‘Cracking good’ team supports life of service

A rural GP with a “cracking good” health team and a life-long fascination with the life of birds is among AMA members recognised in the 2015 Queen’s Birthday honours.

Dr David Hollands who, with his wife Margaret, has lived and worked in the east Victorian town of Orbost more than 50 years, was awarded a Medal of the Order of Australia for his many decades of service to his community, as well as his enormous contribution to ornithology.

In an interview with his local newspaper, the East Gippsland News, Dr Hollands recalled how, when he and his wife first arrived in Orbost not long after migrating from Britain, local doctors were expected to do “almost everything”, from delivering babies and stitching up cuts to dealing with major trauma cases.

“There was nothing like the air ambulance or helicopter evacuations,” he told the East Gippsland News. “People expected that the local doctor would cope with almost everything.”

Dr Hollands was among 20 GPs, specialists, researchers and educators recognised for their significant contributions to the health of the community and their services to medicine in the Queen’s Birthday Honours List.

AMA President Professor Brian Owler said the diversity and breadth of the accomplishments cited in the awards were testament to the significant contribution to the community made by medical practitioners every day.

Among the recipients is South Australian GP Dr Anh-Tuan Ngo, who had been a doctor in the South Vietnamese army and came to Australia as a refugee with his family in 1984. Since arriving in Australia, Dr Ngo has worked tirelessly, not only to look after his patients, but to serve the local Vietnamese community and support other veterans of the Vietnam War.

Another to be made a Member of the Order of Australia was Victorian GP Dr Barry Christopher who, in addition to his work as a doctor, campaigned for decades to advance Indigenous rights.

In the late 1950s Dr Christopher became President of the Victorian Council for Aboriginal Rights, and was a founding member of the Federal Council for the Advancement of Aborigines and Torres Strait Islanders.

Dr Hollands’ experience is indicative of how important is the role performed by many doctors in their community.

Working in an area that included 35 saw mills as well as major interstate roads, Dr Hollands and his wife – also a doctor – saw plenty of horrific accidents.

“Industrial health and safety was non-existent and alcoholism was absolutely rife – people would arrive at work on Monday still half pickled. So we had an enormous amount of trauma,” he said, adding that the number and severity of road accidents they attended were “just incredible”.

He recounted how 35 people were injured when a tourist bus overturned late at night, and he and another doctor worked for 48 hours straight at the Orbost Hospital, “non-stop setting fractures and sticking tubes in chests and sewing people up”.

Asked about his award, he said that although receiving it was “very nice”, much was due to a “cracking good team”, including his wife, two other doctors and devoted and capable nursing and surgery staff.

In addition to his medical work, Dr Hollands has also been recognised for his enormous contribution to the study of birds.

He told the East Gippsland News of his life-long fascination with ornithology, and his is the author of numerous books including Owls, Frogmouths and Nightjars of Australia, Owls – Journeys Around the World, and Kingfishers and Kookaburras.

“I’ve been a fanatical birder since about eight, so I’m getting an award for something I really love doing,” Dr Hollands said.

Professor Owler said Dr Hollands, Dr Ngo and Dr Christopher were examples of the major contribution made by many AMA members to aspects of life well beyond medicine, and were deserved recipients of Queen’s Birthday Honours.

Adrian Rollins

Bad hearts, poor kidneys cause many an early death

Indigenous people are more than twice as likely as other Australians to report they are in poor health, suffering disproportionately high rates of chronic and life-threatening diseases and impairments that have a significant effect on their quality of life.

In a sobering reminder of just how far there is to go to close the health gap between Indigenous and on-Indigenous Australians, the Australian Institute of Health and Welfare has reported that Aboriginal and Torres Strait Islander people are far more likely to have cardiovascular diseases, breathing problems, mental illness, diabetes, kidney disease, and to have problems with their hearing and sight.

Underlining the scale of the health problems afflicting Indigenous Australians, the Institute estimated that each year the collectively lose 100,000 years of life to premature deaths caused by chronic diseases, disability and injuries.

Cardiovascular disease is the biggest killer, causing a quarter of all Indigenous deaths between 2008 and 2012, followed by cancer (20 per cent of deaths) and injuries and poisonings (15 per cent).

But in some respects the burden of diabetes weighs even more heavily on the Aboriginal and Torres Strait Islander community.

The Institute’s The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2015 report (http://www.aihw.gov.au/publication-detail/?id=60129550168) shows 11 per cent of Indigenous adults had diabetes in 2012-13, while a further 4.7 per cent were at risk of developing the disease.

Related to this, almost 2 per cent had long-term kidney disease – almost four times the rate of the broader community.

This comes at an enormous cost to the community. In 2012-153 alone, Indigenous adults were hospitalised almost 175,000 times because of chronic kidney disease, almost all of them to undergo same-day dialysis. In all, this accounted for almost half of all hospitalisations of Aboriginal and Torres Strait Islanders.

The health disparity between Indigenous Australians and the rest of the community were further underlined by a separate Institute report showing Aboriginal women were twice as likely to die because of complications arising from pregnancy and childbirth.

Between 2008 and 2012, 105 women died from complications of pregnancy and childbirth, a rate of 7.1 deaths per 100,000 women. But among Indigenous women the rate (13.8 per 100,000) was double that among non-Indigenous mothers (6.6 per 100,000).

The results have highlighted calls from the AMA and other health groups for governments around the country to redouble their efforts to the close the health gap.

AMA President Professor Brian Owler said that although there had been some encouraging improvements in child and maternal health, much more needed to be done.

Professor Owler said recently that access to primary health care was especially important in addressing Indigenous disadvantage.

“Achieving equality in health and life expectancy for Aboriginal and Torres Strait Islander peoples is a national priority, but there is still a way to go before we see meaningful and lasting improvements,” the AMA President said. “There is a need for a concerted effort to fund and resource primary health care service providers to detect, treat, and manage chronic health conditions in Aboriginal and Torres Strait Islander communities.”

He said the Federal Government should immediately scrap the Medicare rebate freeze would hit Aboriginal community controlled health services and Aboriginal Medical Services particularly hard, and place enormous pressure on efforts to close the gap.

National Aboriginal Community Controlled Health Organisation Chair Matthew Cooke said that despite some progress in reducing infant mortality, the Institute report highlighted continuing major shortcomings, including for teenagers.

The report found Indigenous children aged between 15 and 18 years were far more likely to be imprisoned than their non-Indigenous counterparts, and were five times more likely to take their own lives.

Adrian Rollins

How to pay for health?

Government funding reform options (as set out in Department of Prime Minister and Cabinet’s Reform of the Federation 2015 Discussion Paper)

Option 1

States and territories handed full responsibility for public hospitals – the Commonwealth would withdraw all funding

Option 2

Hospital benefit scheme

The Commonwealth would establish an MBS-style benefit scheme to fund a proportion of the cost of each hospital procedure, with the states asked to cover any gap between rebate and service cost.

Option 3

Individual care packages

The Commonwealth and states jointly fund individualised care packages for patients with, or at risk of developing, chronic or complex conditions.

Option 4

Regional Purchasing Agencies

The two tiers of government would jointly establish agencies to purchase health services for patients in their catchment areas.

Option 5

National Health Purchasing Agency

Commonwealth-funded agency to commission full suite of services, from primary through to acute, to meet community need.

Reform of the Federation

The Commonwealth Government has committed to produce a White Paper on the Reform of the Federation, working with the states and territories.

According to the Government, the White Paper will seek to clarify roles and responsibilities to ensure that, as far as possible, the states and territories are sovereign in their own sphere. Defining roles and responsibilities in health are a critically important part of this process.

At the time of writing, a Department of Prime Minister and Cabinet Discussion Paper detailing possible options for reform has just been released, and it is expected the Government will release a Green Paper later in the year, after further discussions with the states and territories. This will feed into the development of the Reform of the Federation White Paper, expected to be released in 2016.

Public discussion of the Reform of the Federation process and options for change has hardly begun, but the topic is warming up at heads of government level, and will be further fuelled by the release of the Government‘s discussion paper.

The AMA has been a catalyst for this discussion, helping to ensure that public hospitals funding is a main agenda item at the heads of government leaders’ retreat later this month.

The Health Financing and Economics Committee considered the issue of reform of the Federation at its meeting on 14 February, and its discussions helped inform Federal Council deliberations in a policy breakout session at its meeting on March 13 and 14.

Immediately prior to the last COAG meeting on 17 April, the AMA released the AMA Public Hospital Report Card 2015, which highlighted the declining level of Commonwealth funding for public hospitals, and that public hospitals were not meeting key performance targets even with the current level of funding.

Public hospital funding was also a focus for a high profile and successful policy session at AMA National Conference on 30 May which outlined the impacts of inadequate funding on public hospitals in two states.

So, where is the Federation Reform process up to?

Later this month Australia’s heads of government will have an opportunity to take a leadership approach to considering reform of the federation and how reform could help address some of the big issues facing Australia over the medium to longer term.

The best approach to future roles and responsibilities in health is one of those issues. We need to ensure this debate is framed in a useful way.

The discussion paper canvasses five options for health and hospitals: states and territories take full responsibility for public hospitals; a Medicare-type rebate scheme for all hospital treatments; states and Commonwealth jointly responsible for funding care packages for chronic and complex patients; regional purchasing agencies be funded to purchase health services; and the Commonwealth becomes the single funder of health services and establishes a health purchasing agency.

Early reporting has focused on whether particular proposals for reform will produce more or less accountability and efficiency. These are important features of any arrangements.

But they are not as important as whether reforms will deliver the capacity that public hospitals require to meet the needs of patients for timely and high quality hospital care.

If you ask any patient, they will be interested first and foremost in whether they and their families can expect to receive hospital care when they need it and to a high standard of quality. As doctors we have this interest in common.

This is the basic thing that our public hospitals absolutely need to get right. It’s the first test that should be applied to any options for change.

HFE and other AMA committees will be considering the options to help the AMA influence the development of sensible and practical outcomes for health from the Reform of the Federation process. Your input and views will be valuable as part of this work.

Penetrating neck injury in an isolated medical setting

Clinical record

A 34-year-old man presented to a small rural emergency department at 21:45, arriving by private car from a bush campsite some 45 minutes’ drive away. An empty “stubbie” beer bottle had been recapped and thrown on the fire. It subsequently exploded, showering glass fragments onto surrounding people, one of whom sustained a small penetrating neck injury (PNI) with a piece of glass lodging in his anterior neck.

On arrival at the hospital, the patient had removed the glass and was clutching his neck with paper towels, describing a feeling of blood in the back of his throat, with associated haemoptysis.

He had a Glasgow Coma Scale score of 15, with normal vital signs, and was found to have a 1 cm wound just above his cricoid cartilage slightly to the right of midline. There was minimal active bleeding externally, but air occasionally bubbled from the wound and surgical emphysema was palpable on the right side of his neck. He was most comfortable slightly head down on his right side, and was maintaining O2 saturation of 99% in room air, with no clinical evidence of pneumothorax.

In consultation with Adult Retrieval Victoria, the attending anaesthetic-trained rural general practitioner decided to proceed to rapid sequence intubation (RSI) with an oral endotracheal tube (ETT) before evacuation to a tertiary centre.

With assistance from the nursing staff and a second anaesthetic-trained rural GP, the patient was pre-oxygenated with deep spontaneous breaths and a successful RSI under direct laryngoscopy was performed. For easier insertion, a size 7.5 cuffed ETT was placed. Blood was present on the vocal cords, but the oropharynx was clear.

Mechanical ventilation was carried out initially with a portable unit (Weinmann Medumat Standard-a), on minute volume cycle with a minimum available pressure of 20 cm H2O. Subsequent chest x-ray showed extensive surgical emphysema (Figure) and air mediastinum, at which point he was moved to the operating theatre to allow lower pressure ventilation using an anaesthetic ventilator. The ETT was shifted further down the trachea to tamponade the site of traumatic injury, and reduce bleeding and tissue emphysema.

Assisted ventilation at the hospital continued until 01:38, when the retrieval team arrived by road ambulance some 4 hours later.

He was transferred by road ambulance to the tertiary hospital, arriving at 04:22, where investigation with computed tomography (CT) angiography excluded any vascular injury. A surgical tracheostomy and tracheal repair was undertaken at 12:40 later that day. He spent over 24 hours in the intensive care unit on mechanical ventilation before making a full recovery.

Penetrating neck injury is commonly related to violence in countries such as the United States and South Africa,1 but it is rarer in Australia. This case report highlights the challenges and importance of initial management of a PNI in an isolated medical service, and the importance of health education around campfire safety.

The initial management of a PNI in a patient with a patent airway and who is haemodynamically stable with no signs of vascular injury is generally now considered to involve CT vascular imaging and selective surgical management.2,3 In an isolated medical facility without access to these services, management options are more limited. Initial treatment involves management of actual and potential airway complications together with stabilisation of vascular injury and resultant haemorrhage, with a plan for early evacuation to an appropriate tertiary facility for definitive care.

Our patient was haemodynamically stable and clinically had no obvious evidence of a significant vascular injury. The penetrating glass fragment was described as small, although not seen by the medical staff as the patient had removed it before arrival. The ongoing haemoptysis and palpable surgical emphysema suggested airway injury, and potential risks associated with haematoma formation and airway obstruction during transport led to the decision to perform rapid sequence endotracheal intubation. This is thought to be the safest initial airway management when anatomical structures are preserved,2,4 although definitive surgical airway management would be required at the tertiary centre.

Incorrect ETT placement, inadequate seal, or excessive ventilator pressure, may lead to acute deterioration where tracheal injury exists. This is particularly important in a remote medical setting, where considerable delay can occur before transport to an appropriate tertiary care facility, which could have become a critical issue in our case had the patient not been haemodynamically stable.

Despite standard transport immobilisation protocols, the literature recommends that cervical spine immobilisation is not required unless focal neurological deficits are present.2 Penetrating neck injuries (particularly stabbing) rarely cause spinal cord injury,5 and cervical collars can impede airway visualisation or evidence of other injuries. Our patient had no clinical evidence of spinal cord injury and no mechanism of injury to suggest one, so a cervical collar was not applied, making it easier to intubate as well as to monitor and assess the injury site.

Many outdoor recreation activities involving campfires occur in isolated environments, with limited access to medical and emergency services. In such situations, burns are an increasing concern,6 either from falls or exploding containers.7 This case demonstrates the additional risk of projectiles from exploding containers irresponsibly placed into fires. Although common sense dictates that it is risky to throw sealed containers into open fires, anecdotally it is often done when alcohol consumption is combined with open fires in a relaxed bush environment.

This case suggests that appropriate initial management of PNIs in an isolated rural setting can include careful endotracheal intubation until later surgical management with a definitive surgical airway. In addition, it reinforces the public health message that responsible behaviour reduces risk — particularly when setting an example and providing health education messages to the next generation. This case was unusual, but the clinical and public health lessons it provides are perhaps generalisable.

Lessons from practice

Management of penetrating neck injury in an isolated setting involves stabilisation and endotracheal intubation.
Cervical spine immobilisation is not required with penetrating neck injury unless focal neurological deficits are present.
Rapid sequence intubation is a useful skill for general practitioners to have when working in a rural setting.

X-ray of the patient’s neck and upper chest after initial intubation

Red arrow: surgical emphysema. Black arrow: tip of endotracheal tube.

Coordinated care versus standard care in hospital admissions of people with chronic illness: a randomised controlled trial

Chronic, non-communicable diseases including cardiovascular diseases, oral health care, mental disorders and musculoskeletal diseases comprised 85% of the total burden of illness in Australia and New Zealand in the 2008–09 financial year, incurring direct health care costs of $27 billion.1 Respiratory illness, heart disease and diabetes comprised 80% of the total burden of illness and injury and 70% of health expenditure in Australia in 2004.2,3

Fragmentation of health care with poor coordination and communication among care agencies and a lack of continuity of care are noted as problems.4 As a consequence, some consumers rely heavily on local hospital emergency departments (EDs) to provide ongoing care. Although Australian and overseas studies have emphasised coordination problems in the management of chronic care, little is known about what defines well coordinated care, and what comprises an effective program.5–7

Australian coordinated care experiments between 1997 and 20058 often ended up costing more than standard care, and fewer than half showed an improvement in patient wellbeing.8–10

Western Sydney’s health services to older people and those with chronic illness were reviewed by the (then) Sydney West Area Health Service’s Service Redesign Unit and PricewaterhouseCoopers in 2007.11 The resulting Care Navigation (CN) framework was intended to help patients with chronic illness access services and providers in a more coordinated and timely way, using alternatives to hospital admission where possible for patients with acute deterioration. Those presenting to the ED would have their care more completely coordinated.

We conducted a randomised controlled trial (RCT) to test the hypotheses that, compared with standard care, CN would:

be superior for participants with complex chronic illness, improve quality of life, and reduce emergency re-presentations and hospital readmissions;
extend time to first re-presentation and first readmission, and reduce length of stay; and
have no effect on the mortality rate.

Methods

The study protocol has been published elsewhere.12 Ethics approval was granted by Sydney West Area Health Service Human Research Ethics Committee – Nepean Campus (HREC/09/NEPEAN/55), and ratified by the University of Sydney Research Integrity office.

We conducted a pragmatic RCT. Researchers who collected outcome data or performed statistical analyses were blinded to treatment allocation. Patients and CN nurses were not blinded owing to the nature of the intervention.

Eligible patients who presented to Nepean Hospital ED between 17 May 2010 and 25 February 2011 were identified by an algorithm implemented in the ED patient tracking system, and were approached to consent to participate in the trial. The inclusion algorithm identified patients who had three or more unplanned admissions to a Sydney West Area Health Service hospital in any previous 12-month period and were either aged ≥ 70 years or aged ≥ 45 years if they were of Aboriginal or Torres Strait Islander descent; or aged 16–69 years with at least one admission for a respiratory- or cardiology-related condition. Patients were also eligible if a CN nurse determined that a patient would benefit from receiving CN.

Patients were ineligible if they had previously received CN; were medically unable to participate in study activities (questionnaire completion); were admitted to hospital more than one CN business day before randomisation; or did not provide consent.

Randomisation was stratified by age (≥ 70 years; 16–69 years), and participants were randomly allocated 1 : 1 to CN and standard care. The sequence of treatment allocation was determined by block design. A phone-based randomisation service provided by the National Health and Medical Research Council Clinical Trials Centre was used to allocate treatment arms to participants after consent was given. Participants were followed up for 24 months after randomisation.

Intervention

Three nursing roles were allocated: Inbound, Inflight and Outbound. Two full-time nurses were employed to conduct CN through the recruitment period and for 24 months of follow-up. One nurse conducted the Inbound role — managing patients at presentation to the ED, assessing their current health status and risk of readmission, and directing them to the best method of care in the hospital or community. A second nurse carried out the Inflight role — monitoring the progress of patients’ care and minimising delays to discharge from the hospital ward. The second CN nurse also carried out the Outbound role — reviewing patients’ hospital stay, assessing the need for out-of-hospital care facilities and making arrangements for ongoing care after departure from hospital.

CN nurses used an electronic assessment form to identify medical and psychosocial risks of readmission, and to identify patients in the ED who might not require hospital admission if community-based care could be organised instead.

Data collection

Baseline demographics were collected from New South Wales Health’s Health Information Exchange (HIE) system.

The three primary outcomes of the trial were a reflection of the aims of CN: i) number of re-presentations to a Western Sydney or Blue Mountains EDs; ii) number of readmissions to a Western Sydney or Blue Mountains hospital; and iii) quality of life. Re-presentation and readmission data were collected electronically from the HIE database. Participants completed the EQ-5D-3L questionnaire13 at baseline, 12 and 24 months.

Mortality data were obtained from the National Death Index maintained by the Australian Institute of Health and Welfare. HIE data were used to investigate the time that participants spent in and between hospital visits.

Allied health referral data were obtained from the NSW Health Cerner database. Community health service referral data were obtained from the Community Health Information Management Enterprise (CHIME) and provided by Western Sydney/Nepean Blue Mountains Local Health District Community Health, Information Management and Logistical Support. Medicare Benefits Schedule and Pharmaceutical Benefits Scheme data were provided by Medicare Australia Statistics.

Statistical analyses

Primary analyses were intention-to-treat. The main outcomes were analysed using negative binomial models to estimate the incidence rate ratios of re-presentations and readmissions, and change in EQ-5D score from baseline at 24 months using an analysis of covariance (ANCOVA).

Other outcomes were analysed using negative binomial generalised estimating equation models (length of stay in ED, in ward, and total length of hospital stay; time from arrival in ED to first seen by doctor, and to first allied health referral). For the time-to-event outcomes, time to first ED re-presentation and time to first hospital readmission, we used Kaplan–Meier curves and a Cox proportional hazards model to estimate the hazard ratio.

The total follow-up for each patient was used as an offset. All regression models included treatment arm and the stratification variable (age group) as explanatory variables. Further adjusted analyses were conducted for all outcomes, for sex and the number of ED presentations in the 12 months before randomisation (quartiles). Post-hoc subgroup analyses were conducted on the primary outcomes with respect to age strata; number of ED presentations or hospital admissions in the 12 months before randomisation; whether participants were identified as appropriate for CN by clinician flagging; or whether participants had a carer. A two-sided P of 0.05 or less was considered significant. Data were analysed using SAS, version 9.3 (SAS Institute).

Power calculation

We planned to recruit 500 patients over 12 months and expected a 20% loss to follow-up, leaving a final sample size of 400 with 90% power to detect a 20% reduction in hospital readmissions (rate ratio of 0.8), assuming a 5% significance level and a Poisson distribution with an average of 2.5 admissions per patient over 24 months in the control group, compared with 2.0 in the intervention group. A sample of 400 gave 80% power to detect a 15% reduction in hospital readmissions and a clinically significant difference in presentations. It also allowed us to detect a mean difference of 10 points on the EQ-5D scale, with about 80% power at a 5% significance level. This calculation is based on pilot data that estimated standard deviation of EQ-5D scores to be 35 points.6

Besides the quantitative studies of the effect of CN, a process evaluation gave qualitative insights into the process of the provision of care. Extensive interviews with service providers included tracking how the model of care changed over the course of the intervention. These data will be presented in a subsequent publication.

Results

Five hundred patients were recruited to the study between May 2010 and February 2011. Box 1 shows the flow of participants’ progress through the study. Participant baseline demographic information by study arm is presented in Box 2. Randomisation provided an even distribution between study arms for all demographic variables except sex — the CN group had 55% women compared with 45% in the standard care group. Three-quarters of participants were born in Australia, and four of these were reported in the hospital patient database as being Indigenous. Most participants presented to the ED on a weekday, during the daytime, and 88% were admitted to hospital at their randomisation visit.

Primary outcomes

The comparison of outcomes by treatment type is shown in Box 3. The mean number of ED re-presentations during the 24-month follow-up period was not statistically significantly reduced in the CN group (6.28; 95% CI, 5.44–7.26) compared with the standard care group (7.57; 95% CI, 6.55–8.74). This corresponds to a 17% reduction in re-presentation (95% CI, − 1% to 32%; P = 0.07). Similarly, there was no significant reduction in the mean number of hospital readmissions during the follow-up period in the CN group (4.38; 95% CI, 3.79–5.06) compared with the standard care group (5.16; 95% CI, 4.46–5.96). This corresponds to a 15% reduction (95% CI, − 4% to 30%; P = 0.11). Quality of life at 24 months did not differ significantly between the CN and standard care groups, with a mean difference of zero (95% CI, − 0.10 to 0.09; P = 0.93). Further analyses adjusted for sex and ED presentations before randomisation were similar.

CN had no significant treatment effect on any primary outcome in any of the subgroups analysed (results not shown).

Secondary outcomes

CN did not affect the time to first re-presentation after randomisation (hazard ratio, 1.01; 95% CI, 0.84–1.23; P = 0.89; Box 4A), or the time to first readmission (hazard ratio, 0.93; 95% CI, 0.77–1.13; P = 0.47; Box 4B). CN had no effect on the mean number of hours spent in the ED at the randomisation visit (rate ratio, 0.95; 95% CI, 0.82–1.11; P = 0.54) or over the subsequent 24 months (rate ratio, 0.99; 95% CI, 0.90–1.08; P = 0.80; Box 3). CN did not significantly reduce the mean number of days admitted to a ward at the randomisation visit (rate ratio, 1.2; 95%, CI, 0.82–1.76; P = 0.36) or over the subsequent 24 months (rate ratio, 0.98; 95% CI, 0.82–1.17; P = 0.82; Box 3). CN had no effect on mortality (hazard ratio, 0.92; 95% CI, 0.67–1.26; P = 0.60; Box 4C).

Process outcomes

More than six times the number of patients in the CN group (119/247 [48%]; 95% CI, 42–54) had their medications reviewed by a hospital pharmacist when presenting to hospital than those in the standard care group (19/245 [8%], 95% CI, 5–12); the overall difference was statistically significant (rate ratio, 6.35; 95% CI, 4.03–10.02; P < 0.001). However, there was no difference in the number of prescription medications dispensed over the 24-month follow-up period. CN had no effect on any other inhospital allied health or diagnostic services (results not shown).

Patients in the CN group received more services per year from community health (rate, 13.80; 95% CI, 10.69–17.8) than standard care patients (rate, 7.10; 95% CI, 5.46–9.23); the overall difference was statistically significant (rate ratio, 1.94; 95% CI, 1.35–2.81; P < 0.001). Most of these services were the result of referrals from hospitals (CN rate, 1.00 per year; 95% CI, 0.88–1.13 v standard care rate, 0.38; 95% CI, 0.32–0.45; P < 0.001). CN did not change the number of service payments claimed from the Medicare Benefits Schedule by general practitioners, non-hospital allied health professionals or consultant physicians (results not shown).

Delivery of intervention

CN began in May 2010. Nursing personnel was reduced from two nurses to one nurse on 9 November 2011. The remaining CN nurse reviewed existing risk assessments, updating participants’ requirements where required, but did not carry out any other part of the Inbound CN role due to availability of time and a lack of expertise in ED nursing. CN ceased at Nepean Hospital on 4 April 2012, when the remaining CN nurse left the position. Box 5 depicts the availability of CN nurses along with the number of participants actively in the study in the intervention arm throughout the study period. Per-protocol analyses based on 12 months of follow-up or the period when CN nurses were available demonstrated no difference between standard care and CN in any of the primary or secondary outcomes (results not shown).

Discussion

CN did not improve quality of life or reduce unplanned hospital presentations or admissions despite community health services almost doubling. This study sought to establish whether an energetic hospital care coordination program could enable patients admitted with an exacerbation of chronic illness to receive sufficient assistance in hospital and in the community, to reduce their need for future readmission.

There is a growing body of evidence that outcomes for people living with chronic illness can be improved, and hospital attendances reduced, by redesign of the health care delivery system across primary, secondary and acute sectors to ensure equitable, structured, proactive, coordinated, culturally sensitive care; decision support and clinical information systems that support this care; case management for complex patients; empowerment and support for self-management by patients and their carers; and community mobilisation.4,14,15 The impact of these changes is greatest when multiple, integrated improvements are made in care delivery.16

CN was an attempt to organise these services from a hospital base. However, it was no more effective than the existing processes of care at Nepean Hospital in improving self-reported quality of life, reducing hospital presentations or admissions, reducing the time patients spent in hospital or delaying readmission. CN had no effect on mortality. No intervention effect was detected in any of the subgroups analysed. However, CN did have an impact on the processes of care following discharge. Patients in the intervention group received more services from community health agencies, mainly nursing services.

Patients in the CN group spent the same amount of time in hospital and were referred to inhospital allied health or diagnostic services at the same rates as the standard care group. Delivery of CN was largely within the hospital, with limited arrangements made for ongoing care after departure. While these arrangements presumably reflected the care navigators’ assessment of the participants’ current and expected needs at that time, subsequent changes in their clinical needs would have been managed by health service structures and services that were similar in the two arms of the trial.

Attempts to formally evaluate interventions in health care systems are fraught by changes in the environment of care as staff change, funding sources change, and higher service priorities come to dominate the care scene. CN suffered the effects of all these real-world variations.

While study recruitment achieved the predetermined target of 500 participants and complete data were available for analysis from 492 (98%) at the end of the study, implementation of the intervention varied during the study; in particular, the number of CN nurses reduced from two to one 18 months after recruitment commenced. The second nurse left 4.5 months later, when CN ceased at the hospital, and the final 10 months of the study period had no CN. However, analysis limited to the period when both nurses were available showed no intervention effect on any of the primary or secondary outcomes.

CN during hospital admission with increased referrals for community health services after discharge was too small an intervention in the overall health system to have an impact. Future service development should explore the potential benefits of linking navigated intrahospital care to ongoing, proactive care planning and delivery in the community.

1 Flowchart of participants’ progress through a randomised controlled trial comparing Care Navigation (CN) with standard care for patients with chronic illness, Nepean Hospital, Sydney, May 2010 – February 2013

2 Participant baseline demographic information by study arm

Demographic variable	Care Navigation (n = 247)	Standard care (n = 245)

Age in years at randomisation, mean (SD)	73.3 (12.3)	74.9 (11.8)
Age at randomisation by strata, no. (%)
≥ 70 years	171 (69%)	171 (70%)
16–69 years	76 (31%)	74 (30%)
Sex, no. (%)
Female	135 (55%)	110 (45%)
Male	112 (45%)	135 (55%)
Country or region of birth, no. (%)
Australia	188 (76%)	183 (75%)
Europe	40 (16%)	46 (19%)
Other/not stated	19 (8%)	16 (7%)
Preferred language, no. (%)
English	232 (94%)	219 (89%)
Non-English	10 (4%)	13 (5%)
Not stated	5 (2%)	13 (5%)
Marital status, no. (%)
Married or de facto	117 (47%)	127 (52%)
Single, widowed, separated or divorced	129 (52%)	116 (47%)
Not stated	1 (< 1%)	2 (1%)
Funding source for services (in addition to Medicare), no. (%)
None	166 (67%)	166 (68%)
Private health insurance	10 (4%)	13 (5%)
Department of Veterans’ Affairs card, all types	21 (9%)	12 (4%)
Compensation	2 (1%)	2 (1%)
Not stated	48 (19%)	52 (21%)
Primary SRG assigned to hospital admissions in the 12 months before randomisation, no. (%)*
Cardiology	85 (34%)	89 (36%)
Surgery	58 (23%)	39 (16%)
Respiratory	38 (15%)	49 (20%)
Other†	107 (43%)	97 (40%)
No. of emergency department presentations in the 12 months before randomisation, mean (SD)
1	33 (13)	47 (19)
2–3	92 (37)	88 (36)
4–5	68 (28)	67 (27)
≥ 6	54 (22)	43 (18)
No. of unplanned hospital admissions in the 12 months before randomisation, mean (SD)
0	7 (3)	13 (5)
1	53 (21)	50 (20)
2	53 (21)	45 (18)
3–4	83 (34)	76 (31)
≥ 5	51 (21)	61 (25)
Eligibility criteria used at randomisation visit, no. (%)
Electronic algorithm	181 (73%)	170 (69%)
Clinician flag	66 (27%)	75 (31%)
Unplanned hospital admissions at randomisation, no. (%)	222 (90%)	209 (85%)

SRG = service-related group. * Percentages exceed 100% as some participants with more than one previous admission were listed under more than one primary SRG. † Including gastroenterology; geriatrics; cancer; neurology; renal medicine; rehabilitation; immunology and infectious diseases; endocrinology; non-subspecialty medicine; ear, nose and throat; psychiatry – acute, maintenance, drug and alcohol, unallocated, pain management; renal dialysis; palliative care; gynaecology; or dermatology.

3 Comparison of outcomes of Care Navigation and standard care for the 24 months after randomisation

Outcome

Care Navigation

Standard care

RR/HR/MD (95% CI)

Primary

Mean no. of re-presentations (95% CI)

6.28 (5.44–7.26)

7.57 (6.55–8.74)

RR, 0.83 (0.68–1.01)

0.07

Mean no. of readmissions (95% CI)

4.38 (3.79–5.06)

5.16 (4.46–5.96)

RR, 0.85 (0.70–1.04)

0.11

Quality of life 24 months after randomisation —
mean change in EQ-5D scores (95% CI)

0.14 (0.08–0.21)

0.15 (0.08–0.22)

MD, 0 (− 0.10 to 0.09)

0.93

Secondary

Median time from randomisation to first ED re-presentation, days (IQR)

111 (89–143)

103 (72–148)

HR, 1.01 (0.84–1.23)

0.89

Median time from randomisation to first hospital readmission, days (IQR)

155 (121–205)

144 (102–178)

HR, 0.93 (0.77–1.13)

0.47

Median time from randomisation to death, days (IQR)

—

HR, 0.92 (0.67–1.26)

0.60

Mean length of ED stay, hours (95% CI)

To departure-ready

5.73 (5.37–6.1)

6.81 (5.74–8.08)

RR, 0.84 (0.69–1.02)

0.08

Actual

10.58 (9.91–11.3)

10.71 (10.03–11.44)

RR, 0.99 (0.90–1.08)

0.80

Mean length of stay admitted to a ward, days (95% CI)

5.46 (4.86–6.14)

5.57 (4.76–6.53)

RR, 0.98 (0.82–1.17)

0.82

Mean length of ED stay at randomisation visit, hours (95% CI)

All participants

12.91 (11.59–14.39)

13.55 (12.01–15.28)

RR, 0.95 (0.82–1.11)

0.54

Participants not admitted to a ward

7 (4.69–10.44)

6.52 (5.28–8.07)

RR, 1.07 (0.65–1.76)

0.78

Participants admitted to a ward

13.61 (12.2–15.18)

14.74 (13.01–16.7)

RR, 0.92 (0.79–1.08)

0.32

Length of stay in a ward at randomisation visit

7.01 (4.52–10.87)

5.86 (4.7–7.31)

RR, 1.2 (0.82–1.76)

0.36

ED = emergency department. HR = hazard ratio. IQR =interquartile range. MD = mean difference. RR = rate ratio. All analyses were adjusted for stratification at randomisation (age: ≥ 70 years; 16–69 years). — = Median survival cannot be obtained as cumulative survival did not fall below 50% during the study period.

4 Kaplan–Meier curves by treatment group in the 24 months after randomisation

A. Time to first emergency department re-presentation. B. Time to first hospital readmission. C. Time to death.

5 Number of participants in the intervention group and the availability of the Care Navigation (CN) nurses throughout the study period

Ensuring safe exercise participation in clinical populations: who is responsible?

An overview of recent advances and ongoing challenges in exercise participation-related risk

The benefits of regular physical activity are well established, and the advice to “move more” can be offered to most individuals with little risk. Exercise, where there is a structured movement and activity plan, is recommended as cornerstone management for people with many chronic conditions, but it carries inherent risks that must be considered.1 The responsibility for managing this risk should be shared between primary health providers, patients and exercise professionals, but how well does this work in practice?

The best available evidence suggests the absolute risk of adverse events during exercise in an apparently healthy individual is very low at 0.1–1 adverse events for every 10 000 hours of exercise.2 However, this risk is higher in people with many common chronic conditions.1 In a study of commercial fitness centres, 52% of new members were identified as “higher risk” and 17% as “moderate risk” and in need of a modified exercise prescription,3 yet there is an alarming lack of capacity and effective processes within the fitness industry to manage the increased risk in clients who present with chronic diseases. The highest level of fitness or exercise qualification commonly found in gymnasiums and fitness centres is certifications held by exercise instructors and personal trainers, but they have little or no capacity to manage increased risk (Box).

Historically, a common feature of exercise risk stratification systems is that anyone who is deemed to be at risk is encouraged to obtain clearance from their doctor before they commence exercise. This has placed general practitioners in a difficult position where they are asked to provide a “medical clearance to exercise”, without standardised guidelines. In the general practice setting, it is usually not feasible to establish a patient’s response to an exercise challenge or stress test, and making a judgement about risk on the basis of the available medical history is not always appropriate. Further, the GP may have limited information about the intended exercise program, and who will be responsible for the patient’s wellbeing. Indeed, patients themselves may not know the answer to these questions. GPs have been actively discouraged from providing clearance-to-exercise certificates on the basis that such a clearance represents a transfer of medicolegal responsibility from the exercise or fitness professional to the GP.4

In 2011, a new adult pre-exercise screening system (APSS) was developed by Exercise and Sports Science Australia, Sports Medicine Australia, and Fitness Australia. This system removes the requirement for higher-risk clients to seek a medical clearance. It has been replaced with an instruction to seek “guidance” from an appropriate medical or allied health professional. This reflects a shared responsibility for client care where exercise practitioners have a responsibility to satisfy themselves that they have sufficient information to provide a safe service for the client. However, problems with the use of the tool remain that require interprofessional collaboration and resolution to achieve further progress towards this goal.

Notably, a recent survey of fitness centres suggests that, in practice, the uptake of the new screening tool within the fitness industry has been poor. Of those fitness centres that responded (~10%), only 55% regularly applied the APSS tool, with only 65% regularly using any form of pre-screening at all.5 It is also unclear what type of “guidance” should be sought from medical or allied health professionals. For example, should a GP be providing instruction, and particularly restrictions, on the mode, intensity, duration and frequency of exercise? Or are they simply to provide an indication of the current clinical status of an individual? The former is likely beyond a medical practitioner’s scope and training; the latter beyond the expertise of the non-clinically trained exercise practitioner to safely interpret.

It is clear that an integrated risk-mitigation process remains to be developed. In the interim, it is necessary that GPs have some insight into the goals and limitations of the current system to support their decision making when asked to provide a medical clearance or guidance; or indeed when referring or advising a patient toward engagement in exercise. As a minimum, it is worthwhile for GPs to become aware of the risk-screening protocols and staffing profiles of fitness centres in their communities and to direct patients toward the most appropriate options. GPs can manage the many uncertainties around this process by actively engaging their clinical allies in this field — in accredited exercise physiologists and physiotherapists.

The best model ultimately involves strong referral networks, and shared responsibility for patient risk and outcomes between the medical, allied health and fitness sectors. To ensure the integration of safe and effective exercise services within primary health care, there is a need for relevant professional bodies to work together to establish clearer referral pathways and universal assessment and decision-making guidelines for the identification and management of higher-risk individuals when commencing exercise.

Professionals who work across the fitness industry and exercise health sector

Exercise instructors and personal trainers

Registration with Fitness Australia or an equivalent body requires a relevant fitness qualification (Certificate III in Fitness or higher) and current first aid and CPR certification. Exercise instructors and personal trainers are able to plan, demonstrate and supervise exercise programs for healthy clients, on both individual and group levels.

Exercise scientists

Exercise science is a bachelor level university qualification. University programs accredited by Exercise and Sports Science Australia (ESSA) enable exercise scientists to design and deliver exercise programs and assessments to meet the specific needs of apparently healthy clients, and to deliver exercise programs for clients with illness or injury that have been prescribed by an accredited exercise physiologist (AEP), physiotherapist or an appropriately qualified health professional.

Accredited exercise physiologists

AEPs are recognised allied health professionals who have completed university training in exercise science, pathophysiology and advanced clinical exercise practice. Exercise physiology university programs are accredited by ESSA; AEPs specialise in clinical exercise interventions for people at high risk of developing, or with existing, chronic and complex conditions or injuries.

Facilitators and barriers to implementation of a pragmatic clinical trial in Aboriginal health services

The principles of conducting ethically sound health research involving Aboriginal and Torres Strait Islander peoples have been well documented.1–3 There are, however, many challenges to implementation of these principles and negative experiences have been reported.4–11 A key element to the National Health and Medical Research Council (NHMRC) guidelines for ethical conduct in Aboriginal and Torres Strait Islander health research is the notion of reciprocity — that the benefits of the research be clearly articulated, negotiated and implemented in such a way that it will build community capacity.1 In the context of clinical trials, this includes ensuring that studies test interventions in the settings in which they will eventually be delivered, rather than contrived environments that are conducive to easier trial implementation. Such trials are often referred to as pragmatic randomised controlled trials (PRCTs).12

The Kanyini Guidelines with the Adherence Polypill (KGAP) study was a PRCT that tested whether a polypill-based strategy would improve prescriber and patient adherence to recommended treatments for cardiovascular disease (CVD).13–15 The trial was conducted between 2008 and 2012 across five Australian states in 20 general practices, 11 urban, rural and remote Aboriginal community-controlled health services (ACCHSs) and one government-run Indigenous health service. Participating services were each supported by one to three nominated community pharmacies. Design features that mimicked real-life practice included the prescribing of medicines by treating general practitioners, patient copayment charges for all study and other medicines at standard Pharmaceutical Benefits Scheme rates and the dispensing through community pharmacies. A major challenge to trial implementation was attaining target recruitment rates; only 623 of the target 1000 participants were randomised.16 This led to a longer study duration than anticipated, with concomitant budget pressures.

In this qualitative study, we aimed to identify facilitators and barriers to trial implementation in the ACCHSs and government health service from the perspective of providers and trial participants. The study forms part of a broader trial process evaluation.15

Methods

Fifty-three interviews were conducted with 32 health care providers and 21 Aboriginal and Torres Strait Islander patients at six ACCHSs and the government health service from April to December 2012. (Appendix 1 and Appendix 2). Five ACCHSs that were involved in the trial were unable to participate due to limited capacity at the time when interviews were being conducted. Participants were recruited purposively to yield a maximum variation sample based on location, age, sex, ethnicity, presence of CVD, and medication for patients, and location and profession for providers.

Interviews were conducted at the conclusion of the trial as part of the overall process evaluation and included exploration of experiences regarding trial implementation. Interview guides were developed and iteratively revised to explore themes and issues emerging from earlier interviews. A team of seven researchers, including three Aboriginal researchers, from a range of disciplinary backgrounds (health economics, pharmacy, nursing and public health) who were not involved in the implementation of the trial conducted the interviews. Most interviews were conducted face-to-face, with a small number conducted by telephone for logistic reasons.

Interviews were professionally transcribed and coded by two researchers (H L and L M) using NVivo 9 (QSR International). Twelve transcripts were selected (six patients and six health care providers — pharmacists, GPs, nurses and Aboriginal health workers [AHWs]) and were coded independently by the two researchers. These researchers identified the major themes arising from these 12 interviews and developed an initial coding framework. Insights gained by the research team about the context of the interviews and the local setting were documented and used to aid interpretation. The coding framework was then discussed and refined by a multidisciplinary group comprising the study investigators and the interview team. This included two ACCHS clinicians who were site principal investigators on the trial. The two researchers then coded the remaining interviews and made minor, iterative changes to code definitions.

For this study, we analysed codes specifically relating to issues relating to trial implementation. The randomised controlled trial, including its process evaluation, was approved by seven regional human research ethics committees, including one Aboriginal-specific committee. All participants who contributed data were provided a description of the study by the interviewer and given the opportunity to discuss any concerns before obtaining written consent.

Results

Four principal themes relating to barriers and facilitators for trial implementation were derived. Appendix 3 contains additional quotes that further illustrate the findings.

Health service governance of research

Ensuring community representation in governance of the research was a dominant issue. ACCHSs were invited to participate through initial discussions with senior management and governing boards. Formal memoranda of understanding (MOUs) with the coordinating research institutes were established. Amendments were made to the standard Medicines Australia clinical trial agreement to include intellectual property rights of ACCHSs and the roles and responsibilities associated with data custodianship. The discussions associated with setting up these agreements were critical in establishing mutual roles and responsibilities, data governance, capacity building plans and establishment of funding arrangements. One participant referred to the MOU as being a “landmark document” (GP 23, urban service).

In some instances, these agreements were facilitated by local governance processes. An AHW at an urban ACCHS described how previous negative experiences with external researchers prompted the establishment of a local research committee that would scrutinise external organisations’ research proposals:

In the past, the research that’s been conducted has left some scars … what has helped has been being more organised about having our own research agenda … so if you want to do research [with us then] this is what’s important to us. (AHW 47, urban service)

Motivation to participate

An expectation that the intervention could tangibly address an important health issue was extremely important for both patients and providers:

When you see people that are dying around you that are the same age as you and even younger, it’s all to do with health that they died not taking medication. Maybe if they were given the one pill instead of taking half a dozen they might be still here today. (Patient 4, urban service)

Several participating services had been involved in the Kanyini Vascular Collaboration before the trial and many staff were aware of the treatment gaps documented in the collaboration’s audit of patient records.14 Consequently, there was strong support from health care providers for strategies to address these gaps.

Effectively communicating the need to address these gaps to the community was particularly important. At one urban ACCHS this was done through a community forum and launch of the trial.

A related facilitator of participation was the role played by Aboriginal staff champions. These staff were often the initial point of contact for participants seeking information and were also referred to by other staff. One AHW discussed her role:

At first it was hard to communicate with them. But once it got mentioned once, twice, maybe three times what was in the tablet, what the benefits would be it started sinking into their brains then. (AHW 32, urban service)

Balancing service delivery and research requirements

An important aspect of the research was to incorporate the intervention into usual service delivery. Efforts to streamline the intervention included the prescribing and dispensing of the polypill within existing software platforms, timing pathology tests to coincide with scheduled visits and recruiting community pharmacies that were accessible to the participating sites. Despite these efforts to integrate the intervention into routine care processes, some GPs felt it created “confusion in their management” and “confusion about what they were on when they went into hospital”.

Some providers indicated challenges balancing trial operations with existing workloads. This manifested differently in urban and remote settings. For example, in urban settings, transport services were enlisted to facilitate study visits and access to medicines, potentially leading to limited transport availability for non-trial patients. In remote settings, fly-in fly-out doctors provided services to highly mobile populations. This created substantial challenges for clinic staff to coordinate follow-up study visits. One GP felt that the trial was more suited to urban ACCHSs:

You cannot compare it to an AMS [Aboriginal Medical Service] in Sydney … because we are serving about 200 000 square kilometres at this AMS. … our patients might come into town but they could be based 500 kilometres away … and it’s a very transient place for many of our patients. (GP 40, remote service)

Such logistic challenges inevitably resulted in delays in recruitment and follow-up. To alleviate these challenges the study team committed additional unbudgeted resources to support trial sites.

Research capacity-building challenges

A core study objective was to build health service research capacity through involvement of staff in the clinical trial. Most of those interviewed considered trial participation to be a positive experience, with many staff members describing enhancement of clinical skills, increased awareness of clinical trial processes, and deeper collaborations between the health service and pharmacies.

A key capacity-building initiative was the creation of local Indigenous research fellow (IRF) positions to perform trial coordinator duties. In practice, however, recruitment of suitably trained individuals was challenging and only four positions were filled.

The idea was that we were going to have an [IRF] is a great idea, but it just turned that we didn’t really have anyone that took it on with a passion … [The role] is quite complicated … (GP 3, urban service)

Moreover, like all clinical staff, IRFs frequently had competing responsibilities, and found it difficult to balance their research role with service delivery. This led to staff turnover in the early part of the study, which affected the trial conduct. Overall, most trial sites commented that additional on-site support from research institute staff would have been beneficial. This was easier to provide at those sites located closer to the coordinating research institutes, and those sites tended to manage the trial with fewer challenges.

Discussion

This study examined the often-overlooked views and experiences of patients and health care providers from Aboriginal health services participating in a clinical trial. The key facilitators of participation were the interrelated factors of research governance, patient and provider perception of the need for this research, deployment of effective strategies for communication to the community at large, and enlisting the support of Aboriginal staff champions. These facilitators were tempered by several challenges related to adequate integration of the intervention strategy into routine care processes, large competing demands with routine service delivery, and only partially successful attempts at building local research capacity. These challenges manifested differently due to the highly diverse settings in which the participating services operated.

In Australia, several Indigenous health RCTs have been successfully conducted through established health service–researcher partnerships, particularly in the area of child health.17–19 Many have experienced challenges in meeting recruitment targets and implementing the trials as originally conceived. Occasionally, trials have had to be abandoned altogether due to insurmountable constraints.20 Our findings help determine the factors that both hinder and promote successful conduct of such trials. The integration of complex trial protocols that are not supported by senior management into underresourced health service settings is a recipe for implementation failure. Conversely, trials that address a priority health issue, have had strong health service engagement and adequate local support seem more likely to succeed.

The study was an indepth exploration of issues from a sample that was not necessarily representative of all participants and providers in the trial. Fewer interviews were done in remote sites, and staff who had left the service or participants who had withdrawn by the end of the study were not interviewed.

Although this study was based on a PRCT, such a design will not always be feasible nor acceptable. Alternative designs, such as stepped wedge trials and cluster RCTs of health service interventions, have been successfully implemented in collaboration with ACCHSs.21,22 Other designs, such as crossover studies, interrupted time series analyses and propensity score matching, are also practical and often cheaper to implement. Use of automated de-identified data extraction and opt-out consent processes can considerably reduce data collection burden and reduce demands on Aboriginal health services.22 There is also much to be gained from observational studies, in which routinely collected clinical audits can inform the evidence base about effective health service strategies.14,22–27

Although community participation in prioritising the research question is of fundamental importance, substantial research infrastructure investment in health services is of equal importance. Aboriginal governance and leadership of the research agenda must be in place, and there are now good examples of how large-scale research can incorporate this from the outset.28,29 Associated with this is clear articulation of the resource implications associated with participation and ensuring there is adequate recognition of this within study budgets. The model for capacity building had mixed success, mainly due to the excessive and competing demands on individuals and limited existing research capacity; novel models to increase research capacity are needed.

There is clearly a need for more interventional studies to build the evidence base of what works in Aboriginal health service settings.23,30 It is important that research funding bodies recognise the factors highlighted in this study in their grant schemes. The overall $5 million (around $8000 per randomised patient) spent on the Kanyini GAP trial was several times higher than the amount originally granted and multiple additional funding applications were required. Although guiding statements on appropriate ethical conduct of research involving Aboriginal and Torres Strait Islander peoples acknowledge these issues, project-specific funding schemes tend not to recognise the importance of long-term investments in research capacity building, beyond what is immediately required to complete the project.1,2 In addition to non-project specific schemes, such as the NHMRC Centres for Research Excellence, project-specific loadings for research conducted in collaboration with already overstretched Aboriginal and Torres Strait Islander health services ought to be considered to support local research capacity building and establishing the governance arrangements needed to ensure community support. Such investments would build the evidence base on models associated with success and strengthen the application of reciprocity in the conduct of Aboriginal and Torres Strait Islander research.

Celebrating 10 years of collaboration: the Australian Indigenous Doctors’ Association and Medical Deans Australia and New Zealand

Closing the gap by growing the Aboriginal and Torres Strait Islander medical workforce

This year marks the 10th anniversary of the collaboration between the Australian Indigenous Doctors’ Association (AIDA), the professional association for Aboriginal and Torres Strait Islander doctors and medical students,1 and Medical Deans Australia and New Zealand (Medical Deans), the peak body representing professional entry-level medical education, training and research in Australia and New Zealand.2 In October 2005, AIDA and Medical Deans established an inaugural collaboration agreement formalising our shared commitment to achieving health equality for Aboriginal and Torres Strait Islander people, with a focus on growing the Indigenous medical workforce.

Over the past 10 years, AIDA and Medical Deans have reaffirmed this strong and sustained commitment to achieving our shared objectives through three successive collaboration agreements. Notable milestones have been achieved since 2005, including:

a growth in the Aboriginal and Torres Strait Islander medical student cohort;
co-auspicing of the biennial Leaders in Indigenous Medical Education (LIME) Connection, which brings together a range of key health and medical education stakeholders to share innovative approaches in Indigenous medical education;3
implementation of the Capacity Building for Indigenous Medical Academic Leadership Project to support more Aboriginal and Torres Strait Islander people becoming medical academic leaders;4 and
the National Medical Education Review,5 which highlighted best practice for Australian medical schools in implementing the Indigenous Health Curriculum Framework.6

While all our achievements are significant, we are particularly pleased with the marked growth in the number of Aboriginal and Torres Strait Islander medical students. In 2005, Aboriginal and Torres Strait Islander medical students represented just 0.8% of first-year domestic enrolments. In 2011, this increased substantially to 2.5%, reaching population parity for the first time. In 2014, a record number of about 30 Indigenous medical students completed their degrees, and three universities celebrated their first Aboriginal and Torres Strait Islander medical graduates. These achievements reflect the importance of partnership in supporting Aboriginal and Torres Strait Islander medical students along the education and training pathway, to contribute to a growth in the Indigenous medical workforce.

Although there has been real progress in growing Aboriginal and Torres Strait Islander doctor and medical student numbers, there is still much work to be done in this area, particularly in regards to strengthening recruitment and retention. We envision a future where Aboriginal and Torres Strait Islander doctors and medical students reach a critical mass in the Australian medical workforce; and one in which all doctors are trained to deliver equitable, accessible, high-quality and culturally safe services to Aboriginal and Torres Strait Islander people.

The success of the AIDA and Medical Deans partnership has provided the impetus for similar arrangements to be developed across the medical education and training continuum, such as AIDA’s collaboration agreements with the Committee of Presidents of Medical Colleges and the Confederation of Postgraduate Medical Education Councils. Our achievements have been recognised in Australia and internationally, through presentations on our successes at forums such as the Pacific Region Indigenous Doctors’ Congress (PRIDoC) Conference. PRIDoC provides a culturally safe environment for health and medical professionals of the Pacific region to share and promote culturally safe research and clinical practices for Indigenous peoples.7

The current AIDA–Medical Deans collaboration agreement is due to expire at the end of 2015.8 To ensure that our partnership continues, AIDA and Medical Deans are in the process of developing a new collaboration agreement for 2016–2018. We anticipate launching the new collaboration agreement around the time of the 6th biennial LIME Connection, which will be held in Townsville on 11–13 August 2015. The development of the new AIDA–Medical Deans collaboration agreement is timely, as it coincides with the theme of AIDA’s 2015 conference — “Collaborate, communicate and celebrate” — which will be held in Adelaide on 16–19 September 2015.

We look forward to extending our partnership to continue our work in growing the Indigenous medical workforce and improving health and life outcomes for Aboriginal and Torres Strait Islander people.

[Correspondence] Sustaining progress in maternal and child health in Nepal

Nepal has made substantial progress in reducing maternal and child mortality since 1990.1 With limited resources, the Nepal Government has strived to maintain health services, until the country was hit by a 7·9 Richter scale earthquake on April 25, 2015, followed by another 7·4 Richter scale quake within 3 weeks. The resulting damages are massive, with 600 000 people displaced, 750 000 houses destroyed, 8600 deaths, and 17 000 people injured.2 The economic cost is estimated to be US$5–10 billion.