Aboriginal and Torres Strait Islander Health Performance Framework (HPF) 2012

Tier 3—Responsive—3.09 Discharge against medical advice

The HPF was designed to measure the impact of the National Strategic Framework for Aboriginal and Torres Strait Islander Health (NSFATSIH) and will be an important tool for developing the new National Aboriginal and Torres Strait Islander Health Plan (NATSIHP).

Page last updated: 15 November 2012

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 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’ (i.e., 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 2008 and June 2010, there were 14,052 hospitalisations (excluding private hospitalisations in Tasmania, the ACT and the NT, 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 compared with 0.4% for non-Indigenous Australians.

Indigenous Australians were discharged from hospital against medical advice at five times the rate of non-Indigenous Australians. Discharges from hospital against medical advice are most common for Aboriginal and Torres Strait Islander peoples aged 15–44 years. They are also more common for Indigenous people living in remote and very remote areas. The proportion of discharge against medical advice for Aboriginal and Torres Strait Islander peoples was highest in the NT (4% of all episodes) and lowest in Tasmania and the ACT (around 1% of all episodes).

Among Indigenous Australians who were discharged against medical advice, the most common principal diagnoses for hospitalisations were injury and poisoning (3,125 hospitalisations), followed by diseases of the respiratory system (1,874 hospitalisations). These two groups of diagnoses represented 36% of all hospitalisations for which Indigenous patients were discharged against medical advice. As a proportion of all hospitalisations of Indigenous Australians for each specific diagnoses group, discharge against medical advice was highest for diseases of the skin (5.8%), followed by infectious and parasitic diseases (5.5%).

An analysis of the relative impact of a range of factors found that Indigenous status was the single most significant variable contributing to whether a patient would discharge themselves from hospital against medical advice, even after controlling for the other factors. Other factors that were significant, in order of importance after Indigenous status, were:
  • remoteness of hospital;
  • sex;
  • principal diagnosis;
  • age;
  • state of hospital;
  • remoteness of usual residence; and
  • state/territory of usual residence.Top of Page

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 (see measure 3.08). 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.

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 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). Historical issues, such as segregation and hospital being seen as a place to go to die are also factors to be investigated.

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 168—Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and age group, July 2008 to June 2010
Top of PageFigure 168—Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and age group, July 2008 to June 2010

Source: AIHW National Hospital Morbidity Database

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Figure 169—Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and jurisdiction, 2008–09 to 2009–10
Figure 169—Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and jurisdiction, 2008–09 to 2009–10

Proportions are age-standardised
Source: AIHW National Hospital Morbidity Database

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Figure 170—Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and remoteness, 2008–09 to 2009–10
Figure 170—Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and remoteness, 2008–09 to 2009–10

Proportions are age-standardised
Source: AIHW National Hospital Morbidity Database

Top of Page
Figure 171—Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and principal diagnosis, July 2008 to June 2010
Figure 171—Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and principal diagnosis, July 2008 to June 2010

Proportions are age-standardised
Source: AIHW National Hospital Morbidity Database

Top of Page