{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,12]],"date-time":"2026-09-12T06:08:55Z","timestamp":1789193335423,"version":"build-2803163510"},"reference-count":32,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"14","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["JAHA"],"published-print":{"date-parts":[[2018,7,17]]},"abstract":"<jats:sec xml:lang=\"en\">\n            <jats:title>Background<\/jats:title>\n            <jats:p xml:lang=\"en\">Health system strengthening is needed to improve delivery of secondary prophylaxis against rheumatic heart disease.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec xml:lang=\"en\">\n            <jats:title>Methods and Results<\/jats:title>\n            <jats:p xml:lang=\"en\">\n              We undertook a stepped\u2010wedge, randomized trial in northern Australia. Five pairs of Indigenous community clinics entered the study at 3\u2010month steps. Study phases comprised a 12 month baseline phase, 3 month transition phase, 12 month intensive phase and a 3\u2010 to 12\u2010month maintenance phase. Clinics received a multicomponent intervention supporting activities to improve penicillin delivery, aligned with the chronic care model, with continuous quality\u2010improvement feedback on adherence. The primary outcome was the proportion receiving \u226580% of scheduled penicillin injections. Secondary outcomes included \u201cdays at risk\u201d of acute rheumatic fever recurrence related to late penicillin and\n              <jats:styled-content style=\"fixed-case\">acute rheumatic fever<\/jats:styled-content>\n              recurrence rates. Overall, 304 patients requiring prophylaxis were eligible. The proportion receiving \u226580% of scheduled injections during baseline was 141 of 304 (46%)\u2014higher than anticipated. No effect attributable to the study was evident: in the intensive phase, 126 of 304 (41%) received \u226580% of scheduled injections (odds ratio compared with baseline: 0.78; 95% confidence interval\n              <jats:styled-content style=\"fixed-case\">,<\/jats:styled-content>\n              0.54\u20131.11). There was modest improvement in the maintenance phase among high\u2010adhering patients (43% received \u226590% of injections versus 30% [baseline] and 28% [intensive],\n              <jats:italic>P<\/jats:italic>\n              &lt;0.001). Also, the proportion of days at risk in the whole cohort decreased in the maintenance phase (0.28 versus 0.32 [baseline] and 0.34 [intensive],\n              <jats:italic>P<\/jats:italic>\n              =0.001). A\n              <jats:styled-content style=\"fixed-case\">cute rheumatic fever<\/jats:styled-content>\n              recurrence rates did not differ between study sites during the intensive phase and the whole jurisdiction (3.0 versus 3.5 recurrences per 100\u00a0patient\u2010years,\n              <jats:italic>P<\/jats:italic>\n              =0.65).\n            <\/jats:p>\n          <\/jats:sec>\n          <jats:sec xml:lang=\"en\">\n            <jats:title>Conclusions<\/jats:title>\n            <jats:p xml:lang=\"en\">\n              This strategy did not improve adherence to\n              <jats:styled-content style=\"fixed-case\">rheumatic heart disease<\/jats:styled-content>\n              secondary prophylaxis within the study time frame. Longer term primary care strengthening strategies are needed.\n            <\/jats:p>\n          <\/jats:sec>\n          <jats:sec xml:lang=\"en\">\n            <jats:title>Clinical Trial Registration<\/jats:title>\n            <jats:p xml:lang=\"en\">\n              <jats:styled-content style=\"fixed-case\">URL<\/jats:styled-content>\n              :\n              <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"http:\/\/www.anzctr.org.au\">www.anzctr.org.au<\/jats:ext-link>\n              . Unique identifier:\n              <jats:styled-content style=\"fixed-case\">ACTRN<\/jats:styled-content>\n              12613000223730.\n            <\/jats:p>\n          <\/jats:sec>","DOI":"10.1161\/jaha.118.009308","type":"journal-article","created":{"date-parts":[[2018,7,17]],"date-time":"2018-07-17T09:15:21Z","timestamp":1531818921000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":47,"title":["Improving Delivery of Secondary Prophylaxis for Rheumatic Heart Disease in a High\u2010Burden Setting: Outcome of a Stepped\u2010Wedge, Community, Randomized Trial"],"prefix":"10.1161","volume":"7","author":[{"given":"Anna P.","family":"Ralph","sequence":"first","affiliation":[{"name":"Menzies School of Health Research Darwin Northern Territory Australia"},{"name":"Charles Darwin University Darwin Northern Territory Australia"},{"name":"Royal Darwin Hospital Darwin Northern Territory Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica L.","family":"de Dassel","sequence":"additional","affiliation":[{"name":"Charles Darwin University Darwin Northern Territory Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adrienne","family":"Kirby","sequence":"additional","affiliation":[{"name":"National Health and Medical Research Council Clinical Trials Centre University of Sydney New South Wales Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Clancy","family":"Read","sequence":"additional","affiliation":[{"name":"Telethon Kids Institute University of Western Australia Perth Western Australia Australia"},{"name":"Princess Margaret Hospital for Children Perth Western Australia Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alison G.","family":"Mitchell","sequence":"additional","affiliation":[{"name":"Menzies School of Health Research Darwin Northern Territory Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Graeme P.","family":"Maguire","sequence":"additional","affiliation":[{"name":"Baker Heart and Diabetes Institute Melbourne Victoria Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bart J.","family":"Currie","sequence":"additional","affiliation":[{"name":"Menzies School of Health Research Darwin Northern Territory Australia"},{"name":"Charles Darwin University Darwin Northern Territory Australia"},{"name":"Royal Darwin Hospital Darwin Northern Territory Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ross S.","family":"Bailie","sequence":"additional","affiliation":[{"name":"University of Sydney University Centre for Rural Health Lismore New South Wales Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vanessa","family":"Johnston","sequence":"additional","affiliation":[{"name":"Menzies School of Health Research Darwin Northern Territory Australia"},{"name":"Medical School Australian National University Australian Capital Territory Canberra Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan R.","family":"Carapetis","sequence":"additional","affiliation":[{"name":"Telethon Kids Institute University of Western Australia Perth Western Australia Australia"},{"name":"Princess Margaret Hospital for Children Perth Western Australia Australia"},{"name":"Perth Children's Hospital Perth Western Australia Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_2_2_2","first-page":"1","article-title":"Group A streptococcal diseases and their global burden","volume":"368","author":"Ralph AP","year":"2013","unstructured":"Ralph AP, Carapetis JR. 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