To the Editor:
“... what a difference can be made and how bureaucracies can stuff things up”.
“... systematic testing and treatment of people with high blood pressure and kidney disease dramatically improved blood pressure and resulted in a 50% reduction of deaths”.
“... excellent results were achieved by good management and they were lost when intensity of management was relaxed”.
The above quotes are from an episode of The health report broadcast late last year on Radio National.1 The episode, which described a deterioration in the health of an Indigenous community after a chronic disease treatment program was handed over to a community health board, caused me to take a closer look at the articles in the Journal by Hoy and colleagues on which the claims were based.2,3 I found several issues of concern.
The small numbers of deaths each year in the study community and the analysis and presentation of the death data mean that the conclusions about trends in mortality over time are tenuous. This is highlighted by the discrepancies between the two articles in the terminology used to classify deaths, in the numbers of deaths reported, and in the trends over time. Discrepancies in terminology or numbers of reported deaths are not explained. The declining trend in the number of “natural” deaths described in the 2000 article is not apparent in the “non-renal” deaths in the 2005 article. The rate of “non-renal” death for the period 1996–97 to 1998–99 reported in the 2005 article appears to be increasing rather than declining, as described in the 2000 article (rates for earlier years are not presented in either article). It is clear that, with these small numbers, the reclassification or misclassification of a single death can affect the trends in “renal death” or end-stage renal disease over time, and that the use of “rolling averages” hides the year-to-year variability that would be expected in these data.
The trend over time in the key intermediate outcome indicator of blood pressure control does not support the conclusion regarding impact of the “handover” on the program. The data presented in the 2005 article show a decline in control commencing in the third year. An earlier analysis of the same data showed the decline in blood pressure control began as early as the second year after entry into the program.4 Neither analysis shows any clear change in the declining trend in blood pressure control around the time of “handover” of the program.
While the discussion of the findings of the 2005 article is circumspect, at the time of interview, Hoy conspicuously did not deny the statement of The health report host that the primary cause of the apparent loss of the early impact of the program was the bureaucracy “stuffing up”. The article makes some important points about the operation of chronic disease programs, but makes no mention of the commonly experienced difficulties of sustaining health programs,5,6 or the research requirements for understanding sustainability.7
- 1. Aboriginal health [transcript of radio program]. The health report. ABC Radio National broadcast, 08:30; 7 Nov 2005. Available at: http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s1496205.htm (accessed May 2006).
- 2. Hoy WE, Kondalsamy-Chennakesavan SN, Nicol JL. Clinical outcomes associated with changes in a chronic disease treatment program in an Australian Aboriginal community. Med J Aust 2005; 183: 305-309. <MJA full text>
- 3. Hoy WE, Baker PR, Kelly AM, Wang Z. Reducing premature death and renal failure in Australian Aboriginals. A community-based cardiovascular and renal protective program. Med J Aust 2000; 172: 473-478. <MJA full text>
- 4. Robinson G, Bailie R, Wang Z, et al. A follow-up study of outcomes of the Tiwi Renal Treatment Program. Darwin: NTUniprint, Northern Territory University, 2003.
- 5. Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Educ Res 1998; 13: 87-108.
- 6. Bossert TJ. Can they get along without us? Sustainability of donor-supported health projects in Central America and Africa. Soc Sci Med 1990; 30: 1015-1023.
- 7. Jackson N, Waters E, Anderson L, et al. Criteria for the systematic review of health promotion and public health interventions. Health Promot Int 2005; 20: 367-374.
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