 mg/mmol was also associated with a borderline 63 % increased risk of CVD (95%CI 0.98-2.71). No significant association was observed with mortality from all-causes or chronic disease. Diabetes and a waist-to-hip ratio ≥0.90 independently predicted a two-fold increased risk of a progression to higher ACR levels. CONCLUSIONS: A single measure of moderately increased albuminuria was a strong predictor of renal failure in this population. A single spot urine ACR analysis in conjunction with the KHA Risk Matrix may be a useful and efficient strategy to screen for risk of CKD and progression to dialysis in remote communities. A focus on individuals with diabetes and/or central obesity for strategies to avoid increases in albuminuria may also prevent future CKD and CVD complications.

Barriers to insulin treatment among Australian Torres Strait Islanders with poorly controlled diabetes.

OBJECTIVE: To explore self reported knowledge and attitudes to insulin treatment among a group of adults with poorly controlled diabetes in the Torres Strait islands. DESIGN: Cross-sectional survey in 2014, interviews with 29 adults with HbA1c ≥ 8.5% (69 mmol mol-1 ) and not taking insulin, using Insulin Treatment Appraisal Scale (ITAS) and Barriers to Insulin Treatment Questionnaire (BITQ) scores. SETTING: Five remote Torres Strait Island communities in the Torres Strait region. PARTICIPANTS: Poorly controlled insulin-naïve type 2 diabetics. MAIN OUTCOME MEASURES: BITQ and ITAS scores on items related to knowledge and attitudes to insulin treatment, clinical and demographic measures. RESULTS: Overall, 34% of the cohort had poor glycaemic control. Compared to those with HbA1c ≥ 8.5% and taking insulin (n = 37), the 29 insulin-naïve participants were more obese, more likely to smoke and drink alcohol, have lower mean HbA1c and fewer years with diabetes. Among the insulin-naïve group, those reporting higher 'barriers' (BITQ scores) were older and with lower formal education than those reporting fewer barriers. Torres participants consistently scored low on 'knowledge' items in the ITAS, especially those which would guide insulin initiation (insulin improves glucose control and prevents complications). CONCLUSION: Compared to other published studies, the Torres participants had higher scores for BITQ 'barrier' items and lower 'knowledge' scores. This suggests better education around glycaemic control with medication and discussion of perceptions and exchange of experiences with peers who are taking insulin might improve the uptake of insulin in this high-risk group.