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Tier 3 - Health system performance

3.09 Discharge against medical advice

Key facts

Why is it important?

Aboriginal and Torres Strait Islander people are more likely than non‑Indigenous Australians to leave hospitals without completing treatment. Patient experiences of health care services affect health-related behaviours and health outcomes. People who take their own leave from hospital are more likely to re-present to emergency departments and have higher mortality rates (Shaw 2016).

The measure reported here is based on the extent to which Indigenous Australians ‘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. There have been a limited number of studies on the reasons Indigenous Australians take their own leave from hospital. However, common factors include institutionalised racism; a lack of cultural safety; a distrust of the health system; miscommunication; family and social obligations; isolation and loneliness; a lack of understanding of the treatment they were receiving and the feeling that the treatment had finished; and communication and language barriers between staff and the patient (Shaw 2016).

Findings

What does the data tell us?

Between July 2015 and June 2017, there were 19,915 hospitalisations after which Indigenous Australians left the hospital against medical advice or were discharged at their own risk. After adjusting for differences in the age structure between the two populations, Indigenous Australians were discharged from hospital against medical advice at 6.1 times the rate of non-Indigenous Australians—3.1% of hospitalisations of Indigenous Australians compared with 0.5% (86,071 hospitalisations) for non-Indigenous Australians (Table D3.09.1).

The number of hospitalisations after which Indigenous Australians left hospital or were discharged at their own risk increased from 11 per 1,000 in 2004–05 to 16 per 1,000 in 2016–17 (from 5,608 to 10,214 hospitalisations) in the six jurisdictions with Indigenous identification data of adequate quality (New South Wales, Victoria, Queensland, Western Australia, South Australia, Northern Territory) (Table D3.09.6, Figure 3.09.1).

Figure 3.09.1: Age-standardised rate of hospitalisations where patients left against medical advice/were discharged at own risk (excluding dialysis and mental and behavioural disorders), by Indigenous status, NSW, Vic, Qld, WA, SA and NT, 2004–05 to 2016–17

This line chart illustrates that the rate (per 1,000) of hospitalisations of Indigenous Australians who left against medical advice or were discharged at own risk increased from 11 to 16 per 1,000 over the 2004–05 to 2016–17 period while the non-Indigenous rate increased from 1 to 2 per 1,000.

Source: Table D3.09.6. AIHW analysis of National Hospital Morbidity Database.

Between July 2015 and June 2017, discharge from hospital against medical advice was most common for Indigenous Australians aged 35–44 (7.3% or 4,866 hospitalisations) followed by those aged 25–34 (6.1% or 4,637 hospitalisations) (Table D3.09.1, Figure 3.09.2).

Figure 3.09.2: Proportion of hospitalisations where patients left against medical advice/were discharged at own risk (excluding dialysis and mental and behavioural disorders), by Indigenous status and age group, Australia, July 2015 to June 2017

This bar chart shows that the proportion of hospitalisations where Indigenous Australians left against medical advice or were discharged at own risk increased from 1% for those aged 0–4 to 7.3% for those aged 35–44, but then decreased to 1% for those aged 65 and over. Proportions of hospitalisations for non-Indigenous Australians ranged from 0.2% for those aged 5–14 to 1.1 for those aged 15–24.

Source: Table D3.09.1. AIHW analysis of National Hospital Morbidity Database.

After adjusting for differences in the age structure between the two populations, discharge from hospital against medical advice was more common for Indigenous Australians living in Remote areas (4.6% or 2,837 hospitalisations) and Very remote areas (5.8% or 5,542 hospitalisations) (Table D3.09.4, Figure 3.09.3).

Figure 3.09.3: Age-standardised proportion of hospitalisations where patients left against medical advice/were discharged at own risk (excluding dialysis and mental and behavioural disorders), by Indigenous status and remoteness , Australia, July 2015 to June 2017

This bar chart shows that with the exception of Major cities the proportion of hospitalisations where Indigenous Australians left against medical advice or were discharged at own risk increased with remoteness area; ranging from 1.7% in Inner regional areas to 5.8% in Very remote areas. The proportion for non-Indigenous Australians is similar across remoteness areas. Nationally, the Indigenous proportion is 3.1% compared 0.5% for non-Indigenous.

Source: Table D3.09.4. AIHW National Hospital Morbidity Database.

The proportion of discharge against medical advice for Indigenous Australians ranged from 0.6% of all hospitalisations in Tasmania to 9.2% of all hospitalisations in the Northern Territory (Table D3.09.3, Figure 3.09.4).

Figure 3.09.4: Age-standardised proportion of hospitalisations where patients left against medical advice/were discharged at own risk (excluding dialysis and mental and behavioural disorders), by Indigenous status and jurisdiction, July 2015 to June 2017

This bar chart shows that, nationally, the proportion of hospitalisations where  Indigenous Australians left against medical advice or were discharged at own risk was 3.1%, compared with 0.5% for non-Indigenous Australians. The proportions for Indigenous and non-Indigenous Australians was highest in the Northern Territory (9.2% and 1.0%, respectively) and lowest in Tasmania (0.6% and 0.2%, respectively).

Source: Table D3.09.3. AIHW National Hospital Morbidity Database.

Among Indigenous Australians who were discharged against medical advice, the most common principal diagnoses for hospitalisations were injury and poisoning (4,195 hospitalisations), followed by symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified (2,514 hospitalisations) and respiratory disease (2,297 hospitalisations).

These three groups of diagnoses represented 45% of all hospitalisations that were discharged against medical advice for Indigenous Australians.

When the data are expressed as a proportion of hospitalisations for each specific diagnosis group, and after adjusting for differences in the age structure between the two populations, discharge against medical advice for Indigenous Australians was highest for diseases of the skin and subcutaneous tissue (6.0% or 1,554 hospitalisations) and endocrine, nutritional and metabolic disorders (5.7% or 1,120 hospitalisations) (Table D3.09.7, Figure 3.09.5).

Figure 3.09.5: Age-standardised proportion of hospitalisations where patients left against medical advice/were discharged at own risk (excluding dialysis and mental and behavioural disorders), by Indigenous status and principal diagnosis, Australia, July 2015 to June 2017

This bar chart shows that for Indigenous Australians leaving against medical advice or being discharged at own risk was more common for principal diagnoses of: diseases of the skin and subcutaneous tissue (6%), endocrine, nutritional or metabolic diseases (5.7%) and certain infectious and parasitic diseases (4.6%). For non-Indigenous Australians the most common principal diagnoses were diseases of the skin or subcutaneous tissue (1.2%), injury poisoning and certain other consequences of external causes (1.1%) and endocrine, nutritional and metabolic diseases (0.9%).

Source: Table D3.09.7. AIHW analysis of National Hospital Morbidity Database.

An analysis of the relative impact of a range of factors over the period July 2015 to June 2017 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 important after Indigenous status were principal diagnosis and age group (Table D3.09.10).

Emergency department presentations

Between July 2015 and June 2017, there were 82,095 emergency department presentations for Indigenous Australians when the patient left at their own risk or did not wait. After adjusting for differences in the age structure between the two populations, Indigenous patients were more likely to leave at their own risk or not wait to be seen (7.3%) compared with non-Indigenous patients (5.1% or 717,652 presentations) (Table D3.09.11, Figure 3.09.6).

Figure 3.09.6: Age-standardised proportion of patients in public emergency department presentations who left at their own risk or did not wait, by Indigenous status, July 2015 to June 2017

This bar chart shows that 7.3% of Indigenous patients who presented to the emergency department left at their own risk or did not wait compared with 5.1% of non-Indigenous patients. 2.3% of Indigenous patients and 1.6% of non-Indigenous patients left at their own risk compared with 5.0% of Indigenous and 3.4% of non-Indigenous patients who did not wait.

Source: Table D3.09.11. AIHW analysis of National Non-admitted Patient Emergency Department Care Database.

Indigenous patients left at their own risk, after being attended to by a health care professional but before the episode was complete, for 25,973 of those emergency department presentations. After adjusting for differences in the age structure between the two populations, Indigenous patients were more likely to leave at their own risk (2.3%) compared with non-Indigenous patients (1.6% or 232,379 presentations).

Indigenous patients did not wait to be attended to by a health-care professional for 56,122 emergency department presentations. After adjusting for differences in the age structure between the two populations, Indigenous patients were more likely than non-Indigenous patients not to wait to be seen by a health-care professional, 5.0% of presentations compared with 3.4% (485,273 presentations) (Table D3.09.11).

The proportion of Indigenous patients who left at their own risk or did not wait to be seen was lowest for those from Outer regional areas (6.1%) and highest in Very remote areas (9.3%) (Table D3.09.13, Figure 3.09.7).

Figure 3.09.7: Age-standardised proportion of patients in public emergency department presentations who left at their own risk or did not wait, by Indigenous status and remoteness, July 2015 to June 2017

This bar chart shows that, nationally, the proportion of Indigenous Australians who left at their own risk or did not wait was 7.3% compared with 5.1% of non-Indigenous Australians. For Indigenous Australians this proportion was highest in Very remote areas (9.3%), followed by Remote areas (8.8%) and then Major cities (7.5%). The non-Indigenous proportion decreased as remoteness increased; decreasing from 5.4% in Major cities to 3.3% in Very remote areas.

Source: Table D3.09.13. AIHW analysis of National Non-admitted Patient Emergency Department Care Database.

What do research and evaluations tell us?

A systematic review examined the causes that contribute to discharge against medical advice and ‘take own leave’ events (ACSQHC 2020). The review found repeated themes, including systematic and personal racism, distrust of hospitals and patients feeling misunderstood and unwelcome. A lack of cultural competency, cultural safety in hospitals and health workforce cultural training were also recurrent themes.

A Western Australian study used linked data to explore the determinants of discharge against medical advice among patients experiencing their first in-patient admission for ischaemic heart disease (Katzenellenbogen et al. 2013). One of the findings of this study was that the odds of dismissal against medical advice was not associated with the severity of the event, unlike for non-Indigenous patients. An analysis of paediatric admissions data from 1 January 2011 to 31 December 2015 from two Sydney tertiary paediatric hospitals found that Indigenous children were significantly more likely than non-Indigenous children to discharge against medical advice (Sealy et al. 2019).

Research in hospitals in Western Australia and Alice Springs explored the effects of the employment of Aboriginal and Torres Strait Islander health workers on Indigenous patient experiences. In the Western Australian setting, employing an Aboriginal Health Worker in a cardiology ward facilitated culturally appropriate care, bridged communication divides and reduced discharges against medical advice (Taylor et al. 2009). In the Alice Springs acute care setting, the self-discharge rate fell significantly with the involvement of Aboriginal Liaison Officers (Einsiedel et al. 2013).

The Department of Health of Western Australia undertook a review into ‘take own leave’, which refers to instances in which a patient chooses to leave prior to commencing or completing treatment, and includes discharge against medical advice (Aboriginal Health Policy Directorate 2018). The published paper is intended as a resource to assist health service providers and other stakeholders address ‘take own leave’. Recommendations from the review covered a range of strategies across areas, including cultural competency; consultation, engagement and partnerships; communication and language; culturally safe hospital environments; the Aboriginal workforce; the social determinants of health; alcohol and other drugs; mental health; and use of technology. The review also identified existing Western Australian strategies and programs, including the Aboriginal Interpreting WA Kimberley pilot program; essential items packs for sudden admission patients; nicotine replacement therapy; and the Friends of Royal Perth Hospital volunteer group who assist with connecting with families and assisting with meeting responsibilities like washing and shopping.

A study of the use of Aboriginal interpreters in the Northern Territory found a low rate of interpreter bookings, a declining rate of completed interpreter bookings, and process barriers identified by staff, including booking complexities, time constraints, inadequate delivery of tools and training, and greater convenience of unofficial interpreters (Ralph et al. 2017). Royal Darwin Hospital introduced a package of measures comprising employment of an Aboriginal interpreter coordinator, training for health care providers in working with Aboriginal interpreters, and the promotion of the use of interpreters. An initial evaluation of this intervention found that it was associated with an immediate increase in interpreter bookings and a decline in Indigenous patient self-discharge numbers (The Communicate Study group 2020).

The South Western Sydney Local Health District is cited as a good practice example of having strategies to improve its workforce’s cultural awareness and cultural competency to meet the needs of Indigenous Australian patients (ACSQHC 2017). Actions taken included the establishment of a Respecting the Difference Cultural Awareness Framework, conducting mandatory online and face-to-face cultural awareness training for its workforce and undertaking an independent evaluation of the training’s effectiveness, and progressing an Aboriginal Workforce Strategy.

An analysis of discharge against medical advice cases in a United States hospital estimated these cost the health system 56% more than the cost of patients discharged by medical staff (Aliyu 2002).

Implications

The elevated levels of discharge against medical advice suggest that there are significant issues in the responsiveness of hospitals to the needs and perceptions of Indigenous Australians (see measure 3.08 Cultural competency). Mechanisms for obtaining feedback from Indigenous Australian patients will assist in responding and planning in relation to the rate of discharge against medical advice. The data suggest these issues are important for all age groups, although the issues are most evident for those aged 15–54 years.

One aspect that is not clear from a simple analysis of hospital data on discharge against medical advice by diagnosis is the degree of clinical risk to the patient due to discharging against medical advice. This risk may vary considerably depending on the severity of the diagnosis, and thus the ranking of diagnosis groups may not be the most clinically meaningful way of identifying areas for improvement. A deeper understanding of risks to the patient may assist hospital services in targeting efforts with regard to communication strategies with patients, follow-up care after discharge and communication with health practitioners, notwithstanding the overall need for systemic improvements for culturally competent services.

There are several questions that health service researchers and health service managers need to tackle in devising strategies to achieve more responsive and respectful service delivery. More needs to be known about the reasons for the high rate 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 the health system); and hospital-level factors (such as staff attitudes, hospital policies and the environment). Historical issues, such as segregation and hospitals being seen as a place to go to die, are also factors to be investigated. Hospitals and health services that have implemented successful programs to reduce discharge against medical advice need to be studied, and lessons disseminated. For example, the media has reported that Katherine Hospital has had success in reducing the ‘take own leave’ rate (Cohen 2017). Changes introduced at the hospital included the introduction of highly trained specialist doctors who are invested in the community, regular use of interpreters and consultations with families of Indigenous patients regarding complex treatment plans.

The Australian Health Ministers’ Advisory Council funded work to develop a national framework to address critical contributing and protective factors to reduce the rate of Indigenous Australians taking their own leave and discharging against medical advice from Australian hospitals. This includes addressing factors that affect access to hospital services by Indigenous Australians, developing consumer-centred approaches that improve the health journey and the hospital environment, and improving the capability of hospitals to deliver culturally appropriate care for Indigenous Australians. The framework recommends that conventional thinking focused on the actions of the patient must be turned on its head, with person-centred care seeking to shape health care around a person’s full range of needs and wants as a core principle in preventing and reducing ‘take own leave’ (National Take Own Leave Working Group 2017).

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 key role in reaffirming this commitment and provides a nationally consistent approach (AHMAC 2017). The National Safety and Quality Health Service Standards User Guide for Aboriginal and Torres Strait Islander Health recommends that health service organisations use the Cultural Respect Framework to develop, implement and evaluate cultural awareness and cultural competency strategies (ACSQHC 2017). 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 2019). 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 2019).

The policy context is at Policies and strategies.

References

  • Aboriginal Health Policy Directorate 2018. Aboriginal Patient Take Own Leave. Review and recommendations for improvement. Perth.
  • ACSQHC (Australian Commission on Safety and Quality in Health Care) 2017. National Safety and Quality Health Service Standards User Guide for Aboriginal and Torres Strait Islander Health. Sydney.
  • ACSQHC 2020. Understanding leave events for Aboriginal and Torres Strait Islander peoples and other Australians from health service organisations Systematic Literature Review. Sydney.
  • AHMAC (Australian Health Ministers’ Advisory Council) 2017. Cultural Respect Framework 2016-2026 for Aboriginal and Torres Strait Islander health. Canberra: AHMAC.
  • AIHW (Australian Institute of Health and Welfare) 2019. Cultural safety in health care for Indigenous Australians: monitoring framework. Canberra: Australian Institute of Health and Welfare. 
  • Aliyu Z 2002. Discharge against medical advice: sociodemographic, clinical and financial perspectives. International journal of clinical practice 56:325-7.
  • Cohen H 2017. How Katherine Hospital, once Australia's worst for Indigenous health, became one of the best. abc. Viewed 21/02/2020.
  • Einsiedel LJ, van Iersel E, Macnamara R, Spelman T, Heffernan M, Bray L et al. 2013. Self-discharge by adult Aboriginal patients at Alice Springs Hospital, Central Australia: insights from a prospective cohort study. Australian Health Review 37:239-45.
  • Katzenellenbogen JM, Sanfilippo FM, Hobbs MS, Knuiman MW, Bessarab D, Durey A et al. 2013. Voting with their feet-predictors of discharge against medical advice in Aboriginal and non-Aboriginal ischaemic heart disease inpatients in Western Australia: an analytic study using data linkage. BMC health services research 13:330.
  • National Take Own Leave Working Group 2017. A National Framework to Reduce Taken Own Leave Events Among Aboriginal and Torres Strait Islander Patients.
  • Ralph AP, Lowell A, Murphy J, Dias T, Butler D, Spain B et al. 2017. Low uptake of Aboriginal interpreters in healthcare: exploration of current use in Australia’s Northern Territory. BMC health services research 17:733.
  • Sealy L, Zwi K, McDonald G, Saavedra A, Crawford L & Gunasekera H 2019. Predictors of Discharge Against Medical Advice in a Tertiary Paediatric Hospital. International journal of environmental research and public health 16:1326.
  • Shaw C 2016. An evidence-based approach to reducing discharge against medical advice amongst Aboriginal and Torres Strait Islander patients. Deakin, ACT: AHHA.
  • Taylor KP, Thompson SC, Wood MM, Ali M & Dimer L 2009. Exploring the impact of an Aboriginal Health Worker on hospitalised Aboriginal experiences: lessons from cardiology. Australian Health Review 33:549-57.
  • The Communicate Study group 2020. Improving communication with Aboriginal hospital inpatients: a quasi‐experimental interventional study. The Medical Journal of Australia.

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