The APCC Program has resulted in key changes within Australian primary care and better health outcomes for patients with chronic disease, including:
- Improved patient care through better management of Chronic Disease
- Increased best practice care through better use of information systems (both medical and business systems)
- Evolving roles among practice staff to better meet patient demand
- A cultural shift from individual patient care to population based care
To date, more than 1500 Australian general practices have achieved significant improvements through their involvement in the APCC Program. The following improvements in evidence based clinical measures have been recorded.
The graphs in the following documents are not intended for academic or research reference. They are produced for the purposes of managing, tracking and monitoring improvements through the APCC Program.
Diabetes Prevention and Management Wave (Wave 9)
At 14 months, the Diabetes Prevention and Management Wave (Wave 9) is seeing great improvements across all core measures.
Results of note include:
- There has been a significant reduction in the number of patients with a diagnosis of diabetes who do not have a HBA1C recorded, dropping from 45% to below 30%.
- By month 14, more than 4,510 Diabetes Risk Assessments (DRAs) had been completed for patients by the 37 participating practices and health services, compared to just 64 DRAs recorded at baseline. The Diabetes Risk Assessment Tool (AUSDRISK) is used to identify an individual’s risk of developing Type 2 diabetes within five years.
Click here to see the full results to month 14 of this Wave.
Cardiovascular Disease and Chronic Kidney Disease Wave (Wave 10)
At month three, the Cardiovascular Disease and Chronic Kidney Disease Wave (Wave 10) is seeing early improvements, including some outstanding improvements in the risk assessment and register numbers measures.
Results of note include:
- In the first 3 months of this Wave, the 59 participating general practices and health services completed 5,498 Absolute Risk Assessments for eligible patients.
- 2,900 more patients with chronic kidney disease are recorded on participating general practice and health service registers. Absolute risk is used to identify an individual’s risk of a cardiovascular event occurring within a five-year period.
Click here to see the full results to month 3 of this Wave.
Phase 4, Wave 9 results
At 12 months, Wave 9 on Diabetes Prevention and Management is seeing great improvements across all core measures. The diabetes register shows a decrease in the number of patients on the register consistent with data cleaning activities. The Wave is moving closer to the Program aim of 50% HBA1C <7, sitting at 41.5%. There has also been a significant reduction in HBA1C not recorded, dropping from 45% to 30%. Annual Cycle of Care elements recorded has increased from 5 elements being recorded at baseline to 6.8 recorded (from a possible 17 elements) representing an increase of 36%.
Modifiable Risk Factors recorded has been increasing since baseline where 1.6 out of the 6 risk factors were recorded to now 2.1, this is a 30% increase. Recent PDSA cycles submitted by participating general practices show that some participants are putting systems and processes in place to realise improvements in these areas.Significant improvement has taken place with the number of Diabetes Risk Assessments recorded where only 64 DRATS had been undertaken and recorded on the eligible patient population at baseline, to now 4000 DRATS being completed.
Phase 4, Wave 8 results
Wave 8 on Diabetes Prevention and Management was delivered over an 18 month period and has produced good outcomes, with all measures demonstrating improvement over the Wave duration. Initial fluctuation in the Diabetes register was consistent with data cleansing activities, and the past seven months have seen a steady increase as participants have appropriately coded patients with Diabetes.
Notable achievements were seen in the HbA1c ≤7% measure, which increased by 8.5%. There was also a significant reduction of 10% in the Diabetes HbA1c Not Recorded measure, representing over 1450 patients. Recording of the Annual Cycle of Care increased by 29.9%, from <5 elements to 6 elements (from a possible 17) being recorded whilst modifiable risk factors recording also increased by 30%.
The most significant improvement was observed in the number of Diabetes Risk Assessments (DRATS) being administered and recorded. At baseline only 75 DRATS had been performed and recorded for the eligible patient population, by the end of the wave 5500 DRATS were conducted.
Medicare Local Quality Improvement Partnership Update
The Medicare Local Quality Improvement Partnership (QI Partnership) assists Medicare Locals to implement locally relevant Chronic Disease Improvement Plans (CDIPs) that focus on enhancing the management and prevention of chronic disease. The CDIPs focus on priorities relevant to each Medicare Local, with participating Medicare Locals concentrating on Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Cardiovascular Disease and Diabetes. Additionally, all CDIPs include activities that support the meaningful uptake and use of eHealth in primary care.
Participating Medicare Locals have recruited more than 120 general practices and health services to participate in the QI Partnership, including 23 pharmacies and allied health providers. Medicare Locals will support each general practice and health service to test changes and submit monthly data to qiConnect, enabling monitoring of the impact of these change activities.
Five Medicare Locals have specifically recruited pharmacies, alongside general practices, to improve the screening, prevention and management of Chronic Obstructive Pulmonary Disease. With guidance from Improvement Foundation, these Medicare Locals have defined specific quality improvement measures that pharmacies can collect and submit to qiConnect, enabling pharmacies to meaningfully engage in quality improvement activities.
Phase 3, Wave 9 results
Phase 3, Wave 8 results
Phase 3, Wave 7 results
Phase 3, Wave 6 results
Phase 2, Wave 6 results
To view a PDF analysis of the results for each completed APCC Program topic, please click on the topic name below.
Last Updated 19 January 2015