Monday, September 3, 2012

This blog's first scoop!

I have some news that you probably don't know. It's tucked away hidden in non-secret documents published in academic journals, which took literally minutes of hard work to discover. 

Aboriginal Medical Services are more effective than mainstream general practice!

To qualify that a bit - Aboriginal Community Controlled Health Services are at least as good, and maybe better at cardiovascular disease prevention than mainstream general practice.

So why isn't this widely known?

Let's start from here. If you were to right down what you know about Aboriginal and Torres Strait Islander Health (and you are a non-indigenous reader of this blog!) you would probably come up with words like Gap; poor health outcomes; non-compliance; difficult to reach; poor access; diabetes; renal disease; heart disease. You'll have others, too, many of them negative. If you do a similar exercise for "Aboriginal Medical Service" the most common reporting is of stories of dysfunction and poor governance.

Let me tell you how we know this unknown fact.

This is a paper from the Medical Journal of Australia in 2009, as part of the Kanyini Vascular collaboration. {Declarations - The service I work for is part of this collaboration and was one of the services audited for this paper. And one of the authors, David Peiris is a good friend of mine, who pointed out the comparison to me} They conducted a file audit of 1165 Aboriginal and Torres Strait Islander patients of Aboriginal Community Controlled Health Services to look at their management of cardiovascular risk in these services. The results are summarised in this graph:

Take some time to look at it. It shows for people with different levels of risk of cardiovascular disease (the different colours) which of their risk factors are being treated - blood pressure (BP), Cholesterol (statin), blood thinning (Antiplatelet - aspirin for most people) and combinations of these. The higher your risk, the more you benefit from having all of these treated.

What this graph shows is that there is plenty of room for improvement.

Now on to the second paper, the AUSHeart study from the same authors, who do the same sort of audit but this time for patients in mainstream general practice, and prospective. They included 5293 patients. The similar graph (sadly presented only in black and white!) is below.

We see a similar pattern, with similar risk levels. And again, room for improvement.

But when you compare the actual numbers (get a ruler and and the percentages - that's what I did!) you see that the Aboriginal Community Controlled Health services treat a higher proportion of their patients for their cardiovascular disease and their risk of cardiovascular risk. Let's put that into English. Aboriginal Medical Services are doing better at preventing thier patients from having heart attacks and strokes in the future. For those with established cardiovascular disease, about 60% of people with heart disease get the full recommended treatment in an AMS, and about 50% in mainstream practice. At each level of established and high risk disease, adequate treatment levels are higher. At low risk (where the blance of risk-benefit may be tilted more toward risk) fewer are treated.

This methodology is far from perfect. The differences may not be significant, we may not be comparing like with like. But the bottom line is this:

Aboriginal Community Controlled Health Services are at least as good as mainstream general practice in a common important aspect of preventive care in a population that we say is at higher risk and harder to reach and treat.

In other words, Aboriginal medical services are succeeding in providing quality care in communities that need it most, and other services struggle to reach.

It's early days in being able to quantify the quality of primary care in Australia, and this takes a purely medical model that would be narrower than that espoused by most Aboriginal Medical Services.

However, if you are a health professional, consider going to work in a setting where you are able to be truly effective. If you are interested in policy, then you need to look at the ACCHO sector at what mainstream primary care can learn. And if you are telling the stories of Aboriginal health, you may need to change from a story of unremitting failure, to one of success against the odds.

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