Tier 3—Effective/appropriate/efficient—3.06 Access to hospital procedures

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 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 2005; ABS 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 by-pass 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 the stage of cancer when patients are referred for specialist treatment (Condon et al. 2006; Valery et al. 2006). However, Aboriginal and Torres Strait Islander peoples are less likely to have treatment for cancer (surgery, chemotherapy, radiotherapy) and tend to wait longer for surgery (Valery et al. 2006; Hall et al. 2004). After adjusting for stage at diagnosis, treatment and comorbidities, non-Indigenous Australians had better survival rates than Indigenous patients.

Aboriginal and Torres Strait Islander people with end stage renal failure received kidney transplants at a lower rate than other Australians and had significantly longer overall median waiting times (Yeates et al. 2009). These disparities are not explained by age, sex, comorbidities or the cause of renal disease.

Findings:

In the two years to June 2010, excluding care involving dialysis, 60% of hospital episodes for Aboriginal and Torres Strait Islander peoples had a procedure recorded, compared with 82% of hospital episodes for other Australians.

For Indigenous Australians, 6% of hospitalisation's with a procedure recorded occurred in private hospitals compared with 50% for non-Indigenous Australians. 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 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 (with admissions for cancers, diseases of the digestive system, disease of the musculoskeletal system, diseases of the eye, diseases of the genitourinary system, diseases of the blood, diseases of the nervous system, pregnancy and childbirth, diseases of the ear and mastoid process, and respiratory diseases all increasing the likelihood a procedure will occur);
• remoteness of usual residence;
• age;
• Indigenous status;
• state/territory of residence; and
• sex.

In all states and territories Indigenous Australians were less likely to receive a procedure. Analysis by remoteness shows a steady decline in procedures as remoteness declines. However, the gap between the proportions of Indigenous and non-Indigenous Australians receiving a hospital procedure remains in each area.

Between July 2008 and June 2010, 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 hospitalisation related to diseases of the digestive tract between July 2008 and June 2010, the odds of Aboriginal and Torres Islander patients receiving a corresponding procedure were significantly lower than non-Indigenous patients when the principal diagnosis was complicated or uncomplicated hernias, and diseases of the extrahepatic biliary tree. There was no significant difference where the principal diagnosis was appendicitis, non-neoplastic diseases of the anus or rectum, and malignant neoplasms of the large intestine/rectum.Top of Page

Implications:

Disparities in 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 et al. 2002). An adequate primary health care system is also a prerequisite for effective hospital and specialist services.

Half (49%) of Indigenous Australians had incomes in the bottom 20% of Australian incomes. In 2004–05, 15% of Indigenous Australians in non-remote areas had private health insurance with the main barrier being affordability (65%). 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, which affects treatment options (Valery et al. 2006). Access to non-hospital specialist services for Aboriginal and Torres Strait Islander peoples is known to be well below national averages (Deeble et al. 1998). 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). 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).

Table 41—Proportion of separations with a procedure reported, by principal diagnosis and Indigenous status, July 2008 to June 2010

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Principal diagnosis chapter (excluding dialysis)	Indigenous (%)	Other (%)
Neoplasms	90	96
Diseases of the eye	88	99
Diseases of the blood	88	94
Congenital malfunctions	87	92
Diseases of the ear	80	88
Certain conditions in perinatal period	73	74
Diseases of the musculoskeletal system	72	93
Endocrine, nutritional & metabolic disorders	70	85
Factors influencing health status	68	92
Diseases of the digestive system	67	90
Diseases of the genitourinary system	65	85
Injury, poisoning & external causes	63	74
Pregnancy & child birth	63	79
Diseases of the skin	61	72
Diseases of the circulatory system	59	76
Diseases of the nervous system	57	86
Infectious & parasitic diseases	44	44
Diseases of the respiratory system	42	62
Mental & behavioural disorders	40	55
Symptoms and signs and n.e.c	38	61
Any principal diagnosis	60	82

Source: AIHW analysis of National Hospital Morbidity Database

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Table 42—Hospital procedures, by type of procedure reported and Indigenous status, July 2008 to June 2010 (age standardised)

Procedure type	Indigenous (%)	Other (%)
Procedure on urinary system	37	8
Haemodialysis	36	6
Non-invasive and cognitive and other interventions, n.e.c.	36	49
Imaging services	5	6
Procedures on digestive system	4	9
Procedures on cardiovascular system	3	3
Obstetric procedures	3	3
Procedures on musculoskeletal system	3	5
Dermatological and plastic procedures	3	4
Gynaecological procedures	2	3
Dental services	1	2
Procedures on eye and adnexa	1	2
Procedures on respiratory system	1	1
Procedures on nose and mouth and pharynx	1	1
Procedures on nervous system	1	2
Other	1	2
Total (excluding haemodialysis)	65	94
Total (including haemodialysis)	100	100

Source: AIHW analysis of National Hospital Morbidity Database

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Figure 159—Proportion of hospitalisations with a procedure performed, by Indigenous status and state/territory (excluding care involving dialysis), July 2008 to June 2010

Source: AIHW analysis of National Hospital Morbidity Database

Figure 160—Age-standardised use of coronary procedures for those hospitalised with coronary heart disease, NSW, Victoria, Qld, WA, SA and the NT, July 2008 to June 2010

Source: AIHW analysis of National Hospital Morbidity Database

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