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Tier 1 - Health status and outcomes

1.24 Avoidable and preventable deaths

Key facts

Why is it important?

Avoidable and preventable mortality refers to deaths from conditions that are considered avoidable given timely and effective health care (including disease prevention and population health initiatives) (AIHW 2010; Page et al. 2007). Avoidable deaths have been used in various studies to measure the quality, effectiveness and accessibility of the health system. Deaths from most conditions are influenced by a range of factors in addition to health system performance, including environmental and social factors and health behaviours.

Findings

What does the data tell us?

Avoidable deaths

In the period 2014–2018, there were 7,072 deaths of Aboriginal and Torres Strait Islander people aged 0–74 from avoidable causes in the five jurisdictions with Indigenous identification data of adequate quality (New South Wales, Queensland, Western Australia, South Australia and the Northern Territory combined). This represented 61% of all deaths of Indigenous Australians aged 0–74. For non-Indigenous Australians, deaths from avoidable causes represented 50% of all deaths in this age group.

After adjusting for differences in the age structure between the two populations, Indigenous Australians died from avoidable causes at 3 times the rate of non-Indigenous Australians (312 compared with 103 per 100,000) (Table D1.24.1).

Between 1998 and 2018, there was a significant decline (by 40%) in avoidable mortality rates for Indigenous Australians. The greatest improvement occurred between 1998 and 2006 (a 29% decline), while from 2006 to 2018, the decline was slower (by 17%). Both declines were significant.

There was a significant narrowing of the gap between Indigenous and non-Indigenous Australians in avoidable mortality rates between 1998 and 2018 (by 37%). Most of this improvement occurred between 1998 and 2006 (the gap narrowed significantly by 30%), while from 2006 to 2018, the gap narrowed significantly (by 14%) (Table D1.24.2, Figure 1.24.1).

Over the period 1998 to 2018, the proportion of avoidable deaths in all deaths among Indigenous Australians aged 0–74 decreased from 66% to 58% (Table D1.24.7).

Figure 1.24.1: Age-standardised avoidable mortality rates, persons aged 0–74, by Indigenous status, NSW, Qld, WA, SA and NT combined, 1998–2018

This line graph shows that the avoidable mortality rate for Indigenous persons aged 0 to 74 was decreasing from 506 per 100,000 in 1998 to 303 per 100, 000 in 2017. The gap between Indigenous and non-Indigenous was decreasing from 328 to 205 per 100,000.

Source: Table D1.24.2. AIHW and ABS analysis of the ABS Causes of Death Collection.

The avoidable mortality rate for Indigenous Australians was higher than for non-Indigenous Australians across all age groups. The rate was highest for Indigenous Australians aged 65–74 (1,371 per 100,000) and this age group had the largest difference in rates between Indigenous and non-Indigenous Australians (a difference of 828 per 100,000). The avoidable mortality rate for Indigenous Australians aged 35–44 was 3.6 times the rate for non-Indigenous Australians (241 and 66 per 100,000, respectively) (Table D1.24.3). Indigenous males were more likely to die from avoidable causes than Indigenous females (238 and 168 per 100,000, respectively) (Table D1.24.3, Figure 1.24.2).

Figure 1.24.2: Age-specific avoidable mortality rates, persons aged 0–74, by Indigenous status, age and sex, NSW, Qld, WA, SA and NT, 2014–2018

This bar chart shows that, for all age groups, the rate of avoidable mortality for males was higher than that for females, and the rate for Indigenous was higher than for non-Indigenous; from 5-14 age group, it increased with age; for babies less than 1 year old, the Indigenous rate was 430 per 100,000 for boys and 372 for girls, compared with non-Indigenous rate 202 for boys and 168 for girls, for the age group 65-74, the Indigenous rate was 1,683 per 100,000 for males and 1,496 for females, compared with non-Indigenous rate 700 for males and 387 for females.

Source: Table D1.24.3. AIHW and ABS analysis of the ABS Causes of Death Collection.

After adjusting for differences in the age structure between the two populations, avoidable mortality rates for Indigenous Australians were lowest in New South Wales (216 per 100,000) and highest in the Northern Territory (548 per 100,000). There was little difference in the rate for non-Indigenous Australians across jurisdictions, ranging between 99 and 129 per 100,000. The largest gap in avoidable mortality rates between Indigenous and non-Indigenous Australians was in the Northern Territory (548 and 129 per 100,000, respectively) (Table D1.24.4, Figure 1.24.3).

Figure 1.24.3: Age-standardised avoidable mortality rates, persons aged 0–74, by Indigenous status and jurisdiction, NSW, Qld, WA, SA and NT, 2014–2018

This bar chart shows that the rate of avoidable mortality was highest for Indigenous and non-Indigenous Australians in the Northern Territory (548 per 100,000 for Indigenous and 129 for non-Indigenous), and lowest for Indigenous Australians was in New South Wales (216 per 1, 00,000); the highest rate difference between Indigenous and non-Indigenous among jurisdictions was also in the Northern Territory.

Source: Table D1.24.4. AIHW and ABS analysis of the ABS Causes of Death Collection.

Indigenous Australians living in Remote areas had the highest avoidable mortality rate (479 per 100,000)—more than double the rate of those living in Major cities (217 per 100,000) and 1.7 times the rate of those living in Regional areas (278 per 100,000).

There was little variation in the avoidable mortality rates for non-Indigenous Australians in all remoteness areas, leading to an increase in the avoidable mortality gap between Indigenous and non-Indigenous Australians as remoteness increased (Table D1.24.6, Figure 1.24.4).

Figure 1.24.4: Age-standardised avoidable mortality rates, persons aged 0–74, by Indigenous status and remoteness, NSW, Qld, WA, SA and NT combined, 2014–2018

This bar chart shows that the avoidable mortality rate for Indigenous Australians and the rate difference were highest in Remote areas (479 per 100,000 for Indigenous compared with 117 for non-Indigenous), and lowest in Major cities (217 for Indigenous compared with 95 for non-Indigenous).

Source: Table D1.24.6. AIHW and ABS analysis of the ABS Causes of Death Collection.

Causes of avoidable deaths

In the period 2014–2018, the most common causes of avoidable deaths among Indigenous Australians were ischaemic heart disease (21%), diabetes (12%), suicide (11%), chronic obstructive pulmonary disease (COPD) (8%), cancer (8%) and transport accidents (6%) (Table D1.24.5, Figure 1.24.5).

After adjusting for differences in the age structure between the two populations, the conditions contributing the most to the avoidable mortality gap between Indigenous and non-Indigenous Australians were ischaemic heart disease (26% of the gap in avoidable mortality), diabetes (19% of the gap) and COPD (12% of the gap) (Table D1.24.5).

Figure 1.24.5: Avoidable mortality, persons aged 0–74, by cause of death and Indigenous status, NSW, Qld, WA, SA, NT, 2014–2018

This bar chart shows that the top 3 causes of avoidable mortality for Indigenous Australians were ischaemic heart disease which caused 21% of avoidable mortality, diabetes (12%), suicide (11%); and those for non-Indigenous were cancer (25%), ischaemic heart disease (18%), and suicide (11%).

Source: Table D1.24.5. AIHW and ABS analysis of the ABS Causes of Death Collection.

What do research and evaluations tell us?

A study in the Northern Territory by Li and others (2009) found that the decline in Indigenous avoidable mortality has been greatest for conditions amenable to medical care, for example, neonatal and paediatric care, antibiotics, immunisation, drug therapies, and improved intensive care and surgical procedures. Unlike in the rate for non‑Indigenous people, only marginal change was found for conditions responsive to public health initiatives, such as those caused by smoking and alcohol consumption — suggesting more targeted and culturally appropriate campaigns are required to benefit Aboriginal people (Li et al. 2009).

A study of Indigenous Australians living in Remote Northern Territory communities (Zhao et al. 2014) found that those who utilised primary health care at medium or high levels were associated with reductions in hospitalisation and death than those in the low utilisation group. Higher levels of primary care utilisation for renal disease reduced avoidable hospitalisations by 82–85%, deaths by 72–75%, and years of life lost (YLL) by 78–81%. For ischaemic heart disease the reduction in avoidable hospitalisation was 63–78%, deaths by 63–66% and YLL by 69–73%. This study also estimated that investing $1 in primary health care in Remote Indigenous communities could save between $3.95 and $11.75 in hospital costs in addition to the health benefits for patients.

Hoy and others (2017) analysed deaths among the Tiwi people on Bathurst and Melville Islands off the coast of the Northern Territory between 1960 and 2010 (Hoy et al. 2017). The study illustrated the epidemiological transition of these communities with improvements in preventable infant deaths leading to changes in the demographic and mortality profile of the population over time. High numbers of infant deaths in the 1960s from diarrhoea, respiratory disease and failure to thrive shifted to deaths in older age groups from chronic lung disease, cardiovascular disease and renal failure. The study also illustrated the Barker Hypothesis (Almond & Currie 2011), showing that many children with low birthweight who were once at greater risk of early death are surviving to adulthood but with enhanced susceptibility to chronic disease. Improvements in birthweights and in the prevention and management of chronic disease will lead to continued improvements in mortality. The study also showed a concerning pattern of deaths among 15-45 year olds from non-natural causes such as accidents, suicide, and homicide from the mid-1980s and peaking in the early 2000s, suggesting that improvements in socioeconomic determinants as well as health services for these age groups is needed.

One category among the leading causes of avoidable mortality is invasive infections. Research into severe invasive infections in Indigenous children admitted to intensive care units (ICUs) in Australia between 2002 and 2013 was analysed by Ostrowski and others (2017) (Ostrowski et al. 2017):

  • Invasive infections accounted for 23% of non-elective ICU admissions of Indigenous children. Indigenous children had an admission rate almost 3 times as high as for non-Indigenous children (47.6 per 100,000 children per year compared with 15.9). Staphylococcus aureus was the leading cause in children with sepsis or septic shock and this had much higher rates for Indigenous children than for non-Indigenous children.
  • Although ICU case fatality rates were similar for Indigenous children compared with non‑Indigenous children, the population-based mortality rate was more than twice as high for Indigenous children. Indigenous children admitted to ICUs had more severe illness.
  • This suggests that although once accessing the ICU death rates were similar, at the population level, Indigenous children are at a much higher risk of death from severe invasive infection.
  • A vaccine for Staphylococcus aureus is unlikely to be developed in the near future. Poorer living conditions, remoteness and difficulties in accessing health care may significantly increase the incidence of these infections and their severity. Further research is needed to identify risk factors and develop targeted interventions.

The Australian Institute of Health and Welfare burden of disease analysis (AIHW 2016) examined the impact of around 200 fatal and non-fatal diseases and covers disease impact as well as death. Three indicators are used: total burden of disease (measured in disability-adjusted life years or DALY), fatal burden (measured in YLL) and non-fatal burden (measured in years spent living with a disability or YLD). The results showed:

  • The main causes of total burden of disease were mental and substance-use disorders (19%), suicide (15%), cardiovascular disease (12%), cancer (9%) and respiratory diseases (8%).
  • Compared with non-Indigenous Australians the total disease burden (DALY) is 2.3 times higher for Indigenous Australians, the fatal burden (YLL) is 2.7 times higher for Indigenous Australians, and the non-fatal burden (YLD) is 2 times higher for Indigenous Australians.

The Australian Government Department of Health is undertaking several evaluations of health programs. Two evaluations are summarised here.

The Practice Incentives Program Indigenous Health Incentive (PIP IHI) was introduced in 2010 to support health services to provide improved and more targeted care to Indigenous Australian patients. The introduction of the PIP IHI has led to an increase in the number of health checks provided for Indigenous Australian patients with chronic disease and better access to prescription medicines. A review of the PIP IHI, currently underway, aims to improve the efficiency and effectiveness of the PIP IHI to support general practices to provide culturally appropriate health care to Indigenous Australians with chronic disease. The Department of Health is finalising the PIP IHI review and will provide advice to the government upon its completion.

In 2017, the Australian Government Department of Health undertook two overarching evaluations of the Indigenous Australians’ Health Programme (IAHP) to assess the appropriateness and effectiveness of primary health care for Indigenous Australians and to inform the implementation and refinement of the IAHP. The first is an evaluation of the Australian Government’s investment in Aboriginal and Torres Strait Islander Primary Health Care and has two phases. Phase One, Evaluation Co-design, was completed in mid-2018 with the development of a Monitoring and Evaluation Design Report (DoH 2018a). Phase Two, Evaluation Implementation, commenced in November 2018 and is being undertaken over four years.

The second is an economic evaluation with two phases. Phase One focused on the return on investment of the IAHP and was completed in mid-2018 (DoH 2018b) and showed:

  • Research literature provided evidence of a strong correlation between Aboriginal Community Controlled Health Services (ACCHSs) episodes of care and prevented hospitalisations.
  • The analysis of national data for this project found a preventative effect upon hospitalisations from ACCHSs care.
  • Provision of care through mainstream services is associated with worse health outcomes for Indigenous Australians because mainstream services provide a less comprehensive and less integrated approach.
  • Indigenous Australians may face financial difficulties in accessing mainstream services, and if reliance were to be placed on mainstream services in lieu of ACCHSs, reduced attendance and adherence to treatment is highly likely due to services that may not meet their cultural needs and expectations.

Phase Two will evaluate the return on investment of the IAHP more broadly, starting with identifying and addressing data development needs for robust economic evaluation. This will be undertaken as part of a broader evaluation of primary health care for Indigenous Australians.

Implications

As stated in the Summary report, 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 (PM&C 2020). This may have the effect of overstating the early improvements in Indigenous avoidable mortality rates, while the more recent trends, based on more reliable data, indicate that the progress (although significant) has not been as substantial.

Nonetheless, from 2006 to 2018 there has been an improvement in avoidable mortality rates for Indigenous Australians and this is encouraging. Further sustained effort is required to continue to narrow the gap, as the rates for Indigenous Australians are still 3.1 times as high as for non-Indigenous Australians.

The rate of avoidable deaths is a measure used to assess the quality, effectiveness and accessibility of the health system. Chronic disease and injury are causing the greatest proportion of avoidable deaths for Indigenous Australians and are amenable to both prevention and treatment.

The findings outlined above indicate the following about reducing avoidable deaths:

  • Improvements in avoidable mortality rates are partly a result of advances in health care delivery and improved inter-sectoral services.
  • A broad range of risk factors and conditions such as smoking, injury, mental health issues, substance-use disorders, cardiac health, diabetes prevention and treatment, and renal disease all require service responses across the health care continuum from prevention to tertiary care.
  • Disparities between Indigenous and non-Indigenous Australians can be seen across disease groups, risk factors, age groups (particularly infants and middle and older ages) and remoteness categories, suggesting that policies to drive service delivery should consider the risk factors of disease, across the life course, and be cognisant of location-specific needs and service gaps.
  • The total burden of disease for Indigenous Australians is 2.3 times as high as for non-Indigenous Australians. Higher rates of potentially preventable hospitalisations and avoidable mortality from chronic disease and invasive infections indicate underutilisation of primary health care. This is exacerbated by difficulties accessing health care and the social and environmental determinants of these diseases.

The research and evaluations have shown the role ACCHSs have in providing comprehensive, appropriate and safe care for Indigenous Australians, while mainstream services are less effective. Comprehensive, accessible and well-integrated care is needed, particularly in managing chronic conditions, to prevent hospitalisations and death from avoidable causes. Ensuring services are accessible and appropriate is therefore important to drive further reductions in avoidable deaths.

Understanding the reasons for underutilisation of primary health care at the local level is vital in order to address barriers to accessing care (see measure 3.14 Access to services compared with need) such as distance, cost, availability and cultural safety.

The policy context is at Policies and strategies.

References

  • AIHW (Australian Institute of Health and Welfare) 2010. National Healthcare Agreement: P20-Potentially avoidable deaths 2010. Canberra: AIHW.
  • AIHW 2016 Australian Burden of Disease Study: Impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011. Canberra.
  • Almond D & Currie J 2011. Killing me softly: The fetal origins hypothesis. Journal of economic perspectives 25:153-72.
  • DoH (Australian Government Department of Health) 2018a. Evaluation of the Australian Government’s Investment Aboriginal and Torres Strait Islander Primary Health Care through the Indigenous Australians’ Health Programme, Monitoring and Evaluation Design Report.
  • DoH 2018b. Economic Evaluation of the Indigenous Australians’ Health Programme Phase 1 Report.
  • Hoy WE, Mott SA & McLeod BJ 2017. Transformation of mortality in a remote Australian Aboriginal community: a retrospective observational study. BMJ Open 7:e016094.
  • 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‐ Australian & New Zealand Journal of Public Health 33:544-50.
  • Ostrowski JA, MacLaren G, Alexander J, Stewart P, Gune S, Francis JR et al. 2017. The burden of invasive infections in critically ill Indigenous children in Australia. The Medical Journal of Australia, 206:78-84.
  • Page A, Ambrose S, Glover J & Hetzel D 2007. Atlas of Avoidable Hospitalisations in Australia: ambulatory care-sensitive conditions. Adelaide: PHIDU.
  • PM&C (Department of the Prime Minister and Cabinet) 2020. Closing the Gap Report 2020.
  • Zhao Y, Thomas SL, Guthridge SL & Wakerman J 2014. Better health outcomes at lower costs: the benefits of primary care utilisation for chronic disease management in remote Indigenous communities in Australia's Northern Territory. BMC health services research 14:463.

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