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Indigenous health

Indigenous health Consensus statement 16 March 2020 Open Access

Cardiovascular disease risk assessment for Aboriginal and Torres Strait Islander adults aged under 35 years: a consensus statement

Cardiovascular disease (CVD) is a leading cause of preventable morbidity and mortality in Aboriginal and Torres Strait Islander peoples. This statement from the Australian Chronic Disease Prevention Alliance, the Royal Australian College of General Practitioners, the National Aboriginal Community Controlled Health Organisation and the Editorial Committee for Remote Primary Health Care Manuals communicates the latest consensus advice of guideline developers, aligning recommendations on the age to commence Aboriginal and Torres Strait Islander CVD risk assessment across three guidelines. Main recommendations: In Aboriginal and Torres Strait Islander peoples without existing CVD: CVD risk factor screening should commence from the age of 18 years at the latest, including for blood glucose level or glycated haemoglobin, estimated glomerular filtration rate, serum lipids, urine albumin to creatinine ratio, and other risk factors such as blood pressure, history of familial hypercholesterolaemia, and smoking status. Individuals aged 18–29 years with the following clinical conditions are automatically conferred high CVD risk: ▶type 2 diabetes and microalbuminuria; ▶moderate to severe chronic kidney disease; ▶systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg; ▶familial hypercholesterolaemia; or ▶serum total cholesterol > 7.5 mmol/L. Assessment using the National Vascular Disease Prevention Alliance absolute CVD risk algorithm should commence from the age of 30 years at the latest — consider upward adjustment of calculated CVD risk score, accounting for local guideline use, risk factor and CVD epidemiology, and clinical discretion. Assessment should occur as part of an annual health check or opportunistically. Subsequent review should be conducted according to level of risk. Changes in management as a result of this statement: From age 18 years (at the latest), Aboriginal and Torres Strait Islander adults should undergo CVD risk factor screening, and from age 30 years (at the latest), they should undergo absolute CVD risk assessment using the NVDPA risk algorithm.

Jason W Agostino · Deborah Wong · Ellie Paige · Vicki Wade · Cia Connell · Maureen E Davey · David P Peiris · Dana Fitzsimmons · C Paul Burgess · Ray Mahoney · Emma Lonsdale · Peter Fernando · Leone Malamoo · Sandra Eades · Alex Brown · Garry Jennings · Raymond W Lovett · Emily Banks

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Cardiovascular diseases Research 2 March 2020 Free

Differences in stroke risk and cardiovascular mortality for Aboriginal and other Australian patients with atrial fibrillation

Objectives: To assess the risks of stroke and cardiovascular mortality for Aboriginal and non‐Aboriginal Australians with atrial fibrillation. Design: Retrospective data linkage cohort study. Setting, participants: All people aged 20–84 years hospitalised with atrial fibrillation in Western Australia during 2000–2012. Main outcome measures: Stroke incidence rates and mortality after hospitalisation for atrial fibrillation, and 10‐year risks of stroke and of cardiovascular and all‐cause mortality. Results: Among 55 482 index admissions with atrial fibrillation, 7.7% of 20–59‐year‐old patients and 1.3% of 60–84‐year‐old patients were Aboriginal Australians. A larger proportion of Aboriginal patients aged 20–59 years had CHA2DS2‐VASc scores of 2 or more (59.8% v 21.8%). In 20–59‐year‐old Aboriginal patients, the incidence during follow‐up (maximum, 10 years; median, 7.1 years) of stroke (incidence rate ratio [IRR], 3.2; 95% CI, 2.5–4.1) and fatal stroke (IRR, 5.7; 95% CI, 3.9–8.9) were markedly higher than for non‐Aboriginal patients. Stroke incidence was higher for 60–84‐year‐old patients, but the difference between Aboriginal and non‐Aboriginal patients was smaller (IRR, 1.6; 95% CI, 1.3–2.0). Cardiovascular mortality during follow‐up was also higher for 20–59‐year‐old Aboriginal patients (IRR, 4.4; 95% CI, 4.3–5.9). The hazards of stroke (adjusted HR [aHR], 1.67; 95% CI, 1.22–2.28) and cardiovascular mortality (aHR, 1.47; 95% CI, 1.18–1.83) in younger Aboriginal patients remained significantly higher after multivariable adjustment; age/sex, principal diagnosis of atrial fibrillation, and CHA2DS2‐VASc score were the most influential factors. Conclusion: Stroke risk and cardiovascular mortality are markedly higher for Aboriginal than non‐Aboriginal patients with atrial fibrillation, particularly for patients under 60. Strategies for providing evidence‐based therapies and cardiovascular prevention to Aboriginal people with atrial fibrillation must be improved.

Lee Nedkoff · Erin A Kelty · Joseph Hung · Sandra C Thompson · Judith M Katzenellenbogen

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Child health Letters 3 February 2020 Free

Clinical characteristics of Western Australian children diagnosed with type 2 diabetes before 10 years of age

To the Editor: Over the past decades, the incidence of type 2 diabetes, rarely diagnosed in children and adolescents before the 1990s,1 has been increasing in young people in several populations, including Australia.2,3,4 Early onset type 2 diabetes appears to have a more severe phenotype compared with adult onset type 2 diabetes, and has a high prevalence of complications already present at the time of diagnosis despite the patients’ young age and short duration of the disease.5 We aimed to describe the characteristics of Western Australian children aged less than 10 years diagnosed with type 2 diabetes between June 2000 and June 2017. Demographic and clinical data for children diagnosed with type 2 diabetes during the study period were extracted from the population‐based WA Children's Diabetes Database and via manual review of hospital clinical files. Of the 193 children aged less than 16 years diagnosed with type 2 diabetes in WA during the study period, 12 children were diagnosed at less than 10 years of age, with the youngest aged 6 years and 11 months. These 12 patients had one or both parents diagnosed with type 2 diabetes, 11 children were Aboriginal Australians, one was Māori, 11 were obese (mean body mass index z‐score, 2.38; standard deviation [SD], 0.64); nine were female, and seven had one or more comorbidities. Of the 11 children examined, ten had acanthosis nigricans present on their skin. Three children presented with polyuria and polydipsia, six were unwell with other illnesses and three were asymptomatic. Type 1 diabetes antibodies were negative in seven of eight of the children tested, and the mean glycated haemoglobin level at diagnosis was 75 mmol/mol (mean, 9.0%; SD, 2.4%). Nine patients had one or more diabetes complications present at the time of diagnosis; seven had dyslipidaemia, two had an elevated albumin creatinine ratio, and three had hypertension. Our study describes the common clinical features of early onset type 2 diabetes in young children in WA, such as history of parental type 2 diabetes, Aboriginal heritage, obesity, and female sex, and provides strong evidence for the need to screen children with these risk factors for type 2 diabetes, irrespective of their age. Moreover, the high prevalence of diabetes complications present strongly supports the need for complications screening at the time of diagnosis.

Jacqueline A Curran · Aveni Haynes · Elizabeth A Davis

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Indigenous health Letters 19 August 2019 Free

Screening for perinatal depression and predictors of underscreening: findings of the Born in Queensland study

To the Editor: We agree with San Martin Porter and colleagues1 about the importance of mental health screening during pregnancy and acknowledge the role of the Edinburgh Postnatal Depression Scale (EPDS) in screening in Australia and internationally. In the article, the authors stressed that the EPDS has been validated. However, the high heterogeneity demonstrated during these validation studies suggests that it is not equally valid across all populations and settings.2 The authors also suggested that low uptake of screening with Aboriginal women is related to less frequent attendance to antenatal checks. This interpretation fails to consider broader cultural safety issues surrounding antenatal care, and more specifically, the language and cultural appropriateness of the EPDS.3 This tool has not been validated with Aboriginal and Torres Strait Islander women. Many Aboriginal women find the EPDS language complex and confusing, and providers find using it with Aboriginal women challenging.3 Screening processes need to be acceptable to patients and staff, and seen to be easy to use and helpful, or they are unlikely to be well implemented. The need to consider the language and cultural appropriateness of the tool used was acknowledged in the latest Clinical practice guidelines: pregnancy care.4 The Kimberley Mum's Mood Scale (KMMS) is a locally designed approach to screening Aboriginal women.3 Part 1 is an adaption of the EPDS. Part 2 is a “yarn” between health professionals and women about contextual or psychosocial factors that are important to the women. Health professionals work with women to identify how they are coping (strengths focus) without minimising risk factors. Validation of the KMMS demonstrated clinical efficacy and high levels of user acceptability.5 Women identified that “just yarning” was a positive start to understanding and managing their perinatal mental health. An approach such as the KMMS, which values listening (health professional) and talking (woman), is a positive, contemporary and logical next step from the EPDS. We suggest that all women, Aboriginal and non‐Aboriginal, would benefit from this approach. Traditional screening practices are not enough, but the next generation of screening tools provides new opportunities for women and their health professionals.

Julia V Marley · Emma Carlin · Catherine Engelke

Health services administration Letters 1 July 2019 Free

Cultural respect in general practice: a cluster randomised controlled trial

To the Editor: We refer to Liaw and colleagues’1 recently published study in the Journal. We acknowledge the positive intentions and rigour of this trial, and empathically concur with Thompson and Thackrah’s2 comment that the results of this research “[do] not mean that efforts to improve cultural competence in health care settings should be abandoned”. To the contrary, this study demonstrates the urgent need for more research to improve cultural competence in the health care setting; in particular, the use of culturally safe research methods that truly benefit Aboriginal and Torres Strait Islander peoples and communities.3 Like Thompson and Thackrah,2 we question the authors’ choice of the cultural quotient questionnaire.4 This generic tool is not designed for assessing cultural competence of health professionals when working with Aboriginal and Torres Strait Islander peoples in Australia. Importantly, it lacks recognition of the unique colonial experiences of Aboriginal and Torres Strait Islander peoples and, therefore, it cannot measure health professionals’ understandings or attitudes about such a key part of any cultural training, where we would hope to see change. We suggest the use of a scale that has been designed and validated by Aboriginal and Torres Strait Islander peoples, such as the Cultural Capability Measurement Tool.5 We fear that, if not carefully interpreted, the study findings have the potential to further complicate and undermine the substantial work — endorsed by the National Aboriginal Community Controlled Health Organisation and the Department of Health — being undertaken to develop the cultural safety of Australia’s health system.6 It is crucial that in all areas of Australia’s health system, including Aboriginal and Torres Strait Islander health, we present a reliable, strategically aligned approach consistent with the vision of an Australian health system free of racism and inequality.6 It is important that we continue to work together to harness the energy and commitment of the workforce towards our shared goals. We look forward to the qualitative findings of the research study.

Sophie Hickey · Roianne West

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