This study shows that participating Aboriginal community health centres in Australia had implemented basic systems to support chronic illness care, but there was considerable room for improvement in all system components. Stronger organisational influence and information system components were associated both with better performance in process of diabetes care and in intermediate outcomes. Additionally, community linkages were specifically related to better performance in process of care, and delivery system design was associated with better intermediate outcomes.
When compared with data from the USA [16
], health centres had similar ACIC scores for community linkages, decision support, delivery system, and clinical information system, but lower scores for organisational influence and self-management support. In many respects the quality of diabetes care in participating health centres is also comparable with national and international data [17
] For example, 70% of patients in our study had HbA1c tested in the past year and 26% had values less than 8% – almost identical to experience reported from the USA [19
To our knowledge, this is the first study to demonstrate quantitative evidence regarding the importance of organisational influence (including goals for chronic care, improvement strategies, and incentives for care) on diabetes care. Wagner and colleagues reported their experience in the chronic condition Breakthrough Series, suggesting the removal of disincentives in practice encourages providers' in delivery of effective chronic illness care [7
]. Financial incentives for diabetes care have been introduced to Australian general practice through Enhanced Primary Care (EPC) and Practice Incentive Program (PIP) [20
]. However, only half of participating centres reported claiming for Medicare rebate using EPC items.
Our study shows better implementation of clinical information systems to be associated with both increased adherence to guideline-recommended processes of diabetes care and improved intermediate outcomes. An ideal information system has three important roles: 1) as a registry for a target population; 2) to provide reminders to primary care teams to comply with guidelines for care; and 3) to provide feedback measures relevant to quality of care [22
]. Our data show the third role to be the least-developed area for current information systems in this study setting, and support the appropriateness of external clinical audit as a useful approach to address such system deficiencies [23
The positive relation between delivery system design and intermediate outcomes of diabetes care is consistent with several previous studies [25
] It is likely that health centres characterised by availability of resident doctors, active specialist outreach, and appropriate client follow-up offer more opportunity for intensive management that might contribute to better diabetes control. Given that many remote community health centres are staffed primarily by nurses and Aboriginal Health Workers (AHWs) and supported by visiting doctors [27
], a feasible approach to improve delivery system design is to assign and strengthen nurses' and AHWs' roles in delivering routine care, and to ensure referral to medical practitioners for consultation and medication adjustment where appropriate [28
]. Features of delivery system design may also be amenable to improving the relative under-utilisation of primary care services by Aboriginal men – a widely recognised phenomenon that is reflected in the study sample.
The apparent poor integration of system components in participating health centres also needs to be addressed in future system development, as isolated upgrading in one component without integrating with another may lead to an increase in costs but not in effectiveness. For example, computerised information systems can generate "pop-up" reminders for healthcare providers, but poor delivery system design characterised by unclear roles among health staff may result in no appropriate action being taken.
The cross-sectional study design limits the confidence with which the observed associations between health centre systems and processes and outcomes of diabetes care can be defined as causal. However, the findings suggest that the Chronic Care Model and the associated ACIC scale will be valuable in assessing and guiding the development of health centre systems in Aboriginal community settings. More research is needed to formally examine the reproducibility of the methods of assessing systems development, and to define the cause-effect relationship between healthcare systems and quality of diabetes care using longitudinal study designs. Such studies may also help clarify resource and management requirements for sustaining improvements in chronic illness care.