Improving Access for our Aboriginal residents to diagnostic Cardiac Catheterisation across northern Hunter New England

21 October 2005
Hunter/New England Area Health Service

This project was entered in the Baxter 2005 NSW Health Awards, Access category.

Entries from the Baxter 2005 NSW Health Awards - full list

Author

Brad Hansen, HNEAHS

Date(s) undertaken: February 2004 to current.

Abstract

Diagnostic Coronary Angiography is an essential procedure to ensure accurate diagnosis and to aid in the determination of appropriate clinical management.

A significant proportion of our residents are of Aboriginal descent with a higher risk of coronary heart disease than their non-Indigenous counterparts and as such it is important they have access to and undergo coronary angiography. According to FLOWINFO (Population Health, Planning and Performance, HNEAHS, 2005) only 35 separations were reported for residents who identified their Aboriginality and resided in the New England in the 3 years 2000-2003.

Following consultation with representatives of northern Hunter New England Aboriginal Health workforce and, as a consequence of existing cardiac services planning, a highly-respected Aboriginal member of our workforce was recruited to the Cardiac Catheterisation Lab Management Committee at Tamworth Hospital to enable effective communication and to establish strong social links with the Aboriginal community and its key representatives.

In the first four months of the Lab (February to June 2004) it was noted that few Aboriginal patients utilised the service. Focus group work and team brainstorming led to the development of a small set of strategies aiming to improve their utilization of the service.

Personal patient support and advocacy along with “word of mouth” were the key strategies applied to promote the service to and within the Aboriginal community with the outcome that, over the following 12 months to June 2005, 40 Aboriginal patients have undergone diagnostic angiography, an increase of 300% on previous Department of Health statistics for our Aboriginal population.

Aim

To ensure equitable and clinically appropriate access to diagnostic angiography for Aboriginal residents to ensure accurate diagnosis to aid in the determination of appropriate clinical management.

Background

Currently there is a high morbidity and mortality from CVD in the northern region of Hunter New England in comparison to NSW as a whole (Chief Health Officer’s Report 2004), particularly for our Aboriginal residents. Early diagnosis and treatment of CVD utilising cardiac catheterisation services has been shown to positively impact on morbidity and mortality.

The team was aware that over the 3 year financial period 2000/03 only 35 residents of our Aboriginal communities underwent an interventional cardiology procedure, either cardiac cath, angiography or stenting (FLOWINFO, Population Health, Planning and Performance, HNEAHS, 2005). In the early stages of the service it was also noted from the Lab’s database that Aboriginal patients were grossly under-represented.

The purpose of this project was to increase the number of Aboriginal patients who underwent a diagnostic angiography as an indicator of whether the strategies implemented to promote their access to the Lab were effective.

Methodology

Being aware of the disparity in access to angiography between our non-Aboriginal and our Aboriginal communities the Management Committee arranged a focus group to concentrate on identifying the barriers/impediments and influences that impact on the Aboriginal patient accessing this important diagnostic and innovative rural service.

As part of cardiac service planning an Aboriginal Health staff focus group was established to contribute their thoughts and identify what their communities were saying about accessing cardiac catheterisation services in general. (There had been recent targeted community focus groups discussing Aboriginal Health service planning.) This feedback, along with the contributions made by the Aboriginal representative on the Management Committee, through brainstorming sessions enabled the formulation of a series of strategies, listed below, to increase participation by the Aboriginal community in the service.

Brainstorming sessions identified several major issues that directly impacted and contributed to Aboriginal patients not wishing to access the angiography service. All the issues were considered to be of equal importance and an implementation plan was developed for the Committee to work from.

Traditional methods of service promotion, e.g. brochure development, articles in local papers, were not considered to be first strategy of choice for the target group. It was recognised that a personal approach and establishing strong relationships with a well established support network would potentially be a more successful model.

Planning and implementation

Committee agreed that there were three key strategies to implement. These included:

1. Close attention to the individual needs of each Aboriginal patient by the service co-ordinator.
2. Support and advocacy by the service’s Aboriginal welfare officer throughout the process.
3. Service promotion by word of mouth from within the Aboriginal community itself.

The issues identified included not only the well known barriers of socio economic disadvantage, but, as importantly, a reluctance, due to a lack of understanding and a “fear” of the procedure, and the environment in which the procedure was performed. There were also issues relating to cultural isolation.

Methods considered effective in this context were related to Lab staff building effective social relationships with key Aboriginal community members and with visible Aboriginal staff representation in the Lab itself.

Each Aboriginal patient is supported from referral to follow-up by the Lab’s co-ordinator and the Aboriginal welfare worker. Arrangements for travel and accommodation are arranged by the welfare worker. Any further arrangements arising in relation to further interventional management are also co-ordinated by the Lab staff to ensure continuity of care. The patients are also referred back to local service providers for cardiac rehabilitation.

Outcomes and Evaluation

There were 35 identified Aboriginal separations for a diagnostic or interventional cardiac procedure in the three year financial period 2000/3 as previously described.

For the first few months from the commissioning of the Tamworth Base Hospital Cath Lab in February 2004 it was noted that there had been very few Aboriginal patients.

In the 12 months since the review and implementation of this project there have been 40 Aboriginal patients who have undergone a diagnostic angiography procedure, a three fold increase.

The strategies implemented have brought about a positive increase in the number of Aboriginal patients being assessed in the Lab. Staff will continue to employ these strategies to build on the gains already achieved and tracking of the number of Aboriginal patients will continue, being reported quarterly to the Cath Lab Management Committee, Tamworth Base Hospital.

The importance and effectiveness of the unique indigenous networks, which help the Aboriginal patient to reach the door of the service, along with the personal support and advocacy provided to each Aboriginal patient throughout the process cannot be underestimated and staff will continue to work closely with the Aboriginal community via the established links to ensure that the benefits achieved are ongoing.

Future scope

Whilst significant gains for our Aboriginal residents have been made in relation to access to this important diagnostic service we still have a long way to go. Disease rates indicate a prevalence of coronary disease to be at 2-3 times that of the non-Aboriginal population and so it is extrapolated that the Cath Lab should be seeing an equivalent ratio for diagnostic assessment.

Whilst the achievement of 40 patients is to be commended we will continue to invest our efforts and resources in this supportive model and look for further ways until we fully meet the needs of the Aboriginal community.

Potential methodology to expand the analysis of the issues of barriers to accessing diagnostic angiography services will take a broader approach and will include focus groups with key Aboriginal community representatives and mapping from a patient perspective.