Findings from a clinical audit in regional general practice of management of patients following acute coronary syndrome.

Patients with acute coronary syndrome (ACS) require ongoing treatment and support from their primary care provider to modify cardiovascular risk factors (including diet, exercise and mood), to receive evidence-based pharmacotherapies and be properly monitored and to ensure their take-up and completion of cardiac rehabilitation (CR). This study assesses adherence to National Heart Foundation guidelines for ACS in primary care in a regional centre in Western Australia. Patients discharged from hospital after a coronary event (unstable angina or myocardial infarction) or a coronary procedure (stent or coronary artery bypass graft) were identified through general practice electronic medical records. Patient data was extracted using a data form based on National Heart Foundation guidelines. Summary statistics were calculated and reported. Our study included 22 GPs and 44 patients in a regional centre. In total, 90% (n=39) of discharge summaries recorded medications. Assessment of pharmacological management showed that 53% (n=23) of patients received four or more classes of pharmacotherapy and that GPs often augmented medication beyond that prescribed at discharge. Of 15 smokers, 13 (87%) had advice to quit documented. Minimal advice for other risk-factor modification was documented in care plans. Patients with type 2 diabetes (n=20) were 70% more likely to receive allied health referral (P=0.02) and 60% more likely to receive advice regarding diet and exercise (P=0.007). However, overall, only 30% (n=13) of those eligible were referred to a dietician, and only 25% were referred to CR (n=10) with six completing CR. Although most GPs did not use standardised tools for mood assessment, 18 (41%) patients were diagnosed as depressed, of which 88% (n=16) were started on antidepressants and 28% (n=6) were referred to a psychologist. Although pharmacotherapy, mood management and smoking cessation management generally followed recommended guidelines, risk factor management relating to diet and exercise by GPs require improvement. Detailed care plans and referral to CR and allied health staff for patient support is recommended.

Hepatitis C polymerase chain reaction testing by GPs.

BACKGROUND: Approximately 75% of patients exposed to the hepatitis C virus will become chronically infected. Polymerase chain reaction (PCR) testing more than 6 months after exposure is necessary to identify this group. This pilot study assessed the practical ap-plication of PCR testing in the general practice context. METHODS: General practitioners of patients newly notified as positive for hepatitis C antibody between 1 August 2007 and 1 August 2012 were invited to participate. They completed a self-administered survey, recording details on the use of hepatitis C PCR testing in their patients. RESULTS: The survey found that 16 patients (46%) did not undergo any PCR testing for hepatitis C. Of those who underwent PCR testing, 11 (58%) were positive on PCR testing but only six (55%) of those with a positive PCR test were retested 6 months later. DISCUSSION: Appropriate use of PCR is necessary to identify patients with chronic hepatitis C and offer appropriate referral and treatment.

It's not just about the HbA1c, Doc! Understanding the psychosocial is also important in managing diabetes?

OBJECTIVE: Despite significant efforts at a primary care level, at least 35% of people with diabetes fail to meet health targets. It is assumed that these poor results are a consequence of the patient not understanding their disease or not caring. This study seeks to understand what really lies behind poor control. DESIGN SETTING AND PARTICIPANTS: A qualitative study using semistructured interviews was conducted in a primary care setting in rural Western Australia. People living with diabetes for at least two years were specifically selected on the basis of whether they had either 'good' (HbA1c < 7%) or 'poor' (HbA1c > 8%) control. RESULTS: Interviews revealed that people understood only too well their disease and their responsibilities. Frequently, either they did not choose to make diabetes a priority in their lives or were unable to make appropriate lifestyle changes which were demanded for good blood sugar control. Their life/social stresses often influenced their glucose control. CONCLUSION: Poor control in our study was not related to lack of knowledge but more to how diabetes was prioritised in their lives. Attention to the patients' priorities is required to accomplish improved glycaemic control.

Boundary crossers, communities, and health: exploring the role of rural health professionals.

Boundary crossers understand the culture and language of community and health service domains and have the trust of both. Rural health professionals living within the communities they serve are ideally placed to harness community capacity so as to influence community-level determinants of health. We analyse five case studies of rural health professionals acting as boundary crossers against indicators of capacity for communities and external agents such as health services working in partnership. A more explicit evidence base for inclusion of community health development in the jobs of rural health professionals is needed.

Improving GP diabetes management - A PDSA audit cycle in Western Australia.

BACKGROUND: Tight glucose, blood pressure and lipid control in patients with diabetes can reduce morbidity and mortality from macro- and micro-vascular complications. However, treatment targets are not being met in a large proportion of patients. Clinical audit involves cycles of evaluation of current activity against standards. It allows problems to be identified and action to be taken to address them. METHODS: Annual retrospective audits over 3 years of random samples of up to 20 patient medical records from 13 general practitioners in the midwest region of Western Australia (n=807). Statistical tests compared the second and third audits with the first in regard to completeness of screening, health indicators, and the proportion of patients within The Royal Australian College of General Practitioners and Diabetes Australia guidelines targets. RESULTS: While there was a significant improvement in lipid monitoring over the study period (p<0.001), monitoring of HbA1c and blood pressure (BP) remained unchanged. Between the first and third audits, a reduction in mean HbA1c (p<0.001), mean total cholesterol (p=0.017), mean LDL cholesterol (p=0.014) and mean systolic BP (p=0.002) was seen. There was an improvement in the proportion of patients achieving cholesterol goals (measured by LDL and reaching a target of HbA1c <7%) between the first and third audits; however the proportion with BP within target declined. In the third audit, 11% of patients on diet alone, 36% on an oral hypoglycaemic agent, 90% on three oral hypoglycaemic agents and 84% of those on insulin were outside the target HbA1c. In the same audit, of those outside target BP, 53% were on no treatment and 65% were only on one type of medication. Eighty-seven percent of patients outside target cholesterol levels had not been prescribed a statin. DISCUSSION: Many of the audited GPs in our study undertreated BP, HbA1c and cholesterol. Improvement in some areas was seen over the study period, which may have been due to the quality assurance activities undertaken. These results reveal a therapeutic opportunity for reducing cardiovascular events in patients with diabetes. More aggressive management of BP and lipids by GPs may see rewards in terms of reducing cardiovascular events in patients with diabetes.

Aboriginal mothers in prison in Australia: a study of social, emotional and physical wellbeing.

OBJECTIVE: To describe the social, emotional and physical wellbeing of Aboriginal mothers in prison. METHODS: Cross-sectional survey, including a Short Form Health Survey (SF-12) and Kessler Psychological Distress Scale (5-item version) administered to Aboriginal women who self-identified as mothers. RESULTS: Seventy-seven Aboriginal mothers in New South Wales (NSW) and 84 in Western Australia (WA) participated in the study. Eighty-three per cent (n=59) of mothers in NSW were in prison for drug-related offences, 64.8% (n=46) of mothers in WA were in prison for offences committed under the influence of alcohol. Sixty-eight per cent (n=52) of mothers in NSW and 35% (n=28) of mothers in WA reported mental health problems. Physical (PCS) and Mental (MCS) component scores of SF-12 varied for mothers in NSW and WA. Mothers in NSW experienced poorer health and functioning than mothers in WA (NSW: PCS 49.5, MCS 40.6; WA: PCS 54.4, MCS 48.3) and high levels of psychological distress (NSW: 13.1; WA 10.1). CONCLUSIONS: Aboriginal mothers in prison have significant health needs associated with physical and mental health, and psychological distress. Implications for public health: Adoption of social and emotional wellbeing as an explanatory framework for culturally secure healthcare in prison is essential to improving health outcomes of Aboriginal mothers in prison in Australia.

A protracted mumps outbreak in Western Australia despite high vaccine coverage: a population-based surveillance study.

BACKGROUND: In 2007-08, a genotype J mumps outbreak occurred among Aboriginal people in northern Western Australia, despite high vaccine coverage. In March, 2015, a second protracted mumps outbreak occurred in northern Western Australia and spread widely across rural areas of the state. This time the outbreak was caused by a genotype G virus and again primarily affected Aboriginal people. We aimed to describe the epidemiology of this outbreak. METHODS: In this population-based surveillance study, we analysed statutory notifications and public health case follow-up data from the Western Australia Notifiable Infectious Diseases Database and vaccination information from the Australian Childhood Immunisation Register. An outbreak case of mumps was notified if the affected person was living in or visiting a community in Western Australia where there was active mumps transmission, and if mumps infection was confirmed by laboratory diagnosis or by an epidemiological link. We analysed case demographics, vaccination status, and age-standardised attack rates in Aboriginal and non-Aboriginal people by region of notification. Laboratory diagnoses were made by real-time RT-PCR, serology, or both, and carried out by the sole public pathology provider in Western Australia. FINDINGS: Between March 1, 2015, and December 31, 2016, 893 outbreak cases were notified. 798 (89%) of 893 outbreak cases were reported in Aboriginal people. 40 (4%) of 893 people were admitted to hospital, and 33 (7%) of 462 men reported orchitis. Mumps attack rates increased sharply with age, peaking in the 15-19 age group. 371 (89%) of 419 people aged 1-19 years were fully vaccinated and 29 (7%) were partly vaccinated. Of the 240 people who tested positive by real-time RT-PCR and had also been tested for mumps-specific IgG and IgM, 165 (69%) were positive for IgG but negative for IgM, indicating the importance of RT-PCR testing for diagnosis in vaccinated populations. None of the cases from the 2007-08 genotype J outbreak were re-notified. INTERPRETATION: The number of mumps outbreaks reported in recent years among highly vaccinated populations, including Indigenous populations, has been growing. More widespread and pre-emptive use of the third dose of measles, mumps, and rubella vaccine might be required to control and prevent future outbreaks in high-risk populations. Research should explore the benefit of increasing the intervals between vaccine doses to strengthen the durability of vaccine protection. FUNDING: None.

Prison health and public health responses at a regional prison in Western Australia.

OBJECTIVE: To describe the health of inmates in a Western Australian regional prison and evaluate the coverage of public health interventions. DESIGN: Cross-sectional audit of all paper-based and electronic medical notes of inmates at one regional prison in Western Australia. SETTING: A mixed medium-security prison in regional Western Australia. PARTICIPANTS: 185 prisoners, 170 men and 15 women. MAIN RESULTS: The prisoners were mainly young (70% < 35 years of age) and Indigenous (84%). Fifty two percent of prisoners had at least one chronic health condition. There was a significantly higher prevalence of diabetes to that found in the general Indigenous population (15% vs 6% p=0.001), and a significantly lower prevalence hepatitis C (4.5%) compared with both national (29-61%) and State (20%) data. Screening for sexually transmitted infections and blood borne viruses within the first month of incarceration was achieved for 43% of inmates. Vaccination coverage for influenza (36%) and pneumococcal disease (12%) was low. CONCLUSION: This study makes visible the burden of disease and reach of public health interventions within a largely Indigenous regional prisoner population. Our study demonstrates that the additional risks associated with being Indigenous remain in a regional Australian prison but also shows that interventions can be delivered equitably to Indigenous and non-Indigenous inmates. IMPLICATIONS: Ongoing monitoring of prisoner health is critical to take advantage of opportunities to improve public health interventions with timely STI and BBV screening and increased vaccinations rates.

Overseas-trained doctors in Indigenous rural health services: negotiating professional relationships across cultural domains.

OBJECTIVE: To examine how OTDs and staff in rural and remote Indigenous health contexts communicate and negotiate identity and relationships, and consider how this may influence OTDs' transition, integration and retention. METHOD: Ten case studies were conducted in rural and remote settings across Australia, each of an OTD providing primary care in a substantially Indigenous practice population, his/her partner, co-workers and Indigenous board members associated with the health service. Cases were purposefully sampled to ensure diversity in gender, location and country of origin. RESULTS: Identity as 'fluid' emerged as a key theme in effective communication and building good relationships between OTDs and Indigenous staff. OTDs enter a social space where their own cultural and professional beliefs and practices intersect with the expectations of culturally safe practice shaped by the Australian Indigenous context. These are negotiated through differences in language, role expectation, practice, status and identification with locus with uncertain outcomes. Limited professional and cultural support often impeded this process. CONCLUSION: The reconstruction of OTDs' identities and mediating beyond predictable barriers to cultural engagement contributes significantly not only to OTDs' integration and, to a lesser extent, their retention, but also to maximising effective communication across cultural domains. IMPLICATIONS: Retention of OTDs working in Indigenous health contexts rests on a combination of OTDs' capacity to adapt culturally and professionally to this complex environment, and of effective strategies to support them.

"If it wasn't for OTDs, there would be no AMS": overseas-trained doctors working in rural and remote Aboriginal health settings.

Australian-trained doctors are often reluctant to work in rural and remote areas and overseas-trained doctors (OTDs) are recruited to practise in many rural Aboriginal medical services. This paper focuses on recent research carried out in Australia to analyse factors affecting OTDs' professional, cultural and social integration and examine their training and support needs. Ten case studies were conducted throughout Australia with OTDs, which also included interviews with spouses/partners, professional colleagues, co-workers, and Aboriginal and Torres Strait Islander community members associated with the health service. Key themes emerging from the data across all informants included the need to better address recruitment, orientation and cross-cultural issues; the importance of effective communication and building community and institutional relationships, both with the local health service and the broader medical establishment.

Australian Aboriginal women prisoners' experiences of being a mother: a review.

PURPOSE: The rise in the incarceration of Aboriginal and Torres Strait Islander mothers is a major public health issue with multiple sequelae for Aboriginal children and the cohesiveness of Aboriginal communities. The purpose of this paper is to review the available literature relating to Australian Aboriginal women prisoners' experiences of being a mother. DESIGN/METHODOLOGY/APPROACH: The literature search covered bibliographic databases from criminology, sociology and anthropology, and Australian history. The authors review the literature on: traditional and contemporary Aboriginal mothering roles, values and practices; historical accounts of the impacts of white settlement of Australia and subsequent Aboriginal affairs policies and practices; and women's and mothers' experiences of imprisonment. FINDINGS: The review found that the cultural experiences of mothering are unique to Aboriginal mothers and contrasted to non-Aboriginal concepts. The ways that incarceration of Aboriginal mothers disrupts child rearing practices within the cultural kinship system are identified. PRACTICAL IMPLICATIONS: Aboriginal women have unique circumstances relevant to the concept of motherhood that need to be understood to develop culturally relevant policy and programs. The burden of disease and cycle of incarceration within Aboriginal families can be addressed by improving health outcomes for incarcerated Aboriginal mothers and female carers. ORIGINALITY/VALUE: To the authors' knowledge, this is the first literature review on Australian Aboriginal women prisoners' experiences of being a mother.

Initiating a PDSA cycle--improving management of diabetes in rural WA.

Diabetes affects 1 million Australians and is the seventh leading cause of death in Australia. General practitioners play an important role in the management of diabetes, especially in rural areas where there is limited access to specialist providers and services.

Improving the management of acute coronary syndrome for Aboriginal and non-Aboriginal patients in a regional hospital.

OBJECTIVES: To determine inequities in clinical adherence to national diagnostic and management guidelines for acute coronary syndrome (ACS) for Aboriginal and non-Aboriginal ACS patients at a regional hospital. METHODS: Covering two study periods (2011-12; 2013-14), records of Aboriginal (n=276) and a random selection of non-Aboriginal patients (n=333) presenting to the Emergency Department with chest pain were retrospectively reviewed using an audit protocol. Groups were compared using logistic regression, controlling for age, sex and comorbidity. RESULTS: Pathway utilisation improved overall, but risk stratification improved only for non-Aboriginal patients (OR=3.34, 95%CI 1.88-5.94). Performance of two troponin measurements increased to 88% for both Aboriginal and non-Aboriginal presentations. Although initially higher for non-Aboriginal presentations, the likelihood of admission was found to be similar in the repeat audit (75.6% vs 78.6%; p=0.60), reflecting a rise in Aboriginal presentations being admitted (OR=2.30, 95%CI 1.27-4.15). There was no significant difference in proportions transferred, receiving angiograms or for ST Elevation Acute Coronary Syndrome (a severe form of Acute Coronary Syndrome) being thrombolysed. Discharge against medical advice remained higher among Aboriginal presentations (OR=4.22, 95%CI 0.88-20.29). CONCLUSIONS AND IMPLICATIONS: Although there was a general improvement in adherence to the chest pain pathway and a reduction in inequity in the treatment of Aboriginal people, there is continuing need for improvement in adherence to guidelines to optimise the management of ACS in this regional setting.

Text 2 treat - using SMS to recall clients for treatment.

Prompt treatment of patients with genital Chlamydia shortens the period of infectivity with benefits to the individual and wider community. With large numbers of genital Chlamydia notifications, predominantly occurring in younger age groups, short message service (SMS) is a potentially useful technology for recalling this patient group quickly and efficiently. In the sexual health unit of Population Health-Midwest, Western Australia, genital Chlamydia cases were recalled for treatment with an SMS. Ninety-four per cent (n = 60) of clients responded to the SMS, with 84% (n = 54) responding on the same day they were contacted. All clients (n = 64) were treated for their infection, with 72% (n = 46) having directly-observed treatment within one day of being informed of their results via SMS. Our results suggest that SMS is a highly effective, youth-friendly communication tool.

"Slowed right down": Insights into the use of alcohol from research with Aboriginal Australians living with HIV.

OBJECTIVE: To describe the role that alcohol plays in the lives of Aboriginal people living with HIV in Western Australia. METHODS: Semi-structured interviews were conducted between February and September 2003 with 20 Aboriginal people who were HIV-positive; almost half the total number of Aboriginal people known to be living with HIV in Western Australia at that time. The main purpose of the study was to document their experiences of living with HIV and aspects of health service delivery. RESULTS: Drinking emerged as a key theme in the majority of interviews. Alcohol had a major role in disinhibition and risk-taking behaviour of both the participants and those they socialized with. It was perceived as a commodity, a way of altering reality, and a pathway through which social connection was maintained and was central to the common narratives of loss, chaos and transformation. Post-diagnosis, alcohol helped with disclosure and temporary blunting of distress as a result of the HIV diagnosis. It also contributed to a lack of capacity to comply with anti-retroviral therapy although narratives also included personal growth and restoration of physical health. CONCLUSIONS: Effective strategies to reduce risk of STIs and HIV and prevent other health problems need to address substance use issues but this also requires amelioration of the structural inequalities that make minority groups vulnerable.

Perinatal HIV transmission and pregnancy outcomes in indigenous women in Western Australia.

BACKGROUND: Implementation of obstetric and neonatal interventions has reduced mother to child transmission of HIV. Health outcomes for Aboriginal people are often worse than for non-Aboriginal people; was this the case for HIV infection in pregnancy? AIMS: To compare the management and outcomes of pregnancy in Aboriginal and non-Aboriginal HIV-positive women in Western Australia (WA). METHODS: A retrospective study of all pregnancies delivered in WA to HIV-infected women from 1991 until 2005. Managed pregnancies were compared in Aboriginal and non-Aboriginal women. Outcome measures were HIV status of the babies, birthweight, rates of caesarean delivery and perinatal mortality. RESULTS: Fifty-six pregnancies occurred in 41 HIV-infected women resulting in 54 live births. Of the 41 women, 16 (39%) were Aboriginal. In regard to birthweight, perinatal mortality, rates of caesarean section and rates of HIV perinatal transmission, there was no significant difference between babies born to Aboriginal and those born to non-Aboriginal mothers. In contrast, of the eight pregnancies, with no contact with the multidisciplinary team, five babies (63%) were infected with HIV (2% vs 63%P = 0.001). There was no case of perinatal HIV infection in 22 pregnancies of the Aboriginal women that received care through the multidisciplinary team; perinatally acquired HIV occurred in the first pregnancy of one of these women before she was aware of her status when she was not managed by the team. CONCLUSIONS: Similar outcomes can be achieved in both HIV-positive Aboriginal and non-Aboriginal women, through intensive, culturally appropriate, multidisciplinary care and without elective caesarean delivery.

Gascoyne Growers Market: a sustainable health promotion activity developed in partnership with the community.

OBJECTIVE: To explore the social, health and economic impact of a farmers' market on a small rural community in the north of Western Australia. DESIGN: Qualitative and quantitative research using a random structured intercept survey, and focus group interviews around four domains of social capital: economic impact, governance and capacity building, healthy public places and social and civic participation. SETTING: The Gascoyne Growers Markets in Carnarvon. SUBJECTS: One hundred consumers and 28 market stallholders. RESULTS: Consumers demonstrated community pride and an increase in fruit and vegetable consumption since they commenced shopping at the markets. The stallholders appear to have gained economically, professionally and socially from the market experience. CONCLUSIONS: The Gascoyne Growers Markets demonstrate a sustainable health promotion activity developed in partnership with the community. It has contributed to the local economy, providing local quality fruit and vegetables directly to the community while also increasing social capital and creating a healthy public space.