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Tier 1 - Health status and outcomes

1.23 Leading causes of mortality

Key facts

Why is it important?

Analysis of leading causes of death can provide insights into the overall health status of different populations, provide a better understanding of the contributing factors, and indicate areas needing policy focus.

Over the period 2014–2018, the all causes age-standardised mortality rate for Aboriginal and Torres Strait Islander people was 1.6 times the rate for non‑Indigenous Australians (917 and 567 deaths per 100,000 population, respectively). Disparities between the Indigenous Australian population and the non-Indigenous Australian population for particular causes of death can provide insight into where policy attention is needed to close the gap.

As the health status of Indigenous Australians improves, premature deaths are expected to decrease over-time.

This measure provides a high-level exploration of leading causes of death which are explored in further detail within subject specific measures within Tier 1 of the Health Performance Framework. The types of diseases causing the most deaths for both Indigenous and non-Indigenous Australians are similar, although occurring at different rates. However, there have been different patterns in the trends for individual causes over time.

The impact of chronic disease is important, which is estimated to be responsible for 70% of the health gap (AIHW 2016). However, some significant health problems will not be reflected in mortality statistics; many conditions that cause serious health problems may not be fatal (such as depression, arthritis and disability) and so do not appear as common causes of death.

Improvements in data quality and changes in the identification of Indigenous status in deaths registrations, as well as the census-based population estimates (used as denominators for calculating mortality rates) have a major bearing on the interpretation of the findings. Mortality rates over the period 1998 to 2006 may be less reliable than rates since 2006, as the reliability of the population estimates used in the statistics lessens the further away the time series moves from the 2016 Census upon which they are based (Dt 2020). This will impact trends differently depending on the cause of death. For some causes of death this may have the effect of overstating early improvements in death rates, while the more recent trends, based on more reliable data, may indicate less progress. This is a significant concern for policy and efforts to close the gap which had sought greater improvement over the past decade.

The mortality time series data tables, available on this website, provide trend analysis pre-2006 and post‑2006 as well as the overall trend in order to illustrate these changes. (For indicators that relate to child mortality, the trend analysis pivots on 2008, which was the baseline year for the now expired target to halve the gap in child mortality rates by 2018.)

The recently established National Agreement on Closing the Gap has identified the importance of making sure Indigenous Australians enjoy long and healthy lives, and that they enjoy high levels of social and emotional wellbeing. This includes specific outcomes, targets and indicators to direct policy attention and monitor progress in areas such as the leading causes of death. Reporting arrangements for the new agreement are being established. The data presented in this report predates the establishment of the Agreement.

Findings

What does the data tell us?

The leading causes of death for Indigenous Australians were: neoplasms (including cancer) (23% of all deaths), circulatory diseases (for example, heart attack) (23%), external causes (for example injury and suicide) (15%), respiratory diseases (9%), and endocrine, metabolic and nutritional disorders (including diabetes) (9%) (Table D1.23.1, Figure 1.23.1). The pattern of the leading causes of deaths of Indigenous Australians were similar across jurisdictions and remoteness areas (Table D1.23.2, Table D1.23.30).

Data on the leading causes of death are available for the period 2014–2018, in five jurisdictions with Indigenous identification data of adequate quality (New South Wales, Queensland, Western Australia, South Australia and the Northern Territory).

Figure 1.23.1: Causes of mortality among Indigenous Australians, NSW, Qld, WA, SA and NT, 2014–2018

The bar chart shows that the top 5 causes of deaths among Indigenous Australians were neoplasms (23%), circulatory diseases (23%), external causes (15%), respiratory diseases (9%) and endocrine, nutritional and metabolic disorders (9%).

Source: Table D1.23.1. AIHW and ABS analysis of the ABS Causes of Death Collection.

For Indigenous Australians aged 44 and under, the leading cause of death was due to external causes, including suicide, injury and poisoning. For those aged 45–54 and 75 and over, the leading cause was circulatory diseases, and for those aged 55–74 it was neoplasms (Table D1.23.3).

Leading causes of mortality gaps

After adjusting for differences in the age structure between the two populations, circulatory diseases accounted for the largest gap in mortality rates between Indigenous and non‑Indigenous Australians (gap of 72 per 100,000). This was followed by endocrine, metabolic and nutritional disorders (including diabetes) (gap of 65 per 100,000); neoplasms (including cancer) (gap of 58 per 100,000); and respiratory diseases (gap of 52 per 100,000) (Table D1.23.2, Figure 1.23.2).

Figure 1.23.2: Gap of age-standardised leading causes of mortality between Indigenous and non-Indigenous Australians, NSW, Qld, WA, SA and NT, 2014–2018

This bar chart that the largest gap in mortality between Indigenous and non-Indigenous Australians was for circulatory diseases with a gap of 72 per 100,000, followed by endocrine, metabolic and nutritional disorders (including diabetes) (65 per 100,000); neoplasms (including cancer) (58 per 100,000); and respiratory diseases (52 per 100,000).

Source: Table D1.23.2. AIHW and ABS analysis of the ABS Causes of Death Collection.

The leading cause contributing to the gap was circulatory diseases in Western Australia, South Australia and the Northern Territory, in New South Wales it was respiratory diseases and in Queensland it was neoplasms (Table D1.23.2).

In Remote areas, circulatory diseases contributed the biggest gap in mortality rates between Indigenous and non-Indigenous Australians (gap of 178 per 100,000). In Non-remote areas respiratory diseases and circulatory diseases were the leading causes (both with gap of 41 per 100,000) (Table D1.23.30).

Deaths due to external causes

For Indigenous Australians, 15% of deaths were due to external causes (Table D1.23.1). The leading causes of death due to external causes were suicide (37%), transport accidents (19%), accidental poisoning (17%) and assault (8%) (Table D1.23.10, Figure 1.23.3). Around 74% of these deaths were for people aged between 15 and 49 (Table D1.23.11).

For non-Indigenous Australians, external causes made up 6% of all deaths (Table D1.23.1). The leading external causes of death for non-Indigenous Australians were suicide (29%), accidental falls (22%) and transport accidents (14%) (Table D1.23.10).

Figure 1.23.3: Deaths from external causes (injury and poisoning), Indigenous Australians, NSW, Qld, WA, SA and NT, 2014–2018

This bar chart shows that the top 3 leading causes were intentional self-harm, which caused 37% of deaths from external causes, transport accidents (19%), and accidental poisoning (17%).

Source: Table D1.23.10. AIHW and ABS analysis of the ABS Causes of Death Collection.

Leading causes of death over time

Between 1998 and 2018, circulatory diseases had one of the largest declines in deaths for both Indigenous Australians and non-Indigenous Australians. After adjusting for differences in the age structure between the two populations, over this period, there was a decline of 61% in death rates due to circulatory diseases for Indigenous Australians, and a 50% decline for non-Indigenous Australians. This resulted in a decrease in the age-standardised gap (79%) in circulatory disease death rates, including a decrease of 34% between 2006 and 2018 (Table D1.23.18).

For both Indigenous and non-Indigenous Australians, after adjusting for differences in the age structure between the two populations, circulatory diseases had the highest age-standardised death rates in 1998 (543 and 292 per 100,000, respectively). In 2018, neoplasms (including cancer) was the leading cause of death for both Indigenous and non-Indigenous Australians (235 and 162 per 100,000, respectively), followed by circulatory diseases (229 and 141 per 100,000, respectively) (Table 1.23-1).

Table 1.23-1: Ranking of mortality rates for selected diseases, by Indigenous status, NSW, Qld, WA, SA and the NT, 1998–2018

Ranking

Indigenous 1998

Non-Indigenous 1998

Indigenous 2018

Non-Indigenous 2018

1

Circulatory diseases

Circulatory diseases

Neoplasms
(including cancer)

Neoplasms
(including cancer)

2

Neoplasms
(including cancer)

Neoplasms
(including cancer)

Circulatory diseases

Circulatory diseases

3

Respiratory diseases

Respiratory diseases

Respiratory diseases

Respiratory diseases

4

Diabetes

External causes
(injury and poisoning)

External causes
(injury and poisoning)

External causes
(injury and poisoning)

5

External causes
(injury and poisoning)

Diabetes

Diabetes

Diabetes

6

Kidney diseases

Kidney diseases

Kidney diseases

Kidney diseases

Source: Tables D1.23.18, D1.23.19, D1.23.20, D1.23.21, D1.23.22, D1.23.23.

For death rates due to kidney diseases, there was a decrease in both the death rate for Indigenous Australians, and the gap between Indigenous and non-Indigenous Australians over the period 1998 to 2018 (61% and 76%, respectively). Between 2006 and 2018, death rates for kidney diseases decreased by 61% and the gap between Indigenous and non-Indigenous Australians decreased by 73% (Table D1.23.23).

Between 1998 and 2018, there was a 33% decline in the death rate due to respiratory diseases for Indigenous Australians. The trend in death rates for respiratory diseases is driven by a decline (34%) between 1998 and 2006, whereas between 2006 and 2018 rates did not change significantly. While the gap in death rates from respiratory disease between Indigenous and non-Indigenous Australians narrowed between 1998–2006, there was no significant change in the gap between 2006–2018 (Table D1.23.21).

Between 1998 and 2018, there was a decrease (31%) in Indigenous deaths due to diabetes, and a 39% decrease in the mortality gap between Indigenous and non-Indigenous Australians. This was partly due to an increase in the mortality rate due to diabetes for non-Indigenous Australians, as well as a decrease in the mortality rate for Indigenous Australians (Table D1.23.22).

Since 2006, after adjusting for differences in the age structure between the two populations, there has been an increase in the age-standardised gap in deaths between Indigenous and non-Indigenous Australians due to neoplasms (including cancer) (260%) (Table D1.23.19, Table D1.23.20, Figure 1.23.4).

Data on the leading causes of death are available for the period 2014–2018, in the five jurisdictions with Indigenous identification data of adequate quality (New South Wales, Queensland, Western Australia, South Australia and the Northern Territory).

Figure 1.23.4: Age-standardised mortality rates for selected causes of death, by Indigenous status, NSW, Qld, WA, SA and NT, 1998 to 2018

This figure has 6 line charts presenting age-standardised mortality rates for selected causes of death. The mortality rate from circulatory diseases decreased from 543 per 100,000 in 1998 to 229 per 100,000 in 2018 for Indigenous Australians, and from 292 to 141 for non-Indigenous Australians. The mortality rate from cancer increased from 221 to 235 per 100,000 for Indigenous Australians, and decreased from 195 to 162 for non-Indigenous. The mortality rate from respiratory diseases for Indigenous decreased from 160 per 100,000 in 1998 to 82 in 2008, and then increased to 109 per 100,000 in 2018, for non-Indigenous Australians, it varied between 47 to 58 per 100,000.  The mortality rate from external causes (injury and poisoning) decreased from 90 in 1998 to 73 per 100,000 in 2018 for Indigenous, and varied between 37 and 44 for non-Indigenous Australians. The mortality rate from diabetes, after a peak in 2000 (121 per 100,000), decreased to 72 in 2018 for Indigenous Australians, and ranged from 13 to 17 for non-Indigenous.  The mortality rate from kidney diseases decreased from 49 in 1998 to 20 per for Indigenous, and from 11 to 8 for non-Indigenous.

Source: Tables D1.23.18, D1.23.19, D1.23.20, D1.23.21, D1.23.22, D1.23.23. AIHW and ABS analysis of the ABS Causes of Death Collection.

Table 1.23-2: Detailed causes of death for circulatory diseases, cancer and respiratory disease, by sex, Indigenous Australians, NSW, Qld, WA, SA and the NT, 2014–2018

Circulatory diseases

Male deaths

Male %

Female deaths

Female %

Total deaths

Total %

Ischaemic heart disease 1,185 63.8 684 46.8 1,869 56.3

   Acute myocardial infarction

402

21.6

286

19.6

688

20.7 

Cerebrovascular disease

229

12.3

271

18.5

500

15.1

    Stroke

178

9.6

228

15.6

406

 12.2

Other heart disease

279

15.0

281

19.2

560

16.9

Rheumatic heart disease

40

2.2

75

5.1

115

3.5

Hypertensive disease

68

3.7

97

6.6

165

5.0

Other

57

3.1

53

3.6

110

3.3

Total circulatory diseases

1,858

100.0

1,461

100.0

3,319

 100.0

Neoplasms (includes cancer, by site of neoplasm)

Male Deaths

Male %

Female Deaths

Female %

Total Deaths

Total %

Cancer - malignant neoplasms

1,762

99.0

1,578

98.1

3,340

98.6

  Digestive organs

559

31.4

410

25.5

969

28.6

    Bowel

139

7.8

114

7.1

253

7.5

    Pancreas

102

5.7

109

6.8

211

6.2

    Oesophagus

100

5.6

29

1.8

129

3.8

    Liver

146

8.2

85

5.3

231

6.8

  Respiratory and intrathoracic organs

487

27.4

395

24.5

882

26.0

    Trachea, Bronchus and Lung

487

27.4

392

24.4

879

25.9

  Ill-defined and unknown primary sites

120

6.7

113

7.0

233

6.9

  Lymphoid, haematopoietic and related tissue

128

7.2

122

7.6

250

7.4

  Female genital organs

. .

. .

166

10.3

166

4.9

    Cervix

. .

. .

66

4.1

66

1.9

  Head and neck

155

8.7

53

3.3

208

6.1

  Breast

3

n.p.

28%

11.7

193

5.7

  Urinary tract

12%

4.4

46

2.9

125

3.7

  Male genital organs

104

5.8

. .

. .

104

3.1

    Prostate

96

5.4

. .

. .

96

2.8

  Other specified malignant neoplasms

126

7.1

84

5.2

210

6.2

Non-malignant neoplasms

18

1.0

31

1.9

49

1.4

Total neoplasms

1,780

100.0

1,609

100.0

3,389

100.0

Respiratory diseases

Male Deaths

Male %

Female Deaths

Female %

Total Deaths

Total %

Chronic lower respiratory diseases

478

70.5

505

71.6

983

71.1

    COPD

427

63.0

429

60.9

856

61.9

    Asthma

20

2.9

43

6.1

63

4.6

Pneumonia and influenza

115

17.0

117

16.6

232

16.8

Other respiratory disease

85

12.5

83

11.8

168

12.1

Total respiratory diseases

678

100.0

705

100.0

1,383

100.0

Source: Tables D1.23.8, D1.23.12, D1.23.14.

What do research and evaluations tell us?

The research literature provides a number of insights into the determinants of mortality among Indigenous Australians. It highlights improvements that can be made to the health system, and the social determinants, to reduce disease-specific death rates.

Findings show that improved management of chronic diseases can prevent the development of life-threatening complications. For example, a study of incidence and survival of acute myocardial infarction found improvements in survival for Northern Territory Indigenous Australians was associated with pre-hospital management of conditions. Specialised coronary care services within hospitals, placed a greater emphasis on post-hospital management which led to improved survival rates of patients (You et al. 2009).

Research has found that chronic disease mortality increased with remoteness, reflecting differentials in health-care and socioeconomic status across areas. This finding was consistent across Australia in most states and territories (Chondur et al. 2014).

Multi-morbidity is found to be associated with increased mortality (Fortin. et al. 2004), and prevalence of multi-morbidity is higher among Indigenous Australians than non-Indigenous Australians (Broe & Radford 2018; Deborah et al. 2018; Hussain et al. 2018).

  • A recent study, based on New South Wales hospital data, found that, after adjusting for age, sex, and socioeconomic status, the prevalence of multi-morbidity among Indigenous Australians was 2.6 times that of non-Indigenous Australians. This difference accounted for a large proportion of the difference in mortality rates between the two groups of patients (Deborah et al. 2018).
  • The prevalence of multi-morbidity was higher among Indigenous Australians in all age groups. In younger age groups this was because of the higher prevalence of mental morbidities, while in the older age group (over 60 years) it was because of physical morbidities (Broe & Radford 2018).

Studies in the Northern Territory found that the largest gains for the Indigenous Australian population in avoidable mortality were for conditions amenable to medical care such as asthma, pneumonia and breast cancer. However, there was only a marginal change for potentially preventable conditions, such as lung cancer, chronic liver disease and cirrhosis, and motor vehicle accidents (Li et al. 2009).

Another study in the Northern Territory found that socioeconomic disadvantage was the leading determinant for gaps in life expectancy between Indigenous and non-Indigenous Australians, accounting for one-third to one-half of the gap (Zhao et al. 2013).

Some progress has been made since the introduction of the Better Cardiac Care project, which aims to reduce mortality and morbidity from cardiac conditions among Indigenous Australians by increasing access to services, better managing risk factors and treatment, and improving coordination of care. Improvements include:

  • The level of access for cardiac-related health services has improved.
  • There have been increases in the proportion of Indigenous Australians who received: Medicare-funded health assessments; cardiac-related diagnostic services under Medicare; and the recommended intervention following hospitalisation for a severe heart attack.
  • The mortality rate from cardiac conditions is declining for Indigenous Australians (AIHW 2019).

Implications

These findings emphasise the need for significant and concerted efforts to continue improving Indigenous health outcomes, both directly through health interventions and services, and by addressing the cultural and social determinants of health.

The health system can contribute to sustained improvements in partnership with Indigenous Australians, through improving the identification of Indigenous clients, health promotion, early detection, chronic disease management, specialist care, and acute care. Acute care services can save the lives of seriously ill or injured people, and there is scope for improvements in timely access to life-saving emergency care for Indigenous Australians.

Access to effective and culturally competent primary health care is vital for meeting the health needs of Indigenous Australians, particularly for detecting and managing health conditions so as to prevent hospitalisation and death. Improved management of chronic diseases can prevent the development of life-threatening complications but cannot cure these diseases. Chronic diseases can be prevented through modifying health risk behaviours, such as increased physical exercise (see measure 2.18 Physical activity), reduced consumption of alcohol (see measure 2.16 Risky alcohol consumption), smoking cessation (see measure 2.15 Tobacco use), and better nutrition (see measure 2.19 Dietary behaviours).

High levels of intentional self-harm highlight the need for cross-sectoral approaches to health, self-esteem and social and emotional wellbeing (see measure 1.18 Social and emotional wellbeing).

The new National Agreement on Closing the Gap has been developed in partnership between all Australian governments and the Coalition of Aboriginal and Torres Strait Islander Peak Organisations. This new Agreement outlines a better way of working, with governments working in genuine partnership with Aboriginal and Torres Strait Islander people to get better outcomes. The National Agreement sets out ambitious targets and new Priority Reforms that will change the way governments work to improve life outcomes experienced by Indigenous Australians. The National Agreement specifically outlines the following outcomes and targets to direct policy attention and monitor progress:

  • Outcome 1 – Aboriginal and Torres Strait Islander people enjoy long and healthy lives.
    • Target – Close the Gap in life expectancy within a generation, by 2031.
  • Outcome 14 – Aboriginal and Torres Strait Islander people enjoy high levels of social and emotional wellbeing.
    • Target – Significant and sustained reduction in suicide of Aboriginal and Torres Strait Islander people towards zero.

The policy context is at Policies and strategies.

References

  • AIHW (Australian Institute of Health and Welfare) 2016. Australian Burden of Disease Study 2011: impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011. Canberra: AIHW.
  • AIHW 2019. Better Cardiac Care measures for Aboriginal and Torres Strait Islander people: fourth national report 2018-19. Canberra: AIHW.
  • Broe G & Radford K 2018. Multimorbidity in Aboriginal and non-Aboriginal people. Medical Journal of Australia 209:16-7.
  • Chondur R, Li SQ, Guthridge S & Lawton P 2014. Does relative remoteness affect chronic disease outcomes? Geographic variation in chronic disease mortality in Australia, 2002-2006. Australian & New Zealand Journal of Public Health 38:117-21.
  • Deborah A , Sanja L, Alys  H, Sandra JE, and & Louisa J 2018. Multimorbidity among Aboriginal people in New South Wales contributes significantly to their higher mortality. The Medical Journal of Australia 209 19-23.
  • PM&C (Department of the Prime Minister and Cabinet) 2020. Closing the Gap Report 2020.
  • Fortin. M, Lapointe. L, Catherine Hudon, Vanasse. A, Ntetu. AL & Maltais. D 2004. Multimorbidity and quality of life in primary care: a systematic review. Health and Quality of Life Outcomes 2.
  • Hussain M, Katzenellenbogen J, Sanfilippo F, Murray K & Thompson S 2018. Complexity in disease management: A linked data analysis of multimorbidity in Aboriginal and non-Aboriginal patients hospitalised with atherothrombotic disease in Western Australia. PloS one 3(8): e0201496.
  • Li SQ, Gray N, Guthridge S, Pircher S, Wang Z & Zhao Y 2009. Avoidable mortality trends in Aboriginal and non‐Aboriginal populations in the Northern Territory, 1985‐2004. Australian & New Zealand Journal of Public Health 33:544-50.
  • You J, Condon JR, Zhao Y & Guthridge S 2009. Incidence and survival after acute myocardial infarction in Indigenous and non-Indigenous people in the Northern Territory, 1992–2004. The Medical Journal of Australia 190:298-302.
  • Zhao Y, Wright J, Begg S & Guthridge S 2013. Decomposing Indigenous life expectancy gap by risk factors: a life table analysis. Population Health Metrics 11:1.

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