Engaging stakeholders in prioritising and addressing evidence-practice gaps in preventive care for Indigenous Australians Jodie Bailie1 Veronica Matthews2 Alison Laycock2 Rosalie Schultz3 ross Bailie1 1University centre for rural health, university of Sydney, Australia 2Menzies School of Health Research, Charles Darwin university, Australia 3Centre for remote health, flinders university, alice springs, Australia I would like to begin by acknowledging the traditional owners of the land on which we meet today, the Kulin nation and I extend my respect to the Aboriginal or Torres Strait Islander people who are present. I would also like to acknowledge my co-authors and in particular Veronica, Rosalie and Ross who are here today. 15th World Congress on Public Health Melbourne, April, 2017

identify and minimise evidence-practice gaps preventable chronic disease - largest contributor to health gap between Indigenous and non-Indigenous Australians recommended best-practice care not consistently provided how to achieve improvement? identify and minimise evidence-practice gaps Preventable chronic disease is the largest contributor to the health differential between Indigenous and non-Indigenous Australians We know that preventive care at the primary health care level allows for earlier detection and management of chronic disease Despite efforts to promote evidence-based preventive care, delivery to Indigenous Australians remains suboptimal with wide variation in the delivery of care between health services. Significant improvement in preventive care delivery could be achieved through identifying and minimising these evidence-practice gaps

aim engage stakeholders across the primary health care system in using aggregate continuous quality improvement data to identify: - priority evidence-practice gaps - barriers and enablers - strategies for improvement We aimed to engage stakeholders across the PHC system in using aggregate continuous quality improvement data to identify: priority evidence-practice gaps in Indigenous preventive care barriers and enablers to addressing the identified gaps and strategies for improvement

continuous quality improvement (CQI) data, 2005 - 2014: - 137 Indigenous PHC centres - 17,108 audited patient records - 367 systems assessments We drew on de-identified preventive health clinical audit data provided by 137 Indigenous health services participating in a research based CQI initiative – the ABCD National Research Partnership. Over 17,000 client records and 367 systems assessments – available for analysis The CQI data from the Partnership provide the most comprehensive picture of the quality of primary care that Indigenous people receive around Australia. So we have a large data set and we wanted to engage stakeholders in the dissemination and interpretation of this data. --------------------- SAT: A structured process to assess the organisational systems of the PHC - These are evaluations by health team of how well organisational systems were working to support preventive care. preventive health clinical audit - based on evidence-based guidelines Bailie R et al, 2010, BMC Health Services Research ; Bailie C et al 2016, Frontiers in Public Health

Engaging Stakeholders in identifying Priority evidence-practice gaps and strategies for improvement (ESP Project) Phase 1 - 19 responses: 15 individuals, 4 groups (n= 62) Phase 2 - 7 responses: 3 individuals, 4 groups (n= 70) Review of report - 5 individuals The ESP Project is an interactive dissemination strategy, engaging a diverse range of stakeholders in using and interpreting the CQI data collected – using an iterative approach with online reports and surveys In phase 1 we presented preventive health CQI data that I was referring to in a previous slide in an aggregate form and asked stakeholders to identify priority evidence- practice gaps In phase 2 , we reported the agreed priority evidence-practice gaps and asked stakeholders to identify the barriers and enablers to addressing these identified gaps [CLICK] Over 130 people participated in the online surveys as part of phase 1 or 2, either as individuals or part of a group Laycock et al, 2016, Frontiers in Public Health; Bailie J et al, 2016, Frontiers in Public Health

recruitment and responses roles - nurse, CQI facilitator, policy staff, Aboriginal and Torres Strait Islander health practitioner, academic, doctor, manager, other jurisdictions - NSW, SA, QLD, WA, NT, Victoria organisations - community-controlled health centre, peak body; government health centre, department; primary health care network; academic institution Stakeholders were from a diverse range of organisations and roles, across multiple jurisdictions.

priority evidence-practice gaps follow-up of abnormal blood pressure, blood glucose levels and lipid profile completing absolute cardiovascular risk assessments recording urinalysis recording lipid profiles recording of enquiry about living conditions, family relationships and substance misuse providing appropriate support and follow-up for clients at risk - emotional wellbeing We identified that there are many aspects of preventive care being delivered relatively well and aspects where there are consistent evidence-practice gaps across the system. The consistent gaps in order of perceived priority were: - Follow-up of abnormal results - Completing absolute cardio vascular risk assessments [CLICK] - Recording of urinalysis and lipid profiles - Recording enquiries about living conditions, family relationships & substance misuse And lastly, providing support and follow-up for clients identified as being at risk with respect to emotional wellbeing. Where aspects of care are not being done well across a range of PHC centres, this is likely due to inadequacies in the broader system

- some improvement from 2007 – 2012 mean health centre record of follow-up plan for abnormal blood pressure, 2005 – 2014, by audit year (n= number of health centres; number of client records) - some improvement from 2007 – 2012 - wide variation for all years with no clear trend As an example, I will present data related to the first priority gap identified regarding follow up of abnormal results. [CLICK] This figure shows the mean health centre record of a follow-up plan for an abnormal blood pressure, between 2005 and 2014, by audit year. So you can see that on average only between 20 – 40 percent of patients with an abnormal blood pressure recorded had a record on file of a plan for follow-up of this abnormal reading. Though there was some improvement there was wide variation amongst health centres with no clear trend in variation.

barriers to addressing identified gaps: - financing and resourcing - recruitment and retention of staff - systems to support community engagement and health literacy - primary health care team structure and function - training and development - effective use of clinical information systems - management support for quality improvement These were the barriers that participants identified, in relation to addressing the gaps in care. AS this is a short presentation I will expend on just a few. In terms of financing and resourcing, Indigenous-specific preventive health assessments were acknowledged as a useful funding stream though there was an expressed need for increased funding and system improvements to deliver follow-up services relating to issues that were identified in the assessment. Workforce issues were frequently identified as impacting on the effectiveness of preventive care, including high staff turn over and skill mix. Development of regional support systems for recruiting and retaining staff, especially Indigenous staff was identified. Recruiting Indigenous staff (particularly local staff) and ensuring effective support, was seen as critical to ensuring community connections and provision of a culturally appropriate service. - Further investment in training to effectively use clinical information systems and decision support tools was identified , for example recall and reminder systems. Improved documentation of care was identified to avoid duplication of efforts and to support team based care.

use of a comprehensive and large-scale data set strengths use of a comprehensive and large-scale data set reflects knowledge held by a range of stakeholders limitations not possible to accurately measure reach or response rates audit data based on recorded delivery of services Strengths Use of a comprehensive and large scale data set Findings represent the feedback from a diverse range of stakeholders Limitations The ESP project has relied, in part, on stakeholders sending reports to others. Thus, a limitation of the study is that it has not been possible to accurately measure the reach of report dissemination and survey response rates. Audit data are based on recorded delivery of services, which generally underestimate actual service delivery.

conclusion six priority evidence-practice gaps in preventive care were identified barriers to addressing these gaps and strategies for improvement were shared findings identify areas of focus for development of barrier- driven, tailored interventions to improve health outcomes Conclusion: So in conclusion, through an iterative process involving many stakeholders six priority evidence-practice gaps were identified along with barriers to and strategies for addressing shared. Findings identify areas of focus for development of barrier-driven, tailored interventions to improve health outcomes. These findings can assist policy-makers and regional health service providers to develop and test barrier-driven interventions at multiple levels of the health system and to guide further research.

Bailie J, Matthews V, Laycock A, Schultz R, Bailie R Bailie J, Matthews V, Laycock A, Schultz R, Bailie R. Preventive Health Care for Aboriginal and Torres Strait Islander People: Final Report. Menzies School of Health Research. June 2016. http://apo.org.au/node/64599 Please find the reference for the report detailing the findings from the ESP Preventive health process. We have the report, plain language brief and data supplements available on the Australian Policy Online portal. Where to? We currently have a manuscript under review that takes the findings I have presented today to a higher level where we identify key drivers to addressing the gaps in preventive care. We will continue to disseminate the findings of the ESP project through the development of plain language briefs, presentations and journal articles.

Jodie Bailie, Research Fellow (Evaluation) jodie.bailie@sydney.edu.au The Centre for Research Excellence in Integrated Quality Improvement is a collaboration between research organisations, universities, service and policy organisations, managers and service providers In conclusion I would also like to acknowledge that the ESP Project is a Flagship project of the Centre for Research Excellence in Integrated Quality Improvement.

priority 2: mean health centre recording of cardiovascular risk assessment, 2005 – 2014, by audit year (n= number of health centres; number of client records) - improving trend in delivery levels, 2012 - 2014 - increase in variation over successive years as some health centres increased delivery of CVRA For CVRA there was a clear improving trend in the delivery levels from 2012 - 2014. There was an increase in variation over successive years as some health centres increased delivery of CVRA.