title: Improvement in rheumatic fever and rheumatic heart disease management and prevention using a health centre-based continuous quality improvement approach.
abstract: BACKGROUND
  Rheumatic heart disease (RHD) remains a major health concern for Aboriginal Australians. A key component of RHD control is prevention of recurrent acute rheumatic fever (ARF) using long-term secondary prophylaxis with intramuscular benzathine penicillin (BPG). This is the most important and cost-effective step in RHD control. However, there are significant challenges to effective implementation of secondary prophylaxis programs. This project aimed to increase understanding and improve quality of RHD care through development and implementation of a continuous quality improvement (CQI) strategy.
  
  
  METHODS
  We used a CQI strategy to promote implementation of national best-practice ARF/RHD management guidelines at primary health care level in Indigenous communities of the Northern Territory (NT), Australia, 2008-2010. Participatory action research methods were employed to identify system barriers to delivery of high quality care. This entailed facilitated discussion with primary care staff aided by a system assessment tool (SAT). Participants were encouraged to develop and implement strategies to overcome identified barriers, including better record-keeping, triage systems and strategies for patient follow-up. To assess performance, clinical records were audited at baseline, then annually for two years. Key performance indicators included proportion of people receiving adequate secondary prophylaxis (≥80% of scheduled 4-weekly penicillin injections) and quality of documentation.
  
  
  RESULTS
  Six health centres participated, servicing approximately 154 people with ARF/RHD. Improvements occurred in indicators of service delivery including proportion of people receiving ≥40% of their scheduled BPG (increasing from 81/116 [70%] at baseline to 84/103 [82%] in year three, p = 0.04), proportion of people reviewed by a doctor within the past two years (112/154 [73%] and 134/156 [86%], p = 0.003), and proportion of people who received influenza vaccination (57/154 [37%] to 86/156 [55%], p = 0.001). However, the proportion receiving ≥80% of scheduled BPG did not change. Documentation in medical files improved: ARF episode documentation increased from 31/55 (56%) to 50/62 (81%) (p = 0.004), and RHD risk category documentation from 87/154 (56%) to 103/145 (76%) (p < 0.001). Large differences in performance were noted between health centres, reflected to some extent in SAT scores.
  
  
  CONCLUSIONS
  A CQI process using a systems approach and participatory action research methodology can significantly improve delivery of ARF/RHD care.
authors.affiliation: Menzies School of Health Research, Darwin, Northern Territory (NT), Australia. anna.ralph@menzies.edu.au.
authors.forename: Anna P
authors.initials: AP
authors.lastname: Ralph
authors.forename: Marea
authors.initials: M
authors.lastname: Fittock
authors.forename: Rosalie
authors.initials: R
authors.lastname: Schultz
authors.forename: Dale
authors.initials: D
authors.lastname: Thompson
authors.forename: Michelle
authors.initials: M
authors.lastname: Dowden
authors.forename: Tom
authors.initials: T
authors.lastname: Clemens
authors.forename: Matthew G
authors.initials: MG
authors.lastname: Parnaby
authors.forename: Michele
authors.initials: M
authors.lastname: Clark
authors.forename: Malcolm I
authors.initials: MI
authors.lastname: McDonald
authors.forename: Keith N
authors.initials: KN
authors.lastname: Edwards
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Carapetis
authors.forename: Ross S
authors.initials: RS
authors.lastname: Bailie
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D005260:Female; D006303:Health Services, Indigenous / Q000458:organization & administration / Q000592:standards; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D015876:Northern Territory; D010401:Penicillin G Benzathine / Q000008:administration & dosage / Q000627:therapeutic use; D058996:Quality Improvement / Q000458:organization & administration; D019984:Quality Indicators, Health Care; D012213:Rheumatic Fever / Q000188:drug therapy* / Q000517:prevention & control; D012214:Rheumatic Heart Disease / Q000188:drug therapy* / Q000517:prevention & control; D012307:Risk Factors; D055502:Secondary Prevention; D017749:Total Quality Management / Q000379:methods* / Q000458:organization & administration; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D010401:Penicillin G Benzathine