Mccalman, JR orcid:0000-0002-3022-3980 ; Continuous quality improvement (CQI) processes for improving clinical care and health outcomes have been implemented by primary health-care services, with resultant health-care impacts. But only 10-20% of gain in health outcomes is contributed by health-care services; a much larger share is determined by social and cultural factors. This perspective paper argues that health care and health outcomes can be enhanced through applying CQI as a systems approach to comprehensive primary health care. Referring to the Aboriginal and Torres Strait Islander Australian context as an example, the authors provide a systems framework that includes strategies and conditions to facilitate evidence-based and local decision making by primary health-care services. The framework describes the integration of CQI vertically to improve linkages with governments and community members and horizontally with other sectors to influence the social and cultural determinants of health. Further, government and primary health-care service investment is required to support and extend integration and evaluation of CQI efforts vertically and horizontally. ; Associated Grant:National Health and Medical Research Council Early Career Fellowship: Developing a Service Integration Toolkit to improve the quality of adolescent mental health promotion services in Cape York: a program of mixed methods research; An Innovation Platform for Systems-Wide Improvement in Indigenous Primary Health Care ; Associated Grant Code:APP1113392; APP 1078927
Background: Aboriginal and Torres Strait Islander Australians experience a greater burden of disease compared to non-Indigenous Australians. Around one-fifth of the health disparity is caused by cardiovascular disease (CVD). Despite the importance of absolute cardiovascular risk assessment (CVRA) as a screening and early intervention tool, few studies have reported its use within the Australian Indigenous primary health care (PHC) sector. This study utilizes data from a large-scale quality improvement program to examine variation in documented CVRA as a primary prevention strategy for individuals without prior CVD across four Australian jurisdictions. We also examine the proportion with elevated risk and follow-up actions recorded. Methods: We undertook cross-sectional analysis of 2,052 client records from 97 PHC centers to assess CVRA in Indigenous adults aged ≥20 years with no recorded chronic disease diagnosis (2012–2014). Multilevel regression was used to quantify the variation in CVRA attributable to health center and client level factors. The main outcome measure was the proportion of eligible adults who had CVRA recorded. Secondary outcomes were the proportion of clients with elevated risk that had follow-up actions recorded. Results: Approximately 23% (n = 478) of eligible clients had documented CVRA. Almost all assessments (99%) were conducted in the Northern Territory. Within this jurisdiction, there was wide variation between centers in the proportion of clients with documented CVRA (median 38%; range 0–86%). Regression analysis showed health center factors accounted for 48% of the variation. Centers with integrated clinical decision support systems were more likely to document CVRA (OR 21.1; 95% CI 5.4–82.4; p < 0.001). Eleven percent (n = 53) of clients were found with moderate/high CVD risk, of whom almost one-third were under 35 years (n = 16). Documentation of follow-up varied with respect to the targeted risk factor. Fewer than 30% with abnormal blood lipid or glucose levels had follow-up management plans recorded. Conclusion: There was wide variation in CVRA between jurisdictions and between PHC centers. Learnings from successful interventions to educate and support centers in CVRA provision should be shared with stakeholders more widely. Where risk has been identified, further improvement in follow-up management is required to prevent CVD onset and reduce future burden in Australia's Indigenous population. Introduction Health inequities between Aboriginal and Torres Strait Islander (respectfully referred to as Indigenous) and non-Indigenous Australians are well documented (1, 2) and are a legacy of colonization, disempowerment and ongoing racial, social and economic inequality (3). It has been estimated that continued inequality accounts for between one-third and one-half of the 10-year life expectancy gap between Indigenous and non-Indigenous people (2, 4), highlighting the importance of addressing the social determinants of health and ensuring equity of access to quality health care. Highly preventable chronic diseases contribute most to the higher rate of poor health and premature death experienced by Aboriginal and Torres Strait Islander people. Cardiovascular disease (CVD), largely driven by the combined effect of several modifiable risk factors such as smoking and obesity, is the leading contributor accounting for one-fifth of the health gap (1). In addition to improving social and economic determinants of health, effective CVD prevention, through regular screening and early intervention, would make a significant contribution to reducing the health gap and disease burden within the Indigenous population (5). Health promotion, prevention, and early treatment services are a key component of Australia's primary health care (PHC) system. Access to PHC for Aboriginal and Torres Strait Islander people is through community-controlled health centers, government-operated community health centers, and private general practitioners (GPs), with some variation across diverse geographies. Aboriginal and Torres Strait Islander community-controlled centers and some government centers operating in predominantly Indigenous communities offer models of comprehensive PHC providing access to doctors, nurses, allied health, social and emotional wellbeing professionals, and medical specialists. Service size, however, varies depending on remoteness, with visiting services a feature of remote locations. A recent national initiative, "Better cardiac care for Aboriginal and Torres Strait Islander people," outlines priority action areas to address inequities in cardiovascular health service delivery between Indigenous and non-Indigenous people (6). Priority actions are staged across the disease continuum and include cardiovascular risk assessment (CVRA) as a key aspect of primary prevention, along with practitioner follow-up and intervention for those identified at risk, such as pharmacotherapy and ongoing culturally appropriate support to facilitate lifestyle modification (5). Absolute CVRA is a screening and management process intended for use by PHC practitioners to calculate the probability of a cardiovascular event within 5 years, taking into account the synergistic effect of multiple risk factors that may be present (7). The risk calculator takes account of age, sex, systolic blood pressure, smoking status, levels of total and high-density lipoprotein cholesterol, and presence of diabetes (7). Despite the importance of CVRA as a screening and early intervention tool, few studies have reported its use within the Indigenous PHC sector or in the broader Australian PHC setting. This reflects the lack of national and jurisdictional data on CVRA and PHC services in general (6). In 2012, the Northern Territory (NT) government implemented a large-scale strategy to strengthen chronic disease prevention in Indigenous communities that included regular CVRA data collection and reporting and the roll-out of an automated CVRA calculator within the electronic medical record system used by government health centers (8). In 2015, a similar calculator was introduced into the Communicare electronic medical record system used by many Aboriginal and Torres Strait Islander community-controlled health centers in the NT and other jurisdictions. This study examines variation in documented CVRA for adults with no prior diagnosis of chronic disease as a primary prevention strategy in Indigenous PHC centers across four Australian jurisdictions (2012–2014). We also report on the proportion of Indigenous people found with elevated risk and the proportion that had subsequent follow-up actions documented. ; Veronica Matthews, Christopher P. Burgess, Christine Connors, Elizabeth Moore, David Peiris, David Scrimgeour . et al.
OBJECTIVES:To examine barriers and facilitators to sustaining a sexual health continuous quality improvement (CQI) programme in clinics serving remote Aboriginal communities in Australia. DESIGN:Qualitative study. SETTING:Primary health care services serving remote Aboriginal communities in the Northern Territory, Australia. PARTICIPANTS:Seven of the 11 regional sexual health coordinators responsible for supporting the Northern Territory Government Remote Sexual Health Program. METHODS:Semi-structured in-depth interviews conducted in person or by telephone; data were analysed using an inductive and deductive thematic approach. RESULTS:Despite uniform availability of CQI tools and activities, sexual health CQI implementation varied across the Northern Territory. Participant narratives identified five factors enhancing the uptake and sustainability of sexual health CQI. At clinic level, these included adaptation of existing CQI tools for use in specific clinic contexts and risk environments (eg, a syphilis outbreak), local ownership of CQI processes and management support for CQI. At a regional level, factors included the positive framing of CQI as a tool to identify and act on areas for improvement, and regional facilitation of clinic level CQI activities. Three barriers were identified, including the significant workload associated with acute and chronic care in Aboriginal primary care services, high staff turnover and lack of Aboriginal staff. Considerations affecting the future sustainability of sexual health CQI included the need to reduce the burden on clinics from multiple CQI programmes, the contribution of regional sexual health coordinators and support structures, and access to and use of high-quality information systems. CONCLUSIONS:This study contributes to the growing evidence on how CQI approaches may improve sexual health in remote Australian Aboriginal communities. Enhancing sustainability of sexual health CQI in this context will require ongoing regional facilitation, efforts to build local ownership of CQI processes and management of competing demands on health service staff. ; Praveena Gunaratnam, Gill Schierhout, Jenny Brands, Lisa Maher, Ross Bailie, James Ward, Rebecca Guy, Alice Rumbold, Nathan Ryder, Christopher K Fairley, Basil Donovan, Liz Moore, John Kaldor, Stephen Bell
Objectives To examine barriers and facilitators to sustaining a sexual health continuous quality improvement (CQI) programme in clinics serving remote Aboriginal communities in Australia. Design Qualitative study. Setting Primary health care services serving remote Aboriginal communities in the Northern Territory, Australia. Participants Seven of the 11 regional sexual health coordinators responsible for supporting the Northern Territory Government Remote Sexual Health Program. Methods Semi-structured in-depth interviews conducted in person or by telephone; data were analysed using an inductive and deductive thematic approach. Results Despite uniform availability of CQI tools and activities, sexual health CQI implementation varied across the Northern Territory. Participant narratives identified five factors enhancing the uptake and sustainability of sexual health CQI. At clinic level, these included adaptation of existing CQI tools for use in specific clinic contexts and risk environments (eg, a syphilis outbreak), local ownership of CQI processes and management support for CQI. At a regional level, factors included the positive framing of CQI as a tool to identify and act on areas for improvement, and regional facilitation of clinic level CQI activities. Three barriers were identified, including the significant workload associated with acute and chronic care in Aboriginal primary care services, high staff turnover and lack of Aboriginal staff. Considerations affecting the future sustainability of sexual health CQI included the need to reduce the burden on clinics from multiple CQI programmes, the contribution of regional sexual health coordinators and support structures, and access to and use of high-quality information systems. Conclusions This study contributes to the growing evidence on how CQI approaches may improve sexual health in remote Australian Aboriginal communities. Enhancing sustainability of sexual health CQI in this context will require ongoing regional facilitation, efforts to build local ownership of CQI processes and management of competing demands on health service staff.
