Better health and ageing for all Australians

Aboriginal and Torres Strait Islander Health Performance Framework - 2010

3.08 Discharge against medical advice

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Why is it important?:

Feedback on patient experiences, and community views of health care services and providers are important for shaping health services and policy. It is important to estimate consumer satisfaction as it is believed to impact on health-related behaviours. For example, satisfied consumers may be more likely to cooperate with treatment, continue using services, maintain a relationship with a specific provider, and actively participate in their own treatment. Australia has a mixed history of systematically seeking feedback from the people for whom health services are intended to benefit. A review of patient satisfaction and experience surveys found jurisdictions had adopted a range of methods for seeking feedback on patient experiences of hospitals and related services (Pearse 2005). Surveying the experiences of Aboriginal and Torres Strait Islander patients poses challenges which have been investigated by some jurisdictions.

The measure reported here is based on the extent to which Aboriginal and Torres Strait Islander people ‘vote with their feet’ (e.g. in discharging themselves from hospital against medical advice). The measure provides indirect evidence of the extent to which hospital services are responsive to Indigenous Australian patients’ needs.

Findings:

Between July 2006 and June 2008, there were 12,780 hospitalisations (excluding private hospitalisations in Tasmania, the Australian Capital Territory and the Northern Territory, and admissions for mental and behavioural disorders) where Aboriginal and Torres Strait Islander people left hospital against medical advice or were discharged at their own risk. This represented around 2% of all hospitalisations for Aboriginal and Torres Strait Islander peoples, which compares with 0.4% for other Australians.

Indigenous Australians were discharged from hospital against medical advice at 6 times the rate of other Australians. Discharges from hospital against medical advice are most common for Aboriginal and Torres Strait Islander peoples aged 15–54 years. They are also more common for Indigenous people living in remote and very remote areas. The proportion of discharges against medical advice for Aboriginal and Torres Strait Islander people was highest in the Northern Territory (3% of episodes) and lowest in Tasmania and the Australian Capital Territory (just under 1% of episodes).

The most common principal diagnoses of hospitalisations of Indigenous Australians who were discharged against medical advice were injury and poisoning (2,912 separations), followed by diseases of the respiratory system (1,566 separations). These two groups of diagnoses represented 35% of all hospitalisations discharged against medical advice. As a proportion of all Indigenous separations for each specific diagnoses group, discharge against medical advice was highest for injury and poisoning and diseases of the skin (5.4%), followed by diseases of the nervous system (4.9%).

An analysis of the relative impact of a range of factors found that Indigenous status was the most significant variable contributing to whether a patient would discharge themselves from hospital against medical advice, even after controlling for the other factors.

Implications:

The significantly elevated levels of discharge against medical advice suggest that there are significant issues in the responsiveness of hospitals to the needs and perceptions of Aboriginal and Torres Strait Islander peoples. Whilst there are major challenges in developing relevant mechanisms for obtaining feedback from Aboriginal and Torres Strait Islander patients, health systems need to design and implement these mechanisms. The data suggest these issues are important for all age groups, although the issues are most evident for those aged 15–54 years.

The Cultural Respect Framework for Aboriginal and Torres Strait Islander Health sets out the overarching commitments Australian jurisdictions have made to achieving the ‘recognition, protection and continued advancement of the inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander peoples’. The Framework proposes that Cultural Respect will be achieved when the health system is a safe environment for Aboriginal and Torres Strait Islander peoples and where cultural differences are respected. Cultural Respect is a commitment that the provision of services offered by the Australian health care system will not wittingly compromise the legitimate cultural rights, practices, values and expectations of Aboriginal and Torres Strait Islander peoples. Practical examples of respectful practices offered in the Framework include:
  • representation on, and cross-cultural input into, governance structures and processes
  • ensuring access to interpreter services
  • where possible and appropriate, co-locating Aboriginal and Torres Strait Islander patients with other individuals who speak the same traditional language
  • having written protocols in place, specific to Aboriginal and Torres Strait Islander women, on maternal and birthing health..
There are several questions for health service researchers and health service managers to tackle in devising strategies to achieve more responsive and respectful service delivery. More needs to be known about the reasons for the high rates of discharge against medical advice across individual factors (such as psychosocial, personal circumstances, health and wellbeing, and cultural issues); community level factors (such as levels of trust or mistrust in system); and hospital level factors (such as staff attitudes, hospital policies and the environment).

The experience of Aboriginal and Torres Strait Islander peoples of health services needs to be routinely evaluated but the mechanisms for doing this need to be better researched. Hospitals and health services that have implemented successful programs to reduce discharge against medical advice need to be studied and lessons disseminated.

Figure 157 – Discharges from hospital against medical advice, by Indigenous status and age group (excluding mental and behavioural disorders), Australia, July 2006 to June 2008


Figure 157 – Discharges from hospital against medical advice, by Indigenous status and age group (excluding mental and behavioural disorders), Australia, July 2006 to June 2008
Note: Total is age standardised
Source: AIHW National Hospital Morbidity Database
Text description of figure 157 (TXT 1KB)

Figure 158 – Age-standardised proportion of hospitalisations ending in discharge against medical advice, by jurisdiction, 2006–07 to 2007–08


Figure 158 – Age-standardised proportion of hospitalisations ending in discharge against medical advice, by jurisdiction, 2006–07 to 2007–08
Source: AIHW National Hospital Morbidity Database
Text description of figure 158 (TXT 1KB)

Figure 159 – Age-standardised proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and remoteness, 2006–07 to 2007–08


Figure 159 – Age-standardised proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and remoteness, 2006–07 to 2007–08
Source: AIHW National Hospital Morbidity Database
Text description of figure 159 (TXT 1KB)

Figure 160 – Age-standardised proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and principal diagnosis, Australia, July 2006 to June 2008


Figure 160 – Age-standardised proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and principal diagnosis, Australia, July 2006 to June 2008
Note: Excludes Mental and Behavioural Disorders
Source: AIHW National Hospital Morbidity Database
Text description of figure 160 (TXT 1KB)

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