Impacts of continuous quality improvement in Aboriginal and Torres Strait islander primary health care in Australia.

Purpose Continuous quality improvement (CQI) programmes have been taken up widely by indigenous primary health care services in Australia, but as yet there has not been a systematic assessment of their focus and achievements. A scoping review of the literature from studies of CQI in indigenous primary health care services was undertaken to explore impacts on service systems, care and client outcomes with the aim of providing guidance on future evaluation efforts. The paper aims to discuss these issues, Design/methodology/approach Searches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews to December 2016 and handsearching of key websites and publications. Studies of CQI programs or activities in Indigenous primary health care services which demonstrated some combination of CQI characteristics, as described by Rubenstein (2013) were included. A two-stage approach to analysis was undertaken. Stage 1 identified the range and scope of literature, and Stage 2 investigated impacts to service systems, care and client outcomes. The Framework for Performance Assessment in Primary Health Care was used to frame the Stage 2 analysis. Findings The majority of Aboriginal community controlled health services have been involved in CQI but there are gaps in knowledge about uptake in general practice and government clinics. There are as many baseline studies as studies on impacts over time. Of the 14 studies included for further analysis, 6 reported on impacts on service systems; all 14 reported on impacts on care and 6 on client outcomes. Changes to services systems are variable and studies of impacts on care and client outcomes show promising though uneven improvements. There are no economic studies or studies addressing community engagement in CQI activities. Research limitations/implications To supplement existing limited knowledge about which service system change strategies are effective and sustainable for which problems in which settings, there needs to be investment in research and development. Research needs to be grounded in the realities of service delivery and contribute to the development of CQI capacity at the service level. Knowledge translation needs to be built into implementation to ensure maximum benefit to those endeavouring on a daily basis to constantly reflect on and improve the quality of the care they deliver to clients, and to the stewardship structures supporting services at regional, state/territory and national levels. Practical implications Improved approaches, methods, data capture and reporting arrangements are needed to enhance existing activity and to ensure maximum benefit to services endeavouring to reflect on and improve quality of care and to the stewardship structure supporting services at regional, state/territory and national levels. Originality/value Although there is a growing body of research evidence about CQI both nationally and internationally, and considerable investment by the federal government in Australia to support CQI as part of routine practice, there has not been a systematic assessment of the achievements of CQI in Indigenous primary health care services. Many unanswered questions remain about the extent of uptake, implementation and impacts. This is a barrier to future investment and regional and local programme design, monitoring and evaluation. The authors conducted a scoping review to address these questions. From this, the authors draw conclusions about the state of knowledge in Australia with a view to informing how future CQI research and evaluation might be intensified.

Implementation of continuous quality improvement in Aboriginal and Torres Strait Islander primary health care in Australia: a scoping systematic review.

BACKGROUND: Continuous Quality Improvement (CQI) programs have been taken up widely by Indigenous primary health care (PHC) services in Australia and there has been national policy commitment to support this. However, international evidence shows that implementing CQI is challenging, impacts are variable and little is known about the factors that impede or enhance effectiveness. A scoping review was undertaken to explore uptake and implementation in Indigenous PHC, including barriers and enablers to embedding CQI in routine practice. We provide guidance on how research and evaluation might be intensified to support implementation. METHODS: Searches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews. Key websites and publications were handsearched. Studies conducted in Indigenous PHC which demonstrated some combination of CQI characteristics and assessed some aspect of implementation were included. A two stage analysis was undertaken. Stage 1 identified the breadth and focus of literature. Stage 2 investigated barriers and enablers. The Framework for Performance Assessment in PHC (2008) was used to frame the analysis. Data were extracted on the study type, approach, timeframes, CQI strategies, barriers and enablers. RESULTS: Sixty articles were included in Stage 1 and 21 in Stage 2. Barriers to implementing CQI processes relate primarily to professional and organisational processes and operate at multiple levels (individual, team, service, health system) whereas barriers to improved care relate more directly to knowledge of best practice and team processes that facilitate appropriate care. Few studies described implementation timeframes, number of CQI cycles or improvement strategies implemented and only two applied a change theory. CONCLUSION: Investigating barriers and enablers that modify implementation and impacts of CQI poses conceptual and methodological challenges. More complete description of CQI processes, implementation strategies, and barriers and enablers could enhance capacity for comparisons across settings and contribute to better understanding of key success factors.

Sustained participation in annual continuous quality improvement activities improves quality of care for Aboriginal and Torres Strait Islander children.

AIM: To determine whether participation in the continuous quality improvement (CQI) Audit and Best Practice for Chronic Disease programme improved care and outcomes for Indigenous children. METHODS: Data were collected from 59 Australian primary health-care centres providing services to Indigenous people and participating in the programme (February 2008 and December 2013). Indigenous children aged less than 2 years and centres that completed three or more consecutive annual audits within the 6-year study period were included. Crude and adjusted logistic generalised estimating equation models were used to examine the effect of year of audit on the delivery of care. Odds ratio (OR) and 95% confidence interval (CI) were calculated. Outcomes were related to age-relevant health issues, including prevention and early intervention. These included administrative, health check, anticipatory guidance and specific health issues. RESULTS: During the audit period, there were 2360 files from 59 centres. Those that had a recall recorded, improved from 84 to 95% (OR 2.44, 95% CI 1.44-4.11). Hearing assessments improved from 52 to 89% (OR 1.37, 95% CI 1.22-1.54). Improvement in anticipatory guidance, treatment and follow-up of medical conditions was almost universal. CONCLUSION: We documented significant improvements in quality of care of Indigenous children. Outcomes and their corresponding treatment and follow-ups improved over time. This appears to be related to services participating in annual CQI activities. However, these services may be more committed to CQI than others and therefore possibly better performing.

Indicators for continuous quality improvement for otitis media in primary health care for Aboriginal and Torres Strait Islander children.

Otitis media is a common, generally self-limiting childhood illness that can progress to severe disease and have lifelong sequelae, including hearing loss and developmental delays. Severe disease is disproportionately prevalent among Aboriginal and Torres Strait Islander children. Primary health care is at the frontline of appropriate prevention and treatment. Continuous quality improvement in the prevention and management of important causes of morbidity in client populations is accepted best practice in primary health care and now a requirement of Australian Government funding to services providing care for Aboriginal and Torres Strait Islander children. To date, there have been no indicators for continuous quality improvement in the prevention and management of otitis media and its sequelae in primary health care. Through an expert group consensus process, seven evidence-based indicators, potentially extractable from electronic health records, have been developed. The development process and indicators are described.

Using Knowledge Translation to Craft "Sticky" Social Media Health Messages That Provoke Interest, Raise Awareness, Impart Knowledge, and Inspire Change.

BACKGROUND: In Australia, there is growing use of technology supported knowledge translation (KT) strategies such as social media and mobile apps in health promotion and in Indigenous health. However, little is known about how individuals use technologies and the evidence base for the impact of these health interventions on health behavior change is meager. OBJECTIVE: The objective of our study was to examine how Facebook is used to promote health messages to Indigenous people and discuss how KT can support planning and implementing health messages to ensure chosen strategies are fit for the purpose and achieve impact. METHODS: A desktop audit of health promotion campaigns on smoking prevention and cessation for Australian Indigenous people using Facebook was conducted. RESULTS: Our audit identified 13 out of 21 eligible campaigns that used Facebook. Facebook pages with the highest number of likes (more than 5000) were linked to a website and to other social media applications and demonstrated stickiness characteristics by posting frequently (triggers and unexpected), recruiting sporting or public personalities to promote campaigns (social currency and public), recruiting Indigenous people from the local region (stories and emotion), and sharing stories and experiences based on real-life events (credible and practical value). CONCLUSIONS: KT planning may support campaigns to identify and select KT strategies that are best suited and well-aligned to the campaign's goals, messages, and target audiences. KT planning can also help mitigate unforeseen and expected risks, reduce unwarranted costs and expenses, achieve goals, and limit the peer pressure of using strategies that may not be fit for purpose. One of the main challenges in using KT systems and processes involves coming to an adequate conceptualization of the KT process itself.

Furthering the quality agenda in Aboriginal community controlled health services: understanding the relationship between accreditation, continuous quality improvement and national key performance indicator reporting.

A rapidly expanding interest in quality in the Aboriginal-community-controlled health sector has led to widespread uptake of accreditation using more than one set of standards, a proliferation of continuous quality improvement programs and the introduction of key performance indicators. As yet, there has been no overarching logic that shows how they relate to each other, with consequent confusion within and outside the sector. We map the three approaches to the Framework for Performance Assessment in Primary Health Care, demonstrating their key differences and complementarity. There needs to be greater attention in both policy and practice to the purposes and alignment of the three approaches if they are to embed a system-wide focus that supports quality improvement at the service level.

A cost effectiveness study of integrated care in health services delivery: a diabetes program in Australia.

BACKGROUND: Type 2 diabetes is rapidly growing as a proportion of the disease burden in Australia as elsewhere. This study addresses the cost effectiveness of an integrated approach to assisting general practitioners (GPs) with diabetes management. This approach uses a centralized database of clinical data of an Australian Division of General Practice (a network of GPs) to co-ordinate care according to national guidelines. METHODS: Long term outcomes for patients in the program were derived using clinical parameters after 5 years of program participation, and the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model, to project outcomes for 40 years from the time of diagnosis and from 5 years post-diagnosis. Cost information was obtained from a range of sources. While program costs are directly available, and costs of complications can be estimated from the UKPDS model, other costs are estimated by comparing costs in the Division with average costs across the state or the nation. The outcome and cost measures are used derive incremental cost-effectiveness ratios. RESULTS: The clinical data show that the program is effective in the short term, with improvement or no statistical difference in most clinical measures over 5 years. Average HbA1c levels increased by less than expected over the 5 year period. While the program is estimated to generate treatment cost savings, overall net costs are positive. However, the program led to projected improvements in expected life years and Quality Adjusted Life Expectancy (QALE), with incremental cost effectiveness ratios of $A8,106 per life-year saved and $A9,730 per year of QALE gained. CONCLUSIONS: The combination of an established model of diabetes progression and generally available data has provided an opportunity to establish robust methods of testing the cost effectiveness of a program for which a formal control group was not available. Based on this methodology, integrated health care delivery provided by a network of GPs improved health outcomes of type 2 diabetics with acceptable cost effectiveness, which suggests that similar outcomes may be obtained elsewhere.

National quality and performance system for Divisions of General Practice: early reflections on a system under development.

BACKGROUND: Governments are increasingly introducing performance management systems to improve the quality and outcomes of health care. Two types of approaches have been described: assurance systems that use summative information for external accountability and internally driven systems that use formative information for continuous quality improvement. Australia recently introduced a National Quality and Performance System (NQPS) for Divisions of General Practice that has the dual purposes of increasing accountability and improving performance. In this article, we ask whether the framework can deliver on its objectives for achieving accountability and fostering performance improvement. We examine the system in terms of four factors identified in a recent systematic review of indicator systems known to improve their use. These are: involving stakeholders in development; having clear objectives; approach to data collection and analysis including using 'soft data' to aid interpretation; and feeding back information. RESULTS: We found that early consultative processes influenced system development. The system promotes the collection of performance information against defined program objectives. Data includes a mix of qualitative and quantitative indicators that are fitted to a conceptual framework that facilitates an approach to performance assessment that could underpin continuous quality improvement at the Division level. Feedback of information to support the development of quality improvement activities has not been fully developed. CONCLUSION: The system currently has elements that, with further development, could support a more continuous quality improvement or assurance based approach. Careful consideration needs to be given to the development of methods for analysis and review of performance indicators, performance assessment and engagement with consumers. The partnership arrangement that supported early development could be expected to serve as an important vehicle for further development.

Divisions of general practice in Australia: how do they measure up in the international context?

BACKGROUND: Since the late 1980s, there has been evidence of an international trend towards more organised primary care. This has taken a number of forms including the emergence of primary care organisations. Underpinning such developments is an inherent belief in evidence that suggests that well-developed primary care is associated with improved health outcomes and greater cost-effectiveness within health systems. In Australia, primary care organisations have emerged as divisions of general practice. These are professionally-led, regionally-based, and largely government-funded voluntary associations of general practitioners that seek to co-ordinate local primary care services, and improve the quality of care and health outcomes for local communities. DISCUSSION: In this paper, we examine and debate the development of divisions in the international context, using six roles of primary care organisations outlined in published research. The six roles that are used as the basis for the critique are the ability of primary care organisations to: improve health outcomes; manage demand and control costs; engage primary care physicians; enable greater integration of health services; develop more accessible services in community and primary care settings; and enable greater scrutiny and assurance of quality of primary care services. SUMMARY: We conclude that there has been an evolutionary approach to divisions' development and they now appear embedded as geographically-based planning and development organisations within the Australian primary health care system. The Australian Government has to date been cautious in its approach to intervention in divisions' direction and performance. However, options for the next phase include: making greater use of contracts between government and divisions; introducing and extending proposed national quality targets for divisions, linked with financial or other incentives for performance; government sub-contracting with state-based organisations to act as purchasers of care; pursuing a fund-holding approach within divisions; and developing divisions as a form of health maintenance organisation. The challenge for the Australian Government, should it wish to see divisions' role expand, is to find mechanisms to enable this without compromising the relatively strong GP engagement that increasingly distinguishes divisions of general practice within the international experience of primary care organisations.

Emergent themes in the sustainability of primary health care innovation.

A synthesis of the findings of the five studies of sustainability of primary health care innovation across six domains (political, institutional, financial, economic, client and workforce) yielded three main themes. These were: the importance of social relationships, networks and champions; the effect of political, financial and societal forces; and the motivation and capacity of agents within the system. The need for routine assessment of the sustainability of primary health care innovations is discussed. Given the dearth of literature on the sustainability of primary health care innovation, there is potential to develop a program of research directed towards a future synthesis of evidence.

Reflections on expert consensus: a case study of the social trends contributing to obesity.

BACKGROUND: In Australia, as elsewhere in the developed world, researchers and policy makers have expressed concern about rising rates of obesity. Explanations for the increasing weight of the Australian population have focused on both declining levels of physical activity and changes in food consumption patterns. METHODS: The primary aim of our study was to determine the views of obesity, dietary and physical activity experts, about the most important social trends that have contributed to Australia's obesogenic environment over the last 50 years. We used a modified Delphi technique to successfully contact 50 such experts to obtain their views on this topic. The process involved a semi-structured interview with each expert to identify the trends and then a round of ranking of the trends by these experts. A second aim was to comment on the utility of expert opinion in public policy. RESULTS: The experts identified the most important social trends as 'escalating car reliance', 'increasing "busy-ness" and lack of time' and 'rising use of convenience and pre-prepared food'. Because we asked experts to explain their responses, a diversity of opinion emerged on both the aetiology of these trends and how the environment is embodied to produce rising levels of obesity. CONCLUSION: We reflect on the implications of this dissensus for the utility of expert opinion in public policy and argue that one way through the smorgasboard of competing expert explanations for health differentials, including obesity levels, is practice-based evidence gathered through community level action research.

Aged care services for indigenous people in the Australian Capital Territory and surrounds: analysing needs and implementing change.

OBJECTIVE: To ascertain and meet current and anticipated needs for residential care and other services by older Indigenous people in the Australian Capital Territory (ACT) and region. METHODS: With advice from a reference group, qualitative and quantitative data were gathered from 98 older (45 years and over) Indigenous people in the ACT and region during 1999/2000. Indigenous and non-Indigenous researchers worked closely throughout all phases of the research. We helped participants with immediate problems identified during the interviews and worked directly with the Government funding body to implement the findings. RESULTS: No one expressed a current need for residential services. In terms of future needs, 50% of respondents favoured an arrangement where an existing mainstream provider of aged care accommodated a cluster of Indigenous people in the same facility as non-Indigenous people. Thirty-two per cent preferred an Indigenous-run organisation. Our study also revealed a broad range of health problems and needs. Assessment using the Resident Classification Scale showed that 70% required a low level of care and 4% needed a high level of care. CONCLUSION: The research identified the needs and provided a health profile of older Indigenous people in the ACT and region. This then provided policymakers with evidence on which they acted to provide appropriate aged care services. IMPLICATIONS: Collaboration between Indigenous and non-Indigenous researchers can access high-quality information, and partnership between researchers and policymakers can improve Indigenous services.

Development and initial validation of a measure of coordination of health care.

OBJECTIVE: To describe the development and initial validation of the self-administered Client Perceptions of Coordination Questionnaire. DESIGN: The instrument was developed between 1996 and 1997 through iterative item generation; within a framework of six domains of coordination, addressed across four sectors of health care provision. SETTING: 1193 individuals with complex and chronic health care needs as judged by their general practitioners (GPs), who were participants in a 2-year randomized controlled trial of a coordinated care intervention in Australia. Other samples were collected in one general practice (98) and from attendees of a chronic pain management course (29). MAIN MEASURES: Face and content validity, completion rates, transferability, internal consistency, and construct validity of the 32-item instrument. RESULTS: Most items achieved excellent completion and comprehension rates. The instrument was transferable to another chronically unwell population. Cronbach's alpha of the entire instrument was 0.92, and for six individual scales scores ranged from 0.31 to 0.86. The six scales based on principal components analysis were acceptability, received care, GP, nominated provider, client comprehension, and client capacity. The first four scales were satisfactory, but the client scales were inadequate with poor internal consistency, and convergent and discriminant validity. People with chronic pain syndromes had significantly worse experiences for almost all items, supporting construct validity. CONCLUSION: This instrument is one of the first to attempt to measure coordination of health care. Its strengths include ease of completion, transferability, and promising psychometric properties and construct validity. Problems capturing data about the patient's contribution to coordination highlight a lack of theoretical development in this area. A valid measure of coordination should be useful in needs assessment, program evaluation, and individual provider/practice audit, and would contribute to research into the experience and measurement of patient-focused care.

Will he get back to normal? Survival and functional status after intensive care therapy.

The study aim was to address healthcare workers' and patients' questions about the likely level of recovery at 6 months of patients admitted to an Australian intensive care unit (ICU). Ninety-three consecutive, eligible adults were identified and followed prospectively. Severity of illness on admission was assessed using Acute Physiological and Chronic Health Evaluation (APACHE II), while functional status at 6 months was evaluated using the Sickness Impact Profile (SIP). Cumulative mortality was 25%. Admission severity of illness was associated with survival at 6 months (P < or = 0.001). Fifty-one (78%) of the 70 survivors were interviewed. Admission severity of illness scores correlated with functional status at 6 months (r = 0.34, P = 0.01), a finding reported in only one other study. More than half of those interviewed had returned to near pre-admission functional status. Those with poor functional status included high proportions of people with chronic illness and head injury. Overall, physical recovery was more complete than psychosocial recovery. The findings provide useful information for addressing questions relating to physical and psychosocial recovery, appetite, sleep patterns and return to work post discharge.

Impediments to change in an Australian trial of coordinated care.

OBJECTIVES: To identify impediments to change at the local level in an Australian trial of coordinated care. METHODS: Qualitative data were collected from in-depth interviews with key stakeholders, analysis of policy and other documents and the observation of trial processes. We developed an analytical framework that included four domains: agreeing trial goals and objectives; overcoming the financial barriers to producing effective care; reducing costs; and improving continuity of care. In each of these domains, we examined the strategies and processes adopted by the trial as well as the perceptions, actions and reactions of the various stakeholders to the evolving model. RESULTS: The trial had mixed success in implementing its key strategies in each of the four domains. Stakeholders did not fully endorse the trial's key goals and strategies, general practitioners were unable to become effective purchasers, increased gatekeeping was never fully realised, cost-saving strategies were not taken up and improvements in continuity of care were impeded by limited provider networks and general practitioner reluctance to collaborate with other providers. Thus the system had some key features of a coordinated care model but none of the qualities that were needed to operationalise them. CONCLUSIONS: The trial's approach to coordinating care and its use of market mechanisms to remove the financial barriers to effective care were insufficient for motivating behaviour change in the context of a system that is structured by powerful social processes and relationships.

The demise of a planned randomised controlled trial in an urban Aboriginal medical service.

To fill a gap in knowledge about the effectiveness of brief intervention for hazardous alcohol use among Indigenous Australians, we attempted to implement a randomised controlled trial in an urban Aboriginal Medical Service (AMS) as a joint AMS-university partnership. Because of low numbers of potential participants being screened, the RCT was abandoned in favour of a two-part "demonstration project". Only 16 clients were recruited for follow-up in six-months, and the trial was terminated. Clinic, patient, Aboriginal health worker, and GP factors, interacting with study design factors, all contributed to our inability to implement the trial as designed. The key points to emerge from the study are that alcohol misuse is a difficult issue to manage in an Indigenous primary health care setting; RCTs involving inevitably complex study protocols may not be acceptable or sufficiently adaptable to make them viable in busy, Indigenous primary health care settings; and "gold-standard" RCT-derived evidence for the effectiveness of many public health interventions in Indigenous primary health care settings may never be available, and decisions about appropriate interventions will often have to be based on qualitative assessment of appropriateness and evidence from other populations and other settings.