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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.

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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
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, 2007-8Source: AIHW 2011, Age-standardised deaths per 100,000


Cvd hospitalisation rates 2007 8 source aihw 2011 age standardised hospitalisations per 100 000
CVD hospitalisation rates, 2007-8 Australia:Source AIHW 2011: Age standardised hospitalisations per 100,000



Age standardised rates for “ACS” avoidable admissions by Queensland Health District, 2003-6Source: 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



Adjusted incidence rate ratios for CHD events in FNQ Aboriginal and TSI adults, 2000-7 (n=1706)Source: McDermott et al, MJA, 2011


Glycemia and albuminuria especially when combined predict much of the gap in chd incidence
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 much of the “gap” in CHD incidence

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

Rehab

“pushback” – CCDP preventive approach


Improve preventive systems for cd management
Improve preventive systems for CD management much of the “gap” in CHD incidence


Cluster Randomised Trial of HW-managed diabetes care system improvement in the Torres Strait, 1999-2001.


Hospitalisation of people with diabetes, improvement in the Torres Strait, 1999-2001.Torres Strait, 1999-2002 (n=921), Cape York 2002-3 (n=240): Proportion of diabetics hospitalised for avoidable conditions in previous 12 months


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.


Getting Better at Chronic Care (GBACC) in North Queensland: a cluster RCT of community health worker care co-ordination in remote FNQ settingsRobyn McDermott, Barbara Schmidt, Vickie Owens, Cilla Preece, Sean Taylor, Adrian Esterman


“Getting better at chronic care” a cluster RCT of community health worker care co-ordination in remote FNQ settingsCluster 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
GBACC: mixed methods evaluation in 3 phases a cluster RCT of community health worker care co-ordination in remote FNQ settings


12 participating communities intervention sites in phase 1 randomly allocated
12 Participating Communities a cluster RCT of community health worker care co-ordination in remote FNQ settings*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: a cluster RCT of community health worker care co-ordination in remote FNQ settings

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

Allocated to waitlist group: 6 sites

(n=113 patients)

Allocation

Follow up

Lost to follow-up (n=16)

  • Moved away (12)

  • Died (4)

Lost to follow up (n=6)

  • Moved away (3)

  • Died (2)

  • Withdrew from study (1)

Analysis

Analysedfor primary outcome,

n= 84 (84%)

Analysed for primary outcome, n=108 (96%)


Clinical care processes at baseline and follow up
Clinical care a cluster RCT of community health worker care co-ordination in remote FNQ settingsprocesses at baseline and follow up (%)


Hba1c measures at baseline and follow up by group absolute values gbacc phase 1 trial results
HbA1c measures a cluster RCT of community health worker care co-ordination in remote FNQ settingsat baseline and follow-up by group, absolute values: GBACC Phase 1 trial results


Fnq hospital a voidance trial cairns innisfail m areeba 2014 16

FNQ Hospital a cluster RCT of community health worker care co-ordination in remote FNQ settingsAvoidance TrialCairns, Innisfail, Mareeba2014-16

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 self-management 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
2012-13 FY ED and Separations (patients) management of “frequent flyers” in FNQ hospitals –


Fnq hat trial design
FNQ HAT Trial design management of “frequent flyers” in FNQ hospitals –

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
The patient journey, FNQ HAT management of “frequent flyers” in FNQ hospitals –

Patient identified as eligible by EDIS/HBCISand invited to participate in the trial

Consent not obtained

Not in trial, usual care

Care co-ordinatorconducts baseline assessment and interview, arranges GP referral and GP consent to be in trial

Consent obtained

Randomisation

Usual care group:

Offer of shared record, Referrals to AHPs

Intervention group:

GPMP, referrals, CDM tool, Care co-ordination, self management training and support

Data capture and QI reports to GPs from ED/IP and CDM tool

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
Why a management of “frequent flyers” in FNQ hospitals –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
Expanding the impact of our research management of “frequent flyers” in FNQ hospitals –Source:Duryea, Hochman, Parfitt. Research Global: Feb 2007.

Research impact scope

Traditional

quality domain

National

benefits

Research

outputs:

eg

Discoveries

Publications

Patents

Research

Transfer:

Engagement

with end

users

Research

Outcomes:

New

products

or services

Research

Impact:

Value

added,

Improvements

achieved


Association between PHC resourcing (staff) and costs of hospitalisation among diabetics in FNQ remote communities, 2001-5 (Gibson, Segal, McDermott 2011)


ACKNOWLEDGEMENTS hospitalisation among diabetics in FNQ remote communities, 2001-5

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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