Aboriginal and Torres Strait Islander Health Performance Framework - 2010

3.05 Differential access to key hospital procedures

Page last updated: 26 May 2011

Why is it important?:

Australians with illnesses that can be effectively treated by hospital-based medical and surgical procedures should have equitable access to these procedures. Studies have shown that while Aboriginal and Torres Strait Islander peoples, are more likely to be hospitalised than other people they are less likely to receive a medical or surgical procedure while in hospital (Cunningham 2002; ABS & AIHW 2005; ABS & AIHW 2008). The disparities are not explained by diagnosis, age, sex or place of residence (Cunningham 2002).

There is some information available on patterns of access for particular conditions. For patients admitted to hospital with coronary heart disease, access to coronary angiography can be important in diagnosis and establishment of a course of treatment. Coronary heart disease may be treated medically (with drugs) or through repairing the heart’s blood vessels, either using a medical procedure (percutaneous coronary interventions) or a surgical procedure (coronary artery by-pass grafts). A study of patients admitted to Queensland hospitals for acute myocardial infarction (heart attack) between 1998 and 2002 found that rates of coronary procedures among Indigenous Australian patients were 22% lower than rates for other patients (Coory & Walsh 2005).

Several studies have shown Aboriginal and Torres Strait Islander people have poorer survival for cancer. This is partly explained by the stage of cancer when patients are referred for specialist treatment (Condon et al. 2006; Valery et al. 2006). However, Aboriginal and Torres Strait Islander peoples are less likely to have treatment for cancer (surgery, chemotherapy, radiotherapy) and tend to wait longer for surgery (Hall et al. 2004; Valery et al. 2006). After adjusting for stage at diagnosis, treatment and comorbidities, non-Indigenous Australians had better survival than Indigenous patients.

Aboriginal and Torres Strait Islander people with end stage renal failure have a lower rate of kidney transplants and significantly longer overall median waiting times to receive a transplant (Yeates et al. 2009). These disparities are not explained by age, sex, comorbidities or the cause of renal disease.

Findings:

In the two years to June 2008, excluding care involving dialysis, 59% of hospital episodes for Aboriginal and Torres Strait Islander people had a procedure recorded, compared with 81% of hospital episodes for other Australians.

For Indigenous Australians, 6% of hospitalisations with a procedure recorded occurred in private hospitals compared with 50% for non-Indigenous Australians. There are many factors associated with the likelihood of receiving a procedure when admitted to hospital. An analysis of the combined impact of a range of factors found that the most significant factors (in order or importance) were:
  • whether the hospital was a public or private hospital;
  • the number of additional diagnoses recorded for a patient;
  • the principal diagnosis for which a person is admitted (with admissions for cancers, diseases of the skin, diseases of the eye, diseases of the genitourinary system, diseases of the blood, pregnancy and childbirth, and diseases of the ear and mastoid process all increasing the likelihood a procedure will occur);
  • Indigenous status;
  • remoteness of usual residence;
  • and jurisdiction of residence.
In all states and territories Indigenous Australians were less likely to receive a procedure. Analysis by remoteness shows a steady decline in procedures as remoteness declines. However, the gap between Indigenous and non-Indigenous remains in each area.

Between July 2006 and June 2008, among those hospitalised with coronary heart disease, Aboriginal and Torres Strait Islander people were half as likely to receive coronary procedures such as coronary angiography and revascularisation procedures.

For hospitalisation related to diseases of the digestive tract, between July 2005 and June 2008, Aboriginal and Torres Islander people were more likely to receive a corresponding procedure when the principal diagnosis was appendicitis, but significantly less likely to receive a corresponding procedure where the principal diagnosis was complicated or uncomplicated hernias, diseases of the extrahepatic biliary tree and non-neoplastic diseases of the anus or rectum. These results were statistically adjusted for age, sex, hospital type, urgency of admission, remoteness of usual residence and several co-morbidities (Moore et al. 2008).

Implications:

Disparities in access to hospital procedures are likely to reflect a range of factors, including ‘systemic practices, not ill-intentioned but still discriminatory, and almost invisible in the patient provider encounter’ (Fisher & Weeramanthri 2002). An adequate primary health care system is a prerequisite for effective hospital and specialist services. Aboriginal and Torres Strait Islander patients with chronic disease sometimes present later in the course of these illnesses, which affects treatment options (Valery et al. 2006). Access to non-hospital specialist services for Aboriginal and Torres Strait Islander peoples is known to be well below national averages (Deeble et al. 1998). Other factors that have been suggested include: that the presence of comorbidities limits treatment options (although this does not explain the difference in coronary procedures outlined above); clinical judgments concerning post procedural compliance; communication issues, including difficulties for a patient whose main language is not English; and patient knowledge and attitudes, e.g. fatalistic attitudes towards cancer. Physical, social and cultural distance from health services also play a role, along with financial issues patients and their families face when seeking treatment in specialist referral services (Shahid et al. 2009; Miller & Knott 2010).

Effective strategies will require a better understanding of the factors leading to the observed disparities. Improvements in the primary care sector will increase early detection, referrals and improve support for patients following discharge. A range of measures have been taken by the Australian Government and jurisdictions to support outreach specialist services for people living in remote areas. The measures presented here suggest that under-provision of specialist services for Aboriginal and Torres Strait Islander peoples persists, and that further efforts are required to improve access. In addition to governments, clinicians and clinical colleges could also play a role in reviewing decision making processes and relevant data to identify what drives differential access to procedures and develop strategies to address these issues (Fisher & Weeramanthri 2002).

Table 59 – Proportion of separations with a procedure reported, by principal diagnosis and Indigenous status, Australia, July 2006 to June 2008

Principal diagnosis chapter
Indigenous
Other
%
%
Diseases of the eye
93
98
Congenital malfunctions
89
93
Diseases of the blood
88
94
Neoplasms
86
96
Diseases of the ear
77
87
Factors influencing health status(a)
75
92
Certain conditions in perinatal period
74
70
Diseases of the musculoskeletal system
70
92
Diseases of the genitourinary system
64
86
Endocrine, nutritional & metabolic disorders
64
82
Diseases of the digestive system
63
88
Injury, poisoning & external causes
61
73
Pregnancy & child birth
60
77
Diseases of the circulatory system
57
74
Diseases of the skin
56
72
Diseases of the nervous system
52
82
Diseases of the respiratory system
40
61
Mental & behavioural disorders
38
53
Infectious & parasitic diseases
37
40
Total
59
81
(a) Excludes care involving dialysis
Source: AIHW analysis of National Hospital Morbidity Database

Table 60 – Proportion of separations with a procedure reported, by type of procedure and Indigenous status, Australia, July 2006 to June 2008

Procedure type
Indig.
Other
%
%
Procedure on urinary system
47
8
Haemodialysis
46
6
Non-invasive and cognitive and other
interventions, n.e.c.
34
47
Imaging services
6
5
Procedures on digestive system
4
9
Dermatological and plastic procedures
4
4
Procedures on cardiovascular system
4
4
Obstetric procedures
3
3
Dental services
3
4
Procedures on musculoskeletal system
3
5
Procedures on respiratory system
2
1
Gynaecological procedures
1
3
Procedures on eye and adnexa
1
2
Procedures on nervous system
1
1
Procedures on nose and mouth and pharynx
-
1
Procedures on ear and mastoid process
-
-
Total (excluding haemodialysis)
66
94
Total (including haemodialysis)
100
100
Source: AIHW analysis of National Hospital Morbidity Database
- Number is less than 0.5

Figure 150 – Proportion of hospitalisations with a procedure performed, by Indigenous status and state/territory (excluding care involving dialysis), July 2006 to June 2008


Figure 150 – Proportion of hospitalisations with a procedure performed, by Indigenous status and state/territory (excluding care involving dialysis), July 2006 to June 2008
Source: AIHW analysis of National Hospital Morbidity Database
Text description of figure 150 (TXT 1KB)

Figure 151 – Use of coronary procedures for those hospitalised with coronary heart disease, NSW, Vic, Qld, WA, SA and NT, July 2006 to June 2008


Figure 151 – Use of coronary procedures for those hospitalised with coronary heart disease, NSW, Vic, Qld, WA, SA and NT, July 2006 to June 2008
Source: AIHW analysis of National Hospital Morbidity Database
Text description of figure 151 (TXT 1KB)

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