Value-based health care for Aboriginal peoples with chronic conditions in the Northern Territory: a cohort study

Introduction

In the Northern Territory (NT), chronic conditions account for 80% of the gap in life expectancy between Aboriginal and non-Aboriginal peoples.¹ Aboriginal peoples suffer a burden of disease 3.4 times that of non-Aboriginal people,² and a preventable hospitalisation rate for chronic conditions 4.3 times higher than that of non-Aboriginal people.³ Over 30% of the NT population of 250,398 identify as Aboriginal peoples, of whom more than 75% reside in remote or very remote areas.⁴

Remote primary health care (PHC) in the NT is predominantly provided by the NT Government and Aboriginal Community Controlled Health Organisations. Remote communities vary in population size from less than 70 to 3000 people and vary in environmental landscape from desert to equatorial, leading to unique logistical service challenges including a high burden of acute care and staff turnover.⁵ The NT Government provides PHC services in 52 remote health clinics and custodial settings to approximately 23,000 Aboriginal patients. Remote health clinics in the NT are predominantly run by remote area nurses and Aboriginal Health Practitioners, with remote medical practitioner services delivered on a fly/drive in/out basis. In addition to the delivery of PHC services, remote clinics provide pharmacy services, population and public health programs, after-hours acute care and emergency retrieval services.⁶

Aboriginal peoples in the NT have identified significant shortcomings in the remote PHC system.⁷ The current model of PHC is described as having poor access, low acceptability, inadequate patient education and poor cultural safety. This erodes trust in health services, leading to disengagement and poor health outcomes.⁷ Value-based health care (VBHC) provides a method to quantify the value and resulting (in)efficiency of health care by identifying and measuring health outcomes that matter to patients.⁸ A key gap, identified by Aboriginal patients in the current remote PHC model, is culturally appropriate self-management support.⁷ It is unknown what impact the gap in self-management support is having on patient activation in chronic care and the use of healthcare resources.

Self-management support is a pillar of the Chronic Care Model⁹ and critical to VBHC, as it must align with what matters to patients (their preferences), to lead to a high level of activation to effectively self-manage chronic conditions. An activated patient has the belief, knowledge, skills and behaviours (including medication adherence) to manage their chronic conditions.¹⁰ Higher levels of activation are associated with reaching treatment targets for chronic conditions, preventative health behaviours and preventative care, while lower levels of activation are associated with delays in accessing care, unfilled prescriptions, low medications possession ratio (MPR) and inattention to medical needs.^11,12 The Patient Activation Measure has been validated internationally to measure patient activation,¹⁰ with items directly and indirectly related to medication and treatment and behaviour change; however, it has not been validated for Aboriginal peoples. In lieu of a validated measure of activation for Aboriginal peoples, a health behaviour indicative of activation is adherence to prescribed medications, using MPR as a proxy marker for activation.

Using MPR as a pragmatic proxy marker for patient activation, our objectives are to investigate associations between activation and (i) achieving chronic conditions secondary prevention treatment targets and (ii) healthcare usage.

Methods

Results

Between 2 April 2020 and 1 April 2022, 5356 patients met the inclusion criteria (Fig. 1), of whom 2764 were female and 2592 were male. Ninety-four patients were excluded from the study as per the above exclusion criteria (Fig. 1). Two patients had missing MPR data, for which 0 was imputed. Of the study participants, only 9% (n = 498) were found to be activated and 91% (n = 4858) were found to be unactivated (Table 1). The mean and median patient age were 53 years for activated patients, significantly higher than for unactivated patients (mean of 48.5 years old and median of 49 years old).

Fig. 1.

Study population.

Discussion

Aboriginal patients in the NT have voiced dissatisfaction over the current PHC model, specifically the lack of self-management support for chronic conditions.⁷ Poor access, low acceptability, inadequate patient education and cultural safety have all been identified as further areas of dissatisfaction.⁷ In lieu of a validated measure of patient activation for Aboriginal peoples, we used MPR as a proxy marker of activation to determine whether the remote PHC system is delivering value for Aboriginal patients with a chronic condition.

We found 9% of patients with chronic conditions were activated, significantly lower than comparable adherence rates (51%) reported in the general Australian population.¹⁸ Activated patients were older, had more chronic conditions and more medication prescribed – that is, they were more unwell; however, they achieved better clinical outcomes. As expected, activated patients also used more healthcare resources in PHC, outpatients and patient travel. Although not significant, there was a trend favouring lower rates of hospitalisation, PPH and emergency department episodes of care and a lower rate of PPH. Notably, unactivated patients also used a high amount of PHC and outpatient care, providing ample opportunities for ‘activation’ if the model of remote PHC can be adjusted to suit Aboriginal patient preferences for cultural safety and self-management support.

Our study supports previous findings that patient activation is associated with achieving treatment targets for blood pressure and lipids.^11,19 Studies by Harvey and colleagues in Aboriginal communities in South Australia similarly found patient activation is associated with improvements in treatment targets (HbA1c, body mass index, triglycerides, total cholesterol and LDL), a decrease in the number of general practice, specialist and hospital visits (P ≤ 0.05) and a significant improvement in inpatient self-management and skill following self-management support.^20,21 In contrast, the activation-associated increase in PHC contacts observed in our study includes medication dispensing episodes, a finding that is expected in the remote model of PHC that includes pharmacy services.

Our work helps identify an opportunity cost of failing to implement effective self-management support programs for remote and vulnerable populations in the NT. The result shows the current system is acute-care focused, inefficient in chronic conditions care, inappropriate and likely of low value to patients.⁷ Self-management support was an identified priority in the NT Chronic Conditions Prevention and Management Strategy 2010–2020; however, responsibility for implementation was unclear.²² If younger patients with less chronic conditions were activated, then cost savings could accrue due to prevention or delay of chronic condition complications. Further research is required to understand the financial implications of improving self-management support and improving patient activation in a costly healthcare delivery environment.

The strengths of this study are the completeness of the PCIS data, data linkage across the health system, a high level of Aboriginal identification and remote PHC clinics acting as the sole dispensary of chronic condition medications. This enabled person-level analysis across the health system. Activated patients achieving treatment targets would be expected to confer a survival advantage, however, a limitation of our study is that survival analysis was not possible due to the short timeframe and small sample size. Noting the value of a statistical life year, A$227,000,²³ we suggest longitudinal research on patient activation outcomes in remote Aboriginal PHC warrants consideration. The absence of a validated instrument to assess patient activation in Aboriginal PHC settings is a further limitation. While we have attempted to capture this concept through a pragmatic proxy, the development of an instrument for use in Aboriginal PHC settings would contribute greatly to service evaluation and improvement, particularly for services where dispensing data is not routinely available. Further prospective research over longer time frames, inclusive of Aboriginal patient perspectives, is required to further understand associations between activation, health service use and health outcomes. Finally, activation was only assessed once in this study. MPR is tracked as a routine service metric across our system and there has been a persistently low activation rate of around 9% between April 2020 and April 2022.

Our study provides a novel application of VBHC methods to Aboriginal PHC. First, by using a patient-centred proxy for activation, we were able to quantify current activation levels or inefficiency of current chronic care that was previously unknown, with 91% of patients remaining unactivated despite significant service engagement. Although our activated cohort were older and sicker and used greater resources, they achieved better clinical outcomes. Second, we suggest that if more patients could be activated at earlier stages in their disease journey, through culturally safe self-management support, more patients would reach their treatment targets and likely reduce demands on more expensive acute care. In addition to increasing value for patients, this would extend gains in Aboriginal life expectancy in the NT from better chronic conditions management and increase value for health system funders through more efficient PHC.²⁴

Conclusion

The current NT Government remote PHC system is providing low-value chronic conditions care for patients. Patient activation is an important metric of healthcare efficiency in Aboriginal PHC settings; we found activated patients achieved better clinical outcomes despite being older and sicker. High-levels of PHC use by unactivated patients posits opportunities for activation if the model of care can be reorientated to suit patient needs. VBHC methods can help identify the low value and resulting inefficiencies generated through failing to align service delivery with patient preferences. Thus, co-designing and implementing models of care with Aboriginal service users can be considered a high value proposition.