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What is the Role of Indigenous Primary Health Care Networks in Quality Improvement?

What is the Role of Indigenous Primary Health Care Networks in Quality Improvement?. Frances C. Cunningham, Anna Sheahan and Ross S. Bailie Centre for Primary Healthcare Systems Menzies School of Health Research, Brisbane. ACSHM National Congress, Canberra 28-30 August 2013. Acknowledgement.

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What is the Role of Indigenous Primary Health Care Networks in Quality Improvement?

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  1. What is the Role of Indigenous Primary Health Care Networks in Quality Improvement? Frances C. Cunningham, Anna Sheahan and Ross S. Bailie Centre for Primary Healthcare Systems Menzies School of Health Research, Brisbane ACSHM National Congress, Canberra 28-30 August 2013

  2. Acknowledgement • Aim • Rationale • Experience-ABCD Projects • Network evidence • Literature review • Results • Conclusion & Discussion Outline

  3. To examine what we know about the role of collaborative networks and QI in Indigenous primary health care: • Experience – ABCD Project/National Research Partnership • Network research: health/non-health networks • Literature review: network/collaboration influences on QI in Indigenous primary health care Aim

  4. Rationale Indigenous health status • Indigenous people living in remote Australian communities: poorest health outcomes of any high-income country population group (Vos et al 2007; AIHW 2011, IHW 42) • Overall life expectancy (AIHW, 2011): • Males: 67.2 years: 11.5 years less than non-Indigenous • Females: 72.9 years: 9.7 years less than non-Indigenous

  5. Rationale Need to strengthen Primary Health Care provision • Strengthening primary health care (PHC) services for Aboriginal and Torres Strait Islander people – critical to reducing health status differences. (Starfield et al. 2005)

  6. The Audit and Best Practice for Chronic Disease (ABCD) Project, the ABCD Extension Project and, currently, the ABCD National Partnership Project aim to improve the quality of care in Indigenous PHC centres. • Use of the audit tools and audit cycle – with One21seventy • The Audit and Best Practice for Chronic Disease (ABCD) Extension Project identified substantial variation in quality of care in Indigenous PHC services. Experience: ABCD & ABCDE Projects Galiwinku, NT

  7. FIGURE 1: Audit and Best Practice for Chronic Disease: annual plan do study act cycle. ABCD Project & CQI

  8. ABCD Project Findings: Wide Variation in Quality Figure 1: Overall delivery of specifieddiabetes services by health centre Range: 4%-77% N=51 Figure 2: Percentages of patients with HbA1c<7% by health centre Range: 0%-55% N=51

  9. ABCDE Project Findings • Variation might be explained in part by engagement of Indigenous PHC centres in collaborative networks providing access to important information and skills • Gardner et al. 2011: • ‘Services that were part of a strong network for CQI were more greatly insulated from barriers • that might otherwise have obstructed efforts.’

  10. Findings: Systematic Reviews on Health Networks/Collaborations

  11. Literature review: network influence on QI in Indigenous PHC • Search conducted on 10 May 2013; over period: January 1995-2013 • Databases: Medline, CINAHL, Embase, Web of Science • Inclusion and exclusion criteria were applied • Two independent reviewers: stages 1, 2 and 3

  12. Search Terms Quality Improvement Terms Linked using “OR” Health Terms Linked using “OR” Networking Terms Linked using “OR” • Quality Assurance, Health Care • Quality Improvement • Program Evaluation • Quality of Health Care • Evaluation studies as Topic • Efficiency • Total Quality management • Cost-Benefit Analysis • Outcome Assessment (health care) • Outcome and Progress Assessment (health care) • Cost Control • Delivery of Health Care • Health services, Indigenous • Primary Health Care • Community Health Services • Social Network (Entry Term) • Models, Organi*ation • Interdisciplinary Communication • Task perfomance and analysis • Organi*ational affiliation • Knowledge management • Collaboration (Entry Term) • Organi*ation and administration • Delivery of Health care, Integrated AND AND Networking, Health and Quality Improvement Terms linked with “AND”

  13. Indigenous - definition • WHO definition – Peoples who: • Identify themselves and are recognised and accepted by their community as Indigenous • Demonstrate historical continuity with pre-colonial and/or pre-settler societies • Have strong links to territories and surrounding natural resources • Have distinct social, economic or political systems • Maintain distinct languages, cultures and beliefs • Form non-dominant groups of society • Resolve to maintain and reproduce their ancestral environments and systems as distinctive peoples and communities. • http://www.who.int/mediacentre/factsheets/fs326/en/ Stage 2: also searched - Aboriginal, Torres Strait Islander, First Nations, American Indian, ethnic groups

  14. n=1080

  15. Settings: US: 4; Mexico: 1; South Africa: 1; The Netherlands: 1; Egypt: 1; Uganda: 1; Pakistan: 1 • Study design: randomised controlled trials: 4; pre- and post-studies: 2; simple survey: 1; descriptive statistics: 2; qualitative: 1 Literature review: study characteristics

  16. Types of Networks/Collaboratives • PHC (NGOs) collaboration: 1 • Community partners and non-health sector department : 1 • Breakthrough Series Collaborative with PHCs: 2 • Primary health care, community mobilisation: 2 • Academe, local health services, communities (Community-Based Practice Research): 4

  17. Community-Based Participatory Research CBPR Conceptual Model: Wallerstein et al. 2010

  18. Impact on QI in Indigenous PHC • Improvement in health outcomes-intervention group, Barcelo 2010, Orobaton 2007 • Improvement in outcomes for intervention groups but no difference between 2 levels of intervention intensity, Levine 2003 • Improved outcomes - some centres, some ethnic groups, not all, El Fakiri 2008  • Implementation of QI processes, Balcazar 2012, Giarratano 2005 • Strengthening of collaboration, Gulzar 2005 • Improvement in health provider knowledge, El Nouman 2009 • Increase in utilisation of PHC services, El Nouman 2009 • Built capacity and resources, Levine 2003, Nacapoy 2008 • Satisfaction with partnership benefits, El Ansari 2004

  19. Strategies/Mechanisms Used • Community and local authority mobilisation, Balcazar 2012, El Nouman 2009, Giarratano 2005 • Culturally specific approaches/interventions, Giarratano 2005, Levine 2003 • Indigenous community participation – intervention development, implementation and evaluation, Levine 2003, Nacapoy 2008 • Change agents identified at 5 levels: individual, interpersonal, organisational, community, policy (ecological approach), Balcazar 2012 • Community-based health workers, (eg, under local clinic supervision), Balcazar 2012, El Fakiri 2008, Giarratano 2005, Levine 2003, Orobaton 2007 • Self-management education, Balcazar, 2012, Barcelo 2010, El Fakiri 2008, El Nouman 2009, Levine, 2003 • Building capacity and resources, Levine 2003, Nacapoy 2008

  20. Strategies/Mechanisms Used • In-service training for PHC personnel,Barcelo 2010, El Nouman, 2009 • Provision of technical advice -national, international professionals,Barcelo 2010 • Community-based advisory board, Balcazar 2012, Levine 2003, Gulzar, 2005 • Health system changes, Barcelo 2010, Giarratano 2005 • Evidence-based guidelines, Barcelo, 2010, El Fakiri 2008, Nakapoy 2008 • Program evaluation, Giarratano 2005, Levine 2003

  21. Conclusion • Project management – clearly defined professional roles/responsibilities within collaboration, el Fakiri, 2008, Nakapoy 2008 • Budget constraints, Barcelo 2010, Gulzar, 2005 • Time requirements, Balcazar 2012, Barcelo 2010 • Avoiding ‘contamination’ of control sites in RCTs, Barcelo 2010 • RCT enrolment, reachability; drop-out rates high, El Fakiri, 2008 • Real-world challenges in maintaining consistency/adherence to study protocols across community partner settings, Nacapoy, 2008 • Balance between science and practice, Levine 2003, Nacapoy 2008 Challenges in Indigenous PHC Collaborations for QI But, Collaboration is Critical to Effective PHC Strategies in Closing the Gap

  22. Contact details: Dr Frances Cunningham: frances.cunningham@menzies.edu.au Thank you References: Cunningham et al 2012 BMJ Quality & Safety 2012; 21(3): 239-49. Varda et al 2012 American Journal of Public Health 2012; 102(3): 564-71. Malby et al 2012 Centre for Innovation in Health Management, University of Leeds, Aveling et al 2012 Journal of Health Organisation and Management, 26(2):158-174. Chambers et al 2012 PLoS ONE 2012; 7(8): e41911. ABCD National Research Partnership: www.menzies.edu.au/abcd

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