Transcript Document

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
Falls in maternal, infant, childhood and infectious deaths in
Aborigines
…. counter-balanced by a new
epidemic of deaths from chronic
diseases.
Excess Death
in Australian Aborigines, 2000
Diabetes 12%
Respiratory 10%
All other 20%
Cardiovascular 31%
Digestive 6%
Life expectancy  > 20 years and
more
Chronic diseases include
type 2 diabetes, hypertension,
renal disease, cardiovascular
disease and chronic lung
disease
Neoplasms 6%
External 15%
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
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
K.D.R.P
Kidney Disease Research and Prevention
– Reduce the impact of chronic 'lifestyle'
diseases diabetes, high blood pressure and
kidney disease.
– Identify and modify risk factors, early
diagnosis and systematic treatment
– 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
Indigenous vs nonIndigenous Australians,
Incidence Rate of Treated ESRD, 1992-2001, by
Age Group
Incidence per million (95% CI)
2500
2000
1500
1000
500
0
0-14
15-24 25-34 35-44 45-54
Age group, years
55-64
65+
Stewart et al, Nephrology, 2004
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
analysis time, yr
4
Survival benefit in nondiabetics, diabetics,
normotensives, hypertensives, prior ACEI, no prior ACEI
Chronic Disease Outreach Program in Australia
Tiwi Islands
Wadeye
Broome
Naiuyu
Bega, Kalgoorlie
Borroloola
Woorabinda
Cherbourg
Tiwi Islands
Tiwi Islands
Darwin
Estimated Rates of Morbidities By Community
50
45
Percent of People Tested
40
Diabetes
Kidney Problem
Hypertension
35
30
25
20
15
10
5
0
Wadeye
Naiuyu
Borroloola
* Rates of morbidities differ by community
Pilot studies are needed to anticipate required services
*
Prevalence of Conditions by Age Group (Borroloola)
80
Diabetes
70
Kidney problem
60
Hypertension
Percent afflicted
50
40
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
“Integrated" nature of Chronic
Diseases
“Integrated" nature of the three
conditions, HT, diabetes and
proteinuria
 using Borroloola as the model.
Prevalence of Chronic Conditions by Age in Tiwi Adults
80
70
60
50
40
30
Obese
Diabetes/IGT
Hypertension
ACR>=3.4
GFR<90
20
10
0
18-29 yr
30-39 yr
40-49 yr
50+ yr
Overlapping morbidities among screened adults in Borroloola
9%
3%
14%
34%
20%
2%
3%
14%
Screened Adults
Renal Disease(46%)
Hypertension (52%)
Diabetes (29%)
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
Diabetes,
n=86, or 27%
3
18
11
6
43
16
5
Hypertension,
n=149, or 47%
12
28
12
9
Percent with one or more conditions including obesity
Wadeye 30%; Naiuyu 57%; Borroloola 70%
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?
Steps in initiating KDRP
activities
1.
2.
3.
4.
5.
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
Critical Components of the
outreach program
•
•
•
•
•
Education and training
Testing (screening)
Treatment
Information systems
Evaluation
A Typical Health Centre in a remote
Indigenous community
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
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
Web based database
Training in progress
Interaction among KDRP staff members
Nurses and
health workers
Nursing Coordinator
Administrative and
computational
support
Program Director
Doctor/Specialist
Community-Base Dialysis Starts and Natural Deaths
in Adults (18+ yr), Annual Rolling Average, mid 2003
20
18
16
Number of People
14
12
10
8
6
4
2
0
Treatment Program Begins
Dialysis Starts
Natural Deaths
Cost Effectiveness Estimates of
Treatment Program (Philip Baker)
1. Cost per patient per year for first 2 years:
< $ 1,200
2. 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
3. Add reduced hospitalisations
4. Add value of a year of death postponed in
prime of life
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 nonIndigenous staff
• Treatment requirements overwhelm the system
where the disease burden is high
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)
Outreach Program: Blood Pressure Changes
in People with Vasoactive Drugs Started or Adjusted
BP, mean (CI)
Everyone, n=174
(treatment for hypertension,
diabetes, renal protection)
BP>=140/90 at Baseline, n=105
160
160
150
150
140
130
SBP
136
130
110
110
90
DBP
88
80
70
MAP
97
81
First BP
Most Recent BP
134
130
120
100
SBP
140
120
104
148
100
90
113
96
MAP
DBP
84
80
70
P<0.001 for all: check this
101
First BP
Most Recent BP
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.
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.
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
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!
KDRP Team
• 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
Thank You