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ObjectiveTo assess current performance and identify opportunities and reforms necessary for positioning a food standards programme to help protect public health against dietary risk factors.DesignA case study design in which a food standards programme’s public health protection performance was analysed against an adapted Donabedian model for assessing health-care quality. The criteria were the food standards programme’s structure (governance arrangements and membership of its decision-making committees), process (decision-making tools, public engagement and transparency) and food standards outcomes, which provided the information base on which performance quality was inferred.SettingThe Australia and New Zealand food standards programme.ParticipantsThe structure, process and outcomes of the Programme.ResultsThe Programme’s structure and processes produce food standards outcomes that perform well in protecting public health from risks associated with nutrient intake excess or inadequacy. The Programme performs less well in protecting public health from the proliferation and marketing of ‘discretionary’ foods that can exacerbate dietary risks. Opportunities to set food standards to help protect public health against dietary risks are identified.ConclusionsThe structures and decision-making processes used in food standards programmes need to be reformed so they are fit for purpose for helping combat dietary risks caused by dietary excess and imbalances. Priorities include reforming the risk analysis framework, including the nutrient profiling scoring criterion, by extending their nutrition science orientation from a nutrient (reductionist) paradigm to be more inclusive of a food/diet (holistic) paradigm.

Traditional public health practice has had a central reliance on data, and the core discipline of epidemiology, in order to inform health policy and priority setting, drive health improvement across whole populations, and target disadvantaged populations. Core public health activities include risk factor and disease surveillance, screening, development of interventions, assurance, and evaluation. Since the 1970s, New Public Health has also emphasized community engagement, health promotion, partnerships, and advocacy. In the last 20 years, and particularly with the sequencing of the human genome and advances in other “-omics,” informatics and a range of technologies, new possibilities have opened up for a much more finely delineated view of the “time-person-place” triad that underpins epidemiology, and the balancing of genetic, biological, environmental, and social determinants of disease. This may lead, we argue in this article, to new preventive and treatment options and the next paradigm shift in public health, namely toward “Precision Public Health” or PPH. However, we also caution against a blind optimism about what technology can achieve on its own, and argue for a solid grounding of PPH on the old verities of public health, namely whole population health improvement and equity.

Cancer will continue to be a leading cause of ill health and death unless we can capitalize on the potential for 30-40% of these cancers to be prevented. In this light, cancer prevention represents an enormous opportunity for public health, potentially saving much of the pain, anguish, and cost associated with treating cancer. However, there is a challenge for governments, and the wider community, in prioritizing cancer prevention activities, especially given increasing financial constraints. This paper describes a method for identifying cancer prevention priorities. This method synthesizes detailed cancer statistics, expert opinion, and the published literature for the priority setting process. The process contains four steps: assessing the impact of cancer types; identifying cancers with the greatest impact; considering opportunities for prevention; and combining information on impact and preventability. The strength of our approach is that it is straightforward, transparent and reproducible for other settings. Applying this method in Western Australia produced a priority list of seven adult cancers which were identified as having not only the biggest impact on the community but also the best opportunities for prevention. Work conducted in an additional project phase went on to present data on these priority cancers to a public consultation and develop an agenda for action in cancer prevention.

Background New approaches are required to address the needs of complex undiagnosed diseases patients. These approaches include clinical genomic diagnostic pipelines, utilizing intra- and multi-disciplinary platforms, as well as specialty-specific genomic clinics. Both are advancing diagnostic rates. However, complementary cross-disciplinary approaches are also critical to address those patients with multisystem disorders who traverse the bounds of multiple specialties and remain undiagnosed despite existing intra-specialty and genomic-focused approaches. The diagnostic possibilities of undiagnosed diseases include genetic and non-genetic conditions. The focus on genetic diseases addresses some of these disorders, however a cross-disciplinary approach is needed that also simultaneously addresses other disorder types. Herein, we describe the initiation and summary outcomes of a public health system approach for complex undiagnosed patients - the Undiagnosed Diseases Program-Western Australia (UDP-WA). Results Briefly the UDP-WA is: i) one of a complementary suite of approaches that is being delivered within health service, and with community engagement, to address the needs of those with severe undiagnosed diseases; ii) delivered within a public health system to support equitable access to health care, including for those from remote and regional areas; iii) providing diagnoses and improved patient care; iv) delivering a platform for in-service and real time genomic and phenomic education for clinicians that traverses a diverse range of specialties; v) retaining and recapturing clinical expertise; vi) supporting the education of junior and more senior medical staff; vii) designed to integrate with clinical translational research; and viii) is supporting greater connectedness for patients, families and medical staff. Conclusion The UDP-WA has been initiated in the public health system to complement existing clinical genomic approaches; it has been targeted to those with a specific diagnostic need, and initiated by redirecting existing clinical and financial resources. The UDP-WA supports the provision of equitable and sustainable diagnostics and simultaneously supports capacity building in clinical care and translational research, for those with undiagnosed, typically rare, conditions. Electronic supplementary material The online version of this article (doi:10.1186/s13023-017-0619-z) contains supplementary material, which is available to authorized users.

Heatwaves have killed more people in Australia than all other natural hazards combined. Climate change is expected to increase the frequency, duration, and intensity of heatwaves and lead to a doubling of heat-related deaths over the next 40 years. Despite being a significant public health issue, heatwaves do not attract the same level of attention from researchers, policy makers and emergency management agencies compared to other natural hazards. The purpose of the study was to identify risk factors that might lead to population vulnerability to heatwave in Western Australia. Heatwave vulnerability and resilience among the population of the State of Western Australia (WA) were investigated by using time series analysis. The health impacts of heatwaves were assessed by comparing the associations between hospital emergency department (ED) presentations, hospital admissions and mortality data, and intensities of heatwave. Risk factors including age, gender, socio-economic status (SES), remoteness, and geographical locations were examined to determine whether certain population groups were more at risk of adverse health impacts due to extreme heat. We found that hospital admissions due to heat-related conditions and kidney diseases, and overall ED attendances, were sensitive indicators of heatwave. Children aged 14 years or less and those aged 60 years or over were identified as the most vulnerable populations to heatwaves as shown in ED attendance data. Females had more ED attendances and hospital admissions due to kidney diseases; while males had more heat-related hospital admissions than females. There were significant dose-response relationships between heatwave intensity and SES, remoteness and health service usage. The more disadvantaged and remotely located the population, the higher the health service usage during heatwaves. Our study also found that some population groups and locations were resilient to extreme heat. We produced a mapping tool, which indicated geographic areas throughout Western Australia with various vulnerability and resilience levels to heatwave. The findings from this study will allow local government, community service organisations, and agencies in health, housing and education to better identify and understand the degree of vulnerability to heatwave throughout the state, better target preparatory strategies, and allocate limited resources to those most in need.

Rare disease registries have now been recognized as a global priority for progress both in monitoring and documenting the natural course, and preventing and treating rare diseases. However, a disease registry is only one element of rare disease translational research. Here, we outline what we believe are ten key components in comprehensive rare disease translational research and describe critical relationships between them. These components are: (i) client–practitioner partnerships; (ii) disease registries; (iii) biobanks; (iv) genomics and other -omics platforms; (v) community-based and population-wide studies; (vi) bioinformatics and high performance computing; (vii) interactions with pharma to facilitate drug discovery; (viii) personalized treatments based on genotype-phenotype correlations; (ix) eHealth and a whole of life record; and (x) regulatory frameworks, particularly with regard to specimen and data sharing, and the return of results. Each component has its own inherent complexity, but if effectively integrated they will provide a comprehensive approach to the future management of rare diseases, and aid health care providers in delivering services to individuals affected with rare diseases. We demonstrate that navigation through the roadmap can provide relevant health stakeholders with a blueprint to understand the challenges and barriers which need to be overcome within and across the constituent components. The rare disease roadmap will assist decision-making at all health stakeholder levels and enable the seamless integration of new knowledge, standard operating procedures and the implementation of best practice.

Advances in our understanding of genetic and rare diseases are changing the face of healthcare. Crucially, the global community must implement these advances equitably to reduce health disparities, including between Indigenous and non-Indigenous peoples. We take an Australian perspective to illustrate some key areas that are fundamental to the equitable translation of new knowledge for the improved diagnosis of genetic and rare diseases for Indigenous people. Specifically, we focus on inequalities in access to clinical genetics services and the lack of genetic and phenomic reference data to inform diagnoses. We provide examples of ways in which these inequities are being addressed through Australian partnerships to support a harmonious and inclusive approach to ensure that benefits from traditional wisdom, community knowledge and shared experiences are interwoven to support and inform implementation of new knowledge from genomics and precision public health. This will serve to deliver benefits to all of our diverse citizens, including Indigenous populations.

Public health relies on technologies to produce and analyse data, as well as effectively develop and implement policies and practices. An example is the public health practice of epidemiology, which relies on computational technology to monitor the health status of populations, identify disadvantaged or at risk population groups and thereby inform health policy and priority setting. Critical to achieving health improvements for the underserved population of people living with rare diseases is early diagnosis and best care. In the rare diseases field, the vast majority of diseases are caused by destructive but previously difficult to identify protein-coding gene mutations. The reduction in cost of genetic testing and advances in the clinical use of genome sequencing, data science and imaging are converging to provide more precise understandings of the ‘person-time-place’ triad. That is: who is affected (people); when the disease is occurring (time); and where the disease is occurring (place). Consequently we are witnessing a paradigm shift in public health policy and practice towards ‘precision public health’.

Precision public health is a new field driven by technological advances that enable more precise descriptions and analyses of individuals and population groups, with a view to improving the overall health of populations. This promises to lead to more precise clinical and public health practices, across the continuum of prevention, screening, diagnosis, and treatment. A phenotype is the set of observable characteristics of an individual resulting from the interaction of a genotype with the environment. Precision (deep) phenotyping applies innovative technologies to exhaustively and more precisely examine the discrete components of a phenotype and goes beyond the information usually included in medical charts. This form of phenotyping is a critical component of more precise diagnostic capability and 3-dimensional facial analysis (3DFA) is a key technological enabler in this domain. In this paper, we examine the potential of 3DFA as a public health tool, by viewing it against the 10 essential public health services of the “public health wheel,” developed by the US Centers for Disease Control. This provides an illustrative framework to gage current and emergent applications of genomic technologies for implementing precision public health.

Purpose: It has been argued that rare diseases should be recognized as a public health priority. However, there is a shortage of epidemiological data describing the true burden of rare diseases. This study investigated hospital service use to provide a better understanding of the collective health and economic impacts of rare diseases. Methods: Novel methodology was developed using a carefully constructed set of diagnostic codes, a selection of rare disease cohorts from hospital administrative data, and advanced data-linkage technologies. Outcomes included health-service use and hospital admission costs. Results: In 2010, cohort members who were alive represented approximately 2.0% of the Western Australian population. The cohort accounted for 4.6% of people discharged from hospital and 9.9% of hospital discharges, and it had a greater average length of stay than the general population. The total cost of hospital discharges for the cohort represented 10.5% of 2010 state inpatient hospital costs. Conclusions: This population-based cohort study provides strong new evidence of a marked disparity between the proportion of the population with rare diseases and their combined health-system costs. The methodology will inform future rare-disease studies, and the evidence will guide government strategies for managing the service needs of people living with rare diseases. Genet Med advance online publication 22 September 2016

Background: Examining variation in diabetes care across regions/organizations provides insight into underlying factors related to quality of care. The aims of this study were to assess quality of diabetes care and its variation among Aboriginal community health centres in Australia, and to estimate partitioning of variation attributable to health centre and individual patient characteristics. Methods: During 2005–2009, clinical medical audits were conducted in 62 Aboriginal community health centres from four states/territories. Main outcome measures include adherence to guidelines‐scheduled processes of diabetes care, treatment and medication adjustment, and control of HbA1c, blood pressure, total cholesterol and albumin/creatinine ratio (ACR). Results: Wide variation was observed across different categories of diabetes care measures and across centres: (1) overall adherence to delivery of services averaged 57% (range 22–83% across centres); (2) medication adjustment rates after elevated HbA1c: 26% (0–72%); and (3) proportions of patients with HbA < 7% : 27% (0–55%); with blood pressure < 130/80 mmHg: 36%(0–59%). Health centre level characteristics accounted for 36% of the total variation in adherence to process measures, and 3–11% of the total variation in patient intermediate outcomes; the remaining, substantial amount of variation in each measure was attributable to patient level characteristics. Conclusions: Deficiencies in a range of quality of care measures provide multiple opportunities for improvement. The majority of variation in quality of diabetes care appears to be attributable to patient level characteristics. Further understanding of factors affecting variation in the care of individuals should assist clinicians, managers and policy makers to develop strategies to improve quality of diabetes care in Aboriginal communities. Refereed/Peer-reviewed

Clinical decisions rely on expert knowledge that draws on quality patient phenotypic and physiological data. In this regard, systems that can support patient-centric care are essential. Patient registries are a key component of patient-centre care and can come in many forms such as disease-specific, recruitment, clinical, contact, post market and surveillance. There are, however, a number of significant challenges to overcome in order to maximise the utility of these information management systems to facilitate improved patient-centred care. Registries need to be harmonised regionally, nationally and internationally. However, the majority are implemented as standalone systems without consideration for data standards or system interoperability. Hence the task of harmonisation can become daunting. Fortunately, there are strategies to address this. In this paper, a disease registry framework is outlined that enables efficient deployment of national and international registries that can be modified dynamically as registry requirements evolve. This framework provides a basis for the development and implementation of data standards and enables patients to seamlessly belong to multiple registries. Other significant advances include the ability for registry curators to create and manage registries themselves without the need to contract software developers, and the concept of a registry description language for ease of registry template sharing.

Newborn bloodspot screening has been operating successfully in Australia for almost 50 years. Recently, the development of new technologies and treatments has led to calls for the addition of new conditions to the screening programs. Internationally, it is recognized by governments that national policies for newborn screening should support transparent and evidence-based decision making, and promote consistency between states within a country. Australia is lagging behind the international community, and currently has no national policies or decision-making processes, agreed by government, to support its newborn screening programs. In contrast, New Zealand (NZ), the United Kingdom (UK), and the United States of America (US) have robust and transparent processes to assess conditions for screening, which have been developed by, and have pathways to, government. This review provides detail on the current policy environment for newborn screening in Australia, highlighting that there are a number of risks to the programs resulting from the lack of a decision-making process. It also describes the processes used to assess conditions for newborn screening in the US, UK, and NZ. These examples highlight the benefits of developing a national decision-making process, including ensuring that screening is evidence based and effective. These examples also provide models that might be considered for Australia, as well as other countries currently seeking to introduce or expand newborn bloodspot screening.

Fifteen years into the twenty-first century, the challenges for public health may have changed but have not diminished. Complacency, systems inertia, and national self-interest remain powerful barriers to global and universal health improvement. As joint chief editors for this new specialty journal, we lay out an ambitious mission: to work with the editorial board and colleagues worldwide to create the pre-eminent open access journal for public health practitioners working in policy and practice. The aim of this article is twofold: to scope out the breadth of topics that may be covered in the journal, and to reflect on the kind of difficult but essential conversations that may be possible in such an enterprise. We hope to encourage diverse contributions to the journal that reflect deeply on the contingent nature of public health policy as it is put into practice in a range of contexts and settings across the world, as well as the commonalities that underpin it. This article is structured into four parts: a brief outline of historic and current practice; a discussion of definitional and ethical issues in public health; a reflection on strengths and weaknesses as we see them; and, finally, a set of grand challenges that we hope to address in this journal, which are central to the grandest public health mission of all – changing the world for the better.

To examine the role of specialist outreach in supporting primary health care and overcoming the barriers to health care faced by the indigenous population in remote areas of Australia, and to examine issues affecting its sustainability.A process evaluation of a specialist outreach service, using health service utilisation data and interviews with health professionals and patients.The Top End of Australia's Northern Territory, where Darwin is the capital city and the major base for hospital and specialist services. In the rural and remote areas outside Darwin there are many small, predominantly indigenous communities, which are greatly disadvantaged by a severe burden of disease and limited access to medical care.Seventeen remote health practitioners, five specialists undertaking outreach, five regional health administrators, and three patients from remote communities.The barriers faced by many remote indigenous people in accessing specialist and hospital care are substantial. Outreach delivery of specialist services has overcome some of the barriers relating to distance, communication, and cultural inappropriateness of services and has enabled an over fourfold increase in the number of consultations with people from remote communities. Key issues affecting sustainability include: an adequate specialist base; an unmet demand from primary care; integration with, accountability to and capacity building for a multidisciplinary framework centred in primary care; good communication; visits that are regular and predictable; funding and coordination that recognises responsibilities to both hospitals and the primary care sector; and regular evaluation.In a setting where there is a disadvantaged population with inadequate access to medical care, specialist outreach from a regional centre can provide a more equitable means of service delivery than hospital based services alone. A sustainable outreach service that is organised appropriately, responsive to local community needs, and has an adequate regional specialist base can effectively integrate with and support primary health care processes. Poorly planned and conducted outreach, however, can draw resources away and detract from primary health care.

ObjectivesTo examine the impact of state/territory policy support on (1) uptake of evidence-based continuous quality improvement (CQI) activities and (2) quality of care for Indigenous Australians.DesignMixed-method comparative case study methodology, drawing on quality-of-care audit data, documentary evidence of policies and strategies and the experience and insights of stakeholders involved in relevant CQI programmes. We use multilevel linear regression to analyse jurisdictional differences in quality of care.SettingIndigenous primary healthcare services across five states/territories of Australia.Participants175 Indigenous primary healthcare services.InterventionsA range of national and state/territory policy and infrastructure initiatives to support CQI, including support for applied research.Primary and secondary outcome measures(i) Trends in the consistent uptake of evidence-based CQI tools available through a research-based CQI initiative (the Audit and Best Practice in Chronic Disease programme) and (ii) quality of care (as reflected in adherence to best practice guidelines).ResultsProgressive uptake of evidence-based CQI activities and steady improvements or maintenance of high-quality care occurred where there was long-term policy and infrastructure support for CQI. Where support was provided but not sustained there was a rapid rise and subsequent fall in relevant CQI activities.ConclusionsHealth authorities should ensure consistent and sustained policy and infrastructure support for CQI to enable wide-scale and ongoing improvement in quality of care and, subsequently, health outcomes. It is not sufficient for improvement initiatives to rely on local service managers and clinicians, as their efforts are strongly mediated by higher system-level influences.

OBJECTIVE: To determine which measures of heatwave have the greatest predictive power for increases in health service utilisation in Perth, Western Australia. METHODS: Three heatwave formulas were compared, using Poisson or zero-inflated Poisson regression, against the number of presentations to emergency departments from all causes, and the number of inpatient admissions from heat-related causes. The period from July 2006 to June 2013 was included. A series of standardised thresholds were calculated to allow comparison between formulas, in the absence of a gold standard definition of heatwaves. RESULTS: Of the three heatwave formulas, Excess Heat Factor (EHF) produced the most clear dose-response relationship with Emergency Department presentations. The EHF generally predicted periods that resulted in a similar or higher rate of health service utilisation, as compared to the two other formulas, for the thresholds examined. CONCLUSIONS: The EHF formula, which considers a period of acclimatisation as well as the maximum and minimum temperature, best predicted periods of greatest health service demand. The strength of the dose-response relationship reinforces the validity of the measure as a predictor of hazardous heatwave intensity. IMPLICATIONS: The findings suggest that the EHF formula is well suited for use as a means of activating heatwave plans and identifies the required level of response to extreme heatwave events as well as moderate heatwave events that produce excess health service demand. Language: en

OBJECTIVES To investigate differences in presentation and management of Indigenous and non-Indigenous patients hospitalised with acute myocardial infarction (AMI). DESIGN Retrospective review of hospital medical records. PARTICIPANTS AND SETTING 122 patients with definite or possible AMI admitted to hospitals in the Top End of the Northern Territory (NT) in 1996. MAIN OUTCOME MEASURES Percentage receiving thrombolytic therapy; delays from symptom onset to primary and emergency department presentations, first and diagnostic electrocardiograms, thrombolytic therapy and aspirin; drugs prescribed during hospitalisation. RESULTS Thrombolytic therapy was given to 12/41 Indigenous patients (29%) and 38/81 non-Indigenous patients (47%) (P = 0.06). Presentation delay over 12 hours was the reason for not giving thrombolytic therapy for 14/29 Indigenous patients (48%) and 8/43 non-Indigenous patients (19%) (P < 0.01). Median delay times were longer for Indigenous patients for all six categories of delay, although the difference was significant only for delay to emergency department presentation (10:00 versus 3:26 hours; P < 0.01) and to diagnostic electrocardiogram (8:10 versus 3:50 hours; P < 0.01). Delays were also longer for patients from rural compared with urban areas. Once diagnosed, Indigenous patients were as likely as non-Indigenous patients to receive aspirin (93% versus 96%) and beta-blockers (70% versus 69%) and more likely to receive angiotensin-converting enzyme inhibitors (60% versus 40%; P = 0.03). CONCLUSIONS Delays in presentation affect Indigenous people living in rural and urban areas as well as non-Indigenous people living in rural areas. Concerted efforts are needed to improve health service access in rural areas and to encourage Indigenous people with persistent chest pain to present earlier.

Introduction Race, ethnicity and culture are issues of enduring importance not only in the social sciences, but also in public health. Public health is the organised effort of society to protect, promote and restore the public's health (Last, 1988) and equity of access to services and equality of health outcomes are key concerns. A recent listing of literature, dealing with racial and ethnic disparities in health care, that had been published in two American medical journals over a ten year period, filled 66 pages (Geiger, 1996). In this article, I attempt to briefly address the following questions: firstly, what concepts, and what distortions, hide behind the three words, `ethnicity', `race' and `culture'; and, secondly, can the public health community contribute some clear thinking to the `race' debate? In the first part of this paper, it will be argued that `race' has an undeserved status as an immutable biological variable and that mainstream science has now abandoned the concept it helped to promote. In the second part of the paper, I will draw on the public health literature to justify the abandonment of the term `race' and its replacement by the term `ethnicity' for academic purposes. In the final part, I will examine the possible effect such a change could have in the wider society as one tool to combat racism. The `Race' Concept `Race' is a word used frequently in general conversation and in the media. It is enshrined in legislation, such as the `Racial Discrimination Act' and appears in the titles of academic journals such as `Race and Class'. The race concept has been reified as a result of its widespread use in constructing boundaries that simultaneously include and exclude people and lead to `imagined communities' e.g. `White' Australia and `Asian' migrants (Pettman, 1992). The English word is derived from the Latin word `generare', which means `to beget'. It is defined in Last's Dictionary of Epidemiology (1988) as `persons who are relatively homogenous with respect to biologic inheritance'. The implication is that members are biologically similar to each other and different from the members of other racial groups. There are a number of features that are consistently associated with use of the term `race' in the scientific literature, particularly in past years, but persisting up to the present time (Wolf, 1994). The first feature is the notion that if one could sort people out into physical types, one could impute their moral character. In other words, the sum of physical traits and temperament constitutes a stable bio-moral `essence'. The second feature is the creation of associated hierarchies where the people constructing the hierarchy generally find themselves in the highest stratum with the right to dominate others. The comments by West Australian senator, Ross Lightfoot, that `Aboriginal people in their native state are the lowest colour on the civilisation spectrum' (Price, 1997) are a contemporary expression of this historical hierarchy. The third feature follows from the first two, namely that commentaries based on racial classifications exhibit an ethnocentric bias, a lack of objectivity in analysis and an insensitivity to possible confounding social factors in interpretation. This has been well demonstrated with respect to phrenology and latterly with respect to IQ testing (Kohn, 1995; Gould, 1981). Science, Race and History Science has not been a disinterested observer as the ideology of race, founded on the notion of racial classification, spread. Rather, the power of the race concept, and its height of influence in the 19th and the first half of the 20th century was associated with the rise of Western science. To paraphrase Eric Wolf (1994) speaking about anthropology, science is both offspring and creator of the human condition and ideas about race in the 19th century not only arose from science, but served to orient its inquiries, particularly in the field of physical anthropology. …

This article summarizes the content of recently developed guidelines for health professionals dealing with death in the Northern Territory Aboriginal Australian population. An account is given of the stimulus for the guidelines, the applied research context (the Adult Aboriginal Mortality Project) in which the guidelines were developed, and their initial reception by service providers. The guidelines deal with the time of death and afterwards, when the practical, communicative and cross-cultural challenges that health professionals face are intimately connected. It is argued that, from a mental health perspective, what happens after death is as important as what happens before. The relationship of the guidelines to the other areas of research carried out in the five-year period over which the Mortality Project was conducted is described. A case scenario is also presented to illustrate the real-life difficulties addressed by these guidelines. The potential for such local guideline development to improve co...

This article explores Australian general practitioners' (GPs) views on a novel electronic decision support (EDS) tool being developed for cardiovascular disease management. We use Timmermans and Berg's technology-in-practice approach to examine how technologies influence and are influenced by the social networks in which they are placed. In all, 21 general practitioners who piloted the tool were interviewed. The tool occupied an ill-defined middle ground in a dialectical relationship between GPs' routine care and factors promoting best practice. Drawing on Lipsky's concept of 'street-level bureaucrats', the tool's ability to process workloads expeditiously was of greatest appeal to GPs. This feature of the tool gave it the potential to alter the structure, process and content of healthcare encounters. The credibility of EDS tools appears to be mediated by fluid notions of best practice, based on an expert scrutiny of the evidence, synthesis via authoritative guidelines and dissemination through trusted and often informal networks. Balanced against this is the importance of 'soft' forms of knowledge such as intuition and timing in everyday decision-making. This resonates with Aristotle's theory of phronesis (practical wisdom) and may render EDS tools inconsequential if they merely process biomedical data. While EDS tools show promise in improving health practitioner performance, the socio-technical dimensions of their implementation warrant careful consideration.

Background Early onset and high prevalence of chronic disease among Indigenous Australians call for action on prevention. However, there is deficiency of information on the extent to which preventive services are delivered in Indigenous communities. This study examined the variation in quality of preventive care for well adults attending Indigenous community health centres in Australia. Methods During 2005-2009, clinical audits were conducted on a random sample (stratified by age and sex) of records of adults with no known chronic disease in 62 Indigenous community health centres in four Australian States/Territories (sample size 1839). Main outcome measures: i) adherence to delivery of guideline-scheduled services within the previous 24 months, including basic measurements, laboratory investigations, oral health checks, and brief intervention on lifestyle modification; and ii) follow-up of abnormal findings. Results Overall delivery of guideline-scheduled preventive services varied widely between health centres (range 5-74%). Documentation of abnormal blood pressure reading ([greater than or equal to]140/90 mmHg), proteinuria and abnormal blood glucose ([greater than or equal to]5.5 mmol/L) was found to range between 0 and > 90% at the health centre level. A similarly wide range was found between health centres for documented follow up check/test or management plan for people documented to have an abnormal clinical finding. Health centre level characteristics explained 13-47% of variation in documented preventive care, and the remaining variation was explained by client level characteristics. Conclusions There is substantial room to improve preventive care for well adults in Indigenous primary care settings. Understanding of health centre and client level factors affecting variation in the care should assist clinicians, managers and policy makers to develop strategies to improve quality of preventive care in Indigenous communities.

This article reports on documented levels of depression among people with diabetes attending indigenous primary care centres.Between 2005 and 2009, clinical audits of diabetes care were conducted in 62 indigenous community health centres from four Australian states and territories.The overall prevalence of documented depression among people with diabetes was 8.8%. Fourteen (23%) of the 62 health centres had no record of either diagnosed depression or prescription of selective serotonin reuptake inhibitors among people with diabetes. For the remaining 48 centres, 3.3-36.7% of people with diabetes had documented depression.The results of this study are inconsistent with the evidence showing high prevalence of mental distress among indigenous people. A more thorough investigation into the capacity, methods and barriers involved in diagnosing and managing depression in indigenous primary care is needed.

Background Indigenous Australians have an incidence of end stage kidney disease 8-10 times higher than non-Indigenous Australians. The majority of research studies concerning Indigenous Australians have been performed in rural or remote regions, whilst the majority of Indigenous Australians actually live in urban settings. We studied prevalence and factors associated with markers of kidney disease in an urban Indigenous Australian cohort, and compared results with those for the general Australian population. Methods 860 Indigenous adult participants of the Darwin Region Urban Indigenous Diabetes (DRUID) Study were assessed for albuminuria (urine albumin-creatinine ratio≥2.5 mg/mmol males, ≥3.5 mg/mmol females) and low eGFR (estimated glomular filtration rate < 60 mls/min/1.73 m2). Associations between risk factors and kidney disease markers were explored. Comparison was made with the AusDiab cohort (n = 8,936 aged 25-64 years), representative of the general Australian adult population. Results A high prevalence of albuminuria (14.8%) was found in DRUID, whilst prevalence of low eGFR was 2.4%. Older age, higher HbA1c, hypertension, higher C-reactive protein and current smoking were independently associated with albuminuria on multiple regression. Low eGFR was independently associated with older age, hypertension, albuminuria and higher triglycerides. Compared to AusDiab participants, DRUID participants had a 3-fold higher adjusted risk of albuminuria but not of low eGFR. Conclusions Given the significant excess of ESKD observed in Indigenous versus non-Indigenous Australians, these findings could suggest either: albuminuria may be a better prognostic marker of kidney disease than low eGFR; that eGFR equations may be inaccurate in the Indigenous population; a less marked differential between Indigenous and non-Indigenous Australians for ESKD rates in urban compared to remote regions; or that differences in the pathophysiology of chronic kidney disease exist between Indigenous and non-Indigenous populations.

Background The 2010 influenza vaccination program for children aged 6 months to 4 years in Western Australia (WA) was suspended following reports of severe febrile reactions, including febrile convulsions, following vaccination with trivalent inactivated influenza vaccine (TIV). Methods To investigate the association between severe febrile reactions and TIV, three studies were conducted: (i) rates of febrile convulsions within 72 h of receiving TIV in 2010 were estimated by vaccine formulation and batch; (ii) numbers of children presenting to hospital emergency departments with febrile convulsions from 2008 to 2010 were compared; and (iii) a retrospective cohort study of 360 children was conducted to compare the reactogenicity of available TIV formulations. Findings In 2010, an estimated maximum of 18 816 doses of TIV were administered and 63 febrile convulsions were recorded, giving an estimated rate of 3.3 (95% CI 2.6 to 4.2) per 1000 doses of TIV administered. The odds of a TIV-associated febrile convulsion was highly elevated in 2010 (p, Article summary Article focus Soon after commencement of the 2010 paediatric influenza vaccination program in Western Australia (WA), clinicians noted an apparent increase in children presenting with fever, vomiting and occasionally febrile convulsions, which led to a temporary suspension of the WA program for children under 5 years of age. Three separate analytical studies were undertaken to determine the association between severe febrile adverse events and administration of the 2010 trivalent inactivated influenza vaccine (TIV) to children aged 6 months through 4 years in WA. Key messages The estimated rate of febrile convulsions in children aged under 5 years related to receipt of the 2010 TIV was found to be 3.3 per 1000 doses, more than 200 times higher than the only population-based published estimate. Of the two major brands of TIV used in the program prior to its suspension, the elevated risk of febrile convulsions and other febrile reactions was found to be clearly associated with the Fluvax and Fluvax Junior formulations, manufactured by CSL Biotherapies; the reactions do not appear to be associated with the other TIV formulation. As the biological mechanism has, to date, not been definitively identified, it seems reasonable that countries implement paediatric vaccination programs as usual using vaccine brands other than those of CSL Biotherapies, and undertake enhanced surveillance for febrile reactions and other adverse events in all children under 5 years of age receiving TIV. Strengths and limitations The major limitation of this study is the absence of reliable prospective data from an established, timely surveillance system designed to monitor adverse events resulting from vaccination. Accordingly, several data sources were used to gather numerator and denominator data, some already established and some created ad hoc and requiring retrospective data collection. Its strengths are, first, the consistency of findings using different data sources and the strength of the statistical associations found, and second, the fact that this is the first report of an elevated rate of severe febrile reactions to TIV in children.

Summary • Large scale Australian civilian medical assistance teams were first deployed overseas in 2004. • The deployment of small Forward Teams in the early phase of a health disaster response allows for informed decisions on whether, and in what form, to deploy larger medical assistance teams. • The prime consideration is to support the capacity of local services to respond to the specific needs of the affected population. • In addition, Australian citizens caught up in large numbers in overseas disasters may need health assistance.

Background Previous studies reported high C-reactive protein (CRP) levels in Indigenous Australians, which may contribute to their high risk of cardiovascular disease. We compared CRP levels in Indigenous Australians and the general population, accounting for obesity and other risk factors. Methods Cross-sectional study of CRP and risk factors (weight, height, waist and hip circumferences, blood pressure, lipids, blood glucose, and smoking status) in population-based samples from the Diabetes and Related conditions in Urban Indigenous people in the Darwin region (DRUID) study, and the Australian Diabetes, Obesity and Lifestyle study (AusDiab) follow-up. Results CRP concentrations were higher in women than men and in DRUID than AusDiab. After multivariate adjustment, including waist circumference, the odds of high CRP (>3.0 mg/L) in DRUID relative to AusDiab were no longer statistically significant, but elevated CRP was still more likely in women than men. After adjusting for BMI (instead of waist circumference) the odds for elevated CRP in DRUID participants were still higher relative to AusDiab participants among women, but not men. Lower HDL cholesterol, impaired glucose tolerance (IGT), and higher diastolic blood pressure were associated with having a high CRP in both men and women, while current smoking was associated with high CRP in men but not women. Conclusions High concentrations of CRP in Indigenous participants were largely explained by other risk factors, in particular abdominal obesity. Irrespective of its independence as a risk factor, or its aetiological association with coronary heart disease (CHD), the high CRP levels in urban Indigenous women are likely to reflect increased vascular and metabolic risk. The significance of elevated CRP in Indigenous Australians should be investigated in future longitudinal studies.

Background Australia's Aboriginal and Torres Strait Islander (Indigenous) populations have disproportionately high rates of adverse perinatal outcomes relative to other Australians. Poorer access to good quality maternal health care is a key driver of this disparity. The aim of this study was to describe patterns of delivery of maternity care and service gaps in primary care services in Australian Indigenous communities. Methods We undertook a cross-sectional baseline audit for a quality improvement intervention. Medical records of 535 women from 34 Indigenous community health centres in five regions (Top End of Northern Territory 13, Central Australia 2, Far West New South Wales 6, Western Australia 9, and North Queensland 4) were audited. The main outcome measures included: adherence to recommended protocols and procedures in the antenatal and postnatal periods including: clinical, laboratory and ultrasound investigations; screening for gestational diabetes and Group B Streptococcus; brief intervention/advice on health-related behaviours and risks; and follow up of identified health problems. Results The proportion of women presenting for their first antenatal visit in the first trimester ranged from 34% to 49% between regions; consequently, documentation of care early in pregnancy was poor. Overall, documentation of routine antenatal investigations and brief interventions/advice regarding health behaviours varied, and generally indicated that these services were underutilised. For example, 46% of known smokers received smoking cessation advice/counselling; 52% of all women received antenatal education and 51% had investigation for gestational diabetes. Overall, there was relatively good documentation of follow up of identified problems related to hypertension or diabetes, with over 70% of identified women being referred to a GP/Obstetrician. Conclusion Participating services had both strengths and weaknesses in the delivery of maternal health care. Increasing access to evidence-based screening and health information (most notably around smoking cessation) were consistently identified as opportunities for improvement across services.

Background The diabetes epidemic is associated with huge human and economic costs, with some groups, such as indigenous populations in industrialised countries, being at especially high risk. Monitoring and improving diabetes care at a population level are important to reduce diabetes-related morbidity and mortality. A set of diabetes indicators has been developed collaboratively among the Organisation for Economic Co-operation and Development (OECD) countries to monitor performance of diabetes care. The aim of this review was to provide an overview of diabetes management in five selected OECD countries (Australia, Canada, New Zealand, the US and the UK), based on data available for general and indigenous populations where appropriate. Methods We searched websites of health departments and leading national organisations related to diabetes care in each of the five countries to identify publicly released reports relevant to diabetes care. We collected data relevant to 6 OECD diabetes indicators on processes of diabetes care (annual HbA1c testing, lipid testing, renal function screening and eye examination) and proximal outcomes (HbA1c and lipid control). Results Data were drawn from 29 websites, with 14 reports and 13 associated data sources included in this review. Australia, New Zealand, the US and the UK had national data available to construct most of the 6 OECD diabetes indicators, but Canadian data were limited to two indicators. New Zealand and the US had national level diabetes care data for indigenous populations, showing relatively poorer care among these groups when compared with general populations. The US and UK performed well across the four process indicators when compared with Australia and New Zealand. For example, annual HbA1c testing and lipid testing were delivered to 70-80% of patients in the US and UK; the corresponding figures for Australia and New Zealand were 50-60%. Regarding proximal outcomes, HbA1c control for patients in Australia and New Zealand tended to be relatively better than patients in the US and UK. Conclusions Substantial efforts have been made in the five countries to develop routine data collection systems to monitor performance of diabetes management. Available performance data identify considerable gaps in clinical care of diabetes across countries. Policy makers and health service providers across countries can learn from each other to improve data collection and delivery of diabetes care at the population level.

TO THE EDITOR: Improving access to appropriate, good-quality care in the antenatal and postnatal period is a key part of closing the acknowledged gap between Indigenous and other Australians in perinatal outcomes. Previous research in a large Aboriginal medical service in Queensland demonstrated sustained improvements in perinatal outcome ssociated with a quality improvement approach. Here we describe patterns of the delivery of maternity care and service gaps on a broad scale, using data from baseline clinical audits in 34 Indigenous primary health centres participating in a national quality improvement intervention. Participating services were located across the Northern Territory (Top End and Central Australia), North Queensland, Far West New South Wales and Western Australia. Details of the audit methods have been described previously. Briefly, a random sample of up to 30 clinical records in each service was assessed to determine the degree of adherence to recommended protocols and procedures in the antenatal and postnatal periods. Records of women with an infant aged 2–14 months and who had been resident in the community for at least 6 months of the infant’s gestation were considered eligible for our study. The study was approved by the human research ethics committees in each region, and their Indigenous subcommittees where required. Clinical records of 535 women were assessed. Eighty-nine per cent of the women were Indigenous. However, compared with services in the NT, WA and North Queensland, services in Far West NSW had a higher proportion of nonIndigenous women presenting for antenatal or postnatal care (34% v 0–6%; P < 0.05). Overall, less than half of all women presented for care in the first trimester of pregnancy (Box, page 598). Documentation of routine antenatal investigations and brief interventions or advice regarding health behaviour varied, but generally these services appeared to be underutilised. There was relatively good documentation of follow-up of identified problems relating to hypertension or diabetes, with over 70% of identified women being referred to a general practitioner or obstetrician. However, follow-up of other identified problems, such as inadequate rubella immunity, was poor. Although 53% of women had a recorded postnatal visit, documentation of advice regarding health risk factors during the postnatal period was poor. For about half of all women there was documentation about breastfeeding advice and contraception. But advice about smoking, nutrition or mood (depression) was recorded for only 19%–21% of all women, and advice about sudden infant death syndrome prevention, injury prevention or infection/ hygiene was recorded for only 4%–5% of all women. The clinical audit data presented here indicate that participating services had both strengths and weaknesses in delivering maternal health care. Nevertheless, improving adherence to recommended screening investigations and brief interventions or advice about health behaviours, particularly smoking cessation, in the antenatal and postnatal period were identified as clear areas for improvement across all services. This information represents baseline data to inform the long-term monitoring of a quality improvement intervention. More broadly, it should be useful for informing local, regional and national efforts to promote and assess the quality of primary maternal health care for Indigenous women, and thus help address the persisting unacceptably high rates of poor Indigenous perinatal outcomes in Australia.

Objective: This article explores the role of professional values and the culture of the Australian health care system in facilitating and constraining the implementation of an Aboriginal health policy. Methods: Thirty-five semi-structured in-depth interviews were conducted in a case study on the implementation of the Northern Territory Preventable Chronic Disease Strategy (PCDS). Results: PCDS included three major evidence-based components - primary prevention, early detection and better management. The research revealed that PCDS changed as it was implemented. The values of the medical and nursing professions favoured the implementation of the clinically-based component of PCDS - better management. But there was dissonance between the values of these dominant professional groups and the values and expertise in public health that were necessary to implement fully the primary prevention component of PCDS. While Aboriginal health workers have valuable knowledge and skills in this area, they were not accorded sufficient power and training to influence decision-making on priorities and resources, and were able to exercise only limited influence on the components of the PCDS that were implemented. Conclusion: The findings highlight the role that a myriad of values play in influencing which aspects of a policy are implemented by organizations and their agents. Comprehensive and equitable implementation of policy requires an investigation and awareness of different professional values, and an examination of whose voices will be privileged in the decision-making process. If the advances in developing evidence-based, culturally-appropriate and inclusive policy are to be translated into practice, then care needs to be taken to monitor and influence whose values are being included at what point in the policy implementation process.