title: Effectiveness, cost effectiveness, acceptability and implementation barriers/enablers of chronic kidney disease management programs for Indigenous people in Australia, New Zealand and Canada: a systematic review of mixed evidence.
abstract: BACKGROUND
  Indigenous peoples in Australia, New Zealand and Canada carry a greater burden of chronic kidney disease (CKD) than the general populations in each country, and this burden is predicted to increase. Given the human and economic cost of dialysis, understanding how to better manage CKD at earlier stages of disease progression is an important priority for practitioners and policy-makers. A systematic review of mixed evidence was undertaken to examine the evidence relating to the effectivness, cost-effectiveness and acceptability of chronic kidney disease management programs designed for Indigenous people, as well as barriers and enablers of implementation of such programs.
  
  
  METHODS
  Published and unpublished studies reporting quantitative and qualitative data on health sector-led management programs and models of care explicitly designed to manage, slow progression or otherwise improve the lives of Indigenous people with CKD published between 2000 and 2014 were considered for inclusion. Data on clinical effectiveness, ability to self-manage, quality of life, acceptability, cost and cost-benefit, barriers and enablers of implementation were of interest. Quantitative data was summarized in narrative and tabular form and qualitative data was synthesized using the Joanna Briggs Institute meta-aggregation approach.
  
  
  RESULTS
  Ten studies were included. Six studies provided evidence of clinical effectiveness of CKD programs designed for Indigenous people, two provided evidence of cost and cost-effectiveness of a CKD program, and two provided qualitative evidence of barriers and enablers of implementation of effective and/or acceptable CKD management programs. Common features of effective and acceptable programs were integration within existing services, nurse-led care, intensive follow-up, provision of culturally-appropriate education, governance structures supporting community ownership, robust clinical systems supporting communication and a central role for Indigenous Health Workers.
  
  
  CONCLUSIONS
  Given the human cost of dialysis and the growing population of people living with CKD, there is an urgent need to draw lessons from the available evidence from this and other sources, including studies in the broader population, to better serve this population with programs that address the barriers to receiving high-quality care and improve quality of life.
authors.affiliation: Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia. rachel.reilly@sahmri.com.|Johanna Briggs Institute, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia. rachel.reilly@sahmri.com.|Onemda VicHealth Koori Health Group, School of Population and Global Heath, the University of Melbourne, Carlton, Victoria, Australia. rachel.reilly@sahmri.com.
authors.forename: Rachel
authors.initials: R
authors.lastname: Reilly
authors.affiliation: Menzies School of Health Research, Darwin, Australia.
authors.forename: Katharine
authors.initials: K
authors.lastname: Evans
authors.affiliation: Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia.|Johanna Briggs Institute, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia.|School of Public Health, University of Adelaide, Adelaide, Australia.
authors.forename: Judith
authors.initials: J
authors.lastname: Gomersall
authors.affiliation: Menzies School of Health Research, Darwin, Australia.
authors.forename: Gillian
authors.initials: G
authors.lastname: Gorham
authors.affiliation: Johanna Briggs Institute, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia.
authors.forename: Micah D J
authors.initials: MD
authors.lastname: Peters
authors.affiliation: Baker IDI Heart and Diabetes Institute, Alice Springs, Australia.
authors.forename: Steven
authors.initials: S
authors.lastname: Warren
authors.affiliation: Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia.
authors.forename: Rebekah
authors.initials: R
authors.lastname: O'Shea
authors.affiliation: Menzies School of Health Research, Darwin, Australia.
authors.forename: Alan
authors.initials: A
authors.lastname: Cass
authors.affiliation: Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia.
authors.forename: Alex
authors.initials: A
authors.lastname: Brown
mesh_terms: D001315:Australia / Q000453:epidemiology; D002170:Canada / Q000453:epidemiology; D002908:Chronic Disease; D003362:Cost-Benefit Analysis; D019468:Disease Management; D018450:Disease Progression; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006303:Health Services, Indigenous / Q000191:economics; D006801:Humans; D009520:New Zealand / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D044382:Population Groups; D011320:Primary Health Care / Q000191:economics; D016730:Program Development; D036301:Qualitative Research; D011788:Quality of Life; D006435:Renal Dialysis / Q000191:economics / Q000706:statistics & numerical data*; D051436:Renal Insufficiency, Chronic / Q000191:economics / Q000453:epidemiology / Q000628:therapy*
keywords: Chronic kidney disease; Indigenous health; chronic disease management; systematic review