Addressing Profound Disadvantages to Improve Indigenous Health and Reduce Hospitalisation: A Collaborative Community Program in Remote Northern Territory.

BACKGROUND: Aboriginal people in rural and remote areas of the Northern Territory of Australia have suffered longstanding issues of homelessness and profound health and social inequities. The town and region of Katherine are particularly impacted by such inequities and have the highest rates of homelessness in Australia, composed almost entirely of Aboriginal people who represent 51% of the total population of 24,000 people. The region is serviced by a 60-bed hospital, and a small cohort of frequent attenders (FAs) represent 11% of the Emergency Department (ED) case load. The vast majority of FAs are Aboriginal and have very high burdens of social inequity and homelessness. FAs are a challenge to efficient and effective use of resources for most hospitals around the world, and investment in programs to address underlying social and chronic health issues contributing to frequent attendance have been demonstrated to be effective. METHODS: These are the interim findings of a prospective cohort study using five sources of linked health and related data to evaluate a community-based case management pilot in a culturally competent framework to support frequent attenders to the Katherine Hospital ED. FAs were defined as people with six or more presentations in 12 preceding months. The intervention composed of a community-based case management program with a multi-agency service delivery addressing underlying vulnerabilities contributing to ED presentations. RESULTS: Among this predominantly Aboriginal cohort (91%), there were high rates of homelessness (64%), food insecurity (60%) and alcohol misuse (64%), limited access to transport, and complex comorbidities (average of 2.8 chronic conditions per client). Following intervention, there was a statistically significant reduction in ED presentations (IRR 0.77, 95% CI 0.69-0.85), increased engagement with primary health care (IRR 1.90, 95% CI 1.78-2.03), and ambulance utilisation (IRR 1.21, 95% CI 1.07-1.38). Reductions in hospital admissions (IRR 0.93, 95% CI 0.77-1.10) and aeromedical retrievals (IRR 0.67, 95% CI 0.35-1.20) were not statistically significant. CONCLUSIONS: This study demonstrates the short-term impacts of community-led case management extending beyond the hospital setting, to address causes of recurrent ED presentations among people with complex social and medical backgrounds. Improving engagement with primary care is a particularly important outcome given the national impetus to reduce preventable hospital admissions.

Have purpose-built vaccine refrigerators reduced the cost of vaccine losses in South Australia?

OBJECTIVES: There is limited epidemiological data on the performance of different refrigerator types for vaccine storage in the real world. This study aims to measure if the introduction of purpose-built vaccine refrigerators has reduced the cost of vaccine losses in South Australia. METHODS: Data were taken from a register for all recorded vaccine storage cold chain events in South Australia from 2008 to 2009 and a survey of vaccine providers conducted in 2009. RESULTS: There were 531 respondents to the survey (51% response rate). A greater proportion of cold chain breaches in purpose-built vaccine refrigerators did not lead to a loss of vaccine (10.3%) compared with the other refrigerator types. Purpose-built vaccine refrigerators had a relative risk of 3.31 (95% CI, 2.15-5.11) of a heat event (as opposed to cold event) and were more likely to have a cold chain breach from electrical failure (relative risk ratio 15.05, 95% CI 4.04-56.05) than bar refrigerators. The average cost of loss of vaccine for purpose-built vaccine refrigerators was $2,321.20, which was greater than the cost of vaccine loss from a bar refrigerator of $1,339.06 (95% CI $61.47-1,902.82). CONCLUSIONS: Although purpose-built vaccine refrigerators were less likely to lead to vaccine loss per cold chain breach, they had a greater average cost of vaccine loss per cold chain event because they held a greater volume of vaccine. There is a need for development of Standards to guide purpose-built vaccine refrigerators manufacturing and a review of the National Vaccine Storage Guidelines to place a greater emphasis on the need for back up plans in the event of electrical failure.