Reorienting primary health care for addressing chronic conditions in remote Australia and the South Pacific: review of evidence and lessons from an innovative quality improvement process.

This paper reviews what is known about the challenges of implementing quality improvement programs and draws on data from a systematic continuous quality improvement (CQI) project in remote communities in Australia and Fiji, known as Audit and Best practice for Chronic Disease, to synthesise lessons and discuss the potential for broader application in low and middle income countries, including Pacific Island countries and territories. Although a number of systematic reviews have indicated that quality improvement programs can be effective in changing professional practice and improving the quality of care and patient outcomes, little is known about the key ingredients for change or how services use and implement different strategies to achieve improvements. We identify key features of an innovative CQI model and factors related to implementation that support improvement in diabetes service delivery and intermediate outcomes. Requirements for supporting CQI are identified and the potential for wider application discussed. It is argued that the participatory action research approach supports innovation and broad-based change and the evidence it has produced extends the current knowledge base and facilitates the translation of knowledge into action, for both policy and practice.

Addressing Aboriginal mental health issues on the Tiwi Islands.

OBJECTIVE: This paper provides an overview of the services developed in response to the unique mental health needs of a remote Aboriginal community. We describe an evolving service on the Tiwi Islands in the Northern Territory and the challenges that need to be addressed if the community is to continue to take a leading role in dealing with mental health issues. CONCLUSIONS: The Tiwi Mental Health Service demonstrates that community members are able to identify needs and respond accordingly if they are provided with the relevant information and supported in their decision-making process. The establishment of social governance mechanisms and the long-term commitment by a change agent to facilitate the empowerment process are important keys to success. The main challenge in establishing services in rural Aboriginal communities is to identify and support community strengths, including leaders and cultural practices.

End-stage renal disease in the Northern Territory: current and future treatment costs.

OBJECTIVE: To compare hospital costs of Aboriginal and non-Aboriginal patients having haemodialysis treatment and forecast the future treatment cost. METHODS: The costs of patients with HD in the "Top End" of Australia's Northern Territory were estimated for the financial years 1996/97 and 1997/98 using a hospital costing model. We used an Autoregression Integrated Moving Average model to predict future demand. RESULTS: 165 patients (101 Aboriginal and 64 non-Aboriginal) were treated at a total cost of $12.4 million in this two-year period. These 165 patients represented 0.7% of inpatients, 8.8% of total inpatient costs and 31.6% of total inpatient episodes of care in the Top End region. $9.5 million (77%) was spent on routine haemodialysis treatment and $2.9m (23%) on other hospitalisations. The average cost per routine haemodialysis treatment over the two-year period was $527, or $78 600 per patient treatment year. Hospitalisations for comorbidities occurred in 86% of Aboriginal and 39% of non-Aboriginal patients. Average cost per patient, number of admissions and length of hospital stays were all significantly greater for Aboriginals. We predict an average increase in the number of treatments of 12% each year over the next five years and a five-year cost of $49.8m. CONCLUSIONS: A multipronged strategy designed to reduce the prevalence and costs of renal failure is required.