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USE OF HEALTH SERVICES
Information about the extent to which GPs are used by both Indigenous and other Australians is available from a survey of general practice activity in Australia known as the Bettering the Evaluation and Care of Health (BEACH) survey. See Chapter 7 for more information on the BEACH methodology and for data on consultations between Indigenous people and GPs for the period 2001-02 to 2005-06 (table 7.6).
Over the five-year period 2001-02 to 2005-06, only 1.5% of total consultations were with Aboriginal and Torres Strait Islander patients. This rate of consultation is low, relative to the proportion of Indigenous people in the total population (2.5% at 30 June 2006). These lower figures may be the result of the geographic distribution of GPs not reflecting that of the Indigenous population; lower use of private GP services by Indigenous people where other services such as Aboriginal primary health care services exist; Indigenous people using other services such as hospital emergency departments or pharmacists; failure by GPs to record the Indigenous status of patients; or Indigenous patients not identifying as Indigenous. Supplementary surveys in recent years (Supplementary Analysis of Nominated Data (SAND)) together with investigations of means for better ascertaining the Indigenous status of patients in the BEACH survey, have suggested ways for improving such data in the future.
Alcohol and other drug treatment services
Information on the use of alcohol and other drug treatment services by Aboriginal and Torres Strait Islander people is available from a number of sources, including the Drug and Alcohol Service Report (DASR), the Service Activity Reporting (SAR) data, and the Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS-NMDS). It should be noted that the DASR, SAR and AODTS-NMDS have different collection purposes, scope and counting rules, therefore the resulting data are not comparable.
The DASR collects information from all Australian Government-funded Aboriginal and Torres Strait Islander substance use-specific services. In 2004-05, of the estimated 27,600 clients seen by these services, 78% (21,600) identified as being of Aboriginal and/or Torres Strait Islander origin (AIHW 2006a). Common substances/drugs for which services provided treatment or assistance included alcohol use (100% of services), cannabis (95%), multiple drug use (78%), amphetamines and tobacco/nicotine (61% each).
The SAR collects information from all Australian Government-funded Aboriginal and Torres Strait Islander primary health care services. Around half of these services had treated clients for multiple drug use (53%), benzodiazepines (52%), solvents and inhalants (49%) and petrol (47%). Most services covered issues relating to alcohol use (89%), tobacco/nicotine (84%) and/or cannabis (82%) (AIHW 2006a).
The AODTS-NMDS is a nationally agreed set of common data items collected by in-scope government-funded service providers of clients of alcohol and other drug treatment services (AIHW 2006a). Reported numbers in the 2004-05 annual report on the AODTS-NMDS do not include the majority of services covered by the DASR and SAR collections, as these services are not included in the specific program under which the Australian Government currently reports AODTS-NMDS data. Data for 2004-05, the fifth year of collection, are presented here.
In 2004-05, there were 13,666 closed treatment episodes (10%) involving clients who identified as being of Aboriginal and/or Torres Strait Islander origin (table 10.16) (AIHW 2006a). A closed treatment episode refers to a period of contact between a client and a treatment agency, with defined start and end dates.
Overall, closed treatment episodes involving Aboriginal and Torres Strait Islander clients were most likely to involve alcohol (43%), cannabis (23%), heroin (12%) or amphetamines (11%) - that is, the same four principal drugs of concern as for non-Indigenous Australians - but with alcohol more likely to be nominated (43% compared with 37%) and heroin less so (12% compared with 18%).
Community mental health services
Mental health care is provided by a broad range of services and agencies including care provided by general practitioners, psychologists and medical specialists, as well as through community mental health services. Information on the use of community mental health services by Aboriginal and Torres Strait Islander people is available from the AIHW National Community Mental Health Care Database (NCMHCD). Community mental health care is defined as care which is provided by specialised public mental health services dedicated to the assessment, treatment, rehabilitation and care of non-admitted clients. This excludes specialised mental health care for admitted patients (covered in Chapter 7), support that is not provided by specialised mental health care services, care provided by non-government organisations, and residential care.
Data on the use of community mental health services by Indigenous clients in 2004-05 are presented here. There is likely to be an under-estimation of the actual number of service contacts for Indigenous clients in these data due to data quality issues. In some instances, Indigenous clients may have been reported as non-Indigenous, or they may have been represented within the service contacts with a 'not stated' Indigenous status (AIHW 2007j).
In 2004-05, around 4% of service contacts (224,213) were for clients who identified themselves as Indigenous (table 10.17). After adjusting for differences in the age structures of the Indigenous and non-Indigenous populations, the rate at which community mental health services were accessed by Aboriginal and Torres Strait Islander peoples was 507 service contacts per 1,000 population compared with 220 service contacts per 1,000 population for other Australians - a rate ratio of 2.3. The rate ratio of service contacts for Indigenous Australians and other Australians has increased from 1.4 in 2002-03 and 1.7 in 2003-04, however, this may be due to increased coverage of services and/or improved identification of Aboriginal and Torres Strait Islander clients, rather than an actual increase in the proportion of Indigenous people accessing community mental health services.
Consistent with differences in the age structures of the two populations, Indigenous Australians were more likely than other Australians to have service contacts in the younger age groups and correspondingly lower representation in the older age groups. For example, 24% of service contacts for Indigenous males were for clients aged 15-24 years compared with 17% of service contacts for other Australian males. There were more service contacts for Aboriginal and Torres Strait Islander males than for females (1.6 times) whereas the rates for other Australian males and females were similar.
Hospital services are a major component of expenditure on health services for Aboriginal and Torres Strait Islander people. Although the reasons for which people are hospitalised and the procedures they may undergo in hospital are not necessarily indicative of the health of the total population, information on hospitalisations can provide some insights into the health of the population.
Hospitalisation statistics are limited to information about the conditions for which people are admitted to hospital, thereby excluding service use information regarding those who visited the emergency department but were not admitted, or had hospital outpatient clinic visits, or who made use of other health services, such as GPs and community health clinics. The number and pattern of hospital admissions can also be affected by the variation between hospitals in decisions about whether to admit patients or to treat them as non-admitted patients. Information concerning non-admitted patients is only reported in selected public hospitals and is not always available at the episode-level. Other factors, such as the availability of, and access to, other medical services, may influence hospital utilisation. For example, a rising rate of hospitalisation could mean that health status has deteriorated, or that access to hospitals has improved, or that access to GPs has decreased, or all of these.
Indigenous Australians are less likely than other Australians to undergo a procedure once admitted to hospital. It is not known which factors cause this disparity. Presentation late in the course of the illness, the presence of co-morbidities and communication difficulties are some of the suggested factors that may be involved (AHMAC 2006). Along with data on hospitalisations, this section provides information on hospital procedures recorded for Indigenous and other Australians.
Hospitalisation rates for Indigenous people are influenced by their relatively poor health status, as well as their access to hospital and other health services (AIHW 2007b). Reported hospitalisation rates in the Indigenous population are also influenced by the quality of Indigenous identification in hospital records, which varies among the states and territories (see Chapter 7, 7.9 IDENTIFICATION OF INDIGENOUS PERSONS IN HOSPITAL RECORDS for more detail).
The information presented in this section is for the six jurisdictions which have been assessed as having adequate identification of Indigenous people in hospitalisations data in 2004-05 - New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory. These six jurisdictions represent approximately 96% of the Indigenous population of Australia, however, the information presented here is not necessarily representative of the other two jurisdictions (Tasmania and the Australian Capital Territory).
In Australia, during 2005-06, there were 7.3 million hospitalisations recorded across all jurisdictions (AIHW 2007b). In the same period, around 7.0 million hospitalisations were recorded in New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory combined. Of these, 243,106 or 3.5% were hospitalisations of Indigenous people. The same patient may have been hospitalised more than once during this period. After adjusting for differences in the age structures of the Indigenous and non-Indigenous populations, Indigenous males and females were more than twice as likely to be hospitalised as other Australian males and females.
In 2005-06, in New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory combined, about 94% of hospitalisations involving Indigenous patients were recorded in public hospitals, compared with 60% of hospitalisations of other Australians. While Indigenous patients are not identified well in private hospitals compared with public hospitals, the much lower proportions of hospitalisations of Indigenous patients in private hospitals probably reflects lower attendance at private hospitals by Indigenous patients.
The most common diagnosis for both Indigenous males and females in hospitalisations data in 2005-06 was 'care involving dialysis', which is used in the treatment of chronic kidney disease. In New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory combined, hospitalisation rates for a diagnosis of care involving dialysis accounted for 41% of all hospitalisations involving Indigenous patients, and 11% of hospitalisations for other patients; rates were around 14 times as high for Indigenous Australians compared with other Australians.
Potentially preventable hospitalisations
Potentially preventable hospitalisations provide an indication of the scope for health gain through preventative care and early disease management. These are also referred to as ambulatory care-sensitive conditions and are admissions to hospital that potentially could have been prevented through the provision of appropriate non-inpatient health services. Potentially preventable hospitalisations will never be entirely eliminated, but the variation in rates between Indigenous and non-Indigenous Australians demonstrates considerable potential for strengthening the impact of non-hospital care.
Ambulatory care-sensitive conditions can be broken down into three categories:
In 2005-06, in New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory combined, the rate of hospitalisations due to ambulatory care-sensitive conditions for Indigenous Australians was five times the rate for other Australians. Indigenous Australians were hospitalised for potentially preventable chronic conditions at eight times the rate of other Australians, for potentially preventable acute conditions at twice the rate, and for vaccine preventable conditions at three times the rate of other Australians (graph 10.18). Of the potentially preventable chronic conditions, diabetes complications had the highest hospitalisation rate, with the rate for Indigenous Australians being twelve times the rate for other Australians.
10.18 HOSPITALISATION RATES FOR AMBULATORY CARE SENSITIVE CONDITIONS, by Indigenous status(a) - 2005-06
Age-specific hospitalisation rates by Indigenous status are shown for three different scenarios (graphs 10.19, 10.20 and 10.21). The first scenario which includes all hospitalisations (including dialysis) shows rates of hospitalisations for Indigenous patients and for other patients in all age groups from 25 years onwards. When dialysis was excluded in the second scenario, the difference in hospitalisation rates between Indigenous and non-Indigenous Australians was much smaller. When hospitalisations from both dialysis and ambulatory care sensitive conditions were excluded in the third scenario, much of the difference in hospitalisation rates between Indigenous and other Australians from 25 years onwards was removed. Dialysis and ambulatory care sensitive conditions accounted for 80% of all hospitalisations of Indigenous people aged 45 years or over, compared with 28% for other Australians in this age group.
10.21 HOSPITALISATIONS EXCLUDING DIALYSIS AND AMBULATORY CARE SENSITIVE CONDITIONS, by Indigenous status and age(a) - 2005-06
Hospitalisations and procedures
Procedures are clinical interventions (surgical interventions and interventions that require specialised training or special facilities or equipment) such as X-rays and chemotherapy. One or more procedures can be reported for each hospitalisation, but many hospital admissions will not involve procedures.
Around half (48%) of all hospitalisations of Indigenous Australians (excluding dialysis hospitalisations) did not have a procedure reported. Around 16% of Indigenous hospitalisations had one procedure reported, 16% had two procedures reported, 8% had three procedures reported and 11% had four or more procedures reported (table 10.22).
While Indigenous Australians were more likely to be hospitalised than other Australians, they were less likely to undergo a procedure once admitted to hospital. Indigenous Australians were twice as likely as other Australians to have no procedures recorded and less likely than other Australians to have 1 to 9 procedures recorded. They were, however, more likely to have 10 or more procedures recorded, probably reflecting higher rates of co-morbidities and case complexity.
For almost all principal diagnoses, Indigenous patients were less likely than other patients to have a procedure recorded (graph 10.23). The greatest disparities between Indigenous and other Australians in the proportion of hospitalisations with a procedure reported were seen in hospitalisations for diseases of the nervous system, diseases of the respiratory system, and symptoms, signs and abnormal findings (e.g. breathing abnormalities, nausea and vomiting, fever of unknown origin).
Indigenous Australians are less likely to undergo a procedure once admitted to hospital than other Australians but it is not known which factors cause this disparity. This can include institutionalised racism (AMA 2007) which has been defined as 'systemic practices not ill-intentioned, but still discriminatory, and almost invisible to the patient provider encounter' (AHMAC 2006). Presentation late in the course of the illness, the presence of co-morbidities and communication difficulties are some of the other suggested factors that may be involved (AHMAC 2006).
10.23 HOSPITALISATIONS WITH A PROCEDURE RECORDED, by principal diagnosis and Indigenous status(a) - 2005-06
A study by Coory and Walsh (2005), which followed patients admitted to Queensland hospitals for acute myocardial infarction (AMI) between 1998 and 2002, found that rates of coronary procedures among Indigenous patients were significantly lower (by 22%) than among other patients with AMI.
The AIHW report Aboriginal and Torres Strait Islander people with coronary heart disease: further perspectives on health status and treatment, outlines the disparities between Aboriginal and Torres Strait Islander people and other Australians in the health status and treatment of coronary heart disease (CHD), including the use of coronary procedures in hospital (AIHW 2006b). Among those Australians hospitalised with CHD in 2002-03, Indigenous Australians were less likely than other Australians to receive key coronary investigations and procedures, such as coronary angiography and revascularisation. This was evident across all age groups.
In 2002-03, there were 4,126 hospitalisations of Indigenous Australians with CHD as the principal diagnosis, compared with 113,109 hospitalisations of other Australians. After adjusting for differences in the age structures of the Indigenous and non-Indigenous populations, the angiography and revascularisation rates for Aboriginal and Torres Strait Islanders were 40% lower than the rate for other Australians (rate ratios of 0.6 for both). Revascularisation procedures include percutaneous coronary intervention (PCI) and coronary artery bypass grafts (CABG). Similar results were observed when PCI and CABG were analysed separately, with Indigenous Australians generally less likely to receive these procedures than other Australians across all age groups for those hospitalised for CHD. The age-adjusted procedure rate for PCI is around 40% lower than other Australians, while the age-adjusted rate for CABG is 20% lower (age standardised rate ratio of 0.6 and 0.8 respectively).
Indigenous Australians with CHD tended to be more complex cases (as measured by the number of co-morbidities). However, the complexity of cases did not explain the lower procedure rate in Indigenous Australians compared with other Australians. In 2002-03, Aboriginal and Torres Strait Islander people with CHD were less likely to undergo a coronary procedure across all levels of complexity. The largest difference in procedure rates between Indigenous Australians and other Australians occurred in the least complex groups (no or 1-2 co-morbidities present). In these groups, Indigenous Australians were just over half as likely to have had a coronary procedure.
Treatment for cancer
A study of 815 Indigenous and 810 non-Indigenous patients diagnosed with cancer in Queensland between 1997 and 2002 found that after adjustment for stage at diagnosis, treatment and co-morbidities, non-Indigenous Australians had better survival rates than Indigenous patients. Indigenous patients were less likely to have had treatment for cancer (e.g. surgery, chemotherapy, radiotherapy) and were more likely to have waited longer for surgery than non-Indigenous patients (Valery et al 2006).
A study in Western Australia of patients who had a cancer registration in the state between 1982 and 2001 found that Indigenous women were as likely as non-Indigenous women to undergo breast-conserving surgery for breast cancer, but Indigenous men were less likely than non-Indigenous men to receive radical prostatectomy for prostate cancer. Indigenous people were also less likely than non-Indigenous people to receive surgery for lung cancer (Hall et al 2004).