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Tier 1 - Health status and outcomes

1.02 Top reasons for hospitalisation

Key facts

Why is it important?

Hospitalisation rates indicate the occurrence in a population of serious acute illnesses or conditions that require hospital treatment, and the access to and use of hospital treatment by people with such conditions. Hospitalisation rates for a particular disease do not directly indicate the level of occurrence of that disease in the population. Rates of hospitalisation are also impacted by access to primary care services (see measure 3.07 Selected potentially preventable hospital admissions) and other health services.

Hospitalisation rates are based on the number of hospital episodes of care rather than on the number of individual people who are hospitalised. A person who has frequent hospitalisations for the same disease is counted multiple times in the hospitalisation rate. For example, each kidney dialysis treatment is counted as a separate hospital episode, so that each person receiving three dialysis treatments per week contributes approximately 150 hospital episodes per year. Therefore, it is important to separate hospitalisation rates for dialysis from rates for other conditions. This is indicated in the Findings section of this measure.

Each hospitalisation involves a principal diagnosis (that is, the problem that was chiefly responsible for the patient's episode of care) and additional diagnoses where applicable (that is, conditions or complaints either coexisting or arising during care). This report focuses on the principal diagnosis for each hospitalisation. Analysis of additional diagnoses is available at www.aihw.gov.au.

Hospitalisation data feature across multiple measures in this report. This measure provides an overview of hospital admissions for Aboriginal and Torres Strait Islander people to serve as an introduction to other measures which provide more detail on the interaction between Indigenous Australians and the hospital sector. Tier 3 measures on health system performance (such as 3.06 Access to hospital procedures, 3.09 Discharge against medical advice and 3.14 Access to services compared with need) provide further insight into Indigenous Australians’ access to the hospital sector, experience within the sector and barriers to accessing specific hospital services.

There are some instances where the gap in hospitalisation rates between Indigenous and non-Indigenous Australians is reported and this should be treated with caution. For hospitalisation data, this gap can be useful in understanding and comparing access to services. However, unlike many health outcomes this gap does not necessarily reflect a disparity that needs to be closed in the short to medium term, particularly if it reflects where services are better addressing previously unmet need.

Findings

What does the data tell us?

Between July 2015 and June 2017, there were over 1 million hospitalisations for Indigenous Australians (including dialysis). After adjusting for differences in the age structure between the two populations, Indigenous Australians were hospitalised at 2.3 times the rate for non-Indigenous Australians (Table D1.02.5).

Excluding dialysis, there were 542,917 hospitalisations for Indigenous Australians (340 per 1,000). After adjusting for differences in the age structure between the two populations, Indigenous Australians were hospitalised at 1.3 times the rate as for non-Indigenous Australians (Table D1.02.1).

Top reasons for hospitalisation

Between July 2015 and June 2017, the leading cause of hospitalisation was care involving dialysis (461,806 hospitalisations), which accounted for 46% of all hospitalisations for Indigenous Australians. The rate of care involving dialysis for Indigenous Australians was 11 times the rate of non‑Indigenous Australians.

Among Indigenous Australians, injury and poisoning was the second leading cause of hospitalisation (6.8%), followed by diseases of the respiratory system (5.2%), symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified (5.2%), and pregnancy, childbirth and the puerperium (5.0%). For non-Indigenous Australians, care involving dialysis was also the leading cause of hospitalisation (11.6%), diseases of the digestive system was the second leading cause (10%), followed by; symptoms, signs and abnormal clinical and laboratory findings (8.3%), injury and poisoning (7.1%),  and diseases of the circulatory system (5.4%). (Table D1.02.5, Figure 1.02.1).

Figure 1.02.1:  Proportion of hospitalisations by principal diagnosis, for Indigenous Australians, Australia, July 2015 to June 2017

The bar chart shows the top 3 causes of hospitalisation were Care involving dialysis (46%), Injury, poisoning and other external causes (7%), and Respiratory system diseases (5%).

Source: Table D1.02.5. AIHW analysis of National Hospital Morbidity Database.

Hospitalisation trend over time

Between 2004–06 and 2015–17, there was an increase of 528,200 in the number of hospitalisations for Indigenous Australians—51% of the increase was for dialysis. After excluding dialysis, 12% of the increase was for signs, symptoms and abnormal clinical and laboratory findings, followed by 12% for injury and poisoning (Table D1.02.9).

After adjusting for differences in the age structure within the Indigenous population between 2004–05 and 2016–17, hospitalisation rates (excluding dialysis) increased by 48% for Indigenous Australians.

This increase was faster for Indigenous Australians compared with non-Indigenous Australians. This resulted in a widening of the gap in hospitalisation rates between Indigenous and non-Indigenous Australians (from a gap of 8.2 per 1,000 in 2004–05 to a gap of 101 per 1,000 in 2016–17) (Table D1.02.4, Figure 1.02.2). This was in the six jurisdictions that had Indigenous identification data of adequate quality (New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory) combined.

Figure 1.02.2: Hospitalisation rates (excluding dialysis) (age-standardised), by Indigenous status, NSW, Vic, Qld, WA, SA and NT, 2004–05 to 2016–17

The line graph shows that the rate of hospitalisation for Indigenous Australians increased from 303 per 1,000 in 2004–05 to 401 per 1,000 in 2016–17, while it increased from 295 per 1,000 to 355 per 1,000 for non-Indigenous Australians.

Source: D1.02.4. AIHW analysis of National Hospital Morbidity Database.

Hospitalisation by age

Hospitalisation rates (excluding dialysis) were higher for Indigenous Australians compared with non‑Indigenous Australians in all age groups below 65. The greatest difference was for those aged 45–54 (179 per 1,000). The hospitalisation rate for Indigenous Australians was highest for those aged 65 years and over (877 per 1,000) (Table D1.02.2, Figure 1.02.3).

Figure 1.02.3: Age-specific hospitalisation rates (excluding dialysis), by Indigenous status, Australia, July 2015 to June 2017

The column chart shows that the rate of hospitalisation for children aged 0 to 4 was 311 per 1,000 for Indigenous and 242 per 1,000 for non-Indigenous. From 5 years of age, the hospitalisation rate increased with age for both Indigenous and non-Indigenous Australians. The largest gap occurred in the 45–54 age group (508 per 1,000 for Indigenous Australians compared with 330 per 1,000 for non-Indigenous Australians). For people aged 65 and over, the Indigenous rate (877 per 1,000) was lower than the non-Indigenous rate (983 per 1,000).

Source: Table D1.02.2. AIHW analysis of National Hospital Morbidity Database.

Excluding dialysis, there were variations in the top reasons for hospitalisation in different age groups among Indigenous Australians. In young Indigenous children (0–4 years), the top reason was diseases of the respiratory system (79 per 1,000). For those aged 15–44, the top reason for hospitalisation was pregnancy, childbirth and the puerperium (74 per 1,000 for 15–24 years and 68 per 1,000 for 25–44 years), followed by injury and poisoning (43 per 1,000 for 15–24 years and 60 per 1,000 for 25–44 years). The highest proportion of hospitalisations among Indigenous Australians aged 45–54 and 55–64 was due to symptoms, signs and abnormal clinical and laboratory findings (65 and 70 per 1,000, respectively). For those aged 65 and over, the top reason was diseases of the circulatory system (111 per 1,000) (Table D1.02.8).

Among those aged 15 years and over, Indigenous Australians had higher hospitalisation rates due to dialysis, compared with non-Indigenous Australians. The differences increased with age (except for those age 65 and over) and the biggest difference was for those aged 55–64 years (1,314 per 1,000).

Hospitalisation by sex

After adjusting for differences in the age structure between the two populations, Indigenous males were 1.2 times as likely as non-Indigenous males to be hospitalised (395 and 329 per 1,000, respectively). Indigenous females were 1.3 times as likely as non-Indigenous females to be hospitalised (477 and 376 per 1,000, respectively) (Table D1.02.2).

Hospitalisation by jurisdiction

Among Indigenous Australians, the highest hospitalisation rate (excluding dialysis) was in the Northern Territory (497 per 1,000) followed by Western Australia (365 per 1,000) and Queensland (358 per 1,000) (Table D1.02.1, Figure 1.02.4).

Figure 1.02.4: Hospitalisations (excluding dialysis) for Indigenous Australians, by jurisdiction, July 2015 to June 2017

The column chart shows the rate of hospitalisation (excluding dialysis) for Indigenous Australians was highest in the Northern Territory (497 per 1,000), followed by Western Australia (365 per 1,000), and Queensland (358 per 1,000); the lowest was in Tasmania (201 per 1,000).

Source: Table D1.02.1. AIHW analysis of National Hospital Morbidity Database.

After adjusting for differences in the age structure between the two populations, the gap in hospitalisation rates between Indigenous and non-Indigenous Australians was highest in the Northern Territory (240 per 1,000), followed by Western Australia (127 per 1,000) and South Australia (123 per 1,000) (Table D1.02.1).

Hospitalisation by remoteness

From July 2015 to June 2017, the hospitalisation rate for Indigenous Australians (excluding dialysis) was higher in Remote areas (466 per 1,000) compared with Non-remote areas (307 per 1,000). The pattern was the same in most jurisdictions, excluding Tasmania, where the hospitalisation rates were higher for Indigenous Australians living in Non-remote areas (Table D1.02.13).

After adjusting for differences in the age structure between the two populations, the largest gap in hospitalisation rates between Indigenous and non-Indigenous Australians was in Remote and Very remote areas (258 and 235 per 1,000 respectively) (Table D1.02.3, Figure 1.02.5).

Figure 1.02.5: Hospitalisations (excluding dialysis) (age-standardised), by Indigenous status and remoteness, Australia, July 2015 to June 2017

The column chart shows that the rate of hospitalisation for Indigenous Australians was highest in Remote areas (599 per 1,000), followed by Very remote areas (546 per 1,000) and the lowest rate was in Major cities (373 per 1,000); for non-Indigenous Australians, the highest rate occurred in Inner regional and Outer regional areas (359 per 1,000), followed by Major cities (349 per 1,000) and the lowest rate was in Very remote areas (311 per 1,000).

Source: Table D1.02.3.  AIHW analysis of National Hospital Morbidity Database.

Same-day and overnight hospitalisation

Same-day acute hospitalisations (including dialysis) for Indigenous Australians were 2.9 times the rate for non-Indigenous Australians (621 compared with 217 per 1,000). Same-day acute hospitalisations (excluding dialysis) for Indigenous Australians was 86% as high compared with non-Indigenous Australians (150 and 174 per 1,000, respectively).

Overnight acute hospitalisation rates for Indigenous Australians was 1.8 times the rate for non-Indigenous Australians (257 compared with 146 per 1,000) (Table D1.02.10).

Same-day hospitalisations due to care involving dialysis for Indigenous Australians was 11 times the rate for non-Indigenous Australians (471 and 43 per 1,000, respectively).

After excluding dialysis, same-day hospitalisation rates for Indigenous Australians was highest for symptoms, signs and abnormal clinical and laboratory findings (21 per 1,000), and for non-Indigenous Australians was highest for digestive system diseases (26 per 1,000) (Table D1.02.11).

For Indigenous and non‑Indigenous Australians, overnight hospital admissions was highest for pregnancy and childbirth (44 and 30 per 1,000, respectively) (Table D1.02.12).

What do research and evaluations tell us?

In Australia, hospital services are provided by both public and private hospitals. Hospitals provide a range of services for admitted patients (elective care, maternity services and medical and surgical services). Non-admitted patient services are mostly located in public hospitals and include emergency department services and outpatient clinics (Australian Institute of Health and Welfare 2020). Primary health care can play a pivotal role in closing the gap in Indigenous health and helping to lower health inequalities and hospitalisation rates. Aboriginal Community Controlled Health Services (ACCHS) and other Indigenous specific primary health care deliver culturally appropriate primary health care across Australia, however many Indigenous Australians must, or choose to, access health care through mainstream services (DoH 2017).

Research shows that optimal primary health care access in the Northern Territory has reduced hospitalisation significantly (Zhao et al. 2013). Primary care in remote Indigenous communities was also shown to be associated with cost-savings to public hospitals and health benefits to individual patients (Zhao et al. 2014). Evidence suggests that access to primary health care can be improved when it is tailored to the needs of, and owned or managed by Indigenous Australians (Davy et al. 2016).

In 2017, the Australian Government released My Life My Lead - Opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health: Report on the national consultations (My Life, My Lead). These consultations provided an opportunity for Indigenous communities and leaders, governments, non‑government and the private sector to inform the refresh of the National Aboriginal and Torres Strait Islander Health Plan 2013‑2023. The My Life My Lead consultations highlighted that although there have been significant health gains, poor access to health services contributes to the significant health inequities still experienced by Indigenous Australians (DoH 2017). Although hospitalisation rates are higher for Indigenous Australians than non-Indigenous Australians, they do not access health services to the level expected given their relatively poorer health status. This is partly due to an inadequate supply of Indigenous primary health care services and an inequitable share of mainstream programs. While Indigenous Australians under-utilise mainstream health services and many prefer Indigenous-specific services, mainstream government expenditure still dominates health expenditure for Indigenous Australians (Alford 2014).

Across Australia there is a growing need for out-of-hospital palliative and chronic disease care, a lack of which is leading to an overuse of hospitals. In addition, the high prevalence of chronic diseases and limited access to primary services experienced by many Indigenous Australians has resulted in high hospitalisation rates. There are limited respite services for palliative care patients in the Northern Territory. The establishment of a flexible, community-based and culturally appropriate palliative and chronic disease respite facility in Alice Springs resulted in a reduction in local hospital admissions (Carey et al. 2017).

Several studies have linked multi-morbidity to an increased use of health services, particularly in hospitalisation (Gruneir. et al. 2016). It is therefore consistent that hospitalisation rates are higher amongst Indigenous Australians compared to non-Indigenous Australians, given that prevalence of multi-morbidity is higher amongst Indigenous Australians than non-Indigenous Australians (Hussain et al. 2018):

  • A recent study, based on the New South Wales hospital data, found that, after adjusting for age, sex, and socioeconomic status, the prevalence of multi-morbidity among Indigenous Australians was 2.6 times that of non-Indigenous Australians. This difference accounted for a large proportion of the difference in mortality rates between the two groups of patients.
  • The prevalence of multi-morbidity was higher among Indigenous Australians in all age groups. In younger age groups this was because of the higher prevalence of mental health conditions, while in the older age group (over 60 years) it was because of physical health conditions (Broe & Radford 2018).

Research by Harrold and others (2014) found that the rate of preventable hospitalisations was 2.16 times higher for Indigenous Australians compared with non-Indigenous Australians who lived in the same Statistical Local Area in New South Wales, after controlling for age and sex. The disparity is greatest in rural and remote areas relative to major cities. The largest differences in preventable hospitalisations were for diabetes, chronic obstructive pulmonary disease and rheumatic heart disease. The authors suggested that differences in preventable hospitalisation rates between the Indigenous and non-Indigenous population may be due to less availability of assistance and care at home, greater disease disparity, and access to primary health care. Despite the disparity, the researchers suggested that there is potential to reduce preventable hospitalisations (Harrold. et al. 2014).

Lower access to hospitals and health services can lead to poorer health outcomes. Findings of a project that examined spatial variation in Indigenous Australian women’s access to hospitals with public birthing services and three other types of maternal health services across Australia found that the lowest levels of access to maternal health services are in Remote and Very remote areas. Poorer access to maternal health services is associated with higher rates of pre-term birth and low birthweight (Australian Institute of Health and Welfare 2017).

Implications

Given the high burden of disease, high prevalence of many health conditions and high death rates for Indigenous Australians, it is possible that the current rates of hospitalisations are not yet reflective of the level of need for care. On the one hand it could be evidence of effective management of conditions in primary health care that hospitalisation rates are not higher. However, high rates of Potentially Preventable Hospitalisations (see measure 3.07 Selected potentially preventable hospital admissions) suggest this is not straight forward. On the other hand, high death rates could indicate Indigenous Australians are not receiving appropriate levels of primary or secondary care. This points to a broader issue of access to care, explored further in measure 3.14 Access to services compared with need.

One factor that may be affecting the hospitalisation rates is Indigenous status identification in the hospital data. Improving the accuracy of Indigenous identification in hospitalisation datasets is crucial and can be improved with comprehensive training of data collection staff and establishing procedures in all hospitals to appropriately ascertain Indigenous status for every patient (Australian Institute of Health and Welfare 2013).

Given the high proportion of hospitalisations for Indigenous Australians requiring dialysis (46%), more attention should be given to alternatives that can provide dialysis outside of the hospital system. Innovative use of mobile dialysis units in South Australia and Central Australia have reduced disruption to patients by allowing them to receive treatment closer to home (albeit for short periods), and also have the potential to reduce hospitalisations (Conway et al. 2018; Western Desert Nganampa Walytja Palyantjaku Tjutaku Aboriginal Corporation).

Through concerted action to reduce the incidence and prevalence of underlying conditions, and in preventing or delaying complications through primary health care, it is anticipated reductions in hospitalisations will eventually occur.

Strategies to improve hospital service delivery to Indigenous Australians by improving access and removing barriers to hospital services will improve the patient journey through the health system and improve outcomes for Indigenous Australians.

The policy context is at Policies and strategies.

References

  • AIHW (Australian Insititue of Health and Welfare) 2013. Indigenous identification in hospital separations data: quality report. Canberra: AIHW
  • AIHW 2017. Spatial Variation in Aboriginal and Torres Strait Islander Women's Access to 4 Types of Maternal Health Services. Canberra AIHW.
  • AIHW 2020. Australia's hospitals at a glance 2018-19. Canberra: AIHW.
  • Alford K 2014. Investing in Aboriginal community controlled health makes economic sense. Canberra: National Aboriginal Community Controlled Health Organisation.
  • Broe G & Radford K 2018. Multimorbidity in Aboriginal and non-Aboriginal people. Medical Journal of Australia 209:16-7.
  • Carey TA, Arundell M, Schouten K, Humphreys JS, Miegel F, Murphy S et al. 2017. Reducing hospital admissions in remote Australia through the establishment of a palliative and chronic disease respite facility. BMC Palliative Care 16:54.
  • Conway J, Lawn S, Crail S & McDonald S 2018. Indigenous patient experiences of returning to country: a qualitative evaluation on the Country Health SA Dialysis bus. BMC health services research 18:1010.
  • Davy C, Harfield S, McArthur A, Munn Z & Brown A 2016. Access to primary health care services for Indigenous peoples: A framework synthesis. International Journal for Equity in Health 15:163.
  • DoH (Australian Government Department of Health) 2017. My Life My Lead - Opportunities for strengthening approaches to the social determinants and cultural determinants of Indigenous health: Report on the national consultations. Canberra.
  • Gruneir. A, Bronskill. SE, Maxwell. CJ, Bai. YQ, Kone. AJ, Thavorn. K et al. 2016. The association between multimorbidity and hospitalisation is modfied by individual demographics and physician continuity of care: a restrosepctive cohort. BMC Health Serv Res 16.
  • Harrold. TC, Randall. DA, Falster. MO, Sanja L & Louisa J 2014. The Contribution of Geography to Disparities in Preventable Hospitalisations between Indigenous and Non-Indigenous Australians. PloS one.
  • Hussain M, Katzenellenbogen J, Sanfilippo F, Murray K & Thompson S 2018. Complexity in disease management: A linked data analysis of multimorbidity in Aboriginal and non-Aboriginal patients hospitalised with atherothrombotic disease in Western Australia. PloS one 3(8): e0201496.
  • Western Desert Nganampa Walytja Palyantjaku Tjutaku Aboriginal Corporation. The Purple Truck
  • Zhao Y, Thomas SL, Guthridge SL & Wakerman J 2014. Better health outcomes at lower costs: the benefits of primary care utilisation for chronic disease management in remote Indigenous communities in Australia's Northern Territory. BMC health services research 14:463.
  • Zhao Y, Wright J, Guthridge SL & Lawton P 2013. The relationship between number of primary health care visits and hospitalisations: evidence from linked clinic and hospital data for remote Indigenous Australians. BMC health services research 13:466.

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