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Australian Chronic Disease Outreach Program: Screening and Treatment for Remote Communities

Learn about the Australian Chronic Disease Outreach Program and how it organizes and delivers chronic disease care in remote Indigenous communities. Discover the screening and treatment algorithms, as well as the impact of the program in reducing sickness, hospital admissions, and deaths from chronic diseases.

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Australian Chronic Disease Outreach Program: Screening and Treatment for Remote Communities

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  1. The Australian Chronic Disease Outreach Program Wendy Hoy Srinivas Kondalsamy Chennakesavan Kidney Disease Research and Prevention & Centre for Chronic Disease, The University of Queensland Australia Presentated on behalf of Australian CDOP by Ivor Katz South African Chronic Disease Outreach Program Bellagio Meeting, March 2004

  2. Respiratory 10% All other 20% Digestive 6% Neoplasms 6% External 15% Excess Death in Australian Aborigines, 2000 Falls in maternal, infant, child-hood and infectious deaths in Aborigines …. counter-balanced by a new epidemic of deaths from chronic diseases. Life expectancy  > 20 years and more Diabetes 12% Cardiovascular 31% Chronic diseases include type 2 diabetes, hypertension, renal disease, cardiovascular disease and chronic lung disease Chronic diseases are the causes of about 66% of all excess deaths They are intimately related, share risk factors, share markers, are easily and cheaply diagnosed, and respond to standard treatments

  3. In this presentation • Brief history of the Australian chronic disease program and the role of such programs for a community • Screening & treatment algorithms • How they organised and delivered chronic disease care in remote Indigenous communities in Australia

  4. K.D.R.PKidney Disease Research and Prevention • Reduce the impact of chronic 'lifestyle' diseases diabetes, high blood pressure and kidney disease. • Identifyandmodify risk factors, early diagnosisand systematictreatment • Evolved from a Program in a remote Australian Aboriginal Community (Tiwi Islands), which showed marked reduced sickness, hospital admissions, ESRD and natural deaths • KDRP model is being used in other communities and countries • Offered free of charge

  5. 2500 2000 1500 1000 500 0 0-14 15-24 25-34 35-44 45-54 55-64 65+ Indigenous vs nonIndigenous Australians, Incidence Rate of Treated ESRD, 1992-2001, by Age Group Incidence per million (95% CI) Age group, years Stewart et al, Nephrology, 2004

  6. Cumulative Mortality, Controls vs Treatment Cohort in People with Established Renal Disease (ACR 34+) .4 33% .3 Controls .2 15% .1 Treatment 0 0 1 2 3 4 analysis time, yr Survival benefit in nondiabetics, diabetics, normotensives, hypertensives, prior ACEI, no prior ACEI

  7. Chronic Disease Outreach Program in Australia Tiwi Islands Wadeye Borroloola Naiuyu Broome Bega, Kalgoorlie Woorabinda Cherbourg

  8. Tiwi Islands Tiwi Islands Darwin

  9. Estimated Rates of Morbidities By Community 50 Diabetes 45 Kidney Problem 40 Hypertension 35 30 Percent of People Tested 25 20 15 10 5 0 Wadeye Naiuyu Borroloola * Rates of morbidities differ by community * Pilot studies are needed to anticipate required services

  10. Prevalence of Conditions by Age Group (Borroloola) 80 Diabetes 70 Kidney problem 60 Hypertension 50 40 Percent afflicted 30 20 10 0 0 <20 20-39 40-59 60+ Age group. years * Rates increase with age * Tells us something about pathophysiology * Provides the case for repeated testing throughout adult life

  11. “Integrated" nature of Chronic Diseases “Integrated" nature of the three conditions, HT, diabetes and proteinuria  using Borroloola as the model.

  12. Prevalence of Chronic Conditions by Age in Tiwi Adults 80 Obese 70 Diabetes/IGT 60 Hypertension 50 ACR>=3.4 40 GFR<90 30 20 10 0 18-29 yr 30-39 yr 40-49 yr 50+ yr

  13. Overlapping morbidities among screened adults in Borroloola 9% 3% 14% 34% 20% 2% 14% 3% Screened Adults Renal Disease(46%) Hypertension (52%) Diabetes (29%)

  14. The Case for Integrated Chronic Disease Screening: Coexistence of Morbidities in Adults in Community C (n=315). Renal , n=110, or 35% Obesity, n=85, or 27% 19 24 5 7 18 Diabetes, n=86, or 27% 3 11 6 43 Hypertension, n=149, or 47% 16 5 12 28 12 9 Percent with one or more conditions including obesity Wadeye 30%; Naiuyu 57%; Borroloola 70%

  15. Aboriginal Chronic Disease Outreach Program • How to get started? • What are the priority areas to be covered? • What are the principles involved? • What are the services provided and supported by KDRP? • Population screened and treated • Clinical information and patient management system – What is it?

  16. Steps in initiating KDRP activities • Concerned communities express interest in Programs • Develop a working partnership and understanding • They approach funders and stakeholders for advocacy and funding • They establish an integrated system of care for chronic diseases • They constantly evaluate the outcomes and provide repeated feedback on the levels of service delivery/ clinical activities and hard endpoints

  17. Critical Components of the outreach program • Education and training • Testing (screening) • Treatment • Information systems • Evaluation

  18. A Typical Health Centre in a remote Indigenous community

  19. Principles of testing (screening) • Keep it simple - the health worker should be able to perform and interpret the testing • Try to combine processes with other tests and procedures e.g. urine with STD testing, immunisation etc • Don’t measure things you won’t act on! • Optimise on-site testing and provide immediate feedback – an opportunity to educate

  20. Treatment • Follows standard evidence based guidelines • Protocols approved by the ethics committees • Primarily, focus on better blood pressure management and use medications in a stepwise manner

  21. Web based database

  22. Training in progress

  23. Interaction among KDRP staff members Nurses and health workers Administrative and computational support Doctor/Specialist Nursing Coordinator Program Director

  24. Community-Base Dialysis Starts and Natural Deaths in Adults (18+ yr), Annual Rolling Average, mid 2003 Treatment Program Begins 20 Dialysis Starts 18 Natural Deaths 16 14 12 10 8 Number of People 6 4 2 0 91/92 92/93 93/94 94/95 96/96 96/97 97/98 98/99 99/00 00/01 .01/02 .02/03 .90/91

  25. Cost Effectiveness Estimates of Treatment Program (Philip Baker) • Cost per patient per year for first 2 years: < $ 1,200 • Savings in dialysis avoided (mean treatment time 2.1 years) $700,000 to $3.1 million. • Range depends of what renal failure rates would have done in absence of intervention • Add reduced hospitalisations • Add value of a year of death postponed in prime of life

  26. Barriers faced in implementing the outreach program • Remoteness • Usually the KDRP staff members visit the health centres at least once a month spending a minimum of 4days to 2 weeks. Return flight to Borroloola from Darwin-$1200; C/W Brisbane-Sydney ($180). One AUD$=4.3Rand • Lack of resources: Staff, equipments, facilities • Competing demands of urgent/emergency care • Ignorance of the integrated nature of chronic disease • Frequent absenteeism and high turnover of non-Indigenous staff • Treatment requirements overwhelm the system where the disease burden is high

  27. Positive Outcomes Estimated participation of adults; • Naiuyu, 90% • Borroloola, 75% • Wadeye, 58% Adherence to Protocols • BP repeated in 75% of people with previously unrecognised high BP • HbA1c done in 91% of diabetics • Further testing in 83% of people with suspicious glucose levels • Urine ACR done in 86% of people with urine protein by dipstick 84% of diabetics and 76% of hypertensives • Serum creatinine measured in 96% with ACR 34+ (>=300mg/g)

  28. 160 160 148 SBP 150 150 SBP 140 140 136 134 130 130 130 120 120 MAP 113 MAP 110 110 104 101 100 100 DBP 96 97 DBP 90 90 88 84 80 80 81 70 70 First BP Most Recent BP First BP Most Recent BP Outreach Program: Blood Pressure Changes in People with Vasoactive Drugs Started or Adjusted Everyone, n=174 (treatment for hypertension, diabetes, renal protection) BP>=140/90 at Baseline, n=105 BP, mean (CI) P<0.001 for all: check this

  29. Positive Outcomes Recent data and events has resulted in considerable respect and progress for the program which is very encouraging These successes include: • KDRP participated in guidelines formulation (screening and treatment) for CD in Aboriginal Australia, - now been officially incorporated into the protocols of primary care in each region, and in national guidelines • Fed govt is to fund ‘per capita primary care allocation’ to give each community or health service it funds i.e. health workers will be qualified to bill on behalf of their local clinic!!! ) Medicare or now funding "prevention!!! " • The model is based around health workers doing most of the work.

  30. Positives • Aboriginal communities access medicines through federally funded Pharmaceutical Benefits Scheme" = ACEI and hypoglycemics and statins etc are no longer capped • Fed govt will now provide for free the Ferret IT systems for primary care and recall to all communities and services that need it.(IT service is vital to track data and outcomes) • Other regions and communities now coming to KDRP for support and guidence.

  31. Positives • KDRP has stimulated the national "chronic disease" NGOs to combine to form a "Chronic Disease Alliance" that has the ear of govt and considerable fund raising capabilities... it is a coalition of Australian Kidney Foundation, national Heart Foundation, the Stroke Foundation, and Diabetes Australia... they have made Aboriginal health one of their main areas of focus • KDRP working with a Health Services and health Economics Group of some prestige (University of Wollongong), using CD health profiles generated from KDRP data, to develop a needs'based chronic disease health care model, and estimate the resources required and the cost-benefits

  32. Positives Sustainability • Northern Territory Health Services has appointed several chronic disease coordinators: each having repsonsibility to develop and support CD activities in a regional cluster of clinics • The Tiwi Health Board (to which 1st KDRP program was handed over) went broke, abandoned all programs which they considered elective!!!.   (They were poorl;y trained in knowledge of health issues and priorities, and fiscal and admin matters, and many consider they were set up to fail) KDRP now restarted on Tiwi Islands • Borroloola continues to work with KDRP, using the guidelines and database and using KDRP nurse coordinator as a paid copnsultant!  

  33. Nursing Coordinators Jo Scheppingen Suresh Sharma Kiernan McKendry Rebecca Davey Gaye Gokal Mandy Halkett Health Workers Admin Phillip Hoy Ron Ninnis Kim Abbey Computing Support Peter Warner Lars Gronholt KDRP Team

  34. Thank You

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