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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Introduction

The review and updating of the first (2005) edition of the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people (‘National Guide’) is a joint initiative of the National Aboriginal Community Controlled Health Organisation (NACCHO) and The Royal Australian College of General Practitioners (RACGP) National Faculty of Aboriginal and Torres Strait Islander Health. The National Guide is a practical resource intended for all health professionals delivering primary healthcare to Aboriginal and/or Torres Strait Islander people. Its purpose is to provide GPs and other health professionals with an accessible, user-friendly guide to best practice in preventive healthcare for Aboriginal and Torres Strait Islander patients.

This second edition of the National Guide comprises:

  • the National Guide, which contains evidence statements, recommendations, risk calculation tables and an outline of the development of the guide
  • the evidence base: the collection of evidence underpinning the guide and recommendations (electronic only) (see the Methodology section ‘Searching the evidence base and drafting recommendations’)
  • a child and adult lifecycle summary chart listing activities recommended at each age group.

The National Guide is being integrated into clinical software over time to support primary healthcare professionals to implement best practice by providing them with accessible, accurate and up-to-date preventive health information relevant to Aboriginal and Torres Strait Islander people. For further information contact the RACGP National Faculty of Aboriginal and Torres Strait Islander Health on 03 8699 0499 or email aboriginalhealth@racgp.org.au.

Purpose

The National Guide is intended for all health professionals delivering primary healthcare to the Aboriginal and Torres Strait Islander population. This includes general practitioners (GPs), Aboriginal and Torres Strait Islander health workers, nurses and those specialists with a role in delivering primary healthcare. The National Guide makes specific recommendations regarding the elements of a preventive health assessment across the lifecycle of the Aboriginal and Torres Strait Islander population.

The aim of the National Guide is to provide an up-to-date, evidence-based national resource that can help inform health providers and policy makers on a defined set of activities that are of particular relevance to Aboriginal and Torres Strait Islander people.

These activities may prevent disease, detect early and unrecognised disease, and promote health in the Aboriginal and Torres Strait Islander population while allowing for variations based on regional and local circumstances. The health status of Torres Strait Islander people is very similar to that of the Aboriginal population, and the information in the National Guide can be applied to both population groups.

How to use the guide

Using the recommendations

All health professionals delivering primary healthcare to Aboriginal and/or Torres Strait Islander patients should use the recommendations to enhance the clinical care they provide. The National Guide aims to complement the RACGP Guidelines for preventive activities in general practice (the ‘red book’) by dealing with health issues that are specific to the Aboriginal and Torres Strait Islander population.

Cross referencing with the RACGP red book

The chosen subject areas in the National Guide represent the key health issues that are amenable to primary healthcare intervention and contribute to morbidity and mortality in the Aboriginal and Torres Strait Islander population. Where issues common in the general Australian population have not been dealt with in this guide (eg. urinary incontinence), GPs are encouraged to cross-reference with the red book. The red book is a synthesis of evidence-based guidelines from Australian and international sources and provides recommendations for everyday use in general practice.

Using local guidelines

Healthcare providers (particularly in regional and remote areas) are also encouraged to refer to local guidelines, where appropriate and available, in order to optimise preventive health assessments. Many of the recommendations in the National Guide describe health problems that may be of concern only in certain regional areas. For example, trichiasis screening is only appropriate for an elderly Aboriginal patient who was raised in a trachoma endemic area (see Chapter 6: Eye health). Consequently, many recommendations highlight the importance of clinical discretion in decision making.

Appraising current preventive practice

Healthcare providers should use the National Guide to systematically appraise current preventive practice, especially where recommendations for the general population have previously been applied to Aboriginal and Torres Strait Islander patients. Providers may also benefit by appraising certain screening activities for which there are ‘good practice points’ (ie. expert opinion based recommendations but little current evidence). Inappropriate preventive interventions may draw resources away from activities known to improve the health of the Aboriginal and Torres Strait Islander population, such as risk factor modification and immunisation programs.

Why preventive health assessments are necessary

A systematic and comprehensive approach to prevention

There is strong evidence that the delivery of clinical preventive health services improves health outcomes. These services include immunisation, screening for asymptomatic disease, chemoprophylaxis (using medication to prevent the onset of disease), counselling and other ways to encourage patient behavioural change, as well as primary healthcare influences over environmental factors.

See the Methodology section ‘Developing recommendations’.

Opportunity to improve Aboriginal and Torres Strait Islander health equality

Primary care providers often miss opportunities for the prevention of chronic disease and associated complications in the Aboriginal and Torres Strait Islander population, and miss opportunities to identify if patients are of Aboriginal and/or Torres Strait Islander origin.

Health service utilisation data indicate that Aboriginal and Torres Strait Islander people are high users of publicly provided services such as public hospitals and community health services and low users of medical, pharmaceutical, dental and other health services that are, for the most part, privately provided.1

Overall, in 2008–09, the potentially preventable hospitalisation rate for Aboriginal and Torres Strait Islander people (14 564 per 100 000 population) was 4.9 times the rate for other Australians (2956 per 100 000).2 Potentially preventive chronic diseases and injury are conditions causing the greatest proportion of excess deaths for Aboriginal and Torres Strait Islander people.3

Despite the overall health needs being higher for Aboriginal and Torres Strait Islander people, in 2008–09, average Medicare Benefits Schedule (MBS) expenditure per person was $363 for Aboriginal and Torres Strait Islander people and $621 for non-Indigenous Australians, a ratio of 0.58.1 The average Pharmaceutical Benefits Schedule (PBS) expenditure per person was $250 for Aboriginal and Torres Strait Islander people and $338 for non-Indigenous Australians, a ratio of 0.74.1

When preventive opportunities are missed, this can lead to a higher dependency on hospital care, which increases health costs. The Aboriginal and Torres Strait Islander population has much higher rates of hospital admission for almost every health problem than other Australians.2 Consequent life expectancy is much lower – Aboriginal and Torres Strait Islander males in 2005–07 had a life expectancy of 67 years, 11.5 years fewer than non-Indigenous males2 (based on the Australian Bureau of Statistics revised ‘direct method’ to account for the under-identification of Aboriginal and Torres Strait Islander deaths adopted in 2009).

Return on investment

Many chronic diseases within the Aboriginal and Torres Strait Islander population are unrecognised by patients. This has been well documented for diseases known for their insidious onset, such as diabetes, hypertension, cardiovascular disease and chronic renal failure. The preventive approach requires the ‘service to seek the patient’ while the patient is asymptomatic. It involves activity for primary prevention (to prevent the onset of disease), secondary prevention (to detect preclinical disease for cure or prevention of disease progression) and to a less extent, tertiary prevention (to minimise the consequences for those who already have disease). Preventive health assessments also involve the assessment of comorbidities in patients who already have a chronic disease.

The preventive approach to health has shown return on investment in non-Indigenous Australians, especially federal expenditure on immunisation, public health campaigns and the incorporation of preventive measures into primary care.4 Aboriginal and Torres Strait Islander people have a significant capacity to benefit from preventive healthcare. Given the reduced access to preventive healthcare by Aboriginal and Torres Strait Islander people and the huge burden of undiagnosed disease, effort needs to focus on measures to ensure that Aboriginal and Torres Strait Islander patients who are symptomatic of disease, as well as those who do not yet know they have disease (subclinical), have access to help.

Identifying Aboriginal and Torres Strait Islander patients

Implementing preventive health assessments requires healthcare providers to identify the target population. Research shows that where general practices take systematic action to improve their identification processes, there is a corresponding increase in the number of correctly identified patients.5 Identifying Aboriginal and Torres Strait Islander status is a necessary precondition for participating in the Closing the Gap initiative, agreed by the Australian Government and the Council of Australian Governments in 2008.6 

Without practice awareness, a patient who is of Aboriginal and/or Torres Strait Islander origin cannot benefit from the measures in the Australian Government’s Indigenous Chronic Disease Package.6 These include key measures available under the Practice Incentives Program Indigenous Health Incentive and PBS Co-payment Measure. For more information see www.medicareaustralia.gov.au/ provider/incentives/pip/forms-guides.jsp#N10068.

The RACGP paper, Identification of Aboriginal and Torres Strait Islander people in Australian general practice, assists health professionals in identifying Aboriginal and Torres Strait Islander patients5

All health professionals have an important role in facilitating the identification of Aboriginal and Torres Strait Islander patients. In order for a person to identify as being Aboriginal and/or Torres Strait Islander and accept this being recorded on their medical records, a culturally supportive and culturally safe environment needs to be established and continuously demonstrated. Several guidelines have been developed to assist GPs with this issue.5,7,8

Implementing preventive health interventions

Most preventive interventions are efficiently delivered opportunistically in the clinical encounter where primary healthcare services are available. Others are delivered through integrated approaches between primary healthcare providers and other services such as in the planning and delivery of breast cancer screening.

Using multiple strategies

Implementing preventive health assessment and interventions ideally involves strategies for both patients and healthcare providers. Usually multiple strategies are most effective, as exemplified by those used to increase adult vaccination (see Chapter 11: Respiratory health). These strategies may include opportunistic screening (case finding) and reminder systems within clinic settings, as well as outreach programs such as vaccination in non-traditional settings.

A preventive assessment may be undertaken in a single session between patient and health provider, which may or may not simultaneously address other concerns the patient may have, or be delivered incrementally over a number of sessions. Whether clinic based or community based, systems used to deliver a preventive assessment need to support a holistic assessment of the patient in recognition of the interdependence of many risk factors and determinants of disease.

Undertaking interventions

A preventive health assessment should be undertaken by healthcare providers who have the capacity to undertake, or to arrange for, appropriate management of any abnormalities found during the assessment. Providers should be aware of the potential psychosocial impact of preventive care, particularly when screening results in the diagnosis of a new condition. Informed consent should be obtained for the screening and adequate counselling provided when the patient is advised of the result.

Appropriate health policies

A supportive health policy is critical to implementing a preventive health assessment. Examples include financial incentives and workforce support. Those who have been screened need to be treated, so an effective screening program will increase the demand for care, yet many health services for Aboriginal and Torres Strait Islander people are under-resourced. Plans to reduce premature and excess Aboriginal and Torres Strait Islander morbidity and mortality need to include investment in the management of previously unrecognised diseases.

Medicare and the Practice Incentives Program Indigenous Health Incentive

General practitioners may undertake preventive activities recommended in the National Guide as part of their usual consultations. Medicare benefits are payable for a medical examination or test on a symptomless patient by that patient’s own medical practitioner in the course of normal medical practice, to ensure the patient receives any medical advice or treatment necessary to maintain his/her state of health.

Medicare rebates for preventive health assessments are available for all Aboriginal and/or Torres Strait Islander people of any age through an annual health assessment (Medicare Item 715). General practitioners are advised to check the requirements in the current online MBS before claiming these items. They need to be aware of, and comply with, the requirements of the specific MBS descriptors when providing services. The National Guide contains advice on almost all elements of the requirements to claim this rebate.

Other MBS rebates can support preventive health assessments of the Aboriginal and Torres Strait Islander population, including:

  • telehealth rebates (eg. item 2100)
  • follow up assessments by allied health professionals including Aboriginal and Torres Strait Islander health workers (AHWs) across Australia (eg. item 81300) or AHWs in the Northern Territory only or practice nurses (eg. item 10987)*
  • follow up of GP management plans by AHWs across Australia (eg. item 10950) or AHWs in the Northern Territory only (eg. item 10997)*
  • immunisation by AHWs in the Northern Territory only (eg. item 10988)*
  • antenatal services in RRMA 3–7 areas by AHWs in the Northern Territory only* (or midwives/nurses) (eg. 16400).

In addition, preventive health assessments can be supported through ‘CTG’ scripts, which provide copayment relief for PBS prescriptions for patients who identify as Aboriginal and/or Torres Strait Islander. Health services can also receive incentive payments for identifying Aboriginal and/or Torres Strait Islander patients and offering these patients a health assessment. The Practice Incentives Program is outlined at www.medicareaustralia.gov.au/ provider/incentives/pip/index.jsp.

* Check MBS eligibility requirements. The Australian Health Practitioner Regulation Agency is currently nationally registering Aboriginal and Torres Strait Islander health practitioners, which may affect the eligibility of AHWs (those not registered as ‘practitioners’) to claim MBS rebates, while broadening eligibility for practitioners.

References

  1. Australian Institute of Health and Welfare. Expenditure on health for Aboriginal and Torres Strait Islander people 2008–09. Health and welfare expenditure series no. 44. Cat. no. HWE 53. Canberra: AIHW, 2011.
  2. Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander people, an overview 2011. Cat. no. IHW 42. Canberra: AIHW, 2011.
  3. Office for Aboriginal and Torres Strait Islander Health. Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: Department of Health and Ageing, 2010.
  4. Applied Economics. Returns on investment in public health. An epidemiological and economic analysis prepared for the Department of Health and Ageing. Canberra: Department of Health and Ageing, 2003.
  5. The RACGP National Faculty of Aboriginal and Torres Strait Islander Health. Identification of Aboriginal and Torres Strait Islander people in Australian general practice. South Melbourne: The RACGP, 2011.
  6. Close the Gap is ‘a commitment made in 2008 by all Australian governments to work towards a better future for Aboriginal and Torres Strait Islander people under the National Indigenous Reform Agreement of the Council of Australian Governments (COAG). It aims to close the gap of Aboriginal and Torres Strait Islander disadvantage in areas such as health, housing, education and employment’. See www.health.gov.au/tackling-chronic-disease.
  7. Kelaher M, Parry A, Day S, Paradies Y, Lawlor J, Solomon L. Improving the identification of Aboriginal and Torres Strait Islander people in mainstream general practice. Melbourne: The Lowitja Institute, 2010.
  8. Australian Institute of Health and Welfare. National best practice guidelines for collecting Indigenous status in health data sets. Cat. no. IHW 29. Canberra: AIHW, 2010.
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