Australian Primary Health Care Services Research Articles

(200) THE ROLE OF AI IN STI DIAGNOSIS

Abstract Introduction Rates of notifiable Sexually Transmitted Infections (STIs) have been escalating in Australia over the last ten years. In 2013 there were 102 000 notifiable STI cases, including Chlamydial, Gonococcal and Syphilis; this has steadily climbed over the previous ten years to 159 000 cases in 2023. In particular there have been higher rates of STIs in the Northern Territory and Queensland states; with 2302 cases per 100 000 and 650 cases per 100 000 respectively. In recent years there has been a lot of discussion about the role and use of Artificial Intelligence (AI) in healthcare. With developing technology and improved image analysis, the role of AI software in healthcare and aiding in the diagnosis of dermatological conditions has been a hot topic. Objective Access to and engagement with Australian primary healthcare services for assessment of a possible STI is fraught with difficulty for a myriad of reasons. Access to General Practitioners (GP) and primary health care within Australia has been very difficult in recent years due to a shortage of GPs throughout the country. This has had a particularly significant effect in states such as the Northern Territory and Queensland which have large geographical footprints and many rural communities that have traditionally struggled to retain local GPs, and often have to drive for greater than 3 hours to reach an alternate medical facility (primary care or emergency department). STIs are also typically stigmatised and shamed which further discourages individuals to seek medical help. Methods On review of the literature; AI image analysis has been shown to have been of benefit for diagnosis and surveillance of dermatological conditions such as; skin cancer, psoriasis, atopic dermatitis etc. It has been shown to be of use as an adjunct to the clinician, increasing the sensitivity and accuracy of screening for these dermatological conditions. Results As discussed above, STIs are on the rise within the Australian population over recent years. We propose that AI image analysis could assist with the assessment and diagnosis of STI in the Australian community in the following ways. Risk stratification using non-AI software to triage STI risk based on known risk factors; such as unprotected sexual activity, number of sexual partners, previous STIs etc. AI image analysis to aid with diagnosis of STIs; as per the dermatological examples this would assess a picture taken of genital lesions and compare to a data-base to determine likelihood a STI and triage those that require urgent clinician review (Noting that this would need to be a secure database given the intimate nature of the images). This could also be linked into automated formal STI pathology request generation if the AI image analysis is of high concern for an STI (and the AI program has been shown to have good sensitivity and accuracy) to aid in early diagnosis and treatment. Conclusions In particular the use of an AI image analysis service would be of greater benefit in large rural communities such as the Northern Territory and Queensland, where access to medical care can be limited. Disclosure No.

The contribution of group work to the goals of comprehensive primary health care.

Group work, such as peer support and health promotion is an important strategy available to comprehensive primary health care. However, group work and how it contributes to the goals of comprehensive primary health care has been under-researched and under-theorised. In this 5-year study, we partnered with seven Australian primary health care services, and drew on service reports, two rounds of staff interviews (2009-2010 and 2013, N=68 and 55), 10 community assessment workshops (N=65), a client survey (N=315) and case tracking of clients with diabetes (N=184, plus interviews with 35 clients, and five practitioners) and clients with depression (N=95, plus interviews with 21 clients, and 11 practitioners). We conducted a rapid literature review of existing research on group work, and developed a model showing a group work reinforcing cycle. We examined the nature of the groups run, and the benefits staff and clients perceived. Benefits were grouped into four main themes: (a) social support, including for clients of the Aboriginal services, opportunities to celebrate their cultural identity, (b) improving skills and knowledge, (c) increasing access to services and (d) empowerment and solidarity. The perceived collective and individual benefits aligned with a comprehensive primary health care vision. However, the individualism stressed by neoliberal-driven health policy threatened the provision of group work and its potential collectivist benefits. There are multiple benefits of group work in primary health care that cannot be achieved through individual work, highlighting the importance of policy and organisational support for group work.

Interprofessional teamwork in comprehensive primary healthcare services: Findings from a mixed methods study

ABSTRACTThis article draws on data from a 5-year project that examined the effectiveness of Comprehensive primary healthcare (CPHC) in local communities. A hallmark of CPHC services is interprofessional teamwork. Drawing from this study, our article presents factors that enabled, or hindered, healthcare teams working interprofessionally in Australian primary healthcare (PHC) services. The article reports on the experiences of teams working in six Australian PHC services (four managed by state governments, one non-government sexual health organisation, and one Aboriginal community-controlled health service) during a time of significant health sector restructure. Findings are drawn from two key methods: an online survey of practitioners and managers (n = 154), and interviews with managers and practitioners (n = 60) from the six study sites. The majority of survey respondents worked with other health professionals in their service to provide interprofessional care to clients. Processes included formal team meetings, case conferencing, referring clients to other health professionals if needed, informal communication with other health professionals about clients, and team-based delivery of care. A range of interrelated factors affected interprofessional work at the services, from contextual, organisational, processual, and relational domains. Funding cuts and policy changes that saw a reorientation and re-medicalisation of South Australian services undermined interprofessional work, while a shared CPHC culture and commitment among some staff was helpful in resisting some of these effects. The co-location of services was a factor in PHC teams working interprofessionally and not only enabled some PHC teams to work more interprofessionally but also created barriers to interprofessional teamwork through disruption resulting from restructuring of services. Our study indicates the importance of decision makers taking into account the potential effects of policy and structural changes on interprofessional teamwork. Decision makers should strive to minimise unintended negative effects of changes on the functioning of interprofessional teams.

Change management in an environment of ongoing primary health care system reform: A case study of Australian primary health care services.

Globally, health reforms continue to be high on the health policy agenda to respond to the increasing health care costs and managing the emerging complex health conditions. Many countries have emphasised PHC to prevent high cost of hospital care and improve population health and equity. The existing tension in PHC philosophies and complexity of PHC setting make the implementation and management of these changes more difficult. This paper presents an Australian case study of PHC restructuring and how these changes have been managed from the viewpoint of practitioners and middle managers. As part of a 5-year project, we interviewed PHC practitioners and managers of services in 7 Australian PHC services. Our findings revealed a policy shift away from the principles of comprehensive PHC including health promotion and action on social determinants of health to one-to-one disease management during the course of study. Analysis of the process of change shows that overall, rapid, and top-down radical reforms of policies and directions were the main characteristic of changes with minimal communication with practitioners and service managers. The study showed that services with community-controlled model of governance had more autonomy to use an emergent model of change and to maintain their comprehensive PHC services. Change is an inevitable feature of PHC systems continually trying to respond to health care demand and cost pressures. The implementation of change in complex settings such as PHC requires appropriate change management strategies to ensure that the proposed reforms are understood, accepted, and implemented successfully.

Gender inequalities in cardiovascular risk factor assessment and management in primary healthcare

ObjectivesTo quantify contemporary differences in cardiovascular disease (CVD) risk factor assessment and management between women and men in Australian primary healthcare services.MethodsRecords of routinely attending patients were sampled from 60...

Primary health care reform, dilemmatic space and risk of burnout among health workers.

Health system changes may increase primary health care workers' dilemmatic space, created when reforms contravene professional values. Dilemmatic space may be a risk factor for burnout. This study partnered with six Australian primary health care services (in South Australia: four state government-managed services including one Aboriginal health team and one non-government organisation and in Northern Territory: one Aboriginal community-controlled service) during a period of change and examined workers' dilemmatic space and incidence of burnout. Dilemmatic space and burnout were assessed in a survey of 130 staff across the six services (58% response rate). Additionally, 63 interviews were conducted with practitioners, managers, regional executives and health department staff. Dilemmatic space occurred across all services and was associated with higher rates of self-reported burnout. Three conditions associated with dilemmatic space were (1) conditions inherent in comprehensive primary health care, (2) stemming from service provision for Aboriginal and Torres Strait Islander peoples and (3) changes wrought by reorientation to selective primary health care in South Australia. Responses to dilemmatic space included ignoring directives or doing work 'under the radar', undertaking alternative work congruent with primary health care values outside of hours, or leaving the organisation. The findings show that comprehensive primary health care was contested and political. Future health reform processes would benefit from considering alignment of changes with staff values to reduce negative effects of the reform and safeguard worker wellbeing.

Comprehensive primary health care under neo-liberalism in Australia

This paper applies a critical analysis of the impact of neo-liberal driven management reform to examine changes in Australian primary health care (PHC) services over five years. The implementation of comprehensive approaches to primary health care (PHC) in seven services: five state-managed and two non-government organisations (NGOs) was tracked from 2009 to 2014. Two questions are addressed: 1) How did the ability of Australian PHC services to implement comprehensive PHC change over the period 2009–2014? 2) To what extent is the ability of the PHC services to implement comprehensive PHC shaped by neo-liberal health sector reform processes? The study reports on detailed tracking and observations of the changes and in-depth interviews with 63 health service managers and practitioners, and regional and central health executives. The documented changes were: in the state-managed services (although not the NGOs) less comprehensive service coverage and more focus on clinical services and integration with hospitals and much less development activity including community development, advocacy, intersectoral collaboration and attention to the social determinants. These changes were found to be associated with practices typical of neo-liberal health sector reform: considerable uncertainty, more directive managerial control, budget reductions and competitive tendering and an emphasis on outputs rather than health outcomes. We conclude that a focus on clinical service provision, while highly compatible with neo-liberal reforms, will not on its own produce the shifts in population disease patterns that would be required to reduce demand for health services and promote health. Comprehensive PHC is much better suited to that task.

Revisiting the ability of Australian primary healthcare services to respond to health inequity.

Equity of access and reducing health inequities are key objectives of comprehensive primary health care. However, the supports required to target equity are fragile and vulnerable to changes in the fiscal and political environment. Six Australian primary healthcare services, five in South Australia and one in the Northern Territory, were followed over 5 years (2009-2013) of considerable change. Fifty-five interviews were conducted with service managers, staff, regional health executives and health department representatives in 2013 to examine how the changes had affected their practice regarding equity of access and responding to health inequity. At the four state government services, seven of 10 previously identified strategies for equity of access and services' scope to facilitate access to other health services and to act on the social determinants of health inequity were now compromised or reduced in some way as a result of the changing policy environment. There was a mix of positive and negative changes at the non-government organisation. The community-controlled service increased their breadth of strategies used to address health equity. These different trajectories suggest the value of community governance, and highlight the need to monitor equity performance and advocate for the importance of health equity.

Consistency of denominator data in electronic health records in Australian primary healthcare services: enhancing data quality.

The quality of data derived from primary healthcare electronic systems has been subjected to little critical systematic analysis, especially in relation to the purported benefits and substantial investment in electronic information systems in primary care. Many indicators of quality of care are based on numbers of certain types of patients as denominators. Consistency of denominator data is vital for comparison of indicators over time and between services. This paper examines the consistency of denominator data extracted from electronic health records (EHRs) for monitoring of access and quality of primary health care. Data collection and analysis were conducted as part of a prospective mixed-methods formative evaluation of the Commonwealth Government's Indigenous Chronic Disease Package. Twenty-six general practices and 14 Aboriginal Health Services (AHSs) located in all Australian States and Territories and in urban, regional and remote locations were purposively selected within geographically defined locations. Percentage change in reported number of regular patients in general practices ranged between -50% and 453% (average 37%). The corresponding figure for AHSs was 1% to 217% (average 31%). In approximately half of general practices and AHSs, the change was ≥ 20%. There were similarly large changes in reported numbers of patients with a diagnosis of diabetes or coronary heart disease (CHD), and Indigenous patients. Inconsistencies in reported numbers were due primarily to limited capability of staff in many general practices and AHSs to accurately enter, manage, and extract data from EHRs. The inconsistencies in data required for the calculation of many key indicators of access and quality of care places serious constraints on the meaningful use of data extracted from EHRs. There is a need for greater attention to quality of denominator data in order to realise the potential benefits of EHRs for patient care, service planning, improvement, and policy. We propose a quality improvement approach for enhancing data quality.

Importance of community engagement in primary health care: the case of Afghan refugees.

Refugees can experience problems accessing and utilising Australian primary health care services, resulting in suboptimal health outcomes. Little is known about the impact of their pre-migration health care experiences. This paper demonstrates how the Afghan pre-migration experiences of primary health care can affect engagement with Australian primary care services. It considers the implications for Australian primary health care policy, planning and delivery. This paper is based on the international experiences, insights and expert opinions of the authors, and is underpinned by literature on Afghan health-seeking behaviour. Importantly, Afghanistan and Australia have different primary health care strategies. In Afghanistan, health care is predominantly provided through a community-based outreach approach, namely through community health workers residing in the local community. In contrast, the Australian health care system requires client attendance at formal health service facilities. This difference contributes to service access and utilisation problems. Community engagement is essential to bridge the gap between the Afghan community and Australian primary health care services. This can be achieved through the health sector working to strengthen partnerships between Afghan individuals, communities and health services. Enhanced community engagement has the potential to improve the delivery of primary health care to the Afghan community in Australia.

Developing a good practice model to evaluate the effectiveness of comprehensive primary health care in local communities.

BackgroundThis paper describes the development of a model of Comprehensive Primary Health Care (CPHC) applicable to the Australian context. CPHC holds promise as an effective model of health system organization able to improve population health and increase health equity. However, there is little literature that describes and evaluates CPHC as a whole, with most evaluation focusing on specific programs. The lack of a consensus on what constitutes CPHC, and the complex and context-sensitive nature of CPHC are all barriers to evaluation.MethodsThe research was undertaken in partnership with six Australian primary health care services: four state government funded and managed services, one sexual health non-government organization, and one Aboriginal community controlled health service. A draft model was crafted combining program logic and theory-based approaches, drawing on relevant literature, 68 interviews with primary health care service staff, and researcher experience. The model was then refined through an iterative process involving two to three workshops at each of the six participating primary health care services, engaging health service staff, regional health executives and central health department staff.ResultsThe resultant Southgate Model of CPHC in Australia model articulates the theory of change of how and why CPHC service components and activities, based on the theory, evidence and values which underpin a CPHC approach, are likely to lead to individual and population health outcomes and increased health equity. The model captures the importance of context, the mechanisms of CPHC, and the space for action services have to work within. The process of development engendered and supported collaborative relationships between researchers and stakeholders and the product provided a description of CPHC as a whole and a framework for evaluation. The model was endorsed at a research symposium involving investigators, service staff, and key stakeholders.ConclusionsThe development of a theory-based program logic model provided a framework for evaluation that allows the tracking of progress towards desired outcomes and exploration of the particular aspects of context and mechanisms that produce outcomes. This is important because there are no existing models which enable the evaluation of CPHC services in their entirety.

Service providers' views of community participation at six Australian primary healthcare services: scope for empowerment and challenges to implementation.

Community participation is a key principle of comprehensive primary health care (PHC). There is little literature on how community participation is implemented at Australian PHC services. As part of a wider study conducted in partnership with five South Australian PHC services, and one Aboriginal community controlled health service in the Northern Territory, 68 staff, manager, regional health executives, and departmental funders were interviewed about community participation, perceived benefits, and factors that influenced implementation. Additional data were collected through analysis of policy documents, service reports on activity, and a web-based survey completed by 130 staff. A variety of community participation strategies was reported, ranging from consultation and participation as a means to improve service quality and acceptability, to substantive and structural participation strategies with an emphasis on empowerment. The Aboriginal community controlled health service in our study reported the most comprehensive community participation. Respondents from all services were positive about the benefits of participation but reported that efforts to involve service users had to compete with a centrally directed model of care emphasising individual treatment services, particularly at state-managed services. More empowering substantive and structural participation strategies were less common than consultation or participation used to achieve prescribed goals. The most commonly reported barriers to community participation were budget and lack of flexibility in service delivery. The current central control of the state-managed services needs to be replaced with more local management decision making if empowering community participation is to be strengthened and embedded more effectively in the culture of services.

Community assessment workshops: a group method for gathering client experiences of health services

Community assessment workshops were developed to gather client experiences of primary health care services in Australia. Primary health care services are particularly concerned with working with disadvantaged populations, for whom traditional client survey methods such as written surveys may not be inclusive and accessible. Service staff at six Australian primary health care services, including two Aboriginal-specific services, invited participants to attend workshops in 2011-2012. Participants were offered transport, childcare and an interpreter, and provided with reimbursement for their time. Ten workshops were run with a total of 65 participants who accessed a variety of services and programmes. A mix of age and gender was achieved. The workshops yielded detailed qualitative data and quantitative rankings for nine service qualities: holistic, effective, efficient, culturally respectful, used by those most in need, responsive to the local community, increasing individual control, supports and empowers the community, and mix of treatment, prevention and promotion. Discussions were audio recorded and transcribed for qualitative analysis. The workshop approach succeeded in being (i) inclusive, reaching users from disadvantaged sections of the community; (ii) comprehensive, providing ratings and discussion that took account of the whole service; (iii) richly descriptive, with researchers able to generate detailed feedback; and (iv) more empowering than traditional client survey methods, by allowing more control to participants and greater benefits than surveys of individuals. The community assessment workshops are a method that could be widely applied to health service evaluation research where the goal is to reach disadvantaged communities and provide ratings and detailed analysis of the experience of users. The participants and the research benefited from the group approach, and the workshops provided valuable, actionable information to the health services. Recruitment of users, particularly those from culturally diverse backgrounds, remains one of the key challenges facing evaluators.