The rise and rise of chronic disease in Far North Queensland A new Centre for Chronic Disease Prevention at JCU Cairns Snapshot of past, current and future work Robyn McDermott MBBS, FAFPHM, MPH, PhD. Director CCDP, JCU Cairns CBH Grand Rounds Friday 28 March 2014. Block “A” Lecture Theatre 12.15-1.30pm Today • Brief background and selected past and current descriptive work in far north Queensland • Approach of the CCDP • Interventions • Where are we heading? Some “political arithmetic of crowd disease” in Australia: CVD Death rates, 2007-8 Source: AIHW 2011, Age-standardised deaths per 100,000 CVD hospitalisation rates, 2007-8 Source AIHW 2011: Age standardised hospitalisations per 100,000 Prevalence of diabetes, Indigenous NQ (WPHC) and Australia (AusDiab), 1999-2000 60 50 40 Non-Indigenous Aboriginal Torres Strait Islander 30 20 10 0 15-24 25-34 35-44 45-54 55-64 65+ Age standardised rates for “ACS” avoidable admissions by Queensland Health District, 2003-6 Source: QHAPDC, 2007 (rates per 100,000) Ambulatory Care Sensitive (ACS) avoidable hospitalisations for selected chronic diseases, Queensland, 1999-2006. Source: QAPDC, 2007, rates per 100,000 Potentially Preventable Hospitalisations in SA (2007-9) - Top 15 Adjusted incidence rate ratios for CHD events in FNQ Aboriginal and TSI adults, 2000-7 (n=1706) Source: McDermott et al, MJA, 2011 Measure IRR 95% CI Obesity 1.7 1.01-2.8 High BP (>140/90) 1.5 1.01-2.3 Smoking 1.4 0.9-2.2 Low HDL (<1.0mmol/l) 1.3 0.9-1.9 High TG (>=2.0 mmol/l) 1.9 1.3-2.7 IFG (FBG 5.5-6.9 mmol/l) 1.3 0.8-2.2 Diabetes (FBG >=7.0) 2.4 1.6-3.6 Micro-albuminuria 1.4 0.9-2.3 Macro-albuminuria 4.6 2.9-7.1 Glycemia and albuminuria, especially when combined, predict much of the “gap” in CHD incidence • Baseline prevalence of high glycemia is >25% • Baseline prevalence of albuminuria (>3.4 mmol/l) = 33.5% • Those with diabetes at baseline were 5.5 (4.2-7.3) times more likely to have albuminuria than those without diabetes • Adjusted CHD IRR for both diabetes and albuminuria = 5.9 (3.4-10.1) Risk accumulation along the care continuum Low birth weight Maternal diabetes in pregnancy Epigenetics Adolescent adiposity Poor nutrition Smoking High BP Lipids Glycaemia etc Screening and Secondary prevention in primary care Death Hospitalisation for complications “pushback” – CCDP preventive approach Rehab Improve preventive systems for CD management Cluster Randomised Trial of HW-managed diabetes care system improvement in the Torres Strait, 1999-2001. Study Design and Patient Recruitment 21 eligible clinics Baseline data collection Random allocation 8 intervention sites (250 patients: mean age 52.1, SD 13.1 yr) 51 patients added to regs 13 control sites (305 patients: mean age 52.4, SD 13.9 yr) Diabetes outreach team 1. Diabetologist 2. Nutritionist 3. Diabetes healthcare worker 4. Podiatrist 121 patients added to regs Intervention Recall and reminder system Health worker training Regular phonecalls Newsletter Workshop 19 patients lost to follow-up Follow-up data collection (282 patients) 30 patients lost to follow-up Follow-up data collection (396 patients) Hospitalisation of people with diabetes, Torres Strait, 19992002 (n=921), Cape York 2002-3 (n=240): Proportion of diabetics hospitalised for avoidable conditions in previous 12 months 30 25 20 DR HospTorres Other hosp Torres DR Hosp Cape Other Hosp Cape 15 10 5 0 1999 2000 2002 2003 Can improved care processes be sustained with rising caseloads and current workforce configuration? Snapshot from Island in the Central Group Torres, 2009. Incident cases 3%, younger ages, increasing obesity Source: Forbes et al, 2012. Measure 2004, n=34 2009, n=67 ANDIAB 2009 Age 54 52.4 56.8 Median HbA1c 9.35 9.53 8.0 Current smokers (%) 29% 30% 10% % “good” glycemic control (A1c<7%) 16 20 26 % taking insulin 16% 32% 35% % without albuminuria 25% 33% 67% Mean weight, kg (BMI) 96.14 (34.7) 101.74 (35.9) N/A (30.2) Getting Better at Chronic Care (GBACC) in North Queensland: a cluster RCT of community health worker care coordination in remote FNQ settings Robyn McDermott, Barbara Schmidt, Vickie Owens, Cilla Preece, Sean Taylor, Adrian Esterman “Getting better at chronic care” Cluster RCT of health-worker led case management for high risk clients Aim: Test if HW-led care for high risk poorly managed adults with complicated T2DM would improve care processes (checks, referrals, self management) and outcomes Primary outcome: improved HbA1c Secondary outcomes: Improved QoL, reduced CVD risk factors and complications (avoidable hospitalisations) Mixed methods evaluation in 3 phases NHMRC Partnership Project, 2011-2015 GBACC: mixed methods evaluation in 3 phases Phase 1 (Intervention period: March 2012 – Sept 2013) • Randomised controlled trial of intensive case management by IHWs Phase 2 (Nov 2013 – Feb 2014) • Review of lessons learned • Implementation plan Phase 3 (May 2014 – June 2015) • Economic analysis • Rollout of model 12 Participating Communities *Intervention sites in phase 1 (randomly allocated) Torres and NPA HHS • Badu* • Bamaga • Injinoo* • New Mapoon • Seisia • Umagico* Cape York HHS • Kowanyama* • Mapoon* • Mareeba (Mulungu) Cairns and Hinterland HHS • Mossman Gorge (ACYHC)* • Napranum • Yarrabah (GYHS) PHASE 1: COCONSORT DIAGRAM: GBACC, 2012-14, 2012-14RCT) Enrolment: 12 sites recruited and 327 patients assessed as eligible Baseline data collected, n=213 Excluded: 114 patients declined to participate Group randomisation: 12 sites Intervention: 6 sites (n=100 patients) Received intervention, n=100 Lost to follow-up (n=16) • • Allocated to waitlist group: 6 sites (n=113 patients) Allocation Follow up Lost to follow up (n=6) • • • Moved away (12) Died (4) Moved away (3) Died (2) Withdrew from study (1) Analysis Analysed for primary outcome, n= 84 (84%) Analysed for primary outcome, n=108 (96%) Clinical care processes at baseline and follow up (%) Baseline Foot check% Endpoint (excluding 22 loss of follow up) Control n=113 Intervention n=100 Control n=107 intervention n=84 No No % (95% CI) No % (95% CI) No % (95% CI) 31.0 (21.8-40.2) 38 35.5 (26.3-44.7) 26 31.0 (20.9-41.0) 50 % (95% CI) 44.2 (35.0-53.5) 31 Seen by DM educator 46 % Seen by dietician % 22 40.7 (31.6-49.9) 52 52.0 (42.1-61.9) 41 38.3 (29.0-47.6) 44 52.4 (41.6-63.2) 19.5 (12.1-26.8) 30 30.0 (20.9-39.1) 21 19.6 (12.0-27.2) 37 44.0 (33.3-54.8) Dentist check % 20 17.7 (10.6-24.8) 13 13.0 (6.3-19.7) 9 8.4 (3.1-13.7) 15 17.9 (9.6-26.5) ECG check% 37 32.7 (24.0-41.5) 42 42.0 (32.2-51.8) 34 43.9 (34.4-53.4) 35 40.5 (29.8-51.1) Eye check % 54 47.8 (38.5-57.1) 42 42.0 (32.2-51.8) 56 52.3 (42.8-61.9) 37 44.0 (33.3-54.8) Smoker % 38 34.5 (25.6-43.5) 34 35.1 (25.5-44.7) 33 31.2 (22.4-40.4) 34 41.5 (30.7-52.2) Blood sugar selfmonitor % 45 40.9 (31.6-50.2) 46 46.0 (36.1-55.9) 63 59.4 (50.0-68.9) 44 52.4 (41.6-63.2) Taking insulin% 55 48.7 (39.4-58.0) 40 40.0 (30.3-49.7) 47 43.9 (34.4-53.4) 40 47.6 (36.8-58.4) Dyslipidemia % 83 73.5 (65.2-81.7) 84 84.0 (76.7-91.3) 91 85.0 (78.2-91.9) 76 90.5 (84.1-96.8) Taking lipid lowering medicines% 5 4.4 (0.6-8.3) 3 3.0 (-0.4-6.4) 3 2.8 (-0.4-6.0) 5 6.0 (0.8-11.1) Albuminuria and taking ACEi or ARB drugs Adherent to all medicines Had Fluvax 46 88.5 (79.6-97.3) 47 88.7 (80.0-97.4) 58 82.9 (73.9-91.8) 51 89.5 (81.4-97.6) 53 46.9 (37.6-56.2) 55 55.0 (45.1-64.9) 57 53.3 (43.7-62.8) 41 48.8 (38.0-59.6) 50 44.2 (35.0-53.5) 66 66.0 (56.6-75.4) 51 47.7 (38.1-57.2) 50 59.5 (48.9-70.2) HbA1c measures at baseline and follow-up by group, absolute values: GBACC Phase 1 trial results 11.5 11 10.5 Control 10 Intervention 9.5 9 8.5 Baseline Endpoint FNQ Hospital Avoidance Trial Cairns, Innisfail, Mareeba 2014-16 Health Innovation Fund Project Overview Funded by QH (CARU) Neil Beaton, Mary Streatfield, Robyn McDermott Aim: to evaluate a new approach to community-based management of “frequent flyers” in FNQ hospitals – Hospital Avoidance Trial, 2013-16 Background: Pilot HAP in Cairns showed a dramatic reduction in ED and inpatient episodes in 68 frequent flyers using a nurse-led case management approach. • Pragmatic RCT of intensive community-based case management of frequently hospitalised adults with chronic conditions in 3 CHHHS sites • 530 patients in 3 sites randomly assigned to • 265 Intervention: usual care plus shared electronic record including CDM tool, close case management (caseload for each care co-ord =<40) and selfmanagement training and support • 265 “controls”: usual care (referral to a medical home with offer of shared record) • Eligibility criteria: 8 or more ED/inpatient episodes in the previous 12 months • Evaluation endpoints: Avoidable ED visits or hospital admissions over 18 months, care processes (GPMP, referrals, self management training), intermediate clinical indicators (HbA1c, BP, Lipids, UACR/eGFR), disease progression, quality of life • Economic (DRGs and AQoL) and process evaluation 2012-13 FY ED and Separations (patients) Number of Visits Cairns >=5 >=8 ED Inpatient Total 1,105 543 2,979 324 187 1,006 ED Inpatient Total 751 122 1,077 235 40 352 ED Inpatient Total 369 95 682 104 32 234 ED Inpatient Total 2,225 760 4,738 663 259 1,592 Mareeba Innisfail Total of three sites FNQ HAT Trial design Patient recruitment 3 sites, n=530 Baseline interviews + data collection Randomisation Control group: n=265 Usual best practice care GPMP, cdmNet audit & feedback Intervention group: n=265 GPMP, cdm tool audit & feedback + Case manager Process evaluation including fidelity of implementation Follow up data collection: Interviews, ED & inpatient episodes Cdm tool audit, HIC/PBS, costings Follow up data collection: Interviews, ED & inpatient episodes Cdm tool audit, HIC/PBS, costings The patient journey, FNQ HAT Patient identified as eligible by EDIS/HBCISand invited to participate in the trial Consent not obtained Not in trial, usual care Consent obtained Care co-ordinator conducts baseline assessment and interview, arranges GP referral and GP consent to be in trial Randomisation Usual care group: Offer of shared record, Referrals to AHPs Data capture and QI reports to GPs from ED/IP and CDM tool Intervention group: GPMP, referrals, CDM tool, Care coordination, self management training and support Self management training GPMP and referrals, care co-ordinator Allied health and medical specialists Other services as required Hospital admissions and ED visits Why a Randomised Controlled Trial Design? • RCT is the most robust study design which will give the highest level of evidence: all previous published studies looking at hospital avoidance (a complex intervention in a complex environment) were uncontrolled before-and-after designs – weak evidence for policy change and unable to be properly evaluated economically • Controls provide the counterfactual for robust clinical and economic analysis • Randomisation deals with selection/allocation bias • Controls deal with secular trends in exposures and outcomes, regression to the mean and changes in the policy and fiscal environment. • Good pilot data gives a clear effect size so a robust power calculation (sample size) will ensure the question can be clearly answered without (too much) statistical error • Will be publishable and in the public domain, not sit on the shelf • High scientific quality will be competitive for matching NHMRC Partnership Project Grant funding Expanding the impact of our research Source: Duryea, Hochman, Parfitt. Research Global: Feb 2007. Traditional quality domain Research impact scope Research outputs: Research Transfer: Research Outcomes: Research Impact: eg Discoveries Publications Patents Engagement with end users New products or services Value added, Improvements achieved National benefits Association between PHC resourcing (staff) and costs of hospitalisation among diabetics in FNQ remote communities, 2001-5 (Gibson, Segal, McDermott 2011) 4000 Diabetes-related hospital admissions> and PHC Staffing^ (All FTE staffing levels) 3000 13 2000 10 2 21 5 4 1 1000 11 8 12 15 20 6 14 17 7 0 18 .005 .01 .015 .02 Mean phc staffing per person Communities Fitted values >Jan2001-Dec2005.^2003/04-Dec2005.Source:QldHealth. C-Coeff: -0.6862*(0.05sig) .025 ACKNOWLEDGEMENTS The CCDP is supported by QH Senior Clinical Research Fellowship and the Australian Primary Health Care Research Institute (APHCRI) as a PHC Centre for Research Excellence (CRE) GBACC is supported by NHMRC Partnership project grant 570149 FNQ HAT is funded by QH (CARU) CCDP and CRE team includes: Admin: Jacqui Lavis and Sally McDonald Clinical Epidemiology: Sandy Campbell*, Robyn McDermott*, Klaus Gebel, Linton Harriss Biostatistics/informatics: Haider Mannan, Arindam Dey Community-based prevention studies group: Alan Clough*, Caryn West* PhD students: Ashleigh Sushames, Sean Taylor*, Barb Schmidt, Jan Robertson, Dympna Leonard, Russell Hayes, Richard Turner, Malcolm Forbes* (Masters) Health Economics: Kenny Lawson Clinical Research Associates: Vickie Owens, Cilla Preece Collaborating institutions: QH, UniSA, SAHMRI, UQ, Melbourne University, Baker-IDI, Menzies School of Health Research, Apunipima CYHC, Gurinny, Mulungu, AHCSA, QAIHC, UNSW *Receiving NHMRC or NHF Fellowship support
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