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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 • 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, 2007-8Source AIHW 2011: Age standardised hospitalisations per 100,000
Prevalence of diabetes, Indigenous NQ (WPHC) and Australia (AusDiab), 1999-2000
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 • 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 Rehab “pushback” – CCDP preventive approach
Cluster Randomised Trial of HW-managed diabetes care system improvement in the Torres Strait, 1999-2001.
Hospitalisation of people with diabetes, 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”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
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 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%)
HbA1c measures at baseline and follow-up by group, absolute values: GBACC Phase 1 trial results
FNQ Hospital Avoidance 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
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 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? • 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 researchSource: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 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