Improving the quality of diabetes care in general practice

Objective: The evidence treatment gap for patients with type 2 diabetes.
Design: A summary of convenience sample of seven general practices.
Setting: Metropolitan and rural Victoria, Australia.
Participants: 561 patients of general practices (75% from rural general practices).
Main outcome measures: Demographic data, duration of diabetes, diabetes complications, HbA1c and lipid levels, blood pressure and score on PHQ-9.
Results: Patients with depression show more severe, progressive and intensively treated diabetes. The prevalence of depression in diabetes is about twice that of the general population.
Conclusion: Australian guidelines for diabetes should recommend screening for depression.

Greater Green Triangle Risk Factor Study

Very limited data exist for chronic diseases and their risk factors and behaviours in the Greater Green Triangle (GGT) region, or anywhere in rural Australia. To identify health problems and to target interventions and monitor their impact it is necessary to have objective data on chronic disease risk factors. Three cross-sectional surveys were carried out in 2004, 2005 and 2006 in the GGT region in the south east of Australia. In 2004 the survey area was the Limestone Coast in South Australia, 2005 the Corangamite Shire in the south west of Victoria, and in 2006 the Wimmera district in central western Victoria. The data comprises physical measurements and results of blood samples that were taken from patients by specially trained survey nurses. It also comprises data extracted from follow up survey questionnaires that were sent to each patient who returned them through the mail.

Cholinesterase Research Outreach Project (CROP): measuring cholinesterase activity and pesticide use in an agricultural community

BACKGROUND: Australian farmers and their workers are exposed to a wide variety of pesticides. Organophosphate (OP) insecticides are a widely used class of pesticide used for animal husbandry practices (Naphthalophos for sheep dipping, jetting and drench), crop production for pest control (Dimethoate) and in public health (Maldison for head lice). Acute poisonings with this class of insecticide are reported among agricultural workers and children around the globe, due to the inhibition of acetylcholinesterase (AChE). Less is known about chronic exposures. Regular monitoring of erythrocyte AChE will enable farmers to identify potential exposure to organophosphate insecticides and take action to reduce exposures and improve their health and safety practices. This study aims to assess and improve the integration of AChE monitoring into routine point of care health clinics, and provide farming and non-farming people with a link between their AChE activity and their household chemical and agrichemical use. METHODS/DESIGN: The research will target individuals who work on mixed farming enterprises and routinely using OPs (n = 50) and non-farmers (n = 30). Baseline data are collected regarding demographic, health conditions and behaviours, Kessler 10 (K10) scores, chemical use and personal protection. Baseline anthropometric measures include height, weight, hip and waist circumference, body fat analysis and, biochemical analysis of fasted total serum cholesterol, triglycerides, low-density cholesterol (LDL), high-density cholesterol (HDL) and blood glucose. Analysis of erythrocyte cholinesterase (EAChE) activity is also conducted using a finger prick test. Testing of EAChE is then repeated in all participants every 3 weeks for a maximum of three times over a period 10 weeks. Participants are provided with full feedback and counselling about their EAChE activity after each reading and a detailed summary provided to all participants at the completion of the study. Data will be analysed using repeated measures within a general linear model. DISCUSSION: This work will provide an evidence base and recommendations for the integration of EAChE monitoring into Australian rural health clinics, leading to research which will further quantify pesticide exposure both on the farm and in the home, highlighting the importance of sustaining and providing a safe work and home environment for farming communities. TRIAL REGISTRATION: ACTRN12613001256763.

Oncology service initiatives and research in regional Australia

OBJECTIVE: This paper reflects on the recent growth of cancer research being conducted through some of Australia's rural centres. It encompasses work being done across the fields of clinical, translational and health services research. DESIGN: This is a collaborative piece with contributions from rural health researchers, clinical and cancer services staff from several different regions. CONCLUSION: The past decade has seen an expansion in cancer research in rural and regional Australia driven in part by the recognition that cancer patients in remote areas experience poorer outcomes than their metropolitan counterparts. This work has led to the development of more effective cancer networks and new models of care designed to meet the particular needs of the rural cancer patient. It is hoped that the growth of cancer research in regional centres will, in time, reduce the disparity between rural and urban communities and improve outcomes for cancer patients across both populations.

Retrospective analysis of cancer survival across South-Western Victoria in Australia

OBJECTIVE: This paper aims to describe cancer survival and examine association between survival and socio-demographic characteristics across Barwon South-Western region (BSWR) in Victoria, Australia. DESIGN: This study is based on the retrospective cohort database of patients accessing oncology services across BSWR. SETTING: Six rural and three urban hospital settings across the BSWR. PARTICIPANTS: The participants were patients who were diagnosed with cancer in 2009. MAIN OUTCOME MEASURES: Overall survival (OS) of participants was the main outcome measure. RESULTS: Total of 1778 eligible patients had four-year OS for all cancers combined of 59.7% (95% CI, 57.4-62.0). Improved OS was observed for patients in the upper socio-economic tertile (64.2%; 95% CI, 60.9-67.5) compared to the middle (59.3%; 95% CI, 55.5-63.1) and lowest tertiles (49.6%; 95% CI, 44.2-54.9) (P < 0.01). On multivariate analyses, higher socio-economic status remained a significant predictor of OS adjusting for gender, remoteness and age (HR [hazard ratio] 0.81; 95% CI 0.74-0.89; P < 0.01). Remoteness was significantly associated with improved OS after adjusting for age, gender and socio-economic status (HR 0.86; 95% CI, 0.77-0.97; P = 0.01). Older age ≥70 years compared to <70 years conferred inferior OS (HR 3.08; 95% CI, 2.64-3.59; P < 0.01). CONCLUSIONS: Our study confirmed improved survival outcomes for patients of higher socio-economic status and younger age. Future research to explain the unexpected survival benefit in patients who lived in more remote areas should examine factors including the correlation between geographical residence and eventual treatment facility as well as compare the BSWR care model to other regions' approaches.

Beyond community-based diabetes management and the COAG coordinated care trial

OBJECTIVE: This article describes the patient management processes developed during the Council of Australian Governments (COAG) coordinated care trial and use of health outcome measures to monitor changes in utilisation patterns and patient well-being over time for a subgroup of 398 patients with type 2 diabetes. DESIGN: The Eyre component of the South Australian (SA) HealthPlus coordinated care trial was a matched geographically controlled study in which the outcomes for the intervention group of 1350 patients were compared with those of a similar control group of 500 patients in another rural health region in SA. SETTING: The trial was carried out on Eyre Peninsula in SA across populations in rural communities and in the main centres of Whyalla, Port Lincoln and Ceduna. Care planning was organised through general practitioner practices and services negotiated with allied health services and hospitals to meet patient needs. SUBJECTS: The SA HealthPlus trial included 1350 patients with chronic and complex illness. A subset of this group comprising 398 patients with type 2 diabetes is described in this report. Patients recruited into the three-year trial were care planned using a patient centred care planning model through which patient goals were generated along with medical management goals developed by clinicians and primary health care professionals. Relevant health services were scheduled in line with best practice and care plans were reviewed each year. Patient service utilisation, progress towards achieving health related goals and patient health outcomes were recorded and assessed to determine improvements in health and well-being along with the cost and profile of the services provided. RESULTS: Significant numbers of patients experienced improved health outcomes as a consequence of their involvement in the trial, and utilisation data showed reductions in hospital and medical expenditure for some patients. These results suggest that methods applied in the SA HealthPlus coordinated care trial have led to improvements in health outcomes for patients with diabetes and other chronic illnesses. In addition, the processes associated with the COAG trial motivated significant organisational change in the Regional Health Service as well as providing an opportunity to study the health and well-being outcomes resulting from a major community health intervention. CONCLUSIONS: The importance of the SA HealthPlus trial has been the demonstrated link between a formal research trial and significant developments in the larger health system with the trial not only leading to improvements in clinical outcomes for patients, but also acting as a catalyst for organisational reform. We now need to look beyond the illness focus of health outcome research to develop population based health approaches to improving overall community well-being.

The impact of coordinated care : Eyre region, South Australia 1997-1999

The SA HealthPlus Coordinated Care Trial in the Eyre Region began in fortuitous circumstances. First, it coincided with the completion of the Eyre Regional Health Service (ERHS) needs assessment in 1996, which highlighted outstanding health service needs and community concerns in relation to health care across the region. Second, although conceived as a formal trial, using standard research techniques, scientific processes and formal control groups to test significant differences between intervention and control groups, the trial did not conform strictly to the rules of social science or pure science and became more an exercise in action research. More significantly still, the Eyre Region became involved in the process, not so much as a way of proving a concept (the SA Health Plus hypotheses around utilisation, funding and health outcomes), but as a way of creating opportunities for change in the regional health system. If nothing else, the region stood to benefit from the implementation of the trial and involvement in the trial process. The present paper outlines the impact of the Eyre Coordinated Care Trial, not in terms of hypotheses and data analysis, but in terms of the impact of the trial processes on systems change and the evolution of an outcome-based health system. Such a system has the potential to deliver improved health outcomes to communities within existing financial resources and make much more effective use of resources by integrating care delivery and encouraging collaboration between health providers. In addition, the success of the change process in Eyre also supports the notion that change is not necessarily predicated upon scientific processes and research outcomes alone, but also upon the human and social structures associated with such endeavours. This perspective also contributes to the debate about the nature and role of science in the advancement of knowledge.