3.09 Discharge against medical advice

Key messages

• In the two-year period July 2017 to June 2019, 4% of all hospitalisations for Indigenous Australians ended with the patient discharged at their own risk without completing treatment (24,278 hospitalisations).
• Of hospitalisations for Indigenous Australians who were discharged at their own risk, the most common principal diagnosis for these hospitalisations (excluding dialysis) was injury and poisoning (4,329 hospitalisations, 18% of all hospitalisations ending in discharge at own risk), followed by respiratory disease (2,623 hospitalisations, 11%), and mental and behavioural disorders (2,475 hospitalisations, 5.4%).
• Between July 2017 and June 2019, there were 100,668 emergency department presentations for Indigenous Australians where the patient did not wait to be seen or left at own risk without completing treatment, accounting for 9% of all emergency department presentations for Indigenous Australians.
• Of the 100,668 emergency department presentations where Indigenous patients did not wait to be seen or left at own risk, 66% (66,704) left prior to being attended by a medical professional and 34% left after being attended but before the episode of treatment was completed.
• Between July 2017 and June 2019, across remoteness areas, Indigenous Australians living in Very remote areas were the least likely to leave hospital at their own risk without completing treatment (1.7% or 2,150 emergency department presentations) but the most likely not to wait to be seen by a medical professional (8.4% or 10,793 emergency department presentations).
• Between 2009–10 and 2018–19, the age-standardised proportion of hospitalisations for Indigenous Australians where the patient was discharged at their own risk decreased from 4.4% to 3.8%. Similarly, the proportion of emergency department presentations for Indigenous Australians where the patient did not wait to be seen or left at their own risk decreased from 9.1% to 8.5% for Indigenous Australians between 2011–12 and 2018–19.
• People who take their own leave from hospital are more likely to re-present to emergency departments and have higher mortality rates.
• A systematic review found that gaps in the quality of health care within the Australian health system are associated with leave events among Indigenous Australians. The review findings suggest that reducing the occurrence of leave events requires better representation of Indigenous Australians in the health workforce and working in partnership with Indigenous Australians during the decision-making process to provide health services that meet the cultural needs of Aboriginal and Torres Strait Islander people.

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’, providing 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 choose to leave hospital prior to commencing or completing treatment. 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).

The rates of Indigenous hospital patients who choose to leave prior to commencing or completing treatment is also used as an indirect measure of cultural safety in the AIHW’s Cultural safety in healthcare for Indigenous Australians: monitoring framework (AIHW 2022).

Findings

What does the data tell us?

In this measure, data are presented for admitted patient hospitalisations, as well as for presentations to emergency departments.

Hospitalisations

Between July 2017 and June 2019, there were 24,278 hospitalisations where Indigenous Australians were discharged at their own risk without completing treatment. Excluding dialysis, this equated to 4% of all hospitalisations for Indigenous Australians. Indigenous males were more likely to be discharged at their own risk than Indigenous females (4.4% and 3.6% of all hospitalisations, respectively) (Table D3.09.2, Table D1.02.1).

Between July 2017 and June 2019, the proportion of hospitalisations among Indigenous Australians ending with discharge at own risk was higher among those aged between 25 and 54 than those in younger or older age groups. Indigenous Australians aged 35–44 had the highest rate of discharge at own risk (7.0% of hospitalisations for this age group), while children aged 0–4 and 5–14 were the least likely to be discharged at their own risk (0.9% and 0.8%, respectively) (Table D3.09.1, Figure 3.09.1).

The proportion of hospitalisations ending in discharge at own risk was higher for Indigenous Australians than non-Indigenous Australians in all age groups (Figure 3.09.1). After adjusting for differences in the age structure between the two populations, the proportion of hospitalisations ending with discharge at own risk was 5.5 times higher for Indigenous Australians that non-Indigenous Australians (Table D3.09.1).

Figure 3.09.1: Proportion of hospitalisations where the patient was discharged at their own risk (excluding dialysis), by Indigenous status and age group, Australia, July 2017 to June 2019

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

From July 2017 to June 2019, the hospitalisations for Indigenous Australians that ended with discharge at own risk was higher for those living in Remote and Very remote areas of Australia (6.3% or 3,654 hospitalisations and 7.3% or 6,351 hospitalisations) than for those living in Major cities (3.0% or 6,039 hospitalisations), Inner regional (2.3% or 2,971 hospitalisations) or Outer regional areas (3.6% or 4,602 hospitalisations) (Figure 3.09.2). In comparison, the proportion of hospitalisations ending with discharge at own risk for non-Indigenous Australians was similar across remoteness areas (0.5% to 0.7%).

After age-standardisation, the proportion of hospitalisations ending with discharge at own risk for Indigenous Australians ranged from 3.5 times as high as for non-Indigenous Australians in Inner regional areas to 9.1 times as high in Very remote areas (Table D3.09.4).

Figure 3.09.2: Proportion of hospitalisations for Indigenous Australians where the patient was discharged at their own risk (excluding dialysis), by remoteness, Australia, July 2017 to June 2019

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

Across the states and territories, Indigenous Australians living in the Northern Territory were the most likely be discharged at their own risk, with almost one-tenth (9.6%) of all hospitalisations (excluding dialysis) ending this way. This was followed by South Australia (5.0% or 1,583 hospitalisations) and Western Australia (4.6% or 3,662 hospitalisations). The proportion of hospitalisations for Indigenous Australians where the patient was discharge at their own risk was lowest in Tasmania (1.1% of all hospitalisations) (Table D3.09.3, Figure 3.09.3).

Figure 3.09.3: Proportion of hospitalisations for Indigenous Australians where the patient was discharged at their own risk (excluding dialysis), by Indigenous status and state and territory, July 2017 to June 2019

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

Among Indigenous Australians who were discharged at their own risk, the most common principal diagnosis for these hospitalisations was injury and poisoning (4,329 hospitalisations, 18% of all hospitalisations ending in discharge at own risk), followed by respiratory disease (2,623 hospitalisations, 11%), and mental and behavioural disorders (2,475 hospitalisations, 5.4%) (Table D3.09.7). Note that this ranking excludes ‘symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified’ (2,935 hospitalisations, 12%).

When the number of hospitalisations where the patient was discharge at own risk are expressed as the proportion of all hospitalisations for each specific diagnostic group, the rate of discharge at own risk for Indigenous Australians was highest for diseases of the skin and subcutaneous tissue (6.9% or 1,589 hospitalisations) and endocrine, nutritional and metabolic disorders (6.6% or 1,358 hospitalisations) and injury and poisoning (5.9%) (Table D3.09.7, Figure 3.09.4).

Figure 3.09.4: Proportion of hospitalisations for Indigenous Australians with the specified principal diagnosis where the patient was discharged at their own risk (excluding dialysis), Australia, July 2017 to June 2019

Note: Percentage of hospitalisation of each specific disease group was calculated as the number of hospitalisations for the specified principal diagnosis that ended in discharge against medical advice divided by the total number of hospitalisations for that principal diagnosis and multiplied by 100.

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

Emergency department presentations

Between July 2017 and June 2019, there were 100,668 emergency department presentations for Indigenous Australians where the patient did not wait to be seen or left at their own risk (9% of all emergency department presentations for Indigenous Australians). This consisted of:

• 66,704 presentations where the patient did not wait to be seen by a health care professional (5.9% of all emergency department presentations for Indigenous Australians)
• 33,964 presentations where the patient left at their own risk without completing treatment, after being seen by a health care professional but before the episode was complete (3.0%).

The proportion of emergency department presentations where the patient did not wait to be seen or left at own risk varied by triage status, with overall higher proportions among less urgent triage categories. Indigenous patients left emergency departments at their own risk or did not wait to be seen in:

• 13% (16,134 presentations) of all non-urgent emergency department presentations for Indigenous Australians,
• 11% (53,404 presentations) of those triaged as semi-urgent,
• 6.7% (25,746 presentations) of those triaged as urgent, and
• 3.5% (4,742 presentations) of those triaged as emergency.

This pattern was driven by presentations where the patient did not wait to be seen by a health care professional rather than where the patient left at their own risk. For example, Indigenous patients did not wait to be seen for 11% of non-urgent presentations compared with 0.5% of emergency presentations. However, the rate at which Indigenous patients left at own risk after being seen by a health care professional was relatively consistent across triage categories, and was lower for presentations categorised as non-urgent (2.3%) compared with presentations categorised as an emergency (3.1%) (Table D3.09.11, Figure 3.09.5).

Figure 3.09.5: Proportion of public emergency department presentations where Indigenous patients did not wait or left at own risk, by triage category, July 2017 to June 2019

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

From July 2017 to June 2019, by age group, the proportion of emergency department presentations where the patients did not wait or left at their own risk was highest for Indigenous Australians aged between 35–44 (12% or 17,564 presentations). Indigenous Australians aged 35–44 were also the most likely to not wait to be seen (7.6% or 11,428 presentations) but were equally as likely as those aged 25–34 to leave at their own risk (both 4.1% or 6,136 and 7,715, respectively) (Table D3.09.16).

The proportion of presentations for Indigenous Australians where the patient did not wait or left at own risk was lowest for those living in Outer regional areas (7.0% or 16,476 presentations) and highest in Very remote areas (10.1% or 12,943 presentations) (Table D3.09.13, Figure 3.09.6). Indigenous Australians living in Very remote areas were the least likely to leave at their own risk (1.7% or 2,150 presentations) but the most likely to not wait to be seen (8.4% or 10,793) (Table D3.09.13).

Figure 3.09.6: Proportion of public emergency department presentations for Indigenous Australians where the patient did not wait or left at own risk, by remoteness, July 2017 to June 2019 

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

Between July 2017 and June 2019, in emergency departments, the proportion of Indigenous Australians who did not wait to be seen or left at their own risk was highest for those living in Victoria (11% or 7,936 presentations), followed by those living in the Australian Capital Territory (10.6% or 1,064) and the Northern Territory (10.5% or 15,023) (Table D3.09.14).

Changes over time

Linear regression was used to examine trends in this data, taking into consideration information from all years available, rather than only the first and last year in the series (see Statistical terms and methods).

Between 2006–07 and 2009–10, the age-standardised proportion of hospitalisations for Indigenous Australians where the patient was discharged at their own risk remained unchanged at 4.4%, and then decreased over the subsequent decade to 2018–19 (from 4.4% to 3.8%). Conversely, the proportion of non-Indigenous Australians being discharged at their own risk increased slightly, from 0.6% to 0.7% over the decade 2009–10 to 2018–19 (Table D3.09.6, Figure 3.09.7).

When the number of hospitalisations where the patient was discharged at their own risk is expressed as a population rate (rather than as proportion of hospitalisations), between 2006–07 and 2018–19, the age-standardised rate of discharge from hospital at own risk among Indigenous Australians increased from 13 to 18 hospitalisations per 1,000 population. In the decade from 2009–10 to 2018–19, the rate increased from 14 to 18 per 1,000 population. Over this period, similar increases were observed among non-Indigenous Australians (from 1.5 to 2.2 per 1,000 population) (Table D3.09.6). The increase in the rate of discharge at own risk likely reflects an overall increase in hospitalisation rates over the same period (see measure 1.02 Top reasons for hospitalisation Table D1.02.4).

Figure 3.09.7: Age-standardised proportion of hospitalisations where the patient was discharged at their own risk (excluding dialysis) and changes in the gap, by Indigenous status, NSW, Vic, Qld, WA, SA and NT, 2006–07 to 2018–19

Note: Rate difference is the age-standardised percentage for Indigenous Australians minus the age-standardised percentage for non-Indigenous Australians. Rate ratio is the age-standardised rate for Indigenous Australians divided by the age-standardised rate for non-Indigenous Australians.

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

Looking at emergency department presentations from 2011–12 to 2018–19, the age-standardised proportion of presentations for Indigenous Australians where the patient did not wait to be seen or left at their own risk decreased from 9.1% to 8.5%. Based on linear regression, the age-standardised proportion declined by 6.5% (equivalent to 0.6 percentage points), while there was little change in the proportion for non-Indigenous Australians (Table D3.09.12, Figure 3.09.8)

For Indigenous Australians, this decline was driven by a 19% reduction in the age-standardised proportion of presentations where the patient did not wait to be seen by a health professional, while the proportion of presentations where the patient left at their own risk increased over the period (Table D3.09.12).

Figure 3.09.8: Age-standardised proportion of public hospital emergency department presentations where the patient left at their own risk/did not wait to be seen, by Indigenous status, Australia, 2011–12 to 2018–19

Note: Rate difference is the age-standardised rate (per 1,000) for Indigenous Australians minus the age-standardised rate (per 1,000) for non-Indigenous Australians. Rate ratio is the age-standardised rate for Indigenous Australians divided by the age-standardised rate for non-Indigenous Australians.

Source: Table D3.09.12. 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. Another systematic review found that gaps in the quality of health care within the Australian health system are associated with leave events among Indigenous Australians. The review findings suggest that reducing the occurrence of leave events requires better representation of Indigenous Australians in the health workforce and working in partnership with Indigenous Australians during the decision-making process to provide health services that meet Aboriginal and Torres Strait Islander cultural needs (Coombes et al. 2022).

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 the Northern Territory explored the effects of the employment of Aboriginal and Torres Strait Islander health workers on Indigenous patient experiences. In the Western Australian study, 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 Northern Territory study, the self-discharge rate fell significantly with the involvement of Aboriginal Liaison Officers in an acute care setting (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.

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 culturally safe 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 2022). 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 2022).

The National Aboriginal and Torres Strait Islander Health Plan 2021-2031 (the Health Plan), released in December 2021, recognises that acute care settings must be accessible, culturally safe and responsive to address the gaps between Indigenous and non-Indigenous experiences in hospitals including the gap in surgery procedures and wait times and the rates of early discharge or discharge against medical advice. Addressing these gaps will require hospitals to implement strategies to better deliver holistic, culturally safe and responsive models of care by improving employment of traditional health workers to provide complementary care and having care coordination pathways with Aboriginal Community Controlled Health Services to deliver care on Country.

The Health Plan is aligned with the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021–2031 (the National Workforce Plan), which aims to increase representation of Indigenous Australians in all health roles and locations across Australia. It sets an ambitious target: for Aboriginal and Torres Strait Islander people to represent 3.43% of the national health workforce by 2031. The National Workforce Plan commits governments to work in partnership with Indigenous Australians to meet this target and to foster a culturally safe and responsive health system.

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. Vol. 17 (ed., Council of Australian Governments). Canberra: AHMAC.
• AIHW (Australian Institute of Health and Welfare) 2022. Cultural safety in health care for Indigenous Australians: monitoring framework. Canberra. 
• Cohen H 2017. How Katherine Hospital, once Australia's worst for Indigenous health, became one of the best. abc. Viewed 21/02/2020.
• Coombes J, Hunter K, Bennett-Brook K, Porykali B, Ryder C, Banks M et al. 2022. Leave events among Aboriginal and Torres Strait Islander people: a systematic review. BMC Public Health 22:1488.
• 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.