3.06 Access to hospital procedures

Why is it important?

Studies have shown that while Indigenous Australians are more likely to be hospitalised than other people they are less likely to receive a medical or surgical procedure while in hospital (Cunningham 2002; ABS & AIHW 2008). The disparities are not explained by diagnosis, age, sex or place of residence (Cunningham 2002). For patients admitted to hospital with coronary heart disease, access to coronary angiography can be important in 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). A study of patients admitted to Qld hospitals for acute myocardial infarction (heart attack) between 1998 and 2002 found that rates of coronary procedures among Indigenous Australian patients were 22% lower than rates for other patients (Coory et al. 2005).

Several studies have shown Aboriginal and Torres Strait Islander peoples have poorer survival rates 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 stage of diagnosis Indigenous Australians are less likely to have treatment for cancer (surgery, chemotherapy, radiotherapy), tend to wait longer for surgery and have lower survival rates for many cancers (Valery et al. 2006; Hall et al. 2004).

The proportion of Aboriginal and Torres Strait Islander people with end stage renal failure who received a kidney transplant was lower (11%) than other Australians (47%) (see measure 1.10).

Findings

In the two years to June 2013, excluding care involving dialysis, 59% of hospital episodes for Aboriginal and Torres Strait Islander peoples had a procedure recorded, compared with 80% of hospital episodes for other Australians. There has been a significant increase in Indigenous hospitalisation rates with a procedure recorded between 2004–05 and 2012–13 in NSW, Victoria, Qld, WA, SA and the NT combined. The increase for Indigenous Australians was faster than for non-Indigenous and the gap has halved.

For Indigenous Australians, 7% of hospitalisations with a procedure recorded occurred in private hospitals compared with 53% for non-Indigenous Australians in the two years to June 2013. 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 2011 and June 2013 the most significant factors (in order or importance) were:

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

In all states and territories, Indigenous Australians were less likely to receive a procedure. Analysis by remoteness shows a decline in hospitalisations with a procedure recorded as remoteness rises. The gap between the proportions of Indigenous and non-Indigenous Australians receiving a hospital procedure is highest in remote areas and lowest in very remote areas, due, in part, to lower rates of procedures for non-Indigenous Australians in very remote areas.

Between July 2011 and June 2013, among those hospitalised with coronary heart disease, Aboriginal and Torres Strait Islander people were nearly half as likely to receive coronary procedures such as coronary angiography and revascularisation procedures.

For hospitalisations related to diseases of the digestive tract between July 2011 and June 2013, the odds of Aboriginal and Torres Islander patients receiving a corresponding procedure were significantly lower than non-Indigenous patients when the principal diagnosis was appendicitis, complicated or uncomplicated hernias, diseases of the extrahepatic biliary tree, and neoplastic diseases of the anus or rectum. There was no significant difference where the principal diagnosis was malignant neoplasms of the large intestine/rectum.

Implications

Disparities in hospital procedures are likely to reflect a range of factors, including 'systemic practices, not illintentioned but still discriminatory, and almost invisible in the patient provider encounter' (Fisher et al. 2002). An adequate primary health care system is also a prerequisite for effective hospital and specialist services.

In the 2012–13 Health Survey, 43% of Indigenous adults had incomes in the bottom 20% of Australian incomes. In the same survey, 20% of Indigenous Australians in non-remote areas reported they had private health insurance with the main barrier being affordability (72%). 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 have impacts on the rate of preventative hospital treatments.

Aboriginal and Torres Strait Islander 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, including difficulties for patients whose main language is not English; and patient knowledge and attitudes, e.g. 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 (Shahid et al. 2009; Miller et al. 2010). Analysis of 2013–14 Medicare data shows that the rate of non-hospital specialist services for Aboriginal and Torres Strait Islander peoples was below national averages. Effective strategies will require a better understanding of the factors leading to the observed disparities.

The measures presented here suggest that 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 et al. 2002).

Heart and cardiovascular conditions make the greatest contribution to the gap in life expectancy between Aboriginal and Torres Strait Islander peoples and other Australians. The extent to which access to effective hospital and other cardiac care is sub-optimal for Aboriginal and Torres Strait Islanders is being addressed in several ways. This includes the National Recommendations for Better Cardiac Care for Aboriginal and Torres Strait Islander People and the Lighthouse Project (see measure 1.05).

Source: AIHW analysis of National Hospital Morbidity Database

Source: AIHW analysis of National Hospital Morbidity Database

Figure 3.06-1 shows the proportion of hospitalisations with a procedure performed (excluding care involving dialysis) between July 2011 and June 2013. Data is presented separately for Aboriginal and Torres Strait Islander peoples who were hospitalised, and non-Indigenous Australians who were hospitalised. Data is presented separately for each jurisdiction. Refer to the findings section of this measure for a description of key results found in this figure.

Source: AIHW analysis of National Hospital Morbidity Database

Figure 3.06-2 shows the age-standardised use of coronary procedures (revascularisation - PCI and CABG, and coronary angiography) for Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians hospitalised with coronary heart disease. Data is presented for NSW, Victoria, Qld, WA, SA and the NT combined, between July 2011 and June 2013. Refer to the findings section of this measure for a description of key results found in this figure.

Source: AIHW analysis of National Hospital Morbidity Database