Open Access Research article

Improvement in rheumatic fever and rheumatic heart disease management and prevention using a health centre-based continuous quality improvement approach

Anna P Ralph12*, Marea Fittock1, Rosalie Schultz3, Dale Thompson1, Michelle Dowden4, Tom Clemens5, Matthew G Parnaby5, Michele Clark6, Malcolm I McDonald7, Keith N Edwards5, Jonathan R Carapetis8 and Ross S Bailie1

Author Affiliations

1 Menzies School of Health Research, Darwin, Northern Territory (NT), Australia

2 Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia

3 Nyangirru Piliyi-ngara Kurantta, Anyinginyi Health Aboriginal Corporation, Tennant Creek, NT, Australia

4 Ngalkanbuy Health Service, Galiwinku, NT, Australia

5 Northern Territory Department of Health and Community Services, Townsville, Australia

6 Queensland Health, Queensland Government, Townsville, Queensland, Australia

7 School of Medicine and Dentistry, Cairns Campus, James Cook University, Townsville, QLD, Australia

8 Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia

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BMC Health Services Research 2013, 13:525  doi:10.1186/1472-6963-13-525

Published: 18 December 2013



Rheumatic heart disease (RHD) remains a major health concern for Aboriginal Australians. A key component of RHD control is prevention of recurrent acute rheumatic fever (ARF) using long-term secondary prophylaxis with intramuscular benzathine penicillin (BPG). This is the most important and cost-effective step in RHD control. However, there are significant challenges to effective implementation of secondary prophylaxis programs. This project aimed to increase understanding and improve quality of RHD care through development and implementation of a continuous quality improvement (CQI) strategy.


We used a CQI strategy to promote implementation of national best-practice ARF/RHD management guidelines at primary health care level in Indigenous communities of the Northern Territory (NT), Australia, 2008–2010. Participatory action research methods were employed to identify system barriers to delivery of high quality care. This entailed facilitated discussion with primary care staff aided by a system assessment tool (SAT). Participants were encouraged to develop and implement strategies to overcome identified barriers, including better record-keeping, triage systems and strategies for patient follow-up. To assess performance, clinical records were audited at baseline, then annually for two years. Key performance indicators included proportion of people receiving adequate secondary prophylaxis (≥80% of scheduled 4-weekly penicillin injections) and quality of documentation.


Six health centres participated, servicing approximately 154 people with ARF/RHD. Improvements occurred in indicators of service delivery including proportion of people receiving ≥40% of their scheduled BPG (increasing from 81/116 [70%] at baseline to 84/103 [82%] in year three, p = 0.04), proportion of people reviewed by a doctor within the past two years (112/154 [73%] and 134/156 [86%], p = 0.003), and proportion of people who received influenza vaccination (57/154 [37%] to 86/156 [55%], p = 0.001). However, the proportion receiving ≥80% of scheduled BPG did not change. Documentation in medical files improved: ARF episode documentation increased from 31/55 (56%) to 50/62 (81%) (p = 0.004), and RHD risk category documentation from 87/154 (56%) to 103/145 (76%) (p < 0.001). Large differences in performance were noted between health centres, reflected to some extent in SAT scores.


A CQI process using a systems approach and participatory action research methodology can significantly improve delivery of ARF/RHD care.

Continuous quality improvement; Rheumatic fever; Rheumatic heart disease; Secondary prophylaxis