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Tier 1 - Health status and outcomes

1.05 Circulatory disease

Key facts

Why is it important?

Circulatory disease is a major cause of morbidity and mortality among Australians. Circulatory disease, also known as cardiovascular disease, includes a range of conditions affecting the heart and blood vessels such as coronary/ischaemic heart disease, stroke and other cerebrovascular diseases. Circulatory disease is more common among Aboriginal and Torres Strait Islander people than non-Indigenous Australians and its onset tends to occur between 10 and 20 years younger than among non-Indigenous Australians (AIHW 2015; Bradshaw et al. 2011; Brown A. 2012; Brown Alex & Kritharides 2017; Katzenellenbogen et al. 2014). Based on self-reported data from the 2018–19 National Aboriginal and Torres Strait Islander Health Survey (Health Survey), Indigenous Australians aged 2–14 years were twice as likely as non-Indigenous Australians of the same age to have a heart or circulatory condition (2.0% compared with 0.9%).

Risk factors such as physical inactivity, obesity, diabetes, high blood pressure and tobacco smoking are more prevalent among Indigenous Australians than non-Indigenous Australians (Gray et al. 2012). Tobacco smoking levels are high among Indigenous adults, although rates have declined in recent years (see measure 2.15 Tobacco use). Acute rheumatic fever and rheumatic heart disease (RHD) are preventable diseases affecting disadvantaged populations. There are high rates of these diseases among Indigenous Australians, particularly among young people, and RHD accounts for 5.1% of the circulatory disease burden for Indigenous Australians (AIHW 2016) (see measure 1.06 Acute rheumatic fever and rheumatic heart disease). Low socioeconomic status is associated both with greater risk of developing circulatory disease and with lower chance of receiving appropriate treatment (Beard et al. 2008; Cunningham 2010).

Burden of disease

In 2011, circulatory diseases were the third leading contributor to the total disease burden for Indigenous Australians (12%) and the leading cause of the gap in disease burden between Indigenous and non‑Indigenous Australians (19% of the total gap).

Coronary heart disease contributes 7.2% to the burden of disease and is the most common contributor for Indigenous males (9%), and the second most common contributor for Indigenous females (5%). Coronary heart disease is the most common cause of the burden of disease for Indigenous Australians aged 45–65 (16%), 65–74 (14%) and 75 and over (14%). Having a stroke is the fifth leading contributor to the burden of disease for Indigenous Australians aged 75 and over (6%) (AIHW 2016).

Findings

What does the data tell us?

Deaths from circulatory diseases

In 2014–2018, circulatory diseases were a leading cause of death for Indigenous Australians (23% of total deaths, or 3,319 deaths). After adjusting for differences in the age structure between the two populations, the circulatory disease death rate for Indigenous Australians was 1.5 times the rate for non-Indigenous Australians (230 per 100,000 compared with 158 per 100,000). Data are reported for the five jurisdictions with Indigenous identification data of adequate quality (New South Wales, Queensland, Western Australia, South Australia and the Northern Territory) (Table D1.23.1).

The leading causes of death from circulatory diseases for Indigenous Australians were ischaemic heart disease, with 1,869 deaths (56%), and cerebrovascular disease, with 500 deaths (15%) (Table D1.23.8).

For Indigenous Australians, there was a decline (61%) in deaths from circulatory diseases between 1998 and 2018. The gap between Indigenous and non-Indigenous Australians significantly narrowed from 251 to 88 per 100,000. Importantly, unlike some other mortality indicators, there has been progress since 2006. From 2006 to 2018 there was a 33% decline in Indigenous Australian mortality rates from circulatory disease (Table D1.23.18, Figure 1.05.1).

 

Figure 1.05.1: Age-standardised mortality rates, circulatory diseases, by Indigenous status, NSW, Qld, WA, SA and NT, 1998–2018

This line graph shows that the mortality rate from circulatory diseases for Indigenous Australians decreased from 543 per 100,000 in 1998 to 229 per 100,000 in 2018. For non-Indigenous, the rate decreased from 292 to 141 per 100,000. The gap decreased from 251 to 88 per 100,000.

Source: Table D1.23.18. AIHW and ABS analysis of the ABS Causes of Death Collection.

Hospitalisation from circulatory diseases

From July 2015 to June 2017, after adjusting for differences in the age structure between the two populations, the hospitalisation rate for circulatory diseases for Indigenous Australians (32 per 1,000) was 1.6 times the rate for non‑Indigenous Australians (20 per 1,000) (Table D1.05.7).

Hospitalisation rates for circulatory diseases were higher for Indigenous Australians than non-Indigenous Australians across all age groups (Figure 1.05.2). The rates were similar for Indigenous males and Indigenous females (both 18 per 1,000). For non‑Indigenous Australians, rates were higher for males (27 per 1,000) compared with females (19 per 1,000) (Table D1.05.6).

Figure 1.05.2: Age-specific hospitalisation rates for a principal diagnosis of circulatory disease, by Indigenous status and age, Australia, July 2015 to June 2017

This bar chart shows that the hospitalisation rate for circulatory diseases increased with age for Indigenous and non-Indigenous Australians and rates were higher for Indigenous Australians in all age groups. For Indigenous Australians aged 0–4 the rate was 2 per 1,000 and for those aged 65 and over the rate was 111 per 1,000. For non-Indigenous Australians aged 0-4 the rate was 1 per 1,000 and for those aged 65 and over the rate was 100 per 1,000.

Source: Table D1.05.6. AIHW analysis of National Hospital Morbidity Database.

After adjusting for differences in the age structure between the two populations, the hospitalisation rate for circulatory diseases for Indigenous Australians varied from 25 per 1,000 in Major cities to 44 per 1,000 in Very remote areas. For non-Indigenous Australians, the rate was highest in Outer regional areas (21 per 1,000) (Table D1.05.8). Hospitalisation rates for circulatory diseases for Indigenous Australians also varied by jurisdiction, the lowest was 16 per 1,000 in Tasmania, and the highest was 48 per 1,000 in the Northern Territory. For non-Indigenous Australians, the rates were lowest in Tasmania (15 per 1,000) and highest in the Northern Territory (25 per 1,000) (Table D1.05.7).

There was a 19% increase in the hospitalisation rate for circulatory diseases for Indigenous Australians in the period from 2004–05 to 2016–17. This was for the six jurisdictions with Indigenous identification data of adequate quality (New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory) (Table D1.05.11, Figure 1.05.3).

Figure 1.05.3: Age-standardised hospitalisation rates for a principal diagnosis of diseases of the circulatory system, NSW, Vic, Qld, WA, SA and NT, 2004–05 to 2016–17

This line graph shows that for Indigenous Australians, the hospitalisation rate for circulatory diseases increased from 27 per 1,000 to 33 per 1,000, while for non-Indigenous Australians the rate was steady at around 20 per 1,000, however dopped to 18 per 1,000 in 2013-14 and 2014-15. The gap between Indigenous and non-Indigenous Australians increased from 6 per 1,000 to 13 per 1,000.

Source: Table D1.05.11. AIHW analysis of National Hospital Morbidity Database.

The leading causes of hospitalisation for circulatory diseases for Indigenous Australians were ischaemic heart diseases (12 per 1,000), and pulmonary and other heart diseases (11 per 1,000) (Table D1.05.9, Figure 1.05.4).

Diabetes and kidney disease are common comorbidities for circulatory diseases. In 2012–13, the hospitalisation rate for Indigenous Australians was 7.3 times the rate for Other Australians (people who have declared they are non-Indigenous and those whose Indigenous status is unknown) when all three diseases were present. Indigenous females were 11 times as likely as Other Australian females to have all 3 diseases (4,684 and 437 per 100,000, respectively) and Indigenous males were 5 times as likely as Other Australian males to have all 3 diseases (3,904 and 777 per 100,000 respectively) (AIHW 2014).

Figure 1.05.4: Age-standardised hospitalisations of Indigenous Australians for a principal diagnosis of diseases of the circulatory system, Australia, July 2015 to June 2017

This bar chart shows that the major circulatory diseases responsible for Indigenous Australians being hospitalised were for ischaemic heart diseases (11.7 per 1,000) and pulmonary heart disease and other forms of heart diseases (11.2 per 1,000); followed by cerebrovascular diseases (3.3 per 1,000) and hypertensive diseases (0.9 per 1,000).

Source: Table D1.05.9. AIHW analysis of National Hospital Morbidity Database.

Indigenous Australians who were hospitalised for coronary heart diseases were 80% as likely to receive a coronary angiography (a diagnostic procedure) than non-Indigenous Australians (44% compared with 54%), and 73% as likely to receive a revascularisation procedure (surgical procedure to restore blood supply to the heart) (23% compared with 32%) (see measure 3.06 Access to hospital procedures) (Table D3.06.9).

The proportion of Indigenous adults hospitalised for a heart attack who received an angiography or revascularisation procedure increased from 32% in 2004–05 to 58% in 2016–17. However, this was still lower than the proportion for non-Indigenous Australians in 2016–17 (67%) (AIHW 2019a).

General Practitioner reported data

Based on the Bettering the Evaluation and Care of Health (2010–15) survey data, 8% of the total problems managed by General Practitioners (GPs) for Indigenous Australians were for circulatory conditions. The most common circulatory problems managed for Indigenous Australians were related to high blood pressure (3.6%).

After adjusting for differences in the age structure between the two populations, the rate of problems managed by GPs relating circulatory conditions were 182 per 1,000 for Indigenous Australians, compared with 168 per 1,000 for Other Australians. The rate of problems managed by GPs relating to high blood pressure were similar—83 per 1,000 encounters for Indigenous Australians and 85 per 1,000 for Other Australians. However, rates were higher for Indigenous Australians than Other Australians for GPs managing problems relating to ischaemic heart disease (1.5 times—17 and 11 per 1,000, respectively) and heart failure (1.7 times—11 and 6 per 1,000, respectively).

Indigenous Australians were less likely than Other Australians to attend a GP for a cardiac check-up (0.6 times—6 and 10 per 1,000, respectively), and saw a GP for atrial fibrillation/flutter (irregular or rapid heart rate) at similar rates to Other Australians (both 14 per 1,000) (Table D1.05.5).

Findings from ABS survey data

Based on self-reported data from the 2018–19 Health Survey, 16% of Indigenous Australians aged 2 and over had a circulatory condition, compared with 11% in 2001 (Table D1.05.1). Indigenous Australians were 1.5 times as likely as non-Indigenous Australians to report having a circulatory condition (23 and 15 per 100, respectively).

Self-reported rates for heart and circulatory conditions increased with age and the greatest relative difference between Indigenous and non-Indigenous Australians was for those aged 2–14 (2.2 times higher for Indigenous Australians) and 25–54 (1.9–2.1 times higher for Indigenous Australians) (Table D1.05.2, Figure 1.05.5).

Figure 1.05.5: Persons (aged 2 and over) reporting heart or circulatory conditions, by Indigenous status and age, 2018–19

This bar chart shows that the rate of self-reported circulatory conditions was higher for Indigenous Australians than non-Indigenous Australians in all age groups. For Indigenous Australians aged 2-14 the rate was 2 per 100 and increased with age to 56 per 100 for those aged 55 and over. For non-Indigenous Australians the rate was 1 per 100 for those aged 2-14 and increased to 44 per 100 for those aged 55 and over.

Source: Table D1.05.2. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19 and National Health Survey 2017–18.

Circulatory conditions were more commonly reported by Indigenous females (17%) than Indigenous males (14%) (Table D1.05.1).

Indigenous Australians living in Remote areas (18%) reported higher rates of circulatory diseases, compared with those in Non-remote areas (15%) (Table D1.05.1). After adjusting for differences in age structure between the two populations, rates of circulatory conditions also varied by jurisdiction, with the lowest rate in Victoria (20 per 100), and the highest in the Northern Territory (25 per 100) (Table D1.05.2, Figure 1.05.6).

Figure 1.05.6: Australians aged 2 and over reporting heart/circulatory conditions, by Indigenous status and jurisdiction, 2018–19

This bar chart shows that, nationally, 23 per 100 Indigenous Australians and 15 per 100 non-Indigenous Australians reported having heart or circulatory conditions. The lowest rate for Indigenous Australians was in Victoria at 20 per 100 and highest in the Northern Territory at 25 per 100. For non-Indigenous Australians, the highest rate was in Tasmania and the Australia Capital Territory at 17 per 100 and the lowest rate was in the Northern Territory at 11 per 100.

Source: Table D1.05.2. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19 and National Health Survey 2017–18.

Based on the ABS Socio-Economic Indexes for Areas (SEIFA) 2016, Indigenous Australians who were aged 15 and over and living in the most disadvantaged areas (1st quintile) were 3 times as likely to report having circulatory conditions as those in the most advantaged areas (5th quintile) (23% compared with 8%). Indigenous Australians were also more likely to report having a circulatory condition if they completed schooling to Year 9 (33%) compared with those who completed Year 12 (17%) (Table D1.05.3).

In 2018–19, of Indigenous Australians self-reporting circulatory conditions, 56% reported also having diabetes and 72% reported also having kidney disease (Table D1.05.3). Results from the 2018–19 Health Survey showed that 75% of Indigenous adults whose blood pressure was measured as high had not reported this to be the case (see measure 1.07 High blood pressure) (Table D1.07.2).

The 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey measured selected biomedical risk factors for Indigenous adults. Of the estimated 91,500 (25%) Indigenous adults who had measured abnormal cholesterol levels, 91% had self-reported that they did not have high cholesterol levels (ABS 2014).

What do research and evaluations tell us?

An examination of evidence on differences in ischaemic heart disease outcomes among Australians between Major cities, Regional and Remote areas of Australia found there was a consistently higher burden observed outside Major cities. However, within Indigenous Australian populations fewer differences by remoteness were observed and some ischaemic heart disease outcomes were not associated with remoteness (Alston et al. 2017).

A Northern Territory study found there was an increase in incidence of acute myocardial infarction between 1992 and 2004, and that over the same period there occurred an improvement in all-cases survival (with and without hospital admission) among Indigenous Australians (You et al. 2009). Another Northern Territory study found that Indigenous Australians were less likely than non‑Indigenous patients to receive in-patient cardiac rehabilitation, prescription of statins on discharge, and were more likely to die in the two years after discharge (Brown A. 2010). Qualitative evidence on the experience of Indigenous patients in Alice Springs identified barriers to care across the care continuum. Brown (2010) concluded that improvements to the delivery of treatments known to be effective would make a significant impact on adverse outcomes (Brown A. 2010). Randall and others (2013) reported that over the period 2000 to 2008, Indigenous Australians in New South Wales had a 37% lower rate of revascularisation in the 30 days after admission with myocardial infarction compared with non-Indigenous Australians (Randall et al. 2013). This disparity was largely due to the hospital of first admission (there were lower revascularisation rates for all patients admitted to smaller Regional and Remote hospitals), a higher comorbidity burden for Indigenous patients and lower rates of private health insurance for Indigenous patients. Patients admitted to smaller more remote hospitals without onsite angiography had increased risk of short-term and long-term mortality (Randall et al. 2012). A study in Western Australia also found gaps in access to cardiac rehabilitation and secondary prevention services for Indigenous Australians (Hamilton et al. 2016). Referral and attendance at cardiac rehabilitation services varied greatly across Western Australia, with lack of referral and enrolment related to a drive time of over 60 minutes to services. Alternative methods of delivery such as home based cardiac rehabilitation via telehealth or mobile health platforms may overcome geographical isolation.

There is evidence the Aboriginal Community Controlled Health Services (ACCHS) primary health-care model has contributed to improved cardiovascular health outcomes for Indigenous Australians (Campbell et al. 2018). Analysis of cardiovascular morbidity and mortality from 1995 to 2004 in a Northern Territory community where the sole provider of health care is an ACCHS found that, compared to all Indigenous Australians in the Northern Territory, the community had lower mortality from all causes and from cardiovascular disease and lower rates of hospitalisation with cardiovascular disease as a primary cause (Rowley et al. 2008). There was also a lower prevalence of diabetes, hypertension, obesity and smoking in the community. Rowley and others (2008) concluded that a likely contributor was the nature of the primary health-care services provided by the ACCHS, including regular outreach to outstation communities. A cardiovascular and pulmonary rehabilitation program designed and provided by an ACCHS in Tasmania to Indigenous Australians with diagnosed chronic heart or respiratory disease or at high risk of developing such conditions was evaluated for the period October 2011 to July 2013 (Davey et al. 2014). The evaluation found that the program increased participation in rehabilitation and led to positive changes in health behaviours, exercise capacity and health related quality of life. Other examples of cardiovascular programs successfully run and monitored by ACCHSs include the Torpedo study, a randomised controlled trial of the use of an electronic decision-support system measuring absolute cardiovascular risk which showed ACCHSs outperforming general practices in managing risk (Panaretto K.S. et al. 2014; Peiris et al. 2012). Data for the 12 months to May 2012 showed ACCHSs had more patients with high cardiovascular risk being prescribed best practice medications compared with general practices (Panaretto Kathryn S et al. 2012; Panaretto K.S. et al. 2014).

A new cohort study of Indigenous and non-Indigenous Australian adults living in remote and urban Australia aims to re-examine systems for the assessment of cardiovascular risk, because current risk assessment techniques are imperfect and there are significant deficiencies in prediction tools (Rémond et al. 2017). The study aims to improve the understanding of factors behind the greater burden of cardiovascular disease among Indigenous Australians, inform the development of more accurate tools for cardiovascular disease risk prediction, and provide a future resource to facilitate early evaluation of new treatments to prevent and manage cardiovascular disease. Framingham risk models and equations are widely used and advocated in guidelines for predicting 10-year risk of developing cardiovascular disease, and there is mounting evidence that local tailoring is often needed to make accurate predictions (Damen et al. 2019). In Australia, clinical guidelines recommend using the 1991 Framingham model developed in the United States, and an updated sex-specific model was published in 2008 (Hua et al. 2017). A study conducted in remote Indigenous communities in Far North Queensland suggested that the 1991 and 2008 Framingham models for assessing cardiovascular risk underestimated the risk by about one-third (Hua et al. 2017). Agostino and others (2020) note that the findings of this and similar studies may not apply to all Indigenous Australians, but indicate that the presence of non-Framingham risk factors (including socioeconomic disadvantage) need to be considered. A longitudinal study in the Northern Territory found that aspirin as a primary prevention may reduce all-cause mortality in Indigenous patients from remote communities who have high cardiovascular risk, while emphasising the need to carefully consider each decision on a case-by-case basis (Zhao Yuejen et al. 2020).

There are limited examples of evaluation in cardiovascular disease management for Indigenous Australians. The Work It Out program, a chronic condition self-management group program, was evaluated for its effect on clinical outcome measures in urban Indigenous Australian adult participants with, or at risk of, cardiovascular disease (Mills et al. 2017). The program ran over 12 weeks, and clients could participate in two or more Work It Out sessions a week, with flexibility for participants to miss sessions due to family and community responsibilities and return to the program at a later date. A Work It Out session consisted of a yarning education session delivered in a culturally-safe environment by a health professional, followed by an individually tailored exercise program undertaken in a group setting. There were 85 eligible participants, recruited from a population with or at risk of chronic disease who attended one of six participating ACCHS in Southeast Queensland between 2012 and 2014. This evaluation found that several measures improved over the short-term, these being increased distance travelled in the six minute walk test; a reduction in weight for participants with extreme obesity; and decreases in systolic blood pressure. These improvements occurred in measures that were more responsive to exercise and behaviour change within shorter time periods, and could be indicative of improvement in other clinical outcome measures over the longer term. The evaluation also noted increased benefits in particular for participants experiencing numerous social and emotional wellbeing conditions, which requires further investigation.

In the 2018–19 Health Survey, 5.2% of Indigenous Australians self-reported they had ‘Heart, stroke and vascular disease’ (ABS 2019). In 2015–2017, there were 2,375 hospitalisations of Indigenous Australians with stroke as the principal diagnosis, 8.3% of hospitalisations with a principal diagnosis of circulatory diseases. The age standardised hospitalisation rate for stroke was 3 per 1,000 for Indigenous Australians. In 2014–2018, 12.2% of the 3,319 deaths from circulatory diseases of Indigenous Australians in New South Wales, Queensland, Western Australia, South Australia and the Northern Territory combined were caused by stroke. The age standardised death rate due to stroke for Indigenous Australians was 34.5 per 100,000. Studies in the Northern Territory showed survival for stroke has improved among both non-Indigenous and Indigenous Australians over time, from 1999–2011 in You and others (2015) (You et al. 2015); and from 1992–2013 in Zhao and others (2015) (Zhao Y. et al. 2015). However, the incidence rate has not changed for both non-Indigenous and Indigenous Australians in the Northern Territory from 1999–2011 (You et al. 2015). Another Northern Territory study of avoidable mortality for Indigenous Australians between 1985 and 2004 found improvements in conditions amenable to medical care but marginal improvement for conditions responsive to preventative measures. The study noted the reduction of deaths from stroke was consistent with improved drug therapies and intensive care, dedicated stroke units and surgical procedures (Li et al. 2009).

A study of data from hospitals participating in the National Stroke Audit of acute services in 2009 found that Indigenous patients with stroke received a reduced quality of care in hospitals and experienced worse outcomes than non-Indigenous patients (Kilkenny et al. 2013). Indigenous patients were less likely than non-Indigenous patients to be treated in a stroke unit and to receive timely allied health assessments. A more recent study of patients presenting to a New South Wales rural referral hospital with ischaemic stroke found that investigation and post-discharge care of Indigenous patients was inferior to non-Indigenous patients (Tiedeman et al. 2019). Indigenous patients were less likely than non-Indigenous patients to have investigations completed, including carotid imaging, and to receive follow up after discharge. This study provides further evidence of the need for change within the health care system, with clinical assessments and service accessibility needing further attention to ensure that stroke intervention and prevention services are optimised for Indigenous Australians by taking account of cultural, social and environmental factors during treatment (Blacker & Armstrong 2019).

Implications

In recent decades, Indigenous mortality rates from circulatory disease have fallen, due to reduced smoking; improved management of high blood pressure and heart disease; and improved treatments for heart attack and stroke. However, circulatory disease remains one of the leading causes of death for Indigenous Australians and high rates of obesity, diabetes and chronic kidney disease threaten to slow or reverse these improvements. This suggests further progress is needed on preventative measures including physical activity, tobacco and alcohol use, and nutrition, as well as improving access to primary health care for timely screening, diagnosis and management of disease, and appropriate treatment in the hospital system.

Cardiovascular disease occurs among Indigenous Australians from a younger age, between 10 and 20 years younger than among other Australians (Brown Alex & Kritharides 2017). A number of organisations, including the Royal Australian College of General Practitioners and National Aboriginal Community Controlled Health Organisation, have issued a joint recommendation that Indigenous adults should undergo cardiovascular risk factor screening from age 18 years at the latest (Agostino et al. 2020). A study conducted between 2010 and 2012 in Australian primary health-care centres showed the importance of raising awareness and assessment of cardiovascular and diabetes risk in young Indigenous Australians and implementing preventive health-care strategies (Crinall et al. 2017). This study showed that while risk factors were being assessed, follow-up of abnormal results was undertaken less thoroughly. There is an opportunity to engage with primary health-care centres to strengthen their capacity to provide preventative health care for young people at risk of cardiovascular disease. This may contribute to reducing the chronic disease burden experienced by Indigenous young people. Agostino and others (2020) also recommend that assessment using the National Vascular Disease Prevention Alliance absolute cardiovascular disease risk assessment algorithm should commence from age 30 at the latest. This algorithm assesses whether patients have these clinical conditions:

  • type 2 diabetes and aged over 60 years
  • type 2 diabetes and microalbuminuria (defined as albumin excretion rate > 20 μg/min or urinary albumin to creatinine ratio [ACR] > 2.5 mg/mmol for males and > 3.5 mg/mmol for females)
  • moderate to severe chronic kidney disease
  • systolic blood pressure of 180 mmHg or greater or diastolic blood pressure of 110 mmHg or greater
  • previous diagnosis of familial hypercholesterolaemia; or
  • serum total cholesterol greater than 7.5 mmol/L.

Patients with any of these conditions are assessed as being at high absolute risk of a future cardiovascular disease event. For other patients the Framingham risk equation is used to calculate their risk of an event in the next five years.

Hospitalisation rates for circulatory disease were higher among Indigenous Australians and the increase in rates over the last 14 years may indicate improved access to care. However despite these improvements Indigenous Australians were still less likely to receive coronary procedures when in hospital than non-Indigenous Australians. While this is partly due to factors like co-morbidities and the treatments available at specific hospitals, there may also be systematic differences in treatment for patients identified as Indigenous, and Indigenous patients may face health-care providers who lack cultural competency training, suggesting improvements in this area are needed (National Heart Foundation of Australia & Australian Healthcare & Hospitals Association 2010).

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 which are fundamental to improving access to quality and effective health care and improve health outcomes for Indigenous Australians. There has been a longstanding commitment by Australian governments to enable this. The Cultural Respect Framework 20162026 plays a key role in reaffirming this commitment and provides a nationally consistent approach (AHMAC National Aboriginal and Torres Strait Islander Health Standing Committee (2016) 2017). The Aboriginal and Torres Strait Islander Health Performance Framework plays a role in monitoring this commitment across several measures (see measure 3.08 Cultural competency). 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 2019c). The 2019 Cultural safety report showed that 84% of Indigenous primary health-care providers had mechanisms to gain advice on cultural matters, while noting the lack of data available for reporting on the policies and practices of mainstream health services (AIHW 2019c). This lack of data presents a challenge to ensuring the availability of culturally safe and effective health services for Indigenous Australians. Walsh and others (2017) note that a better understanding of the factors contributing to the high burden of cardiovascular disease experienced by Indigenous Australians and potential mitigation strategies can assist clinicians in providing care to Indigenous Australians (Walsh & Kangaharan 2017). This includes understanding of cardiovascular disease presentations, realistic and patient-centric management approaches, and support mechanisms applicable to Indigenous communities. Low take-up of private health insurance may also be a factor, with research indicating that, after adjusting for other factors, the strongest association with coronary angiography rates was admissions to private hospitals (Chew et al. 2016; Hua et al. 2017). This presents a barrier to access for Indigenous Australians.

The Lighthouse Hospital Project, funded through the Indigenous Australians’ Health Programme, and run by the Heart Foundation aims to drive systemic change in the acute care sector to change the way hospitals and health services are governed, organised, structured and staffed to address institutional racism and improve care and outcomes for Indigenous Australians who experience acute coronary syndrome (ACS) (Heart Foundation 2020; Verhoeven 2018). It is designed to improve governance, clinical quality, and cultural competence of the health workforce. Each hospital in the program receives the Lighthouse Toolkit, which includes a plan, action areas, quality improvements, and outlines ways hospitals can provide culturally appropriate and clinically competent care for Indigenous Australians and their families. In 2017 phase three expanded the project to 18 hospitals across Australia. The evaluation of phase three of the project highlighted that more than three-quarters of Indigenous Australians with ACS surveyed in Lighthouse Hospitals rated their hospital experience as ‘very good’ or ‘good’.

The National Recommendations from the May 2014 Better Cardiac Care for Aboriginal and Torres Strait Islander People Post-Forum Report focus on five priority areas for action by all jurisdictions, including: early cardiovascular risk assessment and management; timely diagnosis of heart disease and heart failure; guideline-based therapy for acute coronary syndrome; optimisation of health status and provision of ongoing preventive care; and strengthening the diagnosis, notification and follow-up of rheumatic heart disease. The fourth Better Cardiac Care report 2018–19 shows progress against 14 of the 21 recommended indicators, for which updated data were available. There has been improvement across many indicators, such as an increase in the proportion of Indigenous Australians who received Medicare-funded 715 or other ‘general’ health assessments. However, there are still challenges in some areas, for example, Indigenous Australians with suspected or confirmed cardiac disease are less likely than non-Indigenous Australians to be reviewed by a specialist (AIHW 2019b). Barriers to specialist care in Regional and Remote areas need to be better understood and overcome (Brown Alex & Kritharides 2017).

The policy context is at Policies and strategies.

References

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