Aboriginal and Torres Strait Islander Health Performance Framework - 2010
3.04 Chronic disease management
Why is it important?:Chronic diseases such as circulatory disease, diabetes, renal disease, chronic respiratory disease, cancers and chronic mental health conditions are the major causes of morbidity and mortality among Aboriginal and Torres Strait Islander peoples. Better management of these conditions is a key factor in meeting the target of closing the life expectancy gap between Indigenous and non-Indigenous Australians within a generation. Chronic disease is estimated to be responsible for 70% of the health gap (Vos et al. 2007). Effective management of chronic disease can delay the progression of disease, improve quality of life, increase life expectancy, and decrease the need for high-cost interventions. Good quality care for people with chronic disease generally involves multiple health care providers across multiple settings and the engagement of the client and their families in self-management of the condition (NHPAC 2006). Typically, the primary health care provider plays a central role in chronic disease management through systematic or opportunistic screening to identify patients with asymptomatic disease, development of a management plan with the patient and their family, regular assessment of the extent to which the chronic illness is well controlled, regular checks to identify early signs of complications, and referral to specialist care where this is warranted. Chronic disease management requires early access to specialist care where necessary, with primary care providers continuing to play a key role in the management of the disease. To play an effective role in chronic disease management, primary health care services need to take an organised approach reflecting evidence-based guidelines (Wagner et al. 1996; Bodenheimer et al. 2002).
Findings:Medicare claims data show that in 2009-10, after adjusting for differences in age structure, Indigenous Australians were more likely to have received a claimed service for Chronic disease management plans than non-Indigenous Australians. These include GP management plans (76 per 1,000 compared to 47 per 1,000) and team care arrangements (60 per 1,000 compared to 37 per 1,000). Chronic disease management plans are designed to provide rebates for GPs to manage chronic or terminal medical conditions by preparing, coordinating, reviewing or contributing to chronic disease management plans. They apply for a patient who suffers from at least one medical condition that has been present (or is likely to be present) for at least six months or is terminal. Indigenous Australians also had a higher rate of nurse/Aboriginal Health Worker consultations claimed than non-Indigenous Australians (578 per 1,000 compared with 327 per 1,000).
Information on Indigenous Australians receiving care from GPs is available through the Divisions of General Practice National Performance Indicators. Based on data reported from 53 (out of 108) Divisions, 58% of Indigenous patients on practice diabetes registers had an HbA1c test in the last 12 months where the results were recorded on the register, compared with 60% of non-Indigenous Australians. In addition, 56% of Indigenous Australians on the diabetes registers had a cholesterol test, compared with 65% of non-Indigenous Australians (based on 48 of 108 Divisions). These data may be limited by the poor quality of Indigenous identification in the registers.
Information on the management of chronic conditions by Aboriginal and Torres Strait Islander primary health care services is available through OATSIH Services Reporting (OSR) and the Healthy for Life collections. Through the OSR for 2008–09, it was estimated that approximately 65% of services employed a doctor and 86% provided management of chronic illness. Services also report on whether they have systems in place which assist with clinic operational practices, particularly for the provision of services to people with chronic disease. In 2008-09 71% of services reported keeping track of clients needing follow-up, 73% reported they maintained health registers (e.g. chronic disease register), 74% used clinical practice guidelines, and 64% reported they used patient information and recall systems (PIRS) that automatically provide reminders for follow-up and health checks. These have all increased in recent years.
A range of quality improvement approaches are being implemented across general practice and Aboriginal and Torres Strait Islander primary health care services in Australia, including the Australian Primary Care Collaboratives, the Audit and Best Practice for Chronic Disease (ABCD) program (now under the auspice of One21seventy CQI cycle) and the Healthy for Life program. By 2009, 62 health centres were participating in the ABCD program. Earlier research under the ABCD program demonstrated that the proportion of Indigenous Australians with Type 2 diabetes receiving 6-monthly HbA1c tests could be increased from 41% to 72% in remote locations (Bailie et al. 2007).
The Healthy for Life program supports quality improvement processes in 100 services through 57 sites across Australia. In 2009 around 9,960 regular clients of these services had Type 2 diabetes. In the 6 months to December 2009, around 50% had an HbA1c test performed and 59% had their blood pressure assessed. For the services that reported the results of these tests, 70% had HbA1c levels that were higher than the recommended level for people with diabetes (i.e. less than or equal to 7%), and 55% had elevated blood pressure. For Aboriginal and Torres Strait Islander people with coronary heart disease who are regular clients, 64% had their blood pressure assessed in the last 6 months. For the services that reported the results of these tests, 35% of people with coronary heart disease had elevated blood pressure. Healthy for Life national chronic disease data reflects the increasing chronic disease burden in the Australian population.
Implications:The provision of organised chronic disease management in Aboriginal and Torres Strait Islander primary health care services has been demonstrated to result in improvements in various health outcomes (Hoy et al. 1999; Hoy et al. 2000; Rowley et al. 2000; McDermott et al. 2003; Bailie et al. 2007). However, there are significant challenges in sustaining improvements in the management of chronic illnesses (Urbis 2009). Strategies recommended to address these challenges include systematic support to buffer the effects of local factors, transparent work-practice systems backed by written disease management guidelines and manuals, delineated roles for practices for all practitioner types, appropriate staffing and training policies, and raising awareness in communities through education and health promotion with strong local participation (Bailie et al. 2004).
Australian governments are supporting various initiatives to improve chronic disease management including support of the Australian Primary Care Collaboratives and the Healthy for Life program. The Quality Assurance for Aboriginal and Torres Strait Islander Medical Services (QAAMS) program aims to provide culturally appropriate and clinically effective diabetes management through the use of ‘point of care’ pathology tests. The National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes includes health reforms that focus on primary health care. A range of initiatives will improve service quality in both Indigenous and mainstream primary health care settings, including the new Practice Incentives Program (PIP), Indigenous Health Incentive, which supports general practices and Indigenous health services to provide better health care for Indigenous Australians, including best practice management of chronic disease. GP Super Clinics will provide multi-disciplinary, integrated, team-based approaches to deliver better prevention and treatment of chronic disease.
Figure 146 – Percentage of patients on General Practice Diabetes Registers receiving HbA1c and Cholesterol tests in the last 12 months with results recorded on the register, 2007–08
Source: Department of Health and Ageing. National Performance Indicators for Divisions of General Practice.
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Figure 147 – Percentage of respondent Aboriginal and Torres Strait Islander primary health care services that provided management of Chronic Disease, 2004–05 to 2008–09
Source: Department of Health and Ageing Service Activity Report 2004–05, 2005–06, 2006–07, 2007–08, 2008-09
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Figure 148 – Percentage of Aboriginal and Torres Strait Islander regular clients of Healthy For Life Services receiving recommended care 1 January to 30 June 2009
Source: AIHW analysis of Healthy for Life data collection
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Figure 149 – Percentage of Aboriginal and Torres Strait Islander people with diabetes Type 2 receiving recommended care, 12 remote primary care services, Northern Territory, 2003–04 to 2005–06
Source: Bailie et al. (2007)
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