title: Strengthening cardiovascular disease prevention in remote indigenous communities in Australia's Northern Territory.
abstract: BACKGROUND
  In 2012 the Northern Territory Department of Health commenced the Chronic Conditions Management Model - strengthening cardiovascular disease prevention in remote Indigenous communities. Interventions included providing regular functional reporting and decision support to frontline primary health care teams.
  
  
  METHODS
  Longitudinal (three monthly) clinical audits of cardiac prevention services were undertaken between 2012 and 2014. Our primary outcome was population coverage of cardiovascular risk assessment for Indigenous clients aged 20 years and older. Secondary outcomes for those identified at high risk were (i) assessment of modifiable cardiac risk factors, (ii) prescription of risk lowering medications, and (iii) the proportion of high risk clients achieving clinical targets for risk reduction.
  
  
  RESULTS
  As of August 2014, 7266 clients have had their cardiovascular risk assessed, improving population coverage from 23% in mid June 2012 to 58.5%. For 2586 high risk clients, 1728 (67%) and 1416 (55%) were prescribed blood pressure and lipid lowering therapy and for those clinically re-assessed, 1366 (57%) and 989 (40%) were achieving clinical targets for risk reduction for blood pressure and lipids respectively.
  
  
  CONCLUSIONS
  Functional reporting and decision support was associated with improvement in cardiovascular risk assessment coverage and a sustained proportion of high risk clients achieving clinical targets for cardiovascular risk reduction. Further intervention-based research is required to close the gap between identification of risk and risk reduction.
authors.affiliation: Top End Health Service, Primary Health Care Branch, Northern Territory Government, Darwin Australia; Northern Territory Clinical School, Flinders University, Darwin, Australia. Electronic address: Paul.Burgess@nt.gov.au.
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Burgess
authors.affiliation: Top End Health Service, Primary Health Care Branch, Northern Territory Government, Darwin Australia.
authors.forename: Gary
authors.initials: G
authors.lastname: Sinclair
authors.affiliation: Top End Health Service, Primary Health Care Branch, Northern Territory Government, Darwin Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Ramjan
authors.affiliation: Top End Health Service, Primary Health Care Branch, Northern Territory Government, Darwin Australia.
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Coffey
authors.affiliation: Top End Health Service, Primary Health Care Branch, Northern Territory Government, Darwin Australia.
authors.forename: Christine M
authors.initials: CM
authors.lastname: Connors
authors.affiliation: Top End Health Service, Primary Health Care Branch, Northern Territory Government, Darwin Australia.
authors.forename: Leonie V
authors.initials: LV
authors.lastname: Katekar
mesh_terms: D000328:Adult; D000368:Aged; D001315:Australia / Q000453:epidemiology; D002318:Cardiovascular Diseases / Q000097:blood / Q000453:epidemiology* / Q000503:physiopathology / Q000517:prevention & control*; D054869:Clinical Audit; D003695:Delivery of Health Care; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors
keywords: Australia; Cardiovascular diseases; Indigenous Health Services; Prevention; Primary Health Care