Objective: To report the short-term experiences and outcomes of a program to support chronic disease management in three remote communities in Top End Northern Territory and in two Aboriginal Medical Services (AMSs) in Western Australia, and to discuss the implications of findings for health service delivery and policy.
Methods: Programs were health-worker centred. They espoused regular screening of all adults for chronic disease, initiation and modification of treatment where indicated and rigorous documentation. Process measures were documented and rates of hypertension, renal disease and diabetes among adults were calculated.
Results: Rates of hypertension, proteinuria and diabetes rose throughout adult life and multiple diagnoses were common. Most people with these conditions were young or middle age adults. Rates were uniformly excessive relative to AusDiab data, but varied greatly among settings. Adherence to protocols improved, many new diagnoses were made, treatments were started or modified and blood pressures in treated hypertensive people fell. In the NT, productivity was seriously limited by lack of health workers and their absenteeism. In the WA AMSs, executive and staff support carried the programs forward to a sustainable future, despite various challenges.
Conclusions: Integrated chronic disease testing must be repeated throughout adult life for timely diagnosis. Health workers can perform all tasks well, with appropriate supports. Blood pressure outcomes alone predict lower cardiovascular and renal mortality. The findings support incorporation of chronic disease into lifetime health care plans.