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Keywords:

  • Aborigines;
  • Australian;
  • emergency medicine;
  • health;
  • retrospective analysis;
  • urban population

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Objectives

Aboriginal and Torres Strait Islander (ATSI) people have significant health disparity compared with other Australians. The present study examines the characteristics of ATSI patients presenting to three EDs of a single healthcare network to determine whether any healthcare disadvantages exist.

Methods

This is a retrospective audit of 179 795 presentations to the ED from 1 July 2011 to 30 June 2012. Measures included socioeconomic status, general practitioner nomination, triage category status, primary diagnosis recorded, length of stay and the outcome of stay, including numbers leaving before and after medical treatment was commenced.

Results

ATSI people were found to live in the lower socioeconomic regions of the network's catchment area, were more likely to attend the ED (135.5 non-ATSI persons presenting per 1000 non-ATSI persons and 210.4 ATSI persons presenting per 1000 ATSI persons), less likely to nominate a general practitioner (73.3 vs 82.1%; OR 0.60, 95% CI 0.51–0.71), more likely to leave before (5.5 vs 4.0%; OR 1.40, 95% CI 1.09–1.80) or after treatment had commenced (3.2 vs 2.3%; OR 1.43, 95% CI 1.03–1.97), and were more likely to re-attend the ED than non-ATSI people (OR 1.24, 95% CI 1.06–1.46).

Conclusion

ATSI people living in Melbourne's south-east have social and health utilisation inequities, which might have an impact on their health status.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The majority of studies examining Aboriginal and Torres Strait Islander (ATSI) presentations and outcomes to EDs have been undertaken in the Northern Territory and New South Wales.[1-7] One Victorian study analysed ATSI presentations to Victorian hospital EDs, but only reported total presentation rates and rates by respiratory, injury and poisoning, and mental health presentations.[8] Little is known about Victorian ATSI presentations and outcomes within Victorian EDs.

ATSI people are known to have lower life expectancy compared with non-ATSI population groups. The gap, at birth, between ATSI people and other Australians is currently estimated at 11.5 years for men and 9.7 years for women.[9] Closing the gap, a federal government strategy, in response to the Social Justice Report 2005,[10] aims to achieve ATSI health equality within 25 years.[11] Measureable targets to monitor improvements in health have been developed, including closing the life expectancy gap within a generation.[11] The 2011 census showed that Victoria has 6.9% of the ATSI population, making up 0.7% of the Victorian population, with approximately 47% living in metropolitan Melbourne.[12] The Victorian Aboriginal Affairs Framework 2013–2018 identified six strategic action areas, including health, to improve outcome for Victorian ATSI peoples. Eight priority locations were identified to be targeted, where large ATSI populations are found and where the community sought action, or where there was considered to be significant health and social inequality. One of these priority locations identified is the Dandenong-Casey region in metropolitan Melbourne.[13] The Dandenong-Casey region, which includes six local government areas, is serviced by Monash Health (MH). This is the largest healthcare provider in Victoria and provides healthcare to approximately 23% of metropolitan Melbourne.[14] In the 2011 census, the number of ATSI people in these government areas was 3289 (0.36%).[15] MH has three hospitals with EDs, two in the Dandenong-Casey region.

Monitoring of healthcare access and use is an important area of investigation to determine if health inequities exist in indigenous populations, which has been consistently shown in Australian[16, 17] and international research.[18, 19] In the present study, we examine ATSI and non-ATSI presentations to MH EDs over a 1 year period. Characteristics previously reported are examined to determine if an urban Victorian ATSI population has similar patient and presentation characteristics as those previously reported. Characteristics not previously studied are also examined; these include whether a general practitioner (GP) is nominated, the length of stay in the ED and presentations by all disease codes. The characteristics of those whose ATSI status was not recorded are also reported.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The study was approved by MH and Australian Catholic University human research ethics committees. All presentations from 1 July 2011 to 30 June 2012, to MH's three EDs, were retrospectively obtained from MH's ED electronic medical record database (Ascribe Symphony®, Ascribe, Bolton, UK).

Patient characteristics, including age, sex, socioeconomic status (SES) and whether a GP was nominated, were obtained from the index presentation in the time period specified. Presentation characteristics including arrival by ambulance, length of stay, triage category, outcome of presentation and primary diagnosis were obtained from all presentations. ATSI status was determined from the patient self-reporting at the time of triage registration. The SES was determined by the socioeconomic index for areas (SEIFA) developed by the Australian Bureau of Statistics (ABS) from census data.[20] SEIFA scores were categorised into quintiles for analysis. Primary diagnosis was determined from the International Statistical Classification of Diseases and Related Health Problems, Australian Modification (ICD-10-AM) codes, Seventh Edition.

The triage score was determined using the Australasian Triage Scale policy.[21] Presentation rates per person were calculated by dividing the number of presentations to MH by the number of persons presenting. Population presentation rates were calculated per 1000 persons. The population for local government areas that form MH's core patient population was estimated from the 2011 ABS Census of Population and Housing.[15]

Statistical analysis

Data analysis was performed using Stata version 12 (Stata Corporation, College Station, TX, USA).

Logistic regression and χ2 test were used to analyse binary and categorical data. Time from first presentation to the last date, 30 June 2012, was used to determine exposure time. Effect size and 95% confidence interval (CI) are given, rather than P-values, as the numbers of ED presentations in the dataset are very large.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

In total there were 124 138 people who contributed to 179 795 presentations to the MH's three EDs between 1 July 2011 and 30 June 2012. Of these people, 692 (0.6%) were identified as ATSI (Table 1). Information on ATSI status was not obtained on 1086 (0.9%) people. Reasons for not obtaining ATSI status were ‘Patient refused to answer’ (4.5%), ‘Question unable to be asked’ (92.0%) and ‘Not specified’ (0.1%). The remaining 2.9% had missing data. No additional information regarding ATSI status was able to be determined on subsequent presentations to the ED in these patients.

Table 1. ED patient characteristics by ATSI status: Index visit
 Non-ATSIATSIStatus unknownATSI versus Non-ATSI
  1. Data are presented as number (%), median [interquartile range] or OR {95% CI}. Quintiles ordered from lowest SES to highest SES by SEIFA score. *P-value from χ2 analysis. ATSI, Aboriginal and Torres Strait Islander; CI, confidence interval; GP, general practitioner; IQR, interquartile range; OR, odds ratio; SEIFA, socioeconomic index for area; SES, socioeconomic status.

Patients122 3606921086 
(98.6%)(0.6%)(0.9%)
Age, median [IQR] (years)31 [14–54]24 [9–40]32 [18–52]0.99 {0.98–0.99}
Female sex60 140 (49.2)380 (54.9)478 (44.0)0.79 {0.68–0.92}
SES    
1st quintile19.528.820.2<0.001*
2nd quintile19.921.716.0
3rd quintile19.017.817.5
4th quintile20.314.319.7
5th quintile18.714.714.6
Unknown2.52.712.0
GP nominated100 394 (82.1)507 (73.3)675 (62.0)0.60 {0.51–0.71}

The ATSI population presenting to the three EDs were younger (median 24 vs 31 years; odds ratio [OR] 0.99, 95% CI 0.98–0.99), tended to be female (54.9% vs 49.2%; OR 0.79, 95% CI 0.68–0.92), tended to have lower SES by SEIFA score and were less likely to nominate a GP (73.3 vs 82.1%; OR 0.60, 95% CI 0.51–0.71) compared with non-ATSI patients.

Characteristics of total presentations

ATSI had higher presentations for arrival by ambulance (28.0 vs 25.0%; OR 1.17, 95% CI 1.03–1.33) (Table 2). ATSI people were more likely to leave without being seen (5.5 vs 4.0%; OR 1.40, 95% CI 1.09–1.80) and were more likely to leave at own risk after treatment had commenced (3.2 vs 2.3%; OR 1.43, 95% CI 1.03–1.97). No significant difference was found in triage category by ATSI status, length of stay in the ED or admission to hospital.

Table 2. Characteristics of all emergency department presentations by ATSI status
 Non-ATSIATSIUnknownATSI versus non-ATSI
  1. Data are presented as number (%) or OR {95% CI}. *P-value from χ2 analysis. ATSI, Aboriginal and Torres Strait Islander; CI, confidence interval; GP, general practitioner; IQR, interquartile range; LOS, length of stay; NT, not tested; OR, odds ratio.

Presentations177 375 (98.65)1178 (0.66)1248 (0.69) 
Arrival by ambulance44 365 (25.0)330 (28.0)359 (28.8)1.17 {1.03–1.33}
Triage category    
1856 (0.5)10 (0.9)18 (1.4)0.21*
218 627 (10.5)125 (10.6)130 (10.4)
361 625 (34.7)436 (37.0)456 (36.5)
4 and 595 701 (54.0)601 (51.3)633 (51.1)
LOS, median [IQR] (h)3.5 [1.9–6.1]3.5 [1.9–6.4]3.4 [1.7–5.7]1.0 {0.99–1.0}
Outcome    
Admission50 567 (28.5)355 (30.1)332 (26.6)1.08 {0.95–1.23}
Discharged to usual residence109 841 (61.9)682 (57.9)718 (57.5)0.85 {0.73–0.95}
Died or dead on arrival164 (0.1)1 (0.1)4 (0.3)NT
Left without being seen7 117 (4.0)65 (5.5)89 (7.1)1.40 {1.09–1.70}
Left after treatment commenced4 052 (2.3)38 (3.2)41 (3.3)1.43 {1.03–1.97}
Left after clinical advice1 928 (1.1)8 (0.7)19 (1.5)0.62 {0.31–1.25}
Redirected to Monash Health GP clinic3 168 (1.8)24 (2.0)35 (2.8)1.14 {0.76–1.12}
Missing data538 (0.3)5 (0.4)10 (0.8)NT

Injury was the major reason for both ATSI and non-ATSI presentations to the ED (Table 3). Respiratory and digestive disorders were the top two disease disorders for presentation to the ED for both ATSI and non-ATSI.

Table 3. Primary diagnosis of all presentations by ATSI status
 Non-ATSIATSIStatus unknown ATSI versus Non-ATSI OR {95% CI}
  1. Data are presented as number (%) or OR {95% CI}. ATSI, Aboriginal and Torres Strait Islander; CI, confidence interval; ICD-10-AM, International Statistical Classification of Diseases and Related Health Problems, Australian Modification; OR, odds ratio.

Presentations177 375 (98.65)1178 (0.66)1248 (0.69) 
Injury and external causes43 997 (24.8)265 (22.5)305 (24.5)0.88 {0.77–1.01}
Diseases of the respiratory system14 887 (8.4)106 (9.0)83 (6.7)1.08 {0.88–1.32}
Diseases of the digestive system12 912 (7.3)103 (8.7)91 (7.3)1.22 {0.99–1.50}
Diseases of the circulatory system10 324 (5.8)36 (3.1)81 (6.5)0.51 {0.37–0.71}
Infectious and parasitic diseases8 815 (5.0)64 (5.4)48 (3.9)1.10 {0.85–1.41}
Diseases of the genitourinary system8 695 (4.9)36 (3.1)35 (2.8)0.61 {0.44–0.85}
Mental and behavioural disorders6 449 (3.6)54 (4.6)59 (4.7)1.27 {0.97–1.68}
Diseases of the musculoskeletal system5 975 (3.4)33 (2.8)34 (2.7)0.83 {0.58–1.17}
Diseases of the skin/subcutaneous tissue5 592 (3.2)44 (3.7)36 (2.9)1.19 {0.88–1.61}
Disorders of the nervous system4 057 (2.3)34 (2.9)40 (3.2)1.27 {0.90–1.79}
Pregnancy/childbirth/congenital disorders3 947(2.2)30 (2.6)30 (2.4)1.15 {0.80–1.65}
Health services care3 467 (2.0)43 (3.7)25 (2.0)1.90 {1.40–2.58}
Eye/ear disorders3 300 (1.9)22 (1.9)29 (2.3)1.00 {0.66–1.53}
Endocrine and nutrition diseases/disorders1 746 (1.1)13 (1.2)9 (0.8)1.12 {0.65–1.94}
Blood diseases/disorders (excluding cancers)1 145 (0.7)5 (0.4)5 (0.4)0.66 {0.27–1.58}
Neoplasms, including blood cancers676 (0.4)6 (0.5)5 (0.4)1.34 {0.60–3.0}
Not otherwise specified30 255 (17.1)196 (16.6)202 (16.2)0.97 {0.83–1.13}
Missing ICD-10-AM code11 136 (6.3)88 (7.5)131 (10.4)1.21 {0.97–1.50}

ATSI people required more healthcare services (3.7 vs 2.0%; OR 1.90, 95% CI 1.40–2.58) than non-ATSI people. ATSI people had lower presentations for genito-urinary diseases (3.1 vs 4.9%; OR 0.61, 95% CI 0.44–0.85) and circulatory diseases (3.1 vs 5.8%; OR 0.51, 95% CI 0.37–0.71) compared with non-ATSI people. Although not statistically significant, ATSI people tended to have higher OR for presentations for mental and behavioural disorders (4.6 vs 3.6%; OR 1.27, 95% CI 0.97–1.68), digestive diseases (8.7 vs 7.3%; OR 1.22, 95% CI 1.00–1.50) and a lower OR for presentations related to injury (22.5 vs 24.8%; OR 0.88, 95% CI 0.77–1.01). This suggests either that there was no important difference in these presentations or that the present study was not powered sufficiently to detect the observed differences.

Estimation of presentation rates using census population data

The core population MH is estimated at 904 881, of which 3289 (3.6%) were ATSI. Presentation rates from MH data were 1.4 admissions per non-ATSI persons, compared with 1.7 admissions per ATSI persons and 1.1 per unknown ATSI status person. Estimated population presentation rates of individuals was 135.5 per 1000 non-ATSI persons and 210.4 per 1000 ATSI persons. As a result, ATSI people were 1.55 times more likely to attend the ED in financial year 2011–2012 than non-ATSI people.

Analysis of representation rates

Taking into account exposure time, ATSI were more likely to represent to hospital (OR 1.24, 95% CI 1.06–1.46) than non-ATSI in the 2011–2012 financial year. An analysis of representation rates within 72 h of the initial index visit showed no difference between ATSI and non-ATSI patients (data not shown).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

This analysis has confirmed findings in other studies that ATSI people have higher number of presentations to the ED,[22] are younger,[22] female,[4] and are more likely to leave before treatment is commenced or completed.[7, 23] ATSI people were also more likely to represent to the ED than non-ATSI people.[22] A new finding from the present study is that ATSI were less likely to nominate a GP than non-ATSI. The present study also highlights the number of persons whose ATSI status was not identified. ATSI were not distributed evenly across the MH geographical profile, but tended to reside in the lower socioeconomic areas, suggesting ATSI people might experience socioeconomic disadvantage. No difference in equity of healthcare was found in triage category score, admission rates, and length of stay between ATSI and non-ATSI.

Studies have generally shown that ATSI people have a higher number of presentations to EDs than expected for their population.[22] In the only other Victorian study to examine their characteristics, rural ATSI had higher standardised population ED presentation rates, whereas urban ATSI had similar standardised population presentation rates to non-ATSI. Poor ATSI status identification was a possible reason, given that no difference was found in presentation rates in urban ATSI.[8] In an analysis of 2010–2011 Victorian Emergency Minimum Dataset (VEMD) data, no difference in presentation rates between ATSI and non-ATSI people was found for three hospitals in Melbourne's northern suburbs, but only triage categories 4 and 5 patients were analysed.[24] In the present study, urban ATSI had higher crude and population adjusted rates of presentations compared with urban non-ATSI. The difference in the studies might be explained by the fact that MH services the socially and economically disadvantaged Dandenong-Casey areas,[13] which have a sizeable ATSI population, and it has been shown that disadvantaged ATSI are more likely to identify as ATSI.[25]

Victoria has only recently been included in the Australian Institute of Health and Welfare hospital separation data analysis for the monitoring of ATSI health, as it had previously not reached the acceptable 80% ATSI identification status threshold.[26] In the present study, the number of missing ATSI status was relatively small, but could still be influential as the number of ATSI identified was small. The main reason for not recording ATSI status was because of the question not being asked. National guidelines developed for identification of ATSI status recommend that if the ATSI status question is not asked at the time of patient registration, then a person who accompanies the patient should be asked.[27] The status should then be confirmed with the patient at a later date, if possible. To help with ‘closing the gap’, it is important that ATSI status be identified when patients present to the ED. This data are used to determine the effectiveness of health services in meeting ATSI needs, and is used to develop policy, planning and improve services for ATSI people.

One previous study found that ATSI people had higher rates of population-adjusted mental health presentations, similar rates of population-adjusted respiratory disease presentations, and lower rates of population-adjusted injury or poisoning presentations to metropolitan EDs compared with non-ATSI people.[8] Their findings are reflected in the results of the present study. We note in particular that ATSI people had a lower presentation rate of cardiac disorders/diseases. This finding might be because of the younger age distribution of ATSI people in our population, as well as the fewer men presenting to the EDs. However, ATSI people are more likely to develop cardiovascular disease at a younger age[28] and have higher admission rates for cardiovascular disease compared with non-ATSI people.[9] In Victoria, the difference in cardiovascular admissions between ATSI and non-ATSI populations is not as high in comparison with other Australian states.[29]

It was beyond the scope of the present study to determine why there were lower number of ATSI men presenting to the EDs; however, the finding might be because of the lower number of injury and external cause presentations in the ATSI group.

In the present study, the admission rates for ATSI people were higher, but not significantly different with non-ATSI people. In view of the known health inequities between ATSI and non-ATSI people,[9] the admission rates would have been expected to be higher and further research is required to examine this finding.

We also observed a higher rate of ATSI people who left without being seen by medical staff or who left after treatment was commenced but not completed. Studies examining ATSI versus non-ATSI presentations to EDs in New South Wales also found that a higher rate left without being seen and left after treatment commenced in the ATSI group.[2, 3, 5, 23] A recent study analysed 5 years of VEMD data and identified ATSI status as an independent predictor of leaving without being seen. Patients who left without being seen were more likely to re-attend the ED than those who had completed treatment.[30] No study has examined why ATSI people are more likely to leave without being seen or self-discharge from the ED before treatment is complete.

The higher rate of ATSI patients representing to the ED compared with non-ATSI patients could be because of a variety of reasons. However, as representation rates within 72 h of the index visit were no different between the two groups, there is no evidence that this finding was related to the higher rates of leaving without being seen and leaving after treatment commenced in the ATSI group. It was beyond the scope of the present study to examine the reasons for representing.

The lower rate of nominating a regular GP by ATSI people in our study might be another indicator of a health utilisation inequity between ATSI and non-ATSI peoples. It has previously been shown, using the Medicare Benefits Schedule health assessment and health checks records, that Victorian ATSI have lower regular health checks than the national average for ATSI people.[29] We were unable to find any other studies that reported rates of GP nomination at time of ED registration by ATSI patients.

Limitations

There are several limitations to the present study. As discussed, the ATSI status might be underreported because of missing ATSI status. As population rates were based on estimates of the health networks core population and census data, the estimated presentation rates might not be accurate. Given the size of the dataset, it is possible that some of our statistically significant results might not translate to clinical significance. However, the trends observed parallel those reported in previous studies examining ATSI populations.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

In the present study of three urban EDs, we observed that ATSI people have some health service utilisation inequities as evidenced by lower rates of GP nomination, higher rates of having left without being seen and leaving after treatment commenced. No inequity in healthcare was found with regard to triage categorisation, length of stay or admission rates. Future studies should examine why ATSI people are more likely to leave without being seen and after treatment has commenced. EDs should ensure the recording of ATSI status for all patients presenting to the ED to enable development of policy, planning and improvement of services for ATSI people.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The authors acknowledge the contribution of Dr Gary Campaign and Dr George Mnatzaganian in the preparation of the data for the present study.

Author contributions

Study design: CM, RC; data collection and analysis: CM, RC; manuscript preparation: CM, RC, AG, TS, GB.

Competing interests

AG and GB are both Section Editors for Emergency Medicine Australasia.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
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