Enhancing chronic disease screening for Aboriginal and Torres Strait Islander peoples

About

Welcome to the Enhancing chronic disease screening for Aboriginal and Torres Strait Islander Peoples program of work page.

Our work aims to improve the prevention of chronic disease for Aboriginal and Torres Strait Islander Peoples.

More than 35% of Aboriginal and Torres Strait Islander adults report having one or more of diabetes, cardiovascular disease and/or kidney disease (AIHW, 2015).


Prevalence of CVD, diabetes and CKD and their comorbidity among persons aged 18 and over, by Indigenous status, 2011-2013

Prevalence of CVD
(Source: AIHW 2015. Cardiovascular disease, diabetes and chronic kidney disease— Australian facts: Aboriginal and Torres Strait Islander people. Cardiovascular, diabetes and chronic kidney disease series no. 5. Cat. no. CDK 5. Canberra: AIHW.)

The overall aim of the three year program is to reduce the number of heart attacks and strokes through improved assessment and management, according to an absolute risk approach that is consistent with the values of Aboriginal and Torres Strait Islander communities. It promotes a holistic approach to healthcare, including early detection of chronic diseases, learning from high-performing practices, developing ways of applying these lessons across all primary health care services, and engaging with Aboriginal and Torres Strait Islander peoples in shared decision making about their health choices.

This will involve:

  1. Ensuring that updated absolute CVD risk guidelines are applicable for Aboriginal and Torres Strait Islander peoples by:
    1. Ensuring that changes made to the absolute CVD risk equation and recommended risk thresholds for starting pharmacotherapy are appropriate for Aboriginal and Torres Strait Islander peoples.
  2. Developing strategies to support high population coverage of chronic disease risk assessment and appropriate follow-up by:
    1. Identifying services with high coverage of chronic disease risk assessment using routinely collected general practice data
    2. Identifying mechanisms that support high levels of assessment and follow-up through case studies with ‘high performing’ health services
    3. Developing policy and practice options to support chronic disease risk assessment and management
  3. Developing co-designed resources for Aboriginal and Torres Strait Islander peoples to facilitate shared decision-making by:
    1. Engaging with key stakeholders to determine patient needs and priorities, how resources could be implemented effectively, and what formats would be appropriate
    2. Implementing and evaluating resources through engagement with community and user testing

In 2020, the Australian Government Department of Health provided funding for this program of work to improve chronic disease screening for Aboriginal and Torres Strait Islander Peoples.

Ensuring patient-centred care

Local stakeholders will have a vital role to inform all outputs of this work and shape the change that is required to effectively address shortfalls in chronic disease prevention. Prioritising patient-centred care and opportunities for capacity-building are a key part of our approach. This will be achieved through consultation, collaboration and co-design with Aboriginal and Torres Strait Islander research leaders, professional and peak bodies, and community.

The project will depend on the support and cooperation of key stakeholders, including patients, to ensure that solutions that are identified will result in real-world success, address the service gaps in chronic disease care and prevention, and ultimately be embedded and sustained throughout the health system.