3.05 Chronic disease management
Why is it important?
Chronic diseases are the major causes of morbidity and mortality among Aboriginal and Torres Strait Islander peoples (see measures 1.02 and 1.23). Better management of these conditions is a key factor in meeting the target of closing the life expectancy gap between Indigenous and non-Indigenous Australians within a generation. Chronic disease is estimated to be responsible for 70% of the health gap (Vos et al. 2007). Effective management of chronic disease can delay the progression of disease, improve quality of life, increase life expectancy, and decrease the need for high-cost interventions leading to net savings (Thomas, SL et al. 2014).
Good quality care for people with chronic disease often involves multiple health care providers across multiple settings and the engagement of the client and their family in self-management of the condition (NHPAC 2006). Typically, the primary health care provider plays a central role through: identifying patients with asymptomatic disease through systematic or opportunistic screening; developing a management plan with the patient and their family; regularly assessing the extent to which the chronic illness is well controlled; conducting regular checks to identify early signs of complications; and referring to specialist care where this is warranted. To play an effective role in chronic disease management, primary health care services need to take an organised approach, reflecting evidence-based guidelines, underpinned by participation in clinical quality improvement programmes (Panaretto et al. 2014; Wagner et al. 1996; Bodenheimer et al. 2002). The MBS includes items for GP management plans (GPMPs) and team care arrangements (TCAs) to support a structured approach to management of patients with chronic or terminal conditions.
Between 2009–10 and 2013–14 there has been a statistically significant increase in the rate of TCAs and GPMPs claimed by Indigenous Australians under Medicare. Over this five-year period, Medicare services claimed by Indigenous Australians for these items have doubled (from 55 to 114 per 1,000 for GPMPs; and from 44 to 96 per 1,000 for TCAs). In 2013–14, rates were higher for these services for Indigenous Australians than for non-Indigenous Australians (1.6 and 1.7 times respectively). Indigenous Australians also had a higher rate of nurse/Aboriginal health worker consultations claimed (236 per 1,000 compared with 39 per 1,000).
Information on the management of chronic conditions by Indigenous primary health care services is collected in the Online Services Report. In 2012–13, of the 205 services, 79% employed a doctor, 98% provided at least one care planning activity for the management of chronic illness, 95% kept track of clients needing follow-up and 97% used patient information and recall systems that provide reminders for follow-up and health checks.
The national Key Performance Indicators (nKPIs) monitor the performance of the Australian Government-funded Indigenous primary health care organisations against the key process of care and health outcome performance indicators. In December 2013, around 28,000 regular clients of these organisations had Type 2 diabetes. In the six months to December 2013, 49% of these clients had their blood glucose levels tested, with 33% reporting a blood sugar result in the recommended range (the same as in December 2012); and 64% had their blood pressure assessed, with 44% reporting a result in the recommended range (up from 42% in December 2012). Performance against such process of care measures varies widely across organisations. For example, there were 11 organisations that had tested less than 10% of their diabetic patients for HbA1c levels in the previous six months and 9 organisations that had tested more than 90% of their diabetic patients (AIHW 2014w).
Data on care provided to Indigenous clients with coronary heart disease was last provided in June 2011 for the Healthy for Life collection (replaced by the nKPIs). In the six months to June 2011, over 80 Indigenous primary health care organisations provided data on 4,200 Indigenous regular clients with coronary heart disease. Of these clients, 66% had their blood pressure tested in the previous six months and of those, 52% had results in recommended range.
In the 2012–13 Health Survey, 69% of Indigenous Australians with diabetes reported having a blood test to check diabetes control in the previous 12 months and 68% had their feet checked compared with 72% and 74% respectively for non-Indigenous Australians. To manage their diabetes, 30% reported using insulin and 80% had taken lifestyle actions (diet, weight loss, and exercise). Of those who knew they had diabetes, 61% had blood tests results indicating their diabetes was not well managed (compared with 44% for non-Indigenous Australians). This was more common among Indigenous males (72%) than females (53%). Of those with circulatory conditions, 91% reported having their blood pressure checked and 68% their cholesterol checked in the previous 12 months compared with 94% and 76% respectively for non-Indigenous Australians.
A range of studies have identified gaps and variation in the quality of chronic disease management in primary care settings for both Indigenous and non-Indigenous patients (Peiris et al. 2009; Webster et al. 2009; Schierhout et al. 2010; Panaretto et al. 2013). Organised chronic disease management in primary health care services can lead to improved health outcomes (Hoy et al. 1999; Hoy et al. 2000; Rowley et al. 2000; McDermott et al. 2003; Bailie et al. 2007). However, there are significant challenges in sustaining improvements in the management of chronic illnesses (Urbis Pty Ltd 2009). Strategies to address these challenges include transparent work-practice systems backed by written disease management guidelines and manuals, systematic support to buffer the effects of local factors, appropriate staffing and training policies, delineated roles for all practitioner types, and raising awareness in communities through education and health promotion with strong local participation (Bailie et al. 2004).
A range of quality improvement approaches are being implemented across general practice and Aboriginal and Torres Strait Islander primary health care services. Both the NT and Qld have developed indicator reporting with Indigenous health services that have recently been harnessed in the development of the nKPI collection. The Australian Primary Care Collaboratives and the Audit and Best Practice for Chronic Disease Program (now part of One21seventy) have a continuous quality improvement focus.
Australian governments are supporting various initiatives to improve chronic disease management. The Indigenous Australians' Health Programme started on 1 July 2014, to improve the focus on local health needs and better support efforts to achieve health equality (see the Policy and Strategies section). Chronic disease programmes provided through the Indigenous Australians' Health Programme include nationwide tobacco reduction and healthy lifestyle promotion activities, a care coordination and outreach workforce based in Medicare Locals and Aboriginal Community Controlled Health Organisations, and GP, specialist and allied health outreach services serving urban, rural and remote communities.
The Practice Incentives Programme—Indigenous Health Incentive (PIP–IHI) aims to support general practices and Aboriginal and Torres Strait Islander health services to provide better health care for Aboriginal and Torres Strait Islander patients, including best practice management of chronic disease. The PIP–IHI includes payments to GPs for registering with the programme, for registering Indigenous patients with chronic disease and for providing best practice management of chronic disease.
The Medicare Chronic Disease Management items, including GPMPs and TCAs, are used by doctors to plan and coordinate the care of patients who have chronic or terminal medical conditions. These MBS items support the early identification and management of health issues for both Aboriginal and Torres Strait Islander and non-Indigenous Australians. Indigenous patients are also able to access MBS health assessment items. Following a MBS health assessment, Medicare-rebateable follow-up allied heath, practice nurse and Aboriginal and Torres Strait Islander health practitioner service items are also available, on referral from a GP, to people of Aboriginal and Torres Strait Islander descent.
Medicare data has shown an increase in health assessments and chronic disease management items for Indigenous Australians over the last 5 years. This rise is due to a number of factors, including activities undertaken as part of the Indigenous Chronic Disease Package—now part of the Indigenous Australians' Health Programme.
The Medical Outreach Indigenous Chronic Disease Programme aims to improve access to medical specialist, GP, allied and other health services for Aboriginal and Torres Strait Islander peoples. A total of $92.4 million over 3 years from 2013–14 has been committed for this measure.
The Quality Assurance for Aboriginal and Torres Strait Islander Medical Services (QAAMS) programme supports culturally appropriate and clinically effective management of diabetes patients in Aboriginal and Torres Strait Islander communities. This occurs through training, technical support and quality assurance for 'point of care' pathology testing (e.g. HbA1c).
Figure 3.05-1 shows the age-standardised rate (services per 1,000 population) of selected MBS services claimed for Indigenous Australians annually from 2005-06 to 2013-14. Data is presented on the following MBS services: GPMP; TCA; and specialists (total). The graph shows that rates for each of the selected MBS items have increased over time.
Source: Medical Benefits Division, Department of Health
Figure 3.05-2 shows the age-standardised rate (services per 1,000 population) of selected MBS services claimed for Indigenous Australians and non-Indigenous Australians in 2013-14. Data is presented on the following MBS services: GPMP; TCA; allied health (total); practice nurse/AHW; allied health AHW; and specialist. Rates are higher for Indigenous Australians for GPMP, TCA, Practice Nurse/AHW and Allied Health AHW.
Source: Medical Benefits Division, Department of Health
Figure 3.05-3 shows the proportion of Indigenous regular clients with Type 2 diabetes receiving recommended care from Indigenous primary health care services, by remoteness, December 2013.
Source: AIHW analysis of national Key Performance Indicator data