Rationalisation of Diabetes Services for Aboriginal Peoples in Muli Muli, Casino, Jubullum Village and Coraki Box Ridge

Abstract

Before January 2004, management and treatment of Type Two Diabetes in the isolated rural Aboriginal communities of Muli Muli, Casino, Jubullum Village and Coraki Box Ridge were uncoordinated and sporadic. An examination of the data indicated that in the twelve months from 1 January to 31 December 2003, the local diabetes service saw fifteen clients. This is 0.25% of the Aboriginal population of approximately six thousand. These services were limited to consultation with a Diabetes Educator and Dietitian and there were no opportunities for other health professionals to participate in assessment and care. No measurable data existed to demonstrate attendance rates at medical practices, however anecdotal evidence indicated similar low attendance rates and fragmented care.
In September 2003, grant money became available to develop a multi-disciplinary approach to diabetes management amongst this client group. In response, the Primary Health Care Network Project was developed with a model of care that is unique in NSW.
For the first time a one-stop shop approach enabled a team of healthcare workers to assess clients at a clinic. The team included Aboriginal Health professionals, a Physician, an Ophthalmologist, a Medical Scientist, Diabetes Educators, a Podiatrist, Registered Nurses and General Practitioners.
Approximately thirty members of the Aboriginal communities were involved in the planning development and evaluation of this program.
In 2004, one hundred and fifty nine clients were assessed. This is a 960% increase from 2003.
In 2005, one hundred and fifty five clients were assessed. This is an increase of 933% from 2003.

Aim

To increase the attendance rate of Aboriginal people at multi-disciplinary Diabetes Clinics by 20% by December 2005.

Background

Aboriginal people have had a consistently poor level of access to appropriate health care services. Mainstream services and models of care have generally neglected to tailor projects to meet the unique health needs of Aboriginals, with policies and practices often systematically disadvantaging them. (NSW Aboriginal Chronic Conditions 2005:p4)

Diabetes is common in Aboriginal communities, estimated at 10% to 30% whereas it occurs in approximately 3% of the general population. Many of the complications of Diabetes can be managed with effective community based primary health care. (McDermott, Tulip, Schmidt.
2004:p512)

Method Planning and Implementation

Following consultation with the four Aboriginal communities, this cause and effect diagram was developed to assist with identifying the contributing factors that lead to lower life expectancy.

 Causes & Effect

 The coordinator approached health professionals in the area, asking those with the expertise to participate in running a service to manage diabetes and other health problems within the target group. They all first met in January 2004 and developed the following strategies:

• Set up a Diabetes Complication and Assessment Clinic;
• Facilitate access to health services to address the transport issues;
• Assist with medication concordance (Webster Packs);
• Establish registration as a National Diabetes Services Scheme (NDSS) at the Dharah Gibinj (Aboriginal Medical Service Casino);
• Conduct active screening for Type 2 Diabetes and complications;
• Establish an Aboriginal Diabetes Register;
• Produce relevant culturally appropriate health promotion resources specifically for Bundjalung People.

 Outcomes and Evaluation

The graph below demonstrates that the project has reached a group of people at higher than average risk of diabetes complications.  This information, based on eighty-nine clients who have had their health outcome information compared to an Australian National Benchmark of non-Indigenous diabetics. 

 
‘Non-Indigenous clients’ are from the Australian National Diabetes Information Audit & Benchmarking, 2002.

The graph demonstrates that Network clients have higher levels of risk factors for: albuminuria, hypertension, overweight/obesity, and elevated triglyceride and cholesterol levels.  The health outcome indicators are those formulated in the Guidelines for the Current Management of Diabetes Mellitus (NSW Health, p. 2:1996), reflecting current clinical practice for diabetes care, and where possible based on available scientific evidence.

Clinic screening also identified extremely high levels of Strongyloides, a potentially fatal parasite.  Discussions are continuing with The Public Health Unit and other partners to develop appropriate action.

 
The UK Prospective Diabetes Study (1998) was a twenty-year study of Type 2 Diabetes in the United Kingdom.  It found that intensive glucose control policy maintained a lower HbA1c by mean 0.9% over a medium follow up of 10years from diagnosis of type 2 diabetes with the reduction in risk of:

 12% reduction for any diabetes endpoint  24% for cataract extraction
 33% for albuminuria at twelve years.  21% for retinopathy at twelve years
 25% for microvascular endpoints  16% for myocardial infarction

Progression through the Aboriginal Diabetes Complication and Assessment Clinics

 Future Scope

The team has applied for funding in partnership with the University Department of Rural Health (UDRH) North Coast Area Health Service to look at the issues of medication concordance. The application has reached the second round and there has been no further news.

The team has also submitted a grant application to Aboriginal Health Promotion at NSW Health to make a DVD for young Aboriginal people about maintaining health and well-being.

Following the findings from the clinics, the team is working in partnership with UDRH and the Public Health Unit to address the emerging issue of Strongyloides.

In partnership with other community health teams, the PHCN has facilitated an increase in the number of health promotion days in these outlying areas to raise the profile of the health service and in so doing encourage the community to feel comfortable in their presence.

The Aboriginal Diabetes Complication and Assessment Clinic is the first of its kind in Australia.  The team has submitted a paper to the Australian Journal of Rural Health in the hope that others interested in addressing the problems of chronic diseases in Aboriginal communities may be able to learn from our experiences.

References

• National Association of Diabetes Centres 2002. Australian National Diabetes Information Audit and Benchmarking.
• NSW Health Department 1996.  The Principles of Diabetes Care and Guidelines for the Clinical Management of Diabetes Mellitus in Adults.  NSW Health Department.
• NSW Health Department 2003. NSW Health Aboriginal Health Impact Statement and Guidelines.  NSW Health Department.
• NSW Department of Health 2004. NSW Chief Health Officers Report. NSW Health Department
• NSW Health Department 2005.  NSW Aboriginal Chronic Conditions Area Health Service Standards.  NSW Health Department.
• UKPDS Group.  UK Prospective Diabetes Study Group.  Intensive blood glucose control with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998; Vol. 352, 9131: 837 B 853.
• McDermott RA, Tulip F, Schmidt B. Diabetes care in remote northern Australian Indigenous communities. Med J Aust. 2004; 180(10): 512-516.

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