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Tier 3 - Health system performance

3.06 Access to hospital procedures

Key facts

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 people are more likely to be hospitalised than other Australians they are less likely to receive a medical or surgical procedure while in hospital (ABS & AIHW 2008; Cunningham 2002). The disparities are not always explained by diagnosis, age, sex or place of residence and are apparent in public but not private hospitals (Cunningham 2002).

Patients suspected of having cardiac disease should receive appropriate and timely diagnostic services (AIHW 2019a). For patients admitted to hospital with coronary heart disease, access to coronary angiography (a procedure used to detect coronary artery blockage) can be important in the diagnosis and establishment of a course of treatment. Coronary heart disease may be treated with medicines or through repairing the heart’s blood vessels, either using a medical procedure (percutaneous coronary interventions) or a surgical procedure (coronary artery bypass grafts).

Studies have found that Indigenous Australian patients were less likely to receive coronary angiography after controlling for age, comorbidities and remoteness, and Indigenous Australian patients were less likely to be added to the kidney transplantation waiting list during the first year of renal replacement therapy irrespective of differences in patient- or disease-related factors (Khanal et al. 2018; Tavella et al. 2016).

Indigenous Australians compared with non-Indigenous Australians have a much greater risk of developing end-stage kidney disease, but are less likely to receive a kidney transplant (The Transplantation Society of Australia and New Zealand 2019). Indigenous patients who receive a kidney transplant wait longer for an organ donor than non-Indigenous patients and experience significantly worse post-transplant outcomes (see measure 1.10 Kidney disease).

Several studies have shown that Indigenous Australians have a poorer survival rate for cancer. This is partly explained by later diagnosis and referral for specialist treatment (Condon et al. 2006; Valery et al. 2006). However, after controlling for the stage of diagnosis Indigenous Australians are less likely to have treatment for cancer (for example, surgery, chemotherapy or radiotherapy), tend to wait longer for surgery and have lower survival rates for many cancers (Hall et al. 2004; Valery et al. 2006).

There is considerable evidence that poor outcomes in hospitals and health care facilities for Indigenous Australians are related to systemic or institutionalised racism (Bourke et al. 2019; Henry et al. 2004; Malatzky et al. 2020). Improving the cultural safety of hospital environments is integral to improving health outcomes for Indigenous Australians, as they are more likely to seek access to health care and have better outcomes if there are culturally safe and respectful services available (Congress of Aboriginal and Torres Strait Islander Nurses and Midwives 2016). Institutional resistance may require organisational change mandated by standards (Laverty et al. 2017).

Findings

What does the data tell us?

In the two years prior to June 2017, 64% (325,260) of hospitalisations (excluding dialysis) for Indigenous Australians had a procedure recorded, compared with 81% (14,385,257) of hospitalisations for non-Indigenous Australians (Table D3.06.1).

Between 2004–05 and 2016–17, there was a 17% increase in hospitalisations of Indigenous Australians where a procedure was recorded (from 53% to 64%) in the six jurisdictions with Indigenous identification data of adequate quality (New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory). Over the same period, there was a smaller increase in the non-Indigenous rate (0.1%), resulting in a decrease in the gap between Indigenous and non-Indigenous Australians (Table D3.06.11, Figure 3.06.1).

Figure 3.06.1: Proportion of hospitalisations (excluding dialysis) with a procedure recorded (age-standardised), NSW, Vic, Qld, WA, SA and NT, 2004–05 to 2016–17

This line chart shows that for Indigenous Australians the proportion of hospitalisations with a recorded procedure has increased from 53% to 64% over the 2004–05 to 2016–17 period. For non-Indigenous Australians the proportion was constantly higher than the Indigenous proportion and has remained relatively unchanged over the period, at around 80%.

Source: Table 3.06.11. AIHW analysis of National Hospital Morbidity Database.

Hospital sector

For Indigenous Australians, 6% of procedures were performed in private hospitals, compared with 36% for non-Indigenous Australians (Table D3.06.6, Figure 3.06.2).

Figure 3.06.2: Proportion of procedures performed (excluding dialysis) by sector of hospital and Indigenous status, Australia, July 2015 to June 2017

This bar chart shows that 93% of Indigenous Australians attending a public hospital had a procedure recorded compared with 56% of non-Indigenous Australians. Indigenous Australians had lower proportions of recorded procedures in private and private free standing day hospitals (6% and 1% respectively) compared with non-Indigenous Australians (36% and 8% respectively).

Source: Table 3.06.6. AIHW analysis of National Hospital Morbidity Database.

Factors influencing receiving a hospital procedure

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 between July 2015 and June 2017, the most significant factors (in order of importance) were:

  • whether the hospital was public or private
  • the number of additional diagnoses recorded for a patient
  • the principal diagnosis for which a person was admitted
  • Indigenous status
  • state/territory of usual residence
  • age group
  • remoteness of usual residence
  • sex (Table D3.06.13).

Receiving a hospital procedure by age group

Across all age groups, Indigenous Australians were less likely to receive a procedure than non-Indigenous Australians (Table D3.06.1, Figure 3.06.3).

Figure 3.06.3: Proportion of hospitalisations (excluding dialysis) with a procedure recorded by Indigenous status and age group, Australia, July 2015 to June 2017

This bar chart shows that for Indigenous Australians the proportion of hospitalisations with a procedure recorded generally increased with age, from 49% for those aged under 1 to 74% for those aged 65 or older. This trend was similar for non-Indigenous Australians with the proportion increasing from 52% for those aged under 1 to 86% for those aged 55 and above.

Source: Table 3.06.1. AIHW analysis of National Hospital Morbidity Database.

Hospital procedures by remoteness

There was a decrease in hospitalisations with a procedure recorded as remoteness increased. The gap between the proportions of Indigenous and non-Indigenous Australians receiving a hospital procedure was highest in Remote areas (54% compared with 72%). The gap was lowest in Major cities (71% compared with 82%) (Table D3.06.1).

Figure 3.06.4: Proportion of hospitalisations (excluding dialysis) with a procedure recorded by Indigenous status and remoteness, Australia, July 2015 to June 2017

This bar chart shows that for Indigenous Australians the proportion of hospitalisations with a procedure recorded decreased as remoteness area increased; decreasing from 71% in Major cities to 53% in Very remote areas. This trend was similar for non-Indigenous Australians with the proportion decreasing from 82% in Major cities to 67% in Very remote areas.

Source: Table 3.06.1. AIHW analysis of National Hospital Morbidity Database.

Hospital procedures by jurisdiction

The proportion of hospitalisations of Indigenous Australians with a procedure recorded varied from 57% in the Northern Territory to 78% in Tasmania. The gap between the proportions of Indigenous and non-Indigenous Australians receiving a hospital procedure was highest in Western Australia (63% compared with 87%) (Table D3.06.1, Figure 3.06.5).

Figure 3.06.5: Proportion of hospitalisations (excluding dialysis) with a procedure recorded by Indigenous status and jurisdiction, Australia, July 2015 to June 2017

This bar chart shows that, nationally, 64% of hospitalisations for Indigenous Australians had a procedure recorded, which was lower than for non-Indigenous Australians (81%). The proportion for Indigenous Australians was highest in Tasmania (78%) and lowest in the Northern Territory (57%). Proportions for non-Indigenous Australians were highest in Western Australia (87%) and lowest in the Northern Territory (70%).

Source: Table D3.06.1. AIHW analysis of National Hospital Morbidity Database.

Principal diagnosis of hospital procedures

For hospitalisations due to neoplasms (cancer), 91% of Indigenous patients had a procedure, compared with 97% for non-Indigenous patients. The diagnoses that resulted in the biggest difference between Indigenous and non-Indigenous Australians having a procedure recorded are classified as ‘factors influencing health status and contact with health services’ which include ICD-10 codes Z00–Z99 (excluding Z49, care involving dialysis). Between July 2015 and June 2017 69% of Indigenous patients had a procedure, compared with 93% of non-Indigenous patients for this category (Table D3.06.2, Table 3.06-1).

Table 3.06-1: Proportion of hospitalisations with a procedure reported, by principal diagnosis and Indigenous status, Australia, July 2015 to June 2017

 Principal diagnosis chapter (excluding dialysis)

Indigenous (%)

Non-Indigenous (%)

Diseases of the nervous system

62.4

85.1

Factors influencing health status and contact with health services

69.4

93.2

Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

34.2

58.0

Diseases of the digestive system

69.5

87.9

Diseases of the musculoskeletal system and connective tissue

76.1

93.0

Diseases of the respiratory system

45.6

63.9

Diseases of the genitourinary system

61.7

78.4

Diseases of the circulatory system

65.5

77.5

Endocrine and nutritional and metabolic diseases

73.8

85.1

Pregnancy, child birth and the puerperium

64.9

78.1

Mental and behavioural disorders

44.7

66.5

Diseases of the skin and subcutaneous tissue

62.0

71.0

Injury, poisoning and certain other consequences of external causes

58.0

71.3

Diseases of the eye and adnexa

91.0

98.5

Diseases of the ear and mastoid process

82.9

83.5

Neoplasms

91.2

96.6

Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

89.4

94.9

Congenital malformations, deformations and chromosomal abnormalities

86.1

91.9

Certain infectious and parasitic diseases

37.3

48.1

Certain conditions originating in the perinatal period

75.4

75.3

Any principal diagnosis

59.9

80.9

Source: Table D3.06.2.  AIHW analysis of National Hospital Morbidity Database.

Hospital procedures related to coronary heart disease

Between July 2015 and June 2017, among those hospitalised with coronary heart disease, Indigenous Australians were less likely (0.8 times) to receive a coronary angiography compared with non-Indigenous Australians (44% and 54%, respectively), and 0.7 times less likely to receive a revascularisation procedure (23% compared with 32%, respectively) (Table D3.06.9, Figure 3.06.6).

Between 2004–05 and 2016–17, the age-standardised proportion of hospitalisations for acute coronary syndrome events that included either a diagnostic angiography or a definitive revascularisation procedure among Indigenous adults increased from 32% to 58%, compared with an increase from 45% to 67% among non-Indigenous adults (AIHW 2019a).

Figure 3.06.6: Use of selected coronary procedures for those hospitalised with coronary heart disease (age-standardised) by Indigenous status, Australia, July 2015 to June 2017

This bar chart shows that 44% of Indigenous Australians hospitalised with coronary heart disease received a coronary angiography compared with 54% of non-Indigenous Australians. 23% of Indigenous Australians received a revascularisation procedure (either percutaneous intervention or coronary artery bypass grafting) compared with 32% of non-Indigenous Australians.

Source: Table 3.06.9. AIHW analysis of National Hospital Morbidity Database.

Hospital procedures related to the digestive tract

For hospitalisations related to the digestive tract, the rate of Indigenous Australians receiving a procedure was significantly lower than for non-Indigenous patients when a principal diagnosis was:

  • complicated or uncomplicated hernias
  • diseases of the extrahepatic biliary tree
  • appendicitis
  • non-neoplastic diseases of the anus or rectum.

There was no significant difference where the principal diagnosis was malignant neoplasms of the large intestine/rectum (Table D3.06.16).

What do research and evaluations tell us?

A study of patients admitted to Queensland hospitals for acute myocardial infarction (that is, heart attack) between 1998 and 2002 found that the rate of coronary procedures among Indigenous Australian patients was 22% lower than the rate for other patients (Coory & Walsh 2005). A more recent study in South Australia found that Indigenous patients were less likely to receive a coronary angiography after controlling for age, comorbidities and remoteness (Tavella et al. 2016).

A national study of ANZDATA Registry data from 2006–2016 found that Indigenous patients were less likely than non-Indigenous patients to be added to the kidney transplantation waiting list during the first year of renal replacement therapy (Khanal et al. 2018). This disparity was not explained by differences in patient- or disease-related factors. A study conducted in 2005–06 found that treating specialists commonly identified Indigenous patients as ‘non-compliers’ with their dialysis regimes and high-risk kidney transplant candidates, but that this assessment was not systematic or formal (Anderson et al. 2012). There was variation in how specialists weighted these assessments in their decision making and uncertainty about the value of compliance status in predicting post-transplant outcomes. In Victoria, a patient study found that medical comorbidities were the main barrier to kidney transplant listing, but once listed, Indigenous patients had a short waiting time due to accumulated ‘waiting time’ which begins when patients start dialysis (Atkinson & Goodman 2018). International research has found that patient aversion to transplantation (for cultural, social, religious, health or other reasons) may contribute to differential access by particular groups, but a recent study of Indigenous patients in all states and territories, apart from Victoria and Tasmania, found they had a high level of interest in kidney transplantation (Devitt et al. 2017). However, patients experienced multiple communication barriers and felt that they and their families were poorly informed and disempowered about transplantation as an option. While patients needed to navigate cultural and social sensitivities, this did not seem to be a factor in patients’ decision-making. A recent study in Western Australia found that Indigenous kidney recipients experienced poorer outcomes than non-Indigenous recipients and recommended future research be done into factors associated with better outcomes for Indigenous Australian kidney recipients (Howson et al. 2019).

An expert panel undertook a comprehensive review into the hurdles, service gaps and practical challenges faced by Indigenous patients receiving treatment for kidney disease (The Transplantation Society of Australia and New Zealand 2019). The review report, released in 2019, identified measures to address gaps in waitlisting and long-term transplant outcomes and improving Indigenous dialysis patients’ health to improve their capacity to be waitlisted.

Research using data from the National Eye Health Survey 2015–16 found that the cataract surgery coverage rate is significantly lower among Indigenous than non-Indigenous Australians (Foreman et al. 2017). The burden of vision loss is higher among Indigenous Australians due to a much higher prevalence of vision loss associated with unoperated cataracts. A 2010 assessment of waiting times for surgery across remoteness areas found that the disparity for cataract surgery was greater than for other surgical procedures (Kelaher et al. 2010).

Analysis of 2016–17 hospitalisations for colonoscopy found that there was greater use of colonoscopy in areas with higher socioeconomic status, which have a low incidence of bowel cancer and low mortality rates, compared with areas of low socioeconomic status, which have the highest incidence and mortality rates (ACSQHC 2018). The rate of hospitalisations for colonoscopy for Indigenous Australians was 47% lower than the rate for other Australians.

Implications

There is a clear disparity in accessibility and outcomes for hospital procedures between Indigenous and non-Indigenous Australians. This is seen across age, remoteness, jurisdiction and principal diagnosis. This measure has provided a few examples of the disparity within particular disease types, but the hospitalisation data and the use of principal diagnosis chapters is somewhat limited for a full analysis of this complex issue. Academic research can and does provide a deeper exploration of these disparities and the key drivers, as well as providing insight into how hospital services can improve.

Disparities in accessibility and outcomes for 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 also a prerequisite for effective hospital and specialist services.

A significant body of work over the past two decades has sought to raise awareness and embed concepts of cultural respect in the Australian health system that are fundamental to improving access to quality and effective health care and improving health outcomes for Indigenous Australians. There has been a longstanding commitment by Australian governments to enable this. The Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2016–2026: A national approach to building a culturally respectful health system plays a crucial role in reaffirming this commitment and provides a nationally consistent approach (AHMAC 2016). The Aboriginal and Torres Strait Islander Health Performance Framework plays a role in monitoring the commitment to embed cultural respect principles into the Australian health system.

Monitoring is also supported by the Cultural Safety in Health Care for Indigenous Australians: Monitoring Framework which covers three domains: how health care services are provided, Indigenous patients’ experience of health care, and measures regarding access to health care (AIHW 2019b). However, monitoring is limited by a lack of national and state-level data, particularly on the policies and practices of mainstream health services such as hospitals and the experiences of Indigenous Australian patients in hospitals (AIHW 2019b).

While there has been an increase in the proportion of Indigenous Australians who received a hospital procedure and a decrease in the gap between the rates of Indigenous and non-Indigenous Australians receiving a hospital procedure, a wide gap remains. In addition, the rate of discharge against medical advice/at own risk—an indirect measure of cultural safety in hospitals—increased from 11 per 1,000 in 2004–05 to 16 per 1,000 in 2016–17 (see measure 3.09 Discharge against medical advice). These data predate the introduction of the Cultural Respect Framework in 2017.

The Ways of Thinking and Ways of Doing program was developed to ‘translate the systemic, organisational, and clinical elements of the Cultural Respect Framework into routine clinical practice’ (Liaw et al. 2019). A study of the effect of this program in Melbourne and Sydney general practice settings found that it did not significantly influence the Indigenous health check rate or cultural respect levels. The authors suggested that cultural respect programs may require more than 12 months to have a positive effect.

The measures presented here suggest that the under-provision of specialist services for Indigenous Australians 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).

The vast majority of hospital procedures for Indigenous Australians are done in the public hospital system, whereas a much greater share of procedures for non-Indigenous Australians is done in the private hospital system. Low incomes and low take-up of private health insurance are likely having an effect. In the 2016 Census, 37% of Indigenous adults were living in households with incomes in the bottom 20% of Australian incomes. In the 2018–19 National Aboriginal and Torres Strait Islander Health Survey, 21% of Indigenous Australians in Non-remote areas reported they had private health insurance. The lower proportion of procedures per hospitalisation is likely to be associated with private health insurance coverage and lower access to private hospitals. This may influence the rate of preventative hospital treatments. A recent study found that, after adjusting for other factors, the strongest association with coronary angiography rates was admissions to private hospitals (Chew et al. 2016).

Indigenous Australian patients with chronic disease sometimes present later in the course of these illnesses, compared with non-Indigenous Australians, which affects treatment options (Valery et al. 2006). 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, such as for patients whose main language is not English; and patient knowledge and attitudes, for example, fatalistic attitudes towards cancer. Physical, social and cultural distance from health services also play a role, along with financial issues patients and their families may face when seeking treatment in specialist referral services (Miller et al. 2010; Shahid et al. 2009). An analysis of 2015–16 Medicare data shows that the rate of claims for specialist services for Indigenous Australians was below national averages for both in and out-of-hospital care. Effective strategies will require a better understanding of the factors leading to the observed disparities.

Heart and cardiovascular conditions make the greatest contribution to the health gap (AIHW 2016). The National Recommendations for Better Cardiac Care for Aboriginal and Torres Strait Islander People and the Lighthouse Hospital Project (see measure 1.05 Circulatory disease) aim to address the disparities in cardiovascular care. The Lighthouse Hospital Project has found that some key initiatives have led to improvements in care such as the expansion of the Aboriginal Health Workforce, better Indigenous status identification of patients, engaging in effective partnerships with Indigenous communities, fostering champions among clinical staff, patient-centred care and improved communication (Heart Foundation 2020).

The survival rate of Indigenous Australians with end-stage kidney disease that require renal replacement therapy has significantly increased and recent evidence suggests the survival gap has closed between Indigenous and non-Indigenous patients (Lawton et al. 2015). However, there remain disparities and barriers for Indigenous Australians accessing kidney transplantation. Qualitative research has unpacked some of these barriers and their experiences of the health system on the treatment pathway, including information needs, distance and the effect of being away from home (Cass A., Cunningham, J., Snelling, P., Wang, Z & Hoy, W. 2003). For the health system to be more effective in delivering transplantation services to Indigenous Australians, it requires an understanding of their needs and motivations in seeking kidney transplantation (Cass A., Cunningham, J., Snelling, P., Wang, Z & Hoy, W. 2003).

The 2019 Review into kidney transplantation by the Transplantation Society of Australia and New Zealand explored the complex challenges associated with delivering appropriate kidney health services in Remote areas. The review examined the burden of comorbidities affecting suitability for transplantation, waiting lists, the dislocation from moving to transplant centres and the high rates of post-transplant complications. It made 35 recommendations aimed at improving health services requiring close collaboration between consumers, academia, health services, peak bodies and governments. The review also illustrated the systemic biases in the kidney transplant system and identified potential mitigation strategies (Cass Alan 2019; The Transplantation Society of Australia and New Zealand 2019).

Lessons learned from the work to improve the health system in delivering cardiac care and kidney transplantation may also help address other disparities in hospital services for Indigenous Australians.

The policy context is at Policies and strategies.

References

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