3.06 Access to hospital procedures

Key messages

• Between July 2017 and June 2019, 63% of hospitalisations (excluding dialysis) for Aboriginal and Torres Strait Islander people had a procedure recorded. Based on age-standardised rates, Indigenous Australians were less likely to have a procedure recorded than non-Indigenous Australians (difference of 14 percentage points)
• For Indigenous Australians, the proportion of hospitalisations with a procedure recorded was highest for those living in Major cities (68.3%) and the proportion decreased with increasing remoteness of usual residence.
• Between 2009–10 and 2018–19, based on age-standardised rates, there was a 14% increase in hospitalisations of Indigenous Australians where a procedure was recorded.
• Timely diagnosis and treatment are critical for preventing death from coronary heart disease. In the 2-year period July 2017 to June 2019, 46% hospitalisations for coronary heart disease among Indigenous Australians included coronary angiography, and 27% included a revascularisation procedure (crude percentages). Based on age-standardised percentages, the rate of coronary angiography procedures was 6.6 percentage points lower for Indigenous than non-Indigenous Australians, and the rate of revascularisation procedures was 4.8 percentage points lower.
• For hospitalised events for acute coronary syndrome (a subset of hospitalisations for coronary heart disease), the age-standardised proportion that included coronary angiography and/or a definitive revascularisation procedure increased from 35% to 66% among Indigenous adults between 2006–07 and 2018–19, compared with an increase from 50% to 71% among non-Indigenous adults.
• Research indicates that Indigenous patients are less likely than non-Indigenous patients to receive treatment, and experience longer wait times, in relation to cardiovascular disease, kidney disease and cancer. For example, studies have found that Indigenous patients are less likely to receive a coronary angiography (after controlling for age, comorbidities and remoteness), less likely to be added to the kidney transplantation waiting list during the first year of renal replacement therapy (irrespective of differences in patient- or disease-related factors), and less likely to have treatment for cancer (after controlling for stage of diagnosis).
• A recent review emphasises the importance of co-designed and co-created participative approaches to research, implementation and evaluation for the development of new models of transplantation care for Indigenous Australians living with kidney disease.
• Improving the cultural safety of hospital environments is integral to improving health outcomes for Indigenous Australians, as they are more likely to seek access to health care and have better outcomes if there are culturally safe and respectful services.
• The Lighthouse Hospital Project has found that some key initiatives have led to improvements in care such as the expansion of the Aboriginal Health Workforce, better Indigenous status identification of patients, engaging in effective partnerships with Indigenous communities, fostering champions among clinical staff, patient-centred care and improved communication.

Why is it important?

Australians with illnesses that can be effectively treated by hospital-based medical and surgical procedures should have equitable access to these procedures. Historically, studies have shown that while Aboriginal and Torres Strait Islander people are more likely to be hospitalised than other Australians, they are less likely to receive a medical or surgical procedure while in hospital (ABS & AIHW 2008; Cunningham 2002). The disparities relating to this are not always explained by diagnosis, age, sex or place of residence and, are apparent in public but not private hospitals (Cunningham 2002).

Patients suspected of having heart disease should receive appropriate and timely diagnostic services (AIHW 2021a). For patients admitted to hospital with coronary heart disease, access to coronary angiography (a procedure used to detect coronary artery blockage) can be important in the diagnosis and establishment of a treatment plan. Coronary heart disease may be treated with pharmacotherapy or through repairing the heart’s blood vessels, either using a medical procedure (percutaneous coronary interventions) or a surgical procedure (coronary artery bypass grafts).

Studies have found that Indigenous Australian patients were less likely to receive a coronary angiography than non-Indigenous Australians, after controlling for age, comorbidities and remoteness. Indigenous Australian patients were also less likely to be added to the kidney transplantation waiting list during the first year of renal replacement therapy, irrespective of differences in patient- or disease-related factors (Khanal et al. 2018; Tavella et al. 2016).

Indigenous Australians have a much greater risk of developing end-stage kidney disease compared with non-Indigenous Australians, but are less likely to receive a kidney transplant (The Transplantation Society of Australia and New Zealand 2019). Indigenous patients who receive a kidney transplant wait longer for an organ donor than non-Indigenous patients and experience significantly worse post-transplant outcomes (see measure 1.10 Kidney disease).

Several studies have shown that Indigenous Australians have a poorer survival rate for cancer. This is partly explained by later diagnosis and referral for specialist treatment (Condon et al. 2006; Valery et al. 2006). However, after controlling for the stage of diagnosis, Indigenous Australians are less likely to have treatment for cancer (for example, surgery, chemotherapy or radiotherapy), tend to wait longer for surgery and have lower survival rates for many cancers (Hall et al. 2004; Valery et al. 2006) (see measure 1.08 Cancer).

There is considerable evidence that poor outcomes in hospitals and health care facilities for Indigenous Australians are related to systemic or institutionalised racism (Bourke et al. 2019; Henry et al. 2004; Malatzky et al. 2020). Improving the cultural safety of hospital environments is integral to improving health outcomes for Indigenous Australians, as they are more likely to seek access to health care and have better outcomes if there are culturally safe and respectful services available (Congress of Aboriginal and Torres Strait Islander Nurses and Midwives 2016). Institutional resistance may require organisational change mandated by standards (Laverty et al. 2017).

Findings

What does the data tell us?

From July 2017 to June 2019, 63% (385,020) of hospitalisations (excluding dialysis) for Indigenous Australians had a procedure recorded (Table D3.06.1). The proportion of hospitalisations with a procedure recorded was similar between Indigenous males (63.1%) and Indigenous females (62.5%).  

After adjusting for differences in the age structure of the two populations, hospitalisations for Indigenous Australians were less likely to have a procedure recorded than for non-Indigenous Australians (difference of 14 percentage points).

Hospital sector

Between July 2017 and June 2019, of the 385,020 hospitalisations for Indigenous Australians with a procedure recorded, 88% took place in a public hospital (including psychiatric), and 12% in private hospitals (Table D3.06.6). This broadly reflects the distribution of total hospitalisations – for example, in 2020–21, 87% of total hospitalisations for Indigenous Australians occurred in public hospitals (AIHW 2022c).

Factors influencing receiving a hospital procedure

There are many factors associated with the likelihood of receiving a procedure when admitted to hospital. An analysis of the combined impact of a range of factors found that between July 2017 and June 2019, statistically significant factors included:

• whether the hospital was public or private
• the principal diagnosis for which a person was admitted
• the number of additional diagnoses recorded for a patient
• state/territory of usual residence
• age group
• remoteness of usual residence
• sex (Table D3.06.13).

Hospital procedures by age group

Between July 2017 and June 2019, the proportion of hospitalisations for Indigenous Australians where a procedure was performed was generally higher among older age groups – ranging from 53% for hospitalisations of Indigenous infants under 1, to 77% of hospitalisations for those aged 65 and over (Figure 3.06.1).

Across all age groups, hospitalisations for Indigenous Australians were less likely to include a procedure than hospitalisations for non-Indigenous Australians (Table D3.06.1, Figure 3.06.1).

Figure 3.06.1: Proportion of hospitalisations (excluding dialysis) with a procedure recorded, by Indigenous status and age group, Australia, July 2017 to June 2019

Source: Table 3.06.1. AIHW analysis of National Hospital Morbidity Database.

Hospital procedures by remoteness

Between July 2017 and June 2019, for Indigenous Australians, the proportion of hospitalisations with a procedure recorded was highest in Major cities (68.3%), which decreased with increasing remoteness (Table D3.06.1, Figure D3.06.2).

Figure 3.06.2: Proportion of hospitalisations (excluding dialysis) of Indigenous Australians with a procedure recorded, by remoteness, Australia, July 2017 to June 2019

Source: Table 3.06.1. AIHW analysis of National Hospital Morbidity Database.

After adjusting for differences in age structure between the two populations, the gap between the proportions of Indigenous and non-Indigenous Australians receiving a hospital procedure was highest in Remote areas (a difference of 16 percentage points) and lowest in Major cities (a difference of 8.5 percentage points) (Table D3.06.1).

Hospital procedures by state and territory

Between July 2017 and June 2019, the proportion of hospitalisations for Indigenous Australians with a procedure recorded varied by state and territory, with the highest proportion in Tasmania (71%), followed by Victoria (69%) and New South Wales (67%). The Northern Territory had the lowest proportion, with 55% of hospitalisations for Indigenous Australians who had a procedure recorded (Table D3.06.1, Figure 3.06.3).

Figure 3.06.3: Proportion of hospitalisations (excluding dialysis) of Indigenous Australians with a procedure recorded, by state and territory, Australia, July 2017 to June 2019

Source: Table 3.06.1. AIHW analysis of National Hospital Morbidity Database.

After adjusting for the age structure between the two populations, the proportion of Indigenous Australians receiving a hospital procedure were lower across all states and territories compared with non-Indigenous Australians (with the difference ranging from 5–21 percentage points across the jurisdictions) (Table D3.06.1).

Principal diagnosis of hospital procedures

Between July 2017 and June 2019, the proportion of hospitalisations for Indigenous Australians that included at least one procedure was highest for hospitalisations with a principal diagnosis of diseases of the eye and adnexa (93%), followed by cancer and other neoplasms (92%).

For hospitalisations due to neoplasms (cancer), 92% of Indigenous patients had a procedure, compared with 97% for non-Indigenous patients.

Hospitalisations with a principal diagnosis of diseases of the nervous system had the largest absolute difference in procedure rates between Indigenous and non-Indigenous Australians (excluding diagnoses classified as ‘symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified’). Between July 2017 and June 2019, 65% of Indigenous patients with a principal diagnosis of diseases of the nervous system received a procedure, compared with 85% of non-Indigenous patients (difference of 20 percentage points) (Table D3.06.2, Table 3.06-1).

Table 3.06-1: Proportion of hospitalisations with a procedure reported, by principal diagnosis and Indigenous status, Australia, July 2017 to June 2019

Principal diagnosis chapter (excluding dialysis)	Indigenous %	Non-Indigenous %	Absolute difference
Diseases of the eye and adnexa	92.6	98.5	-6.0
Cancer and other neoplasms	92.3	96.7	-4.4
Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism	91.0	95.7	-4.7
Congenital malformations, deformations and chromosomal abnormalities	91.0	94.2	-3.1
Diseases of the ear and mastoid process	82.2	83.4	-1.2
Certain conditions originating in the perinatal period	78.6	77.8	0.8
Musculoskeletal system and connective tissue diseases	78.1	92.8	-14.7
Endocrine and nutritional and metabolic diseases	76.5	86.5	-9.9
Digestive system diseases	71.3	88.1	-16.8
Cardiovascular (circulatory) diseases	68.2	79.1	-10.9
Pregnancy, childbirth and the puerperium	66.5	76.9	-10.4
Nervous system diseases	65.1	85.3	-20.2
Skin and subcutaneous tissue diseases	64.7	71.6	-6.9
Genitourinary system diseases	62.8	78.5	-15.7
Injury, poisoning and certain other consequences of external causes	60.8	72.7	-11.9
Mental and behavioural disorders	51.0	70.6	-19.6
Respiratory system diseases	48.2	64.2	-15.9
Certain infectious and parasitic diseases	39.0	49.1	-10.1
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified	36.6	58.9	-22.3
Factors influencing health status and contact with health services	79.7	94.6	-15.0
Any principal diagnosis	62.9	81.6	-18.7

Note: Data are crude percentages.

Source: Table D3.06.2.  AIHW analysis of National Hospital Morbidity Database.

Hospital procedures related to coronary heart disease

Timely diagnosis and treatment are critical for preventing death from coronary heart disease. Coronary angiography (x-ray imaging to detect narrowed or blocked blood vessels) and definitive revascularisation procedures (surgery to overcome blockages) are essential forms of diagnosis and treatment for coronary heart diseases (AIHW 2021a).

Between July 2017 and June 2019, 46% of hospitalisations for Indigenous Australians for coronary heart disease had a coronary angiography procedure performed, and 27% had a revascularisation procedure.

After adjusting for differences in the age-structure of the two populations, the proportion of hospitalisations for coronary heart disease that included a coronary angiography procedure was 6.6 percentage points lower for Indigenous than non-Indigenous Australians (age-standardised rate of 39.7% and 46.3% respectively), and the proportion that included revascularisation procedures was 4.8 percentage points lower (19.2% and 24.0%, respectively) (Table D3.06.9, Figure 3.06.4).

Figure 3.06.4: Age-standardised proportion of hospitalisations for coronary heart disease where the patient received a coronary angiography or revascularisation procedure, by type of procedure and Indigenous status, Australia, July 2017 to June 2019

Source: Table 3.06.9. AIHW analysis of National Hospital Morbidity Database.

The following analysis relates to hospitalisations for acute coronary syndrome (see box for definition), which are a subset of hospitalisations for coronary heart disease. In addition, adjustments were made to reduce double-counting of hospitalisations for the same person associated with the same event of acute coronary syndrome. The results are based on the three-year period between July 2016 and June 2019 combined (AIHW 2021a).

Among Indigenous adults between July 2016 and June 2019, the proportion of hospitalised events for acute coronary syndrome that included coronary angiography and/or a definitive revascularisation procedure was highest among those aged 18–34 for Indigenous adults (66%), which decreased with increasing age (to 46% among those aged 65 and over). The proportion of Indigenous adults receiving these procedures for hospitalised acute coronary syndrome events was lower compared with non-Indigenous adults across all age groups, except for those aged 18–34 (66% for Indigenous adults compared with 63% for non-Indigenous adults) (AIHW 2021a).

Between July 2016 and June 2019, after adjusting for differences in the age structure between the two populations, 61% of hospitalised events for acute coronary syndrome among Indigenous adults included a coronary angiography or a definitive revascularisation procedure, compared with 70% for non-Indigenous adults.

The age-standardised proportion of acute coronary syndrome events that included a coronary angiography or a definitive revascularisation procedure was lower compared with non-Indigenous adults in all remoteness areas, although the gap between Indigenous and non-Indigenous adults narrowed with increasing remoteness. For Indigenous adults living in Major cities, the rate was 11 percentage points lower than for non-Indigenous adults. This is compared with a gap of 7.1 percentage points for those living in Inner regional areas, 4.6 percentage points for Outer regional areas, and 1.6 and 1.4 percentage points for Remote areas and Very remote areas, respectively (AIHW 2021a).

Hospital procedures related to the digestive tract

For hospitalisations related to the digestive tract, Indigenous Australians were less likely to receive a procedure compared with non-Indigenous patients where the principal diagnosis was:

• complicated or uncomplicated hernias
• diseases of the extrahepatic biliary tree
• appendicitis.

There was no significant difference where the principal diagnosis was malignant neoplasms of the large intestine/rectum or non-neoplastic diseases of the rectum or anus (for example, haemorrhoids) (Table D3.06.16).

Change over time

Between 2009–10 and 2018–19, there was a 14% increase in the age-standardised proportion of hospitalisations for Indigenous Australians where a procedure was recorded, with little change in the proportion for non-Indigenous Australians, resulting in a decrease in the gap between Indigenous and non-Indigenous Australians (Table D3.06.11, Figure 3.06.5). These data are for the six jurisdictions with Indigenous identification of adequate quality over the time period considered (New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory).

Figure 3.06.5: Age-standardised proportion of hospitalisations (excluding dialysis) where a procedure was recorded, by Indigenous status, NSW, Vic, Qld, WA, SA and NT, 2006–07 to 2018–19

Source: Table 3.06.11. AIHW analysis of National Hospital Morbidity Database.

Considering hospitalised events for acute coronary syndrome between 2006–07 and 2018–19, the age-standardised proportion that included either a coronary angiography or a definitive revascularisation procedure among Indigenous adults increased from 35% to 66%, compared with an increase from 50% to 71% among non-Indigenous adults (AIHW 2021a) (Figure 3.06.6).

Figure 3.06.6: Age-standardised proportion of hospitalisations among adults for acute coronary syndrome events where the patient received a coronary angiography and/or a definitive revascularisation procedure, by Indigenous status, NSW, Vic, Qld, WA, SA and NT, 2006–07 to 2018–19

Source: AIHW Better Cardiac Care 2021 – Data Table for Figure 3.3b.

What do research and evaluations tell us?

A study of patients admitted to Queensland hospitals for acute myocardial infarction (that is, heart attack) between 1998 and 2002 found that the rate of coronary procedures among Indigenous Australian patients was 22% lower than the rate for other patients (Coory & Walsh 2005). A more recent study in South Australia found that Indigenous patients were less likely to receive a coronary angiography after controlling for age, comorbidities and remoteness (Tavella et al. 2016).

Recent research into addressing surgical inequity for Indigenous Australians across the health care system explored the barriers and disparities that exist in accessing care at five care points along the surgical journey: perception of need, access to primary care, access to specialist services, access to elective surgery, and surgical outcomes. At all care points, challenges were identified including diverse views of health (a more holistic view, not prioritising non-urgent symptoms), lack of culturally secure care (existence of racism, mistrust, poor communication), lower access to specialist services (geographic barriers, unaffordable, lack of private health insurance, lack of Indigenous Australian specialists), less access to elective surgery (clinician bias, preoperative risk factors, long wait times) and poorer surgical outcomes (as a result of factors including presentation at more advanced stages of disease). Identifying and addressing the social determinants of health and discrimination along the pathway to surgical care are suggested as key to delivering more culturally secure models of care (O'Brien et al. 2021).

A national study of ANZDATA Registry data from 2006–2016 found that Indigenous patients were less likely than non-Indigenous patients to be added to the kidney transplantation waiting list during the first year of renal replacement therapy (Khanal et al. 2018). This disparity was not explained by differences in patient- or disease-related factors. A study conducted in 2005–06 found that treating specialists commonly identified Indigenous patients as ‘non-compliers’ with their dialysis regimes and as high-risk kidney transplant candidates, but that this assessment was not systematic or formal (Anderson et al. 2012). There was variation in how specialists weighted these assessments in their decision making and uncertainty about the value of compliance status in predicting post-transplant outcomes. In Victoria, a patient study found that medical comorbidities were the main barrier to kidney transplant listing, but once listed, Indigenous patients had a short waiting time due to accumulated ‘waiting time’ which begins when patients start dialysis (Atkinson & Goodman 2018). International research has found that patient aversion to transplantation (for cultural, social, religious, health or other reasons) may contribute to differential access by particular groups, but a recent study of Indigenous patients in all states and territories, apart from Victoria and Tasmania, found they had a high level of interest in kidney transplantation (Devitt et al. 2017). However, patients experienced multiple communication barriers and felt that they and their families were poorly informed and disempowered about transplantation as an option. While patients needed to navigate cultural and social sensitivities, this did not seem to be a factor in patients’ decision-making. A recent study in Western Australia found that Indigenous kidney recipients experienced poorer outcomes than non-Indigenous recipients and recommended future research be done into factors associated with better outcomes for Indigenous Australian kidney recipients (Howson et al. 2019).

An expert panel undertook a comprehensive review into the hurdles, service gaps and practical challenges faced by Indigenous patients receiving treatment for kidney disease (The Transplantation Society of Australia and New Zealand 2019). The review report, released in 2019, identified measures to address gaps in waitlisting and long-term transplant outcomes and improving Indigenous dialysis patients’ health to improve their capacity to be waitlisted. Following the review, a National Indigenous Kidney Transplantation Taskforce (NIKTT) was established to implement and evaluate the recommendations from the review (further information is below in the Implications section).

Research using data from the National Eye Health Survey 2015–16 found that the cataract surgery coverage rate is significantly lower among Indigenous than non-Indigenous Australians (Foreman et al. 2017). The burden of vision loss is higher among Indigenous Australians due to a much higher prevalence of vision loss associated with unoperated cataracts. A 2010 assessment of waiting times for surgery across remoteness areas found that the disparity for cataract surgery was greater than for other surgical procedures (Kelaher et al. 2010).

Analysis of 2016–17 hospitalisations for colonoscopy found that there was greater use of colonoscopy in areas with higher socioeconomic status, which have a low incidence of bowel cancer and low death rates, compared with areas of low socioeconomic status, which have the highest incidence and death rates (ACSQHC 2018). The rate of hospitalisations for colonoscopy for Indigenous Australians was 47% lower than the rate for other Australians.

Implications

There is a clear disparity in accessibility and outcomes for hospital procedures between Indigenous and non-Indigenous Australians. This is seen across age, remoteness, jurisdiction and principal diagnosis. This measure has provided a few examples of the disparity within particular disease types, but the hospitalisation data and the use of principal diagnosis chapters is somewhat limited for a full analysis of this complex issue. Academic research can and does provide a deeper exploration of these disparities and the key drivers, as well as providing insight into how hospital services can improve.

Disparities in accessibility and outcomes for hospital procedures are likely to reflect a range of factors, including ‘systemic practices, not ill-intentioned but still discriminatory, and almost invisible in the patient provider encounter’ (Fisher & Weeramanthri 2002). An adequate primary health care system is also a prerequisite for effective hospital and specialist services.

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 crucial role in reaffirming this commitment and provides a nationally consistent approach (AHMAC 2016). 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 modules: culturally respectful health care services, patient experience of health care, and access to health care services. 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 2022a).

While there has been an increase in the proportion of Indigenous Australians who received a hospital procedure and a decrease in the gap between the proportion of Indigenous and non-Indigenous Australians receiving a hospital procedure, a wide gap remains. In addition, the age-standardised proportion of discharge against medical advice or discharge at own risk—an indirect measure of cultural safety in hospitals—decreased from 4.4% to 3.8% from 2006–07 to 2018–19 (see measure 3.09 Discharge against medical advice).

The Ways of Thinking and Ways of Doing program was developed to ‘translate the systemic, organisational, and clinical elements of the Cultural Respect Framework into routine clinical practice’ (Liaw et al. 2019). A study of the effect of this program in Melbourne and Sydney general practice settings found that it did not significantly influence the Indigenous health check rate or cultural respect levels. The authors suggested that cultural respect programs may require more than 12 months to have a positive effect.

The measures presented here suggest that the under-provision of specialist services for Indigenous Australians persists and that further efforts are required to improve access. In addition to governments, clinicians and clinical colleges could also play a role in reviewing decision-making processes and relevant data to identify what drives differential access to procedures and develop strategies to address these issues (Fisher & Weeramanthri 2002).

The vast majority of hospital procedures for Indigenous Australians are done in the public hospital system, whereas a much greater share of procedures for non-Indigenous Australians is done in the private hospital system. Low incomes and low take-up of private health insurance are likely having an effect. In the 2016 Census, 37% of Indigenous adults were living in households with incomes in the bottom 20% of Australian incomes. In the 2018–19 National Aboriginal and Torres Strait Islander Health Survey, 21% of Indigenous Australians in Non-remote areas reported they had private health insurance. The lower proportion of procedures per hospitalisation is likely to be associated with private health insurance coverage and lower access to private hospitals. This may influence the rate of preventative hospital treatments. Research has found that, after adjusting for other factors, the strongest association with coronary angiography rates was admissions to private hospitals (Chew et al. 2016). This also highlights the inequitable access to specialist care for many Indigenous Australians that are largely reliant on the public hospital system.

Indigenous Australian patients with chronic disease sometimes present later in the course of these illnesses, compared with non-Indigenous Australians, which affects treatment options (Valery et al. 2006). Other factors that have been suggested include that the presence of comorbidities limits treatment options (although this does not explain the difference in coronary procedures outlined above); clinical judgments concerning post-procedural compliance; communication issues, such as for patients whose main language is not English; and patient knowledge and attitudes, for example, fatalistic attitudes towards cancer. Physical, social and cultural distance from health services also play a role, along with financial issues patients and their families may face when seeking treatment in specialist referral services (Miller et al. 2010; Shahid et al. 2009). An analysis of 2017–18 Medicare data shows that the rate of claims for specialist services for Indigenous Australians was below non-Indigenous Australians for both in and out-of-hospital care (Table D3.14.23). Effective strategies will require a better understanding of the factors leading to the observed disparities.

In 2018, cardiovascular disease was the second leading contributor to the gap in disease burden between Indigenous and non-Indigenous Australians (AIHW 2021b). The National Recommendations for Better Cardiac Care for Aboriginal and Torres Strait Islander People and the Lighthouse Hospital Project (see measure 1.05 Cardiovascular disease) aim to address the disparities in cardiovascular care. The Lighthouse Hospital Project has found that some key initiatives have led to improvements in care such as the expansion of the Aboriginal Health Workforce, better Indigenous status identification of patients, engaging in effective partnerships with Indigenous communities, fostering champions among clinical staff, patient-centred care and improved communication (Australian Healthcare & Hospitals Association 2021).

The survival rate of Indigenous Australians with end-stage kidney disease that require renal replacement therapy has significantly increased and  evidence suggests the survival gap has closed between Indigenous and non-Indigenous patients (Lawton et al. 2015). However, there remain disparities and barriers for Indigenous Australians accessing kidney transplantation. Qualitative research has unpacked some of these barriers and their experiences of the health system on the treatment pathway, including information needs, distance and the effect of being away from home (Cass A., Cunningham, J., Snelling, P., Wang, Z & Hoy, W. 2003). For the health system to be more effective in delivering transplantation services to Indigenous Australians, it requires an understanding of their needs and motivations in seeking kidney transplantation (Cass A., Cunningham, J., Snelling, P., Wang, Z & Hoy, W. 2003).

The 2019 Review into kidney transplantation by the Transplantation Society of Australia and New Zealand explored the complex challenges associated with delivering appropriate kidney health services in remote areas. The review examined the burden of comorbidities affecting suitability for transplantation, waiting lists, the dislocation from moving to transplant centres and the high rates of post-transplant complications. It made 35 recommendations aimed at improving health services requiring close collaboration between consumers, academia, health services, peak bodies and governments. The review also illustrated the systemic biases in the kidney transplant system and identified potential mitigation strategies (Cass Alan 2019; The Transplantation Society of Australia and New Zealand 2019). A National Indigenous Kidney Transplantation Taskforce (NIKTT) was established to implement and evaluate the recommendations from the review.

A scoping review by the NIKTT identified four key domains of action (each with several recommendations) to address cultural bias in kidney transplantation for Indigenous Australians: Inclusion of Aboriginal and Torres Strait Islander people; Workforce; Service delivery approach and models of care; and Structures and policies (Kelly et al. 2019). The review emphasises the importance of co-designed and co-created participative approaches to research, implementation and evaluation for the development of new models of transplantation care for Indigenous Australians living with kidney disease (University of Adelaide et al. 2020).

The National Aboriginal and Torres Strait Islander Health Plan (the Health Plan), released in December 2021, recognises early access to responsive primary care is key to addressing the higher hospitalisation rates of Indigenous Australians, where presentation often occurs at a later stage of disease and can lead to higher rates of death. The Health Plan emphasises that action to address cardiovascular disease, diabetes, ear, eye and renal health, and rheumatic heart disease, remain key priorities. Lessons learned from the work to improve the health system in delivering cardiac care and kidney transplantation may also help address other disparities in hospital services for Indigenous Australians.

The Health Plan includes priorities in making acute care settings accessible, culturally safe and responsive to address gaps between Indigenous and non-Indigenous experiences in hospitals. These include addressing the gap in surgery procedures and wait times, and in the rates of early discharge or discharge against medical advice. This will require hospitals to implement strategies to better deliver holistic, coordinated and culturally safe models of care including harnessing traditional health workers to provide complementary care, and establishing coordination pathways with Aboriginal Community Controlled Health Services.

The Health Plan has also made identifying and eliminating racism an important priority with several objectives to address racism, improve the cultural safety of mainstream health settings, and to ensure that racism and cultural safety are monitored for holding the health system to account.

The policy context is at Policies and strategies.

References

• ABS (Australian Bureau of Statistics) & AIHW (Australian Institute of Health and Welfare) 2008. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples 2008. Canberra: ABS & AIHW.

• ACSQHC (Australian Commission On Safety And Quality In Health Care) 2018. Third Australian Atlas of Healthcare Variation. Sydney.

• AHMAC (Australian Health Ministers' Advisory Council) 2016. Cultural Respect Framework 2016-2026 for Aboriginal and Torres Strait Islander health. Canberra: AHMAC.

• AIHW 2021a. Better Cardiac Care measures for Aboriginal and Torres Strait Islander people: sixth national report 2021. Canberra: AIHW.

• AIHW 2021b. Australian Burden of Disease Study 2018 – Key findings. Cat. no. BOD 28. Canberra: AIHW. Viewed 19 October.

• AIHW 2022a. Cultural safety in health care for Indigenous Australians: monitoring framework. Canberra: AIHW. 

• AIHW 2022b. Procedures data cubes. Canberra: AIHW

• AIHW 2022c. Admitted patient care 2020–21. Canberra: AIHW.

• Anderson K, Devitt J, Cunningham J, Preece C, Jardine M & Cass A 2012. If you can't comply with dialysis, how do you expect me to trust you with transplantation? Australian nephrologists' views on indigenous Australians' 'non-compliance' and their suitability for kidney transplantation. International Journal for Equity in Health 11:21.

• Atkinson A & Goodman D 2018. Overcoming barriers for Indigenous Australians gaining access to the kidney transplant waiting list. Renal Society of Australasia Journal 14:60.

• Australian Healthcare & Hospitals Association 2021. The Lighthouse Hospital Project. 

• Bourke CJ, Marrie H & Marrie A 2019. Transforming institutional racism at an Australian hospital. Australian Health Review 43:611-8.

• Cass A 2019. What the research says. The Transplantation Society of Australia and New Zealand.

• Cass A, Cunningham, J., Snelling, P., Wang, Z & Hoy, W. 2003. Renal transplantation for Indigenous Australians: identifying the barriers to equitable access, Ethnicity & Health, vol. 8, no. 2, pp. 111-119.

• Chew DP, MacIsaac AI, Lefkovits J, Harper RW, Slawomirski L, Braddock D et al. 2016. Variation in coronary angiography rates in Australia: correlations with socio-demographic, health service and disease burden indices. The Medical Journal of Australia 205:114-20.

• Condon JR, Cunningham J, Barnes T, Armstrong BK & Selva-Nayagam S 2006. Cancer diagnosis and treatment in the Northern Territory: assessing health service performance for Indigenous Australians. Internal Medicine Journal 36:498-505.

• Congress of Aboriginal and Torres Strait Islander Nurses and Midwives 2016. Cultural Safety in policy and practice seminar report: summary and implications. Canberra: CATSINaM. Viewed 17 August 2020.

• Coory MD & Walsh WF 2005. Rates of percutaneous coronary interventions and bypass surgery after acute myocardial infarction in Indigenous patients. The Medical Journal of Australia 182:507-12.

• Cunningham J 2002. Diagnostic and therapeutic procedures among Australian hospital patients identified as Indigenous. The Medical Journal of Australia 176:58-62.

• Devitt J, Anderson K, Cunningham J, Preece C, Snelling P & Cass A 2017. Difficult conversations: Australian Indigenous patients’ views on kidney transplantation. BMC nephrology 18:310.

• Fisher DA & Weeramanthri TS 2002. Hospital care for Aboriginals and Torres Strait Islanders: appropriateness and decision making. The Medical Journal of Australia 176:49-50.

• Foreman J, Xie J, Keel S, van Wijngaarden P, Crowston J, Taylor H et al. 2017. Cataract surgery coverage rates for Indigenous and non-Indigenous Australians: the National Eye Health Survey. The Medical Journal of Australia 207:256-61.

• Hall SE, Bulsara CE, Bulsara MK, Leahy TG, Culbong MR, Hendrie D et al. 2004. Treatment patterns for cancer in Western Australia: does being Indigenous make a difference? The Medical Journal of Australia 181:191-4.

• Henry BR, Houston S & Mooney G 2004. Institutional racism in Australian healthcare: a plea for decency. The Medical Journal of Australia 180:517-20.

• Howson P, Irish AB, D'Orsogna L, Chakera A, Swaminathan R, Perry G et al. 2019. Allograft and patient outcomes between Indigenous and non-Indigenous kidney transplant recipients. Transplantation.

• Kelaher M, Ferdinand A, Ngo S, Tambula N & Taylor H 2010. Access to eye health services among Indigenous Australians. An area level analysis. Melbourne: Indigenous Eye Health Unit, Melbourne School of Population Health, University of Melbourne.

• Kelly J, Dent P, Owen K, Schwartzkopff K & O'Donnell K 2019. Cultural bias Indigenous kidney care and kidney transplantation report.

• Khanal N, Lawton PD, Cass A & McDonald SP 2018. Disparity of access to kidney transplantation by Indigenous and non-Indigenous Australians. The Medical Journal of Australia 209:261-6.

• Laverty M, McDermott DR & Calma T 2017. Embedding cultural safety in Australia’s main health care standards. The Medical Journal of Australia 207:15-6.

• Lawton PD, Cunningham J, Zhao Y, Gray NA, Chatfield MD, Baade PD et al. 2015. Survival of Indigenous Australians receiving renal replacement therapy: closing the gap? The Medical Journal of Australia 202:200-4.

• Liaw S-T, Wade V, Furler JS, Hasan I, Lau P, Kelaher M et al. 2019. Cultural respect in general practice: a cluster randomised controlled trial. Medical Journal of Australia 210:263-8.

• Malatzky C, Haines H & Glenister K 2020. Racism in a place of healthcare: The qualitative case of a rural Australian hospital. Journal of Community Medicine & Health Education 10:Article number: 1000681.

• Miller J, Knott V, Wilson C, Cunningham J, Condon J & Roder Dea 2010. Aboriginal and Torres Strait Islander Cancer Control Research Project. Sydney: Cancer Australia.

• O'Brien P, Bunzli S, Lin I, Bessarab D, Coffin J, Dowsey M et al. 2021. Addressing surgical inequity for Aboriginal and Torres Strait Islander people in Australia's universal health care system: a call to action. ANZ Journal of Surgery 91:238-44.

• Shahid S, Finn L, Bessarab D & Thompson S 2009. Understanding, beliefs and perspectives of Aboriginal people in Western Australia about cancer and its impact on access to cancer services. BMC health services research 9:132.

• Tavella R, McBride K, Keech W, Kelly J, Rischbieth A, Zeitz C et al. 2016. Disparities in acute in-hospital cardiovascular care for Aboriginal and non-Aboriginal South Australians. The Medical Journal of Australia 205:222-7.

• The Transplantation Society of Australia and New Zealand 2019. Improving Access to and Outcomes of Kidney Transplantation for Aboriginal and Torres Strait Islander People in Australia: Performance Report.

• University of Adelaide, Lowitja Institute & Taskforce atNIKT 2020. Cultural bias initiatives to improve kidney transplantation for Aboriginal and Torres Strait Islander people.

• Valery P, Coory M, Stirling J & Green AC 2006. Cancer diagnosis, treatment, and survival in Indigenous and non-Indigenous Australians: a matched cohort study. The Lancet 367:1842-8.