High absolute risk of severe infections among Indigenous adults in rural northern Australia is amplified by diabetes: a 7 year follow up study

Aims: To quantify the risk of hospitalization for infections in Indigenous Australian adults with diabetes in rural and remote communities. Methods: 2787 Indigenous adults including 396 with diabetes at baseline from 19 communities in North Queensland from 1998 to 2007 were included in the study. Main measures were weight, height, waist circumference, blood pressure, fasting glucose, lipids, self-reported tobacco smoking, alcohol intake and physical activity. Baseline data were linked to hospital separation data using probabilistic linkage. The association between diabetes and hospitalization for all causes and infections was investigated using generalized linear model (GLM) and adjusted for other baseline measurements. Results: During a median follow up of 7 years, 461 participants were hospitalized with 762 episodes of infection. 277 patients with diabetes (70%) were hospitalized at least once. 40% (110 in 277) were for community acquired infections. Patients with diabetes were twice as likely to be hospitalized for infections as those without diabetes (adjusted risk ratio 2.1, 95% CI 1.6–2.8), especially for urinary tract infections, cellulitis, and septicaemia. Median length of stay was 6 (IQR 3–13) days for diabetes patients compared to 3.4 days (IQR 2–6.4) for those without diabetes (P < 0.001) Conclusions: In addition to an already high rate of hospitalizations for infections among Indigenous compared to non-Indigenous Australians, diabetes confers an additional risk for severe infections especially urinary tract infection, cellulitis and septicaemia. Recovery is also comparatively slower. Early recognition and management of these infections in the primary care setting may reduce this risk and better control of glycaemia and its risk factors may improve underlying immune dysfunction

CRE in Prevention of chronic conditions in rural and remote high risk populations 2012-15

APHCRI Conversations was a regular program of presentations held at the Department of Health to facilitate exchange between APHCRI Network researchers and Department policymakers. Topics are developed jointly with the Department of Health and involve a range of speakers from APHCRI, including CRE invited experts, CRE Chief Investigators and stream project Chief Investigator

Accuracy of national key performance indicator reporting from two Aboriginal medical services: potential to underestimate the performance of primary health care

Objective: The aim of the present study was to assess the accuracy of extracting national key performance indicator (nKPI) data for the Online Community Health Reporting Environment for Health Services (OCHREStreams) program using the Pen Computer Systems (Leichhardt, NSW, Australia) Clinical Audit Tool (CAT) from Communicare (Telstra Health Communicare Systems, Perth, WA, Australia), a commonly used patient information management system (PIMS) in Aboriginal primary care. Methods: Two Aboriginal Community-Controlled Health Services (ACCHSs) were recruited to the present study. A sample of regular clients aged ≥55 years from each ACCHS was selected and a subset of 13 nKPIs was examined. A manual case note audit of the nKPI subset within Communicare was undertaken by a clinician at each participating ACCHS and acted as a ‘gold standard’ comparator for three query methods: (1) internal Communicare nKPI reports; (2) PenCS CAT nKPI manual filtering (a third-party data-extraction tool); and (3) nKPI data submitted to the Improvement Foundation qiConnect portal. Results: No errors were found in nKPI data extraction from Communicare using the CAT and subsequent submission to the qiConnect portal. However, the Communicare internal nKPI report included deceased clients and past patients, and we can be very confident that deceased clients and past patients are also included in the qiConnect portal data. This resulted in inflation of client denominators and an underestimation of health service performance, particularly for nKPIs recording activity in the past 6 months. Several minor errors were also detected in Communicare internal nKPI reports. Conclusions: CAT accurately extracts a subset of nKPI data from Communicare. However, given the widespread use of Communicare in ACCHSs, the inclusion of deceased clients and past patients in the OCHREStreams nKPI data program is likely to have resulted in systematic under-reporting of health service performance nationally

Temporal variation in cardiovascular disease risk predicted by albuminuria: an opportunity for clinical intervention?

Albuminuria predicts cardiovascular disease (CVD) events but it is likely to vary over time in a nonlinear fashion. The aim of this study was to estimate the potentially differing predictive effect of albuminuria on the risk of CVD or related death over time. Data were from a cohort study of 3505 predominately indigenous adults from remote communities in Queensland, Australia, 1999-2006. Cox Proportional Hazards model analysis of the predictive effects of urinary albumin creatinine ratio on the risk of CVD or CVD-related death was undertaken for incident and prevalent CVD. Analyses sequentially removed those who had a cardiovascular event or related death for the first year through to six years. The baseline prevalence of microalbuminuria was 21.2% and for macroalbuminuria 6.7%. The incidence of CVD was 92 in 13,812 person-years. Microalbuminuria predicted incident CVD with a Hazard Ratio (HR) of 3.0 (95% CI 1.83 - 4.96) and for macroalbuminuria HR 10.8 (95% CI 6.58 - 17.68) and for those with pre-existing CVD, HR 2.6 (95% CI 1.65 - 3.97) and HR 9.7 (95% CI 6.38 - 14.82) respectively. People with macroalbuminuria who survived the first three years had a crude HR of an incident cardiovascular event or death of 13.0 (95% CI 6.45 - 26.39) to a peak of 32.3 (95% CI 8.55 - 121.77) for those who survived the first five years. The hazard appeared to drop in the 6th year although this is based on small numbers.The first three years after finding macroalbuminuria provide a potential window opportunity to actively manage the risk of incident CVD before the risk elevates

Do worms protect against the metabolic syndrome? A systematic review and meta-analysis

Aims: There is increasing evidence on the role of helminth infections in modifying autoimmune and allergic diseases. These infections may have similar effect in other inflammatory processes, such as insulin resistance. This review aims to examine the literature on the effect of helminthic infections on metabolic outcomes in humans. Methods: Using the PRISMA protocol, we searched the literature using PubMed, MEDLINE, and a manual review of reference lists. Human studies published in English after 1995 were included. Four papers were included in this review. Data was extracted and a meta-analysis was conducted using a random-effects model. Heterogeneity was assessed using Tau(2) and I(2) tests. Results: The included studies found that infection was associated with lower glucose levels, less insulin resistance, and/or a lower prevalence of metabolic syndrome (MetS) or type 2 diabetes mellitus (T2DM). Meta-analysis showed that participants with a previous or current helminth infection were 50% less likely to have an endpoint of metabolic dysfunction in comparison to uninfected participants (OR 0.50; 95% CI 0.38-0.66). Conclusion: This review has shown that helminth infections can be associated with improved metabolic outcomes. Understanding of the mechanisms underlying this relationship could facilitate the development of novel strategies to prevent or delay T2DM

Exploring the measure of potentially avoidable general practitioner-type presentations to the emergency department in regional Queensland using linked, patient-perspective data

Objective. To explore measures of potentially avoidable general practitioner (PAGP)-type presentations to the emergency department (ED) of a large regional hospital in northern Queensland. Methods. Linkage of an ED administrative dataset to a face-to-face patient survey of local residents (n = 1000); calculation of Australian Institute of Health and Welfare (AIHW) and Australasian College of Emergency Medicine (ACEM) measures of PAGP-type presentations to the ED; and exploration of these measures with patient-perspective linked data. Results. PAGP-type presenters to the ED were younger in age (median age in years: total cohort: 49; AIHW 38, P , 0.001; ACEM 36, P , 0.001); with the odds of having a chronic condition being less likely for AIHW PAGP-type presenters than other ED presenters (OR (95% CI) 0.54 (0.38–0.77): P = 0.001)) after adjustment for age. PAGP-type presenters nominated reasons of convenience rather than urgency as their rationale for attending the ED, irrespective of measure. The number of PAGP-type presentations to the ED identified by the AIHW measure was more than three-fold higher than the ACEM measure (AIHW: n = 227; ACEM: n = 67). Influencing factors include the low proportion of ED attendees who had a medical consultation time of ,1 h at this hospital site (1-month survey period: 17.8%); and differences between the patient self-report and ED administrative record for 'self-referral to the ED' (Self-referred: Survey 71% vs EDIS 93%, P , 0.001). Conclusions. Identification of PAGP-type presentations to the ED could be enhanced with improvements to the quality of administrative processes when recording patient 'self-referral to the ED', along with further consideration of hospital site variation for the length of medical consultation time

Impact of an integrated community-based model of care for older people with complex conditions on hospital emergency presentations and admissions: a step-wedged cluster randomized trial

Background: Health systems must reorient towards preventative and co-ordinated care to reduce hospital demand and achieve positive and fiscally responsible outcomes for older persons with complex needs. Integrated care models can improve outcomes by aligning primary practice with the specialist health and social services required to manage complex needs. This paper describes the impact of a community-facing program that integrates care at the primary-secondary interface on the rate of Emergency Department (ED) presentation and hospital admissions among older people with complex needs. Methods: The Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) study is a multicentre randomised controlled trial with a stepped wedge cluster design. General practitioners (GPs; n = 14) in primary practice within the Cairns region are considered ‘clusters’ each comprising a mixed number of participants. 80 community-dwelling persons over 70 years of age if non-Indigenous and over 50 years of age if Indigenous were included at baseline with no new participants added during the study. Clusters were randomly assigned to one of three steps that represent the time at which they would commence the OPEN ARCH intervention, and the subsequent intervention duration (3, 6, or 9 months). Each participant was its own control. GPs and participants were not blinded. The primary outcomes were ED presentations and hospital admissions. Data were collected from Queensland Health Casemix data and analysed with multilevel mixed-effects Poisson regression modelling to estimate the effectiveness of the OPEN ARCH intervention. Data were analysed at the cluster and participant levels. Results: Five clusters were randomised to steps 1 and 2, and 4 clusters randomised to step 3. All clusters (n = 14) completed the trial accounting for 80 participants. An effect size of 9% in service use (95% CI) was expected. The OPEN ARCH intervention was found to not make a statistically significant difference to ED presentations or admissions. However, a stabilising of ED presentations and a trend toward lower hospitalisation rates over time was observed. Conclusions: While this study detected no statistically significant change in ED presentations or hospital admissions, a plateauing of ED presentation and admission rates is a clinically significant finding for older persons with complex needs. Multi-sectoral integrated programs of care require an adequate preparation period and sufficient duration of intervention for effectiveness to be measured

Anaemia in early childhood among Aboriginal and Torres Strait Islander children of Far North Queensland: a retrospective cohort study

Objective: Early childhood anaemia affects health and neurodevelopment. This study describes anaemia among Aboriginal and Torres Strait Islander children of Far North Queensland. Methods: This retrospective cohort study used health information for children born between 2006 and 2010 and their mothers. We describe the incidence of early childhood anaemia and compare characteristics of children and mothers where the child had anaemia with characteristics of children and mothers where the child did not have anaemia using bivariate and multivariable analysis, by complete case (CC) and with multiple imputed (MI) data. Results: Among these (n=708) Aboriginal and Torres Strait Islander children of Far North Queensland, 61.3% (95%CI 57.7%, 64.9%) became anaemic between the ages of six and 23 months. Multivariable analysis showed a lower incidence of anaemia among girls (CC/MI p<0.001) and among children of Torres Strait Islander mothers or both Aboriginal and Torres Strait Islander mothers (CC/MI p<0.001) compared to children of Aboriginal mothers. A higher incidence of anaemia was seen among children of mothers with parity three or more (CC/MI p<0.001); children born by caesarean section (CC/MI p<0.001); and children with rapid early growth (CC/MI p<0.001). Conclusion: Early childhood anaemia is common among Aboriginal and Torres Strait Islander children of Far North Queensland. Poor nutrition, particularly iron deficiency, and frequent infections are likely causes. Implications for public health: Prevention of early childhood anaemia in ‘Close the Gap’ initiatives would benefit the Aboriginal and Torres Strait Islander children of Far North Queensland – and elsewhere in northern Australia

Preventable hospitalisations in regional Queensland: potential for primary health?

Objective The aims of this study were to: (1) use local health data to examine potentially preventable hospitalisations (PPHs) as a proportion of total hospital separations and estimated costs to a large regional hospital in northern Queensland, including differences associated with Indigenous status; and (2) identify priority conditions and discuss issues related to strategic local primary health intervention. Methods A cross-sectional analysis was conducted using Queensland Hospital Admitted Patient Data Collection data (July 2012–June 2014) restricted to 51 087 separations generated by 29 485 local residents. PPHs were identified from the International Statistical Classification of Diseases and Related Health Problems 10th Revision Australian Modification (ICD-10-AM) and procedure codes using National Healthcare Agreement definitions. Age-standardised separation rates were calculated using Australian 2001 reference population and associated economic costs were estimated using Australian-refined diagnosis related groups. Results Eleven per cent (n = 5488) of all hospital separations were classified as PPH, and most were for common chronic (n = 2486; 45.3%) and acute (n = 2845; 51.8%) conditions. Because many acute presentations reflect chronic underlying disease, chronic conditions account for up to 76.5% of all PPHs. Age-standardised PPH rates were 3.4-fold higher for Indigenous than non-Indigenous people. Associated 2-year costs were AU$32.7 million, which was 10.7% of estimated total health care expenditure for hospital separations, and were higher for Indigenous (14.9%) than non-Indigenous (9.7%) people. Conclusions High hospitalisation rates and costs for common preventable chronic conditions represent opportunities for primary healthcare interventions. In particular, community-level health services need to be more responsive to the needs of local Indigenous families

How effective are family-based and institutional nutrition interventions in improving children's diet and health? A systematic review

Background: Effective strategies to improve dietary intake in young children are a priority to reduce the high prevalence of chronic non-communicable diseases in adulthood. This study aimed to assess the impact of family-based and school/preschool nutrition programs on the health of children aged 12 or younger, including the sustainability of these impacts and the relevance to socio-economic inequalities. Methods: A systematic review of literature published from 1980 to December 2014 was undertaken. Randomised controlled trials involving families with children aged up to 12 years in high income countries were included. The primary outcomes were dietary intake and health status. Results were presented in a narrative synthesis due to the heterogeneity of the interventions and outcomes. Results: The systematic search and assessment identified 39 eligible studies. 82% of these studies were set in school/preschools. Only one school study assessed the impact of involving parents systematically. The family-based programs which provided simple positive dietary advice to parents and regular follow-up reduced fat intake significantly. School and family-based studies, if designed and implemented well, increased F& V intake, particularly fruit. Effective school-based programs have incorporated role-models including peers, teachers and heroic figures, rewards and increased access to healthy foods. School nutrition programs in disadvantaged communities were as effective as programs in other communities. Conclusions: Family and school nutrition programs can improve dietary intake, however evidence of the long-term sustainability of these impacts is limited. The modest overall impact of even these successful programs suggest complementary nutrition interventions are needed to build a supportive environment for healthy eating generally