Pap smear participation rates, primary healthcare and Indigenous women

To the Editor: As practitioners in a community-controlled Aboriginal and Torres Strait Islander primary healthcare centre, striving to better meet the healthcare needs of our community, we would like to offer some thoughts on a recent article by Coory et al.

An intensive smoking intervention for pregnant Aboriginal and Torres Strait Islander women: a randomised controlled trial

Objective: To determine the effectiveness of an intensive quit-smoking intervention on smoking rates at 36 weeks’ gestation among pregnant Aboriginal and Torres Strait Islander women. Design: Randomised controlled trial. Setting and participants: Pregnant Aboriginal and Torres Strait Islander women (n= 263) attending their first antenatal visit at one of three Aboriginal community-controlled health services between June 2005 and December 2009. Intervention: A general practitioner and other health care workers delivered tailored advice and support to quit smoking to women at their first antenatal visit, using evidence-based communication skills and engaging the woman’s partner and other adults in supporting the quit attempts. Nicotine replacement therapy was offered after two failed attempts to quit. The control (“usual care”) group received advice to quit smoking and further support and advice by the GP at scheduled antenatal visits. Main outcome measure: Self-reported smoking status (validated with a urine cotinine measurement) between 36 weeks’ gestation and delivery. Results: Participants in the intervention group (n = 148) and usual care group (n= 115) were similar in baseline characteristics, except that there were more women who had recently quit smoking in the intervention group than the control group. At 36 weeks, there was no significant difference between smoking rates in the intervention group (89%) and the usual care group (95%) (risk ratio for smoking in the intervention group relative to usual care group, 0.93 [95% CI, 0.86–1.08]; P = 0.212). Smoking rates in the two groups remained similar when baseline recent quitters were excluded from the analysis. Conclusion: An intensive quit-smoking intervention was no more effective than usual care in assisting pregnant Aboriginal and Torres Strait Islander women to quit smoking during pregnancy. Contamination of the intervention across groups, or the nature of the intervention itself, may have contributed to this result

Evaluating performance of and organisational capacity to deliver brief interventions in Aboriginal and Torres Strait Islander medical services

Objective: This study assessed brief intervention (BI) activity and organisation capacity for smoking, nutrition, alcohol and physical activity (SNAP framework) and key clinical prevention activities in four Aboriginal and Torres Strait Islander medical services in Queensland. Methods: A mixed methods design was used including: staff surveys of knowledge and attitudes (n=39), focus groups to discuss perceived barriers and enablers and chart audits (n=150) to quantify existing BI activity. Results: Of 50 clinical staff, 46 participated in the staff survey and focus groups across the four sites. BI was perceived to be important. There was significant variation in completion of records for SNAP risk factors, key clinical and BI activities across the sites. At least one SNAP factor status was recorded in 130/150 (86.7%) patient charts audited and there was a significant trend of increased recording of SNAP factors with increasing number of patient visits. Of those identified at risk 78% received at least one BI. Where risk was identified 65/96 (67.7%) patients required multiple BIs. BI for tobacco use was consistently high across all sites. Only one site recorded regular care planning and Adult Health Checks. Impacting factors included leadership, high staff turnover, multiple medical records and staff health status. Conclusions: Inflexible staff training, competing health priorities and high levels of staff turnover were identified as key barriers to the delivery of BI in clinical settings. The data suggests a good base of existing BI activity for smoking and key clinical activities which may improve with further support

The Treatment of cardiovascular Risk in Primary care using Electronic Decision suppOrt (TORPEDO) study: intervention development and protocol for a cluster randomised, controlled trial of an electronic decision support and quality improvement intervention

Background: Large gaps exist in the implementation of guideline recommendations for cardiovascular disease (CVD) risk management. Electronic decision support (EDS) systems are promising interventions to close these gaps but few have undergone clinical trial evaluation in Australia. We have developed HealthTracker, a multifaceted EDS and quality improvement intervention to improve the management of CVD risk. Methods/design: It is hypothesised that the use of HealthTracker over a 12-month period will result in: (1) an increased proportion of patients receiving guideline-indicated measurements of CVD risk factors and (2) an increased proportion of patients at high risk will receive guideline-indicated prescriptions for lowering their CVD risk. Sixty health services (40 general practices and 20 Aboriginal Community Controlled Health Services (ACCHSs) will be randomised in a 1:1 allocation to receive either the intervention package or continue with usual care, stratified by service type, size and participation in existing quality improvement initiatives. The intervention consists of point-of-care decision support; a risk communication interface; a clinical audit tool to assess performance on CVD-related indicators; a quality improvement component comprising peer-ranked data feedback and support to develop strategies to improve performance. The control arm will continue with usual care without access to these intervention components. Quantitative data will be derived from cross-sectional samples at baseline and end of study via automated data extraction. Detailed process and economic evaluations will also be conducted. Ethics and dissemination: The general practice component of the study is approved by the University of Sydney Human Research Ethics Committee (HREC) and the ACCHS component is approved by the Aboriginal Health and Medical Research Council HREC. Formal agreements with each of the participating sites have been signed. In addition to the usual scientific forums, results will be disseminated via newsletters, study websites, face-to-face feedback forums and workshops. Trial registration: The trial is registered with the Australian Clinical Trials Registry ACTRN 12611000478910