ORIGINAL ARTICLE
Heart, Lung and Circulation (2015) 24, 450–457 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.11.008
Strengthening Cardiovascular Disease Prevention in Remote Indigenous Communities in Australia’s Northern Territory Christopher P. Burgess, PhD, FAFPHM a,b*, Gary Sinclair, MBBCh, FRACGP a, Mark Ramjan, RN, RM a, Patrick J. Coffey a, Christine M. Connors, MPH, FAFPHM a, Leonie V. Katekar, MBioethics, FRACMA a a
Top End Health Service, Primary Health Care Branch, Northern Territory Government, Darwin Australia Northern Territory Clinical School, Flinders University, Darwin, Australia
b
Online published-ahead-of-print 29 November 2014
Background
In 2012 the Northern Territory Department of Health commenced the Chronic Conditions Management Model - strengthening cardiovascular disease prevention in remote Indigenous communities. Interventions included providing regular functional reporting and decision support to frontline primary health care teams.
Methods
Longitudinal (three monthly) clinical audits of cardiac prevention services were undertaken between 2012 and 2014. Our primary outcome was population coverage of cardiovascular risk assessment for Indigenous clients aged 20 years and older. Secondary outcomes for those identified at high risk were (i) assessment of modifiable cardiac risk factors, (ii) prescription of risk lowering medications, and (iii) the proportion of high risk clients achieving clinical targets for risk reduction.
Results
As of August 2014, 7266 clients have had their cardiovascular risk assessed, improving population coverage from 23% in mid June 2012 to 58.5%. For 2586 high risk clients, 1728 (67%) and 1416 (55%) were prescribed blood pressure and lipid lowering therapy and for those clinically re-assessed, 1366 (57%) and 989 (40%) were achieving clinical targets for risk reduction for blood pressure and lipids respectively.
Conclusions
Functional reporting and decision support was associated with improvement in cardiovascular risk assessment coverage and a sustained proportion of high risk clients achieving clinical targets for cardiovascular risk reduction. Further intervention-based research is required to close the gap between identification of risk and risk reduction.
Keywords
Indigenous Health Services Primary Health Care Cardiovascular diseases Australia Prevention
Introduction Aboriginal and Torres Strait Islander (hereafter, respectfully referred to as Indigenous) residents of Australia’s Northern
Territory (NT) suffer a disproportionate burden of chronic conditions – particularly cardiovascular disease (CVD) [1]. For Indigenous NT residents, the incidence of acute myocardial infarcts continues to rise, with age-adjusted CVD related
*Corresponding author at: Top End Health Service, Primary Health Care Branch, Northern Territory Government, PO Box 40596, Casuarina NT 0811. Tel.: +61 8 8922 8220; fax: +61 8 8922 7799; Mob.: +1 206 369 5211., Email: [email protected] © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
451
NT Indigenous CVD Prevention
deaths occurring at more than twice the national average [2,3]. Premature disease onset and worse CVD outcomes in remote areas are salient features [3,4]. While there have been improvements in Indigenous survival following acute myocardial infarction [2], delivery of preventive health services to Indigenous clients of remote primary health care (PHC) services remains low to moderate [5]. Early detection of CVD is problematic because recommended CVD risk assessment methods significantly underestimate risk in the NT Indigenous population [6,7]. Under-recognition of high CVD risk in remote NT and other Indigenous PHC settings has also been described [8,9]. To deal with these challenges, the NT Department of Health has introduced a suite of interventions over the past 10 years aimed at improving chronic conditions care – particularly strengthening preventive care for CVD. These include (i) development of the chronic conditions strategy [10], (ii) documenting structured care pathways (annual Care Plans) in the PHC standard treatment manual and electronic health record for chronic disease diagnoses (iii) inclusion of cardiovascular risk assessment in the regional PHC standard treatment manual – commencing at age 20 with risk adjustment for Indigenous status [11], (iv) introduction of the Primary Care Information System (PCIS) – an electronic health record that includes semi-automated cardiovascular risk assessment decision support complying with the PHC standard treatment manual, (v) workforce reforms and (vi) strong participation in continuous quality improvement auditing cycles. In addition, commencing in 2012, the co-authors of this paper led the design, implementation and governance of the Chronic Conditions Management Model (CCMM). Building on prior experience [12], expertise in health informatics and focussing on three domains (information systems, decision support and delivery design) of the Chronic Care Model [13], our objective was to improve the prevention, early detection and management of chronic conditions in remote communities managed by the NT Department of Health [10]. The CCMM provides support and assistance in the coordination, integration, delivery, documentation and evaluation of chronic disease care. Importantly, information reported to frontline PHC teams is ‘actionable.’ Not only are gaps in care reported but clients in these gaps are readily identifiable to enable targeted recall and intervention. This ‘functional’ reporting has resulted in strong engagement from frontline PHC teams (Box). A strong focus on CVD prevention is mandated through the CCMM. Frontline PHC staff receive regular feedback about (i) target population coverage of cardiovascular risk assessment, (ii) closing gaps between screening and initiation of treatment and (iii) achieving clinical targets for modifiable risk factors for those identified with high cardiovascular risk. The CCMM reports to frontline PHC teams have evolved over time - since November 2013 these have included specific indicators on the management and treatment outcomes of clients with high cardiovascular risk. Our objective in this paper is to describe the outcomes associated with the
Box The Northern Territory Department of Health Chronic Conditions Management Model Chronic Conditions Management Model Monthly functional ‘Recall list’ of clients due
chronic disease care service items Function allows client list to be filtered by selected service item Quarterly functional ‘Traffic Light Report’ of primary health care service performance against program targets and key performance indicators in chronic disease care Function allows clients missing care to be identified and actively recalled 6 month ‘Trend reports’ of PHC service performance in chronic conditions care benchmarked against regional and NT-wide performance Key program surveillance document for health service managers
implementation of the CCMM during the first three years of its operation.
Methods Patients and Clinical Context The NT Department of Health is the single largest provider of PHC services to remote Indigenous peoples in Australia – serving a population of approximately 23,000 Indigenous and 9200 non-Indigenous clients in 49 remote PHC clinics spread over approximately 1.4 million km2. It’s Australia’s toughest PHC setting with challenges ranging from climatic extremes, social isolation, transient acute-care orientated staff, cross-cultural medicine and a high burden of acute care and afterhours work. PHC delivery is typically led by remote area nurses and Aboriginal health practitioners supported by visiting medical officers. Larger communities may have residential medical staff but all remote clinics have dual dispensary and PHC functions. A significant proportion of care is provided opportunistically.
Cardiovascular Risk Assessment In NT remote PHC settings cardiovascular risk is assessed using either (i) colour-coded charts in the PHC standard treatment manual - commencing at age 20 and including a risk adjustment (up 5%) for Indigenous Australians or (ii) by a semi-automated function within the electronic health record that extracts the required patient data when initiated by practitioners [11]. Patients assessed with a five-year cardiovascular risk of 16% or greater are classified as having high cardiovascular risk, those with a five-year cardiovascular risk of 10-15% as moderate and those with cardiovascular risk below 10% as low risk. High cardiovascular risk clients
452
C.P. Burgess et al.
were forwarded to participating PHC teams at the start of each month as an Excel spreadsheet. Approximately every three months, health data were extracted via standardised queries to construct the ‘Traffic Light Report’ providing functional reporting via an Excel spreadsheet on the primary and secondary outcomes detailed above. The data extracted for individual PHC service traffic light reports were compiled for the purposes of our ‘research evaluation’ of the CCMM across the NT. Our research was approved by institutional ethics committees in Central Australia (HREC 14-257) and the Top End of the NT (HREC 14-2252).
are commenced on a chronic disease care plan to initiate risk reducing interventions according to patient wishes and monitor modifiable risk factors over an annual cycle of care.
Outcomes Inclusion criteria for this clinical audit are all Indigenous clients registered with a NT Department of Health remote PHC service in the NT aged 20 years or older on the audit date. Indigenous visitors registered with other service providers and non-Indigenous clients were excluded. Our primary outcome was the proportion of Indigenous clients aged 20 years or older that had cardiovascular risk assessment documented within two years of the audit date. Secondary outcomes for those identified with high cardiovascular risk were (i) the proportions prescribed blood pressure and lipid lowering drugs respectively (TREATMENT), (ii) the proportions who had modifiable risk factors (smoking, blood pressure, total cholesterol) assessed in the year prior to the audit date (PROCESS), (iii) of those assessed, the proportions achieving treatment targets for blood pressure (
Heart, Lung and Circulation (2015) 24, 450–457 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.11.008
Strengthening Cardiovascular Disease Prevention in Remote Indigenous Communities in Australia’s Northern Territory Christopher P. Burgess, PhD, FAFPHM a,b*, Gary Sinclair, MBBCh, FRACGP a, Mark Ramjan, RN, RM a, Patrick J. Coffey a, Christine M. Connors, MPH, FAFPHM a, Leonie V. Katekar, MBioethics, FRACMA a a
Top End Health Service, Primary Health Care Branch, Northern Territory Government, Darwin Australia Northern Territory Clinical School, Flinders University, Darwin, Australia
b
Online published-ahead-of-print 29 November 2014
Background
In 2012 the Northern Territory Department of Health commenced the Chronic Conditions Management Model - strengthening cardiovascular disease prevention in remote Indigenous communities. Interventions included providing regular functional reporting and decision support to frontline primary health care teams.
Methods
Longitudinal (three monthly) clinical audits of cardiac prevention services were undertaken between 2012 and 2014. Our primary outcome was population coverage of cardiovascular risk assessment for Indigenous clients aged 20 years and older. Secondary outcomes for those identified at high risk were (i) assessment of modifiable cardiac risk factors, (ii) prescription of risk lowering medications, and (iii) the proportion of high risk clients achieving clinical targets for risk reduction.
Results
As of August 2014, 7266 clients have had their cardiovascular risk assessed, improving population coverage from 23% in mid June 2012 to 58.5%. For 2586 high risk clients, 1728 (67%) and 1416 (55%) were prescribed blood pressure and lipid lowering therapy and for those clinically re-assessed, 1366 (57%) and 989 (40%) were achieving clinical targets for risk reduction for blood pressure and lipids respectively.
Conclusions
Functional reporting and decision support was associated with improvement in cardiovascular risk assessment coverage and a sustained proportion of high risk clients achieving clinical targets for cardiovascular risk reduction. Further intervention-based research is required to close the gap between identification of risk and risk reduction.
Keywords
Indigenous Health Services Primary Health Care Cardiovascular diseases Australia Prevention
Introduction Aboriginal and Torres Strait Islander (hereafter, respectfully referred to as Indigenous) residents of Australia’s Northern
Territory (NT) suffer a disproportionate burden of chronic conditions – particularly cardiovascular disease (CVD) [1]. For Indigenous NT residents, the incidence of acute myocardial infarcts continues to rise, with age-adjusted CVD related
*Corresponding author at: Top End Health Service, Primary Health Care Branch, Northern Territory Government, PO Box 40596, Casuarina NT 0811. Tel.: +61 8 8922 8220; fax: +61 8 8922 7799; Mob.: +1 206 369 5211., Email: [email protected] © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
451
NT Indigenous CVD Prevention
deaths occurring at more than twice the national average [2,3]. Premature disease onset and worse CVD outcomes in remote areas are salient features [3,4]. While there have been improvements in Indigenous survival following acute myocardial infarction [2], delivery of preventive health services to Indigenous clients of remote primary health care (PHC) services remains low to moderate [5]. Early detection of CVD is problematic because recommended CVD risk assessment methods significantly underestimate risk in the NT Indigenous population [6,7]. Under-recognition of high CVD risk in remote NT and other Indigenous PHC settings has also been described [8,9]. To deal with these challenges, the NT Department of Health has introduced a suite of interventions over the past 10 years aimed at improving chronic conditions care – particularly strengthening preventive care for CVD. These include (i) development of the chronic conditions strategy [10], (ii) documenting structured care pathways (annual Care Plans) in the PHC standard treatment manual and electronic health record for chronic disease diagnoses (iii) inclusion of cardiovascular risk assessment in the regional PHC standard treatment manual – commencing at age 20 with risk adjustment for Indigenous status [11], (iv) introduction of the Primary Care Information System (PCIS) – an electronic health record that includes semi-automated cardiovascular risk assessment decision support complying with the PHC standard treatment manual, (v) workforce reforms and (vi) strong participation in continuous quality improvement auditing cycles. In addition, commencing in 2012, the co-authors of this paper led the design, implementation and governance of the Chronic Conditions Management Model (CCMM). Building on prior experience [12], expertise in health informatics and focussing on three domains (information systems, decision support and delivery design) of the Chronic Care Model [13], our objective was to improve the prevention, early detection and management of chronic conditions in remote communities managed by the NT Department of Health [10]. The CCMM provides support and assistance in the coordination, integration, delivery, documentation and evaluation of chronic disease care. Importantly, information reported to frontline PHC teams is ‘actionable.’ Not only are gaps in care reported but clients in these gaps are readily identifiable to enable targeted recall and intervention. This ‘functional’ reporting has resulted in strong engagement from frontline PHC teams (Box). A strong focus on CVD prevention is mandated through the CCMM. Frontline PHC staff receive regular feedback about (i) target population coverage of cardiovascular risk assessment, (ii) closing gaps between screening and initiation of treatment and (iii) achieving clinical targets for modifiable risk factors for those identified with high cardiovascular risk. The CCMM reports to frontline PHC teams have evolved over time - since November 2013 these have included specific indicators on the management and treatment outcomes of clients with high cardiovascular risk. Our objective in this paper is to describe the outcomes associated with the
Box The Northern Territory Department of Health Chronic Conditions Management Model Chronic Conditions Management Model Monthly functional ‘Recall list’ of clients due
chronic disease care service items Function allows client list to be filtered by selected service item Quarterly functional ‘Traffic Light Report’ of primary health care service performance against program targets and key performance indicators in chronic disease care Function allows clients missing care to be identified and actively recalled 6 month ‘Trend reports’ of PHC service performance in chronic conditions care benchmarked against regional and NT-wide performance Key program surveillance document for health service managers
implementation of the CCMM during the first three years of its operation.
Methods Patients and Clinical Context The NT Department of Health is the single largest provider of PHC services to remote Indigenous peoples in Australia – serving a population of approximately 23,000 Indigenous and 9200 non-Indigenous clients in 49 remote PHC clinics spread over approximately 1.4 million km2. It’s Australia’s toughest PHC setting with challenges ranging from climatic extremes, social isolation, transient acute-care orientated staff, cross-cultural medicine and a high burden of acute care and afterhours work. PHC delivery is typically led by remote area nurses and Aboriginal health practitioners supported by visiting medical officers. Larger communities may have residential medical staff but all remote clinics have dual dispensary and PHC functions. A significant proportion of care is provided opportunistically.
Cardiovascular Risk Assessment In NT remote PHC settings cardiovascular risk is assessed using either (i) colour-coded charts in the PHC standard treatment manual - commencing at age 20 and including a risk adjustment (up 5%) for Indigenous Australians or (ii) by a semi-automated function within the electronic health record that extracts the required patient data when initiated by practitioners [11]. Patients assessed with a five-year cardiovascular risk of 16% or greater are classified as having high cardiovascular risk, those with a five-year cardiovascular risk of 10-15% as moderate and those with cardiovascular risk below 10% as low risk. High cardiovascular risk clients
452
C.P. Burgess et al.
were forwarded to participating PHC teams at the start of each month as an Excel spreadsheet. Approximately every three months, health data were extracted via standardised queries to construct the ‘Traffic Light Report’ providing functional reporting via an Excel spreadsheet on the primary and secondary outcomes detailed above. The data extracted for individual PHC service traffic light reports were compiled for the purposes of our ‘research evaluation’ of the CCMM across the NT. Our research was approved by institutional ethics committees in Central Australia (HREC 14-257) and the Top End of the NT (HREC 14-2252).
are commenced on a chronic disease care plan to initiate risk reducing interventions according to patient wishes and monitor modifiable risk factors over an annual cycle of care.
Outcomes Inclusion criteria for this clinical audit are all Indigenous clients registered with a NT Department of Health remote PHC service in the NT aged 20 years or older on the audit date. Indigenous visitors registered with other service providers and non-Indigenous clients were excluded. Our primary outcome was the proportion of Indigenous clients aged 20 years or older that had cardiovascular risk assessment documented within two years of the audit date. Secondary outcomes for those identified with high cardiovascular risk were (i) the proportions prescribed blood pressure and lipid lowering drugs respectively (TREATMENT), (ii) the proportions who had modifiable risk factors (smoking, blood pressure, total cholesterol) assessed in the year prior to the audit date (PROCESS), (iii) of those assessed, the proportions achieving treatment targets for blood pressure (
