An evaluation of the quality of ear health services for Aboriginal children living in remote Australia: a cascade of care analysis.

BACKGROUND: In the Northern Territory (NT) the prevalence of otitis media (OM) in young Aboriginal children living in remote communities has persisted at around 90% over the last few decades. OM-associated hearing loss can cause developmental delay and adversely impact life course trajectories. This study examined the 5-year trends in OM prevalence and quality of ear health services in remote NT communities. METHODS: A retrospective analysis was performed on de-identified clinical data for 50 remote clinics managed by the NT Government. We report a 6-monthly cascade analysis of the proportions of children 0-16 years of age receiving local guideline recommendations for surveillance, OM treatment and follow-up at selected milestones between 2014 and 2018. RESULTS: Between 6,326 and 6,557 individual children were included in the 6-monthly analyses. On average, 57% (95%CI: 56-59%) of eligible children had received one or more ear examination in each 6-monthly period. Of those examined, 36% (95%CI: 33-40%) were diagnosed with some type of OM, of whom 90% had OM requiring either immediate treatment or scheduled follow-up according to local guidelines. Outcomes of treatment and follow-up were recorded in 24% and 23% of cases, respectively. Significant decreasing temporal trends were found in the proportion diagnosed with any OM across each age group. Overall, this proportion decreased by 40% over the five years (from 43 to 26%). CONCLUSIONS: This cascade of care analysis found that ear health surveillance and compliance with otitis media guidelines for treatment and follow-up were both low. Further research is required to identify effective strategies that improve ear health services in remote settings.

Challenges for Medicare and universal health care in Australia since 2000.

OBJECTIVES: To identify the financing and policy challenges for Medicare and universal health care in Australia, as well as opportunities for whole-of-system strengthening. STUDY DESIGN: Review of publications on Medicare, the Pharmaceutical Benefits Scheme, and the universal health care system in Australia published 1 January 2000 - 14 August 2021 that reported quantitative or qualitative research or data analyses, and of opinion articles, debates, commentaries, editorials, perspectives, and news reports on the Australian health care system published 1 January 2015 - 14 August 2021. Program-, intervention- or provider-specific articles, and publications regarding groups not fully covered by Medicare (eg, asylum seekers, prisoners) were excluded. DATA SOURCES: MEDLINE Complete, the Health Policy Reference Centre, and Global Health databases (all via EBSCO); the Analysis & Policy Observatory, the Australian Indigenous HealthInfoNet, the Australian Public Affairs Information Service, Google, Google Scholar, and the Organisation for Economic Co-operation and Development (OECD) websites. RESULTS: The problems covered by the 76 articles included in our review could be grouped under seven major themes: fragmentation of health care and lack of integrated health financing, access of Aboriginal and Torres Strait Islander people to health services and essential medications, reform proposals for the Pharmaceutical Benefits Scheme, the burden of out-of-pocket costs, inequity, public subsidies for private health insurance, and other challenges for the Australian universal health care system. CONCLUSIONS: A number of challenges threaten the sustainability and equity of the universal health care system in Australia. As the piecemeal reforms of the past twenty years have been inadequate for meeting these challenges, more effective, coordinated approaches are needed to improve and secure the universality of public health care in Australia.

Identifying the key characteristics of a culturally safe mental health service for Aboriginal and Torres Strait Islander peoples: A qualitative systematic review protocol.

BACKGROUND: Mental health inequities between Indigenous and non-Indigenous populations are well documented. There is growing recognition of the role that culturally safety plays in achieving equitable outcomes. However, a clear understanding of the key characteristics of culturally safe mental health care is currently lacking. This protocol outlines a qualitative systematic review that aims to identify the key characteristics of culturally safe mental health care for Aboriginal and Torres Strait Islander peoples, at the individual, service, and systems level. This knowledge will improve the cultural safety of mental health care provided to Indigenous peoples, with a focus on Aboriginal and Torres Strait Islander peoples in Australia. METHODS AND EXPECTED OUTPUTS: Through a review of academic, grey, and cultural literature, we will identify the key characteristics of culturally safe mental health care for Aboriginal and Torres Strait Islander peoples in Australia. We will consider the characteristics of culturally safe care at the individual practitioner, service, and systems levels. PROSPERO REGISTRATION NUMBER: CRD42021258724.

De-problematising Aboriginal young peoples' health and well-being through their voice: An Indigenous scoping review.

BACKGROUND: The continued use of a deficit discourse when researching Aboriginal and Torres Strait Islander Peoples of Australia is problematic. Understanding and challenging the researchers position and the power of the words they use is important. It will ensure we do not persist in framing Aboriginal and Torres Strait Islander People as a problem to be solved. DESIGN: Indigenist review of the evidence of Aboriginal young people's health and well-being. METHODS: This review was conducted using an Indigenist approach to identify texts which amplified the voices of Aboriginal young people of Australia and presents a narrative summary of their accounts. This review is reported in line with the PRISMA-ScR reporting guidelines. RESULTS: Culture and connection are critical components of Aboriginal young people's health and well-being. Aboriginal young people describe feeling of powerlessness to influence health and well-being of their community, and they understood the risks they and their communities faced. Young people identified the importance of connection to culture, community and Elders as crucial to their social and emotional well-being. CONCLUSION: By harnessing an Indigenous analysis, we were able to reveal a strong counter narrative of strength and resilience within their historical, social, and political contexts through the storied accounts of Aboriginal young people. RELEVANCE TO CLINICAL PRACTICE: Most of the currently available evidence about Aboriginal health and well-being is immersed in deficit discourse. Literature reviews being the foundation of research and informing nursing practice, we call for a purposeful shift towards the adoption of an Indigenist strength-based approach which emphasises the strength and resilience of Aboriginal young people.

Exploring HbA1c variation between Australian diabetes centres: The impact of centre-level and patient-level factors.

BACKGROUND: Increasing global diabetes incidence has profound implications for health systems and for people living with diabetes. Guidelines have established clinical targets but there may be variation in clinical outcomes including HbA1c, based on location and practice size. Investigating this variation may help identify factors amenable to systemic improvement interventions. The aims of this study were to identify centre-specific and patient-specific factors associated with variation in HbA1c levels and to determine how these associations contribute to variation in performance across diabetes centres. METHODS: This cross-sectional study analysed data for 5,872 people with type 1 (n = 1,729) or type 2 (n = 4,143) diabetes mellitus collected through the Australian National Diabetes Audit (ANDA). A linear mixed-effects model examined centre-level and patient-level factors associated with variation in HbA1c levels. RESULTS: Mean age was: 43±17 years (type 1), 64±13 (type 2); median disease duration: 18 years (10,29) (type 1), 12 years (6,20) (type 2); female: 52% (type 1), 45% (type 2). For people with type 1 diabetes, volume of patients was associated with increases in HbA1c (p = 0.019). For people with type 2 diabetes, type of centre was associated with reduction in HbA1c (p <0.001), but location and patient volume were not. Associated patient-level factors associated with increases in HbA1c included past hyperglycaemic emergencies (type 1 and type 2, p<0.001) and Aboriginal and Torres Strait Islander status (type 2, p<0.001). Being a non-smoker was associated with reductions in HbA1c (type 1 and type 2, p<0.001). CONCLUSIONS: Centre-level and patient-level factors were associated with variation in HbA1c, but patient-level factors had greater impact. Interventions targeting patient-level factors conducted at a centre level including sick-day management, smoking cessation programs and culturally appropriate diabetes education for and Aboriginal and Torres Strait Islander peoples may be more important for improving glycaemic control than targeting factors related to the Centre itself.

How is Etuaptmumk/Two-Eyed Seeing characterized in Indigenous health research? A scoping review.

Our scoping review sought to consider how Etuaptmumk or Two-Eyed Seeing is described in Indigenous health research and to compare descriptions of Two-Eyed Seeing between original authors (Elders Albert and Murdena Marshall, and Dr. Cheryl Bartlett) and new authors. Using the JBI scoping review methodology and qualitative thematic coding, we identified seven categories describing the meaning of Two-Eyed Seeing from 80 articles: guide for life, responsibility for the greater good and future generations, co-learning journey, multiple or diverse perspectives, spirit, decolonization and self-determination, and humans being part of ecosystems. We discuss inconsistencies between the original and new authors, important observations across the thematic categories, and our reflections from the review process. We intend to contribute to a wider dialogue about how Two-Eyed Seeing is understood in Indigenous health research and to encourage thoughtful and rich descriptions of the guiding principle.

The Simpson-led health sector review: a failure to uphold te Tiriti o Waitangi.

The Health and Disability System Review (the 'Simpson Review') was an opportunity for health sector transformation, particularly in light of the recent damning WAI 2575 Waitangi Tribunal report released during the review process. There appears to have been a concerted effort to engage with the sector, an impressive Maori Expert Advisory Group and an extensive body of available scholarship documenting where improvements could be made. In this viewpoint, the authors, tangata whenua (Indigenous people of the land) and tangata Tiriti (people of te Tiriti) and health scholars and leaders undertook a high-level review of the Simpson Review report and analysed it against key elements of te Tiriti o Waitangi. The Simpson Review was an opportunity to share power, commit to Maori health and embed structural mechanisms, such as the proposed Maori health authority, to uphold te Tiriti o Waitangi. It was also an opportunity to recommit to health equity and eliminate institutional racism. We conclude that the Simpson Review did not take up these opportunities, but instead perpetuated further breaches of te Tiriti.

Ha Ora: secondary care barriers and enablers to early diagnosis of lung cancer for Maori communities.

BACKGROUND: Lung Cancer is the leading cause of cancer deaths in Aotearoa New Zealand. Maori communities in particular have higher incidence and mortality rates from Lung Cancer. Diagnosis of lung cancer at an early stage can allow for curative treatment. This project aimed to document the barriers to early diagnosis and treatment of lung cancer in secondary care for Maori communities. METHODS: This project used a kaupapa Maori approach. Nine community hui (focus groups) and nine primary healthcare provider hui were carried out in five rural localities in the Midland region. Community hui included cancer patients, whanau (families), and other community members. Healthcare provider hui comprised staff members at the local primary healthcare centre, including General Practitioners and nurses. Hui data were thematically analysed. RESULTS: Barriers and enablers to early diagnosis of lung cancer were categorised into two broad themes: Specialist services and treatment, and whanau journey. The barriers and enablers that participants experienced in specialist services and treatment related to access to care, engagement with specialists, communication with specialist services and cultural values and respect, whereas barriers and enablers relating to the whanau journey focused on agency and the impact on whanau. CONCLUSIONS: The study highlighted the need to improve communication within and across healthcare services, the importance of understanding the cultural needs of patients and whanau and a health system strategy that meets these needs. Findings also demonstrated the resilience of Maori and the active efforts of whanau as carers to foster health literacy in future generations.

Mobile Diabetes Telemedicine Clinics for Aboriginal First Nation People With Reported Diabetes in British Columbia.

OBJECTIVES: Our aim in this study was to assess the impact of the Mobile Diabetes Telemedicine Clinic, which serves First Nations communities in British Columbia, on clients' with diabetes condition and management. METHODS: A travelling team visits approximately 120 sites annually. Assessment of persons with diabetes includes interview, physical exam, point-of-care laboratory (glycated hemoglobin, blood glucose, lipid profile, kidney profile) and retinal fundus photographs. Nurses provide education and lifestyle, medication and wellness recommendations. The endocrinologist reviews records and provides further recommendations to primary care providers. To assess the impact at second and later visits, compared with the immediately preceding visit, we measured mean changes in body weight, glycated hemoglobin, urinary albumin:creatinine ratio and estimated glomerular filtration rate, as well as changes in proportions of clients meeting targets for blood pressure, low-density lipoprotein cholesterol, medications, smoking and physical activity. RESULTS: From 2012 to 2018, a total of 3,045 visits were completed by 1,056 clients with diabetes who attended on at least 2 occasions. Mean time since the preceding visit was 1.6 years. Mean change (after vs before) in glycated hemoglobin was 0.06 (95% confidence limit, -0.03 to 0.14), body weight 0.0 kg (-0.2 to 0.2), albumin:creatinine ratio 1.31 mg/mmol (0.27 to 2.35) and estimated glomerular filtration rate -4.8 mL/min (-6.2 to -3.4). The proportion of clients meeting both blood pressure targets (systolic <130 mmHg and diastolic <80 mmHg) increased from 25% at first visit to 33% at the second and 32% at the third or later visits (p<0.001, chi-square test). The proportion of those with low-density lipoprotein cholesterol of <2.0 mmol/L increased from 56% to 62% at the second visit and 69% at the third or later visits (p<0.001). The proportion of those taking renin-angiotensin-aldosterone system inhibitors or other antihypertensive agents and statins increased (p<0.001), and proportions decreased for smoking (p<0.001) and exercising ≥60 min/week (p=0.002). CONCLUSIONS: Weight and diabetic control were stabilized. Most management practices showed improvement.

End-of-life care for Aboriginal and Torres Strait Islander people with cancer: an exploratory study of service utilisation and unmet supportive care needs.

BACKGROUND: Indigenous Australians diagnosed with cancer have substantially higher cancer mortality rates compared with non-Indigenous Australians, yet there is a paucity of information about their end-of-life service utilisation and supportive care needs. PURPOSE: To describe the service utilisation and supportive care needs of Aboriginal and Torres Strait Islander people with cancer at end-of-life. METHOD: Hospital admission data were linked to self-reported data from a study of Indigenous cancer patients from Queensland, Australia during the last year of their life. Needs were assessed by the Supportive Care Needs Assessment Tool for Indigenous Cancer Patients which measures 26 need items across 4 domains (physical/psychological; hospital care; information/communication; practical/cultural). A descriptive analysis of health service utilisation and unmet needs was conducted. RESULTS: In total, 58 Indigenous cancer patients were included in this analysis. All patients had at least one hospital admission within the last year of their life. Most hospital admissions occurred through emergency (38%) and outpatient (31%) departments and were for acute care (85%). Palliative care represented 14% of admissions and 78% died in hospital. Approximately half (48%) did not report any unmet needs. The most frequently reported moderate-to-high unmet need items were worry about the treatment results (17%), money worries (16%) and anxiety (16%). CONCLUSIONS: Utilisation of palliative care services that manage a full range of physical and psychosocial needs was low. Addressing worries about treatment results, finances and generalised anxiety are priorities in this population.

Could health information systems enhance the quality of Aboriginal health promotion? A retrospective audit of Aboriginal health programs in the Northern Territory of Australia.

BACKGROUND: In Australia, health services are seeking innovative ways to utilize data stored in health information systems to report on, and improve, health care quality and health system performance for Aboriginal Australians. However, there is little research about the use of health information systems in the context of Aboriginal health promotion. In 2008, the Northern Territory's publicly funded healthcare system introduced the quality improvement program planning system (QIPPS) as the centralized online system for recording information about health promotion programs. The purpose of this study was to explore the potential for utilizing data stored in QIPPS to report on quality of Aboriginal health promotion, using chronic disease prevention programs as exemplars. We identify the potential benefits and limitations of health information systems for enhancing Aboriginal health promotion. METHODS: A retrospective audit was undertaken on a sample of health promotion projects delivered between 2013 and 2016. A validated, paper-based audit tool was used to extract information stored in the QIPPS online system and report on Aboriginal health promotion quality. Simple frequency counts were calculated for dichotomous and categorical items. Text was extracted and thematically analyzed to describe community participation processes and strategies used in Aboriginal health promotion. RESULTS: 39 Aboriginal health promotion projects were included in the analysis. 34/39 projects recorded information pertaining to the health promotion planning phases, such as statements of project goals, 'needs assessment' findings, and processes for consulting Aboriginal people in the community. Evaluation findings were reported in approximately one third of projects and mostly limited to a recording of numbers of participants. For almost half of the projects analyzed, community participation strategies were not recorded. CONCLUSION: This is the first Australian study to shed light on the feasibility of utilizing data stored in a purposefully designed health promotion information system. Data availability and quality were limiting factors for reporting on Aboriginal health promotion quality. Based on our learnings of QIPPS, strategies to improve the quality and accuracy of data entry together with the use of quality improvement approaches are needed to reap the potential benefits of future health promotion information systems.

Sustained Quality and Service Delivery in an Expanding Point-of-Care Testing Network in Remote Australian Primary Health Care.

CONTEXT.­: Since 2008, the Northern Territory Point-of-Care Testing Program has improved patient access to pathology testing for acute and chronic disease management for remote health services. OBJECTIVE.­: To evaluate the analytical quality, service delivery, and clinical utility of an expanding remote point-of-care testing network. DESIGN.­: Four years (2016-2019) of data on analytical quality, test numbers, and training statistics and 6 months of clinical point-of-care testing data from Abbott i-STATs at remote health services throughout the Northern Territory were analyzed to assess analytical performance, program growth, and clinical utility. RESULTS.­: From 2016 to 2019, point-of-care test numbers increased, with chemistry and blood gas testing more than doubling to 8500 and 6000 tests, respectively, troponin I testing almost doubling (to 6000), and international normalized ratio testing plateauing at 8000 tests. Participation in quality control and proficiency testing was high, with quality comparable to laboratory-based analytical goals. A shift toward flexible training and communication modes was noted. An audit of point-of-care test results demonstrated elevated creatinine, associated with chronic kidney disease management, as the most common clinically actionable patient result. CONCLUSIONS.­: The Northern Territory Point-of-Care Testing Program provides high quality point-of-care testing within remote primary health services for acute and chronic patient management and care. Clinical need, sound analytical performance, flexibility in training provision, and effective support services have facilitated the sustainability of this expanding point-of-care testing model in the remote Northern Territory during the past 11 years.

Primary Health Care attributes in the context of indigenous health.

OBJECTIVES: to assess the attributes of Primary Health Care from the perspective of health professionals, comparing services in the Special Indigenous Health District and the Municipal Health Offices. METHODS: a cross-sectional study in the Upper Rio Negro region, State of Amazonas, with 116 professionals. The data were collected through the Primary Care Assessment Tool. Scores were categorized (≥ 6.6) - strong orientation and (<6.6) - low orientation. The chi-square and maximum likelihood test for crossover analysis. The comparison between professionals the Kruskal-Wallis Test. RESULTS: a higher overall score was observed in the Indigenous Health District (7.2). The same trend was observed individually in the essential and derived attributes. CONCLUSIONS: this work may support strategies that positively impact the management model and work processes from the perspective of strengthening the primary care offered to the population from Rio Negro.

Using developmental evaluation to enhance continuous reflection, learning and adaptation of an innovation platform in Australian Indigenous primary healthcare.

Effective efforts to strengthen health systems need diverse, multi-stakeholder networks working together on complex or 'wicked' problems such as prevention and control of chronic diseases, solutions to which go beyond the role and capability of one organisation. The contextual complexities inherent in 'wicked' problems mean that solutions warrant a systems approach that encompasses innovation and new ways of thinking about, facilitating and implementing collective decision-making processes and change practices.Innovation platforms are a mechanism for facilitating communication and collaboration among diverse stakeholders, promoting joint action and stimulating innovation. Developmental evaluation is an approach that is increasingly being used to evaluate innovative and emergent programmes and projects, as it enables evaluators to provide real-time feedback so that evaluation findings can be used to guide development and adaptations. Developmental evaluation emphasises learning and adaptation, and aligns well with the implementation of innovation platforms that have continuous reflection, learning and adaptation as a specific design principle.Here, we outline our rationale for applying a developmental evaluation to enhance the formation, functioning and outcomes of an innovation platform aimed at accelerating and strengthening large-scale quality improvement efforts in Australian Aboriginal and Torres Strait Islander primary healthcare. We provide examples to explain how the developmental evaluation findings were used for adaptation of the innovation platform and assess to what extent our application of developmental evaluation was consistent with, and reflective of, its essential principles.Our evaluation aligned strongly with the principles of developmental evaluation, and the approach we took was well suited to situations with a developmental purpose, innovation niche and complexity such as innovation platforms. As a result, along with the increasing interest in multi-stakeholder platforms (e.g. innovation platforms) and the inherent challenges with evaluating these complex networks, we anticipate our use of this approach being of interest globally.

Closing the indigenous health gap in Canada: Results from the TransFORmation of IndiGEnous PrimAry HEAlthcare delivery (FORGE AHEAD) program.

AIMS: TransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD) partnered with local clinical and community teams in 11 First Nations (FN) communities across Canada to develop quality improvement (QI) initiatives aimed at improving T2DM. METHODS: Pre-post mixed-methods case study design was used. The 18-month intervention included community and clinical readiness, development of a community diabetes registry and clinical system, and QI activities. Participants consisted of community members, 18 yrs and older, with diabetes. Changes in clinical outcomes and clinical practice guideline (CPG) recommendations were assessed pre and post intervention using multilevel regression (patients nested within communities) adjusted forindividual andcommunity baseline characteristics. RESULTS: No significant change in HbA1c orsBP, but a small reduction indBP(-0.75 mmHg, p < 0.05) and LDL (-0.09 mmol/L, p < 0.05) was observed in 2008 adults with T2DM (mean age: 60·5 (SD:14·6) years; female: 57·2%). Individuals not at CPG targets at baseline had significant reductions in: %HbA1c (N = 616): -0.40 (95%CI:-0·55,-0·24),sBP (N = 561): -7·67 mmHg (95%CI:-9·23, -5·72),dBP (N = 291): -7·46 mmHg (95%CI:-8·69, -6·26), LDL (N = 450): -0·37mmo/l (95%CI:-0·44, -0·29).Annual HbA1c (OR: 1·95; 95%CI:1·66, 2·29), BP (OR: 1·78; 95%CI:1·52, 2·09), LDL (OR: 1·27; 95%CI:1·10, 1·47) and CKD screening (OR: 6·37; 95%CI:5·16, 7·92)increased but retinopathy screening decreased (OR: 0·68; 95%CI:0·57, 0·82). No significant change in foot exams (OR: 0·97; 95%CI:0·76, 1·23) or BMI recordings (OR: 0·96; 95%CI:0·82, 1·12) was seen. Overall, individualsweremorelikely to receive ≥75% of CPG recommended services compared to baseline (OR: 1·51; 95%CI:1·27, 1·80). CONCLUSIONS: FORGE AHEAD is the first Canadian study to demonstrate that a FN community-led QI intervention can lead to diabetes improvements.