Key messages
From July 2017 to June 2019:
- 15% (92,019) of hospitalisations for Aboriginal and Torres Strait Islander people were potentially preventable (excluding dialysis) – a rate of 55 potentially preventable hospitalisations per 1,000 population.
- Potentially preventable hospitalisations fall into three broad categories: vaccine-preventable conditions, acute conditions, and chronic conditions. Indigenous Australians were hospitalised for potentially preventable acute conditions at a rate of 27 hospitalisations per 1,000 population, chronic conditions at a rate of 22 per 1,000, and vaccine-preventable conditions at a rate of 7.9 per 1,000.
- For Indigenous Australians, the leading causes of hospitalisations due to vaccine-preventable conditions were chronic hepatitis B (53% of hospitalisations due to vaccine-preventable conditions) and influenza (33%). Cellulitis (22%) and ear, nose and throat infections (18%) were the leading causes of potentially preventable hospitalisations due to acute conditions among Indigenous Australians. For potentially preventable hospitalisations due to chronic conditions, COPD (30%) and diabetes complications (21%), were the leading causes.
- Potentially preventable hospitalisations were highest for Indigenous Australians living in Remote areas (104 hospitalisations per 1,000 population), followed by Very remote areas (95 per 1,000 population), and lowest in Major cities (39 per 1,000).
- Indigenous Australians were hospitalised for potentially preventable conditions at a rate 2.8 times the non-Indigenous rate (based on age-standardised rates).
- Age-standardised potentially preventable hospitalisation rates for Indigenous Australians increased by 20% between 2013–14 to 2018–19, with increase in the gap between Indigenous and non-Indigenous Australians, from a rate difference of 40 per 1,000 (in 2013–14) to 49 per 1,000 (in 2018–19).
- A study of Indigenous residents living in remote Northern Territory communities found that those who utilised primary health care at medium/high levels were less likely to be admitted to hospital than those in the low utilisation group, and that higher levels of primary care utilisation for renal disease reduced avoidable hospitalisations by 82%–85%, and 63%–78% for ischaemic (coronary) heart disease.
- Comprehensive, accessible and well-integrated care is needed, particularly in managing chronic conditions, in order to prevent hospitalisations and death from avoidable causes. Ensuring services, particularly ACCHS, are accessible and appropriate throughout Australia is therefore important to drive reductions in potentially preventable hospitalisations and avoidable deaths.
Why is it important?
Hospitalisations for conditions that can be effectively treated in a non-hospital setting are referred to as Potentially Preventable Hospitalisations (PPH). This is a key measure of the performance of the health system. In particular, it serves as a proxy measure of access to timely, effective and appropriate primary and community-based care (AIHW 2020). An analysis of the conditions for which people are admitted to hospital reveals that, in many cases, the hospital admission could have been prevented through timely and effective care outside hospital (Li et al. 2009).
Measures of PPH include conditions for which hospitalisation is potentially avoidable through effective preventive measures and early diagnosis or disease management, usually delivered through primary health care (Page et al. 2007). The term ‘PPH’ does not mean that the patient did not require hospitalisation at the time of the admission, but that hospitalisation could potentially have been prevented with effective management in community health care settings (AIHW 2019).
PPH fall into three broad categories:
- vaccine-preventable conditions—for example, influenza, tetanus, whooping cough, chicken pox, measles and so forth.
- acute conditions—including cellulitis (skin infections), urinary tract infections, convulsions/epilepsy, dental conditions, ear nose and throat infections
- chronic conditions—including many forms of cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes complications, asthma, iron deficiency and hypertension.
Systematic differences in hospitalisation rates for Aboriginal and Torres Strait Islander people and non-Indigenous Australians can indicate gaps in the provision of population health interventions (such as immunisation), primary care services (such as early interventions to detect and treat chronic disease), and continuing care support (such as care planning for people with chronic illnesses, e.g., congestive heart failure). Higher hospitalisation rates can also reflect appropriate referral mechanisms and access to hospital care. Among Indigenous Australians, there is also a higher prevalence for the underlying diseases, indicating deficiencies in access to primary health care and prevention/health promotion services. Indigenous Australians are also more likely to live in remote areas where non-hospital alternatives are limited (Gibson & Segal 2009; Li et al. 2009).
Findings
What does the data tell us?
In the period July 2017 to June 2019, there were 92,019 hospitalisations for Indigenous Australians that were potentially preventable. This corresponded to a rate of 55 PPH per 1,000 population, and accounted for 15% of all hospitalisations (excluding dialysis) of Indigenous Australians over the period (Table D3.07.3, Table D1.02.1).
Rates of PPH were higher for Indigenous females (63 hospitalisations per 1,000) than Indigenous males (48 per 1,000). By age group, the rate of PPH for Indigenous Australians was lowest for those aged 5–14 (24 per 1,000) and increased with increasing age to 173 per 1,000 for those aged 65 and over (Table D3.07.1, Figure 3.07.1).
Figure 3.07.1: Potentially preventable hospital admissions, by Indigenous status and age group, July 2017 to June 2019
Source: Table D3.07.1. AIHW analysis of National Hospital Morbidity Database.
PPH rates among Indigenous Australians were lowest for those living in in Tasmania (23 per 1,000) and the Australian Capital Territory (31 per 1,000) and highest in the Northern Territory (107 per 1,000) and Western Australia (69 per 1,000) (Table D3.07.2).
The rate of PPH for Indigenous Australians was higher for those living in in remote than non-remote areas. The rate was highest for those living in Remote areas (104 per 1,000); 2.6 times the rate for those in Major cities (39 per 1,000). Those living in Very remote areas had the second highest rate of PPH for Indigenous Australians (95 per 1,000) (Table D3.07.3, Figure 3.07.2).
Figure 3.07.2: Potentially preventable hospitalisations for Indigenous Australians, by remoteness, Australia, July 2017 to June 2019
Source: Table D3.07.3. AIHW analysis of National Hospital Morbidity Database.
Leading causes of potentially preventable hospitalisations
Between July 2017 and June 2019, among Indigenous Australians, the 5 leading causes of potentially preventable hospitalisations were COPD (10,810 hospitalisations; 12% of all PPH hospitalisations); cellulitis (9,954; 11%); ear, nose and throat infections (7,990; 8.7%); convulsions and epilepsy (7,774; 8.4%); and diabetes complications (7,664; 8.3%) (Table D3.07.5, Figure 3.07.3).
Figure 3.07.3: Top 10 leading causes of potentially preventable hospitalisations of Indigenous Australians, Australia, July 2017 to June 2019 (proportion of potentially preventable hospitalisations)
Source: Table D3.07.5. AIHW analysis of National Hospital Morbidity Database.
The hospitalisation rates for the leading causes of PPH of Indigenous Australians were: 6.5 hospitalisations per 1,000 population for COPD; 6.0 PPH per 1,000 population for cellulitis; 4.8 per 1,000 for ear, nose and throat infections; 4.7 per 1,000 for convulsions and epilepsy; and 4.6 per 1,000 for diabetes complications (Table D3.07.5).
The most common causes of hospitalisations considered potentially preventable varied by age group. Ear, nose and throat infections were the leading cause for Indigenous infants aged under 1 (44 PPH per 1,000 population) and the second leading cause for children aged 1–14 (6.6 per 1,000). Dental conditions were the leading cause of PPH for Indigenous children aged 1–14 (8.1 per 1,000) (Table D3.07.6).
Urinary tract infections were the leading cause of PPH for Indigenous Australians aged 15–24 (3.7 PPH per 1,000) and for those aged 25–44 the leading cause was cellulitis (7.8 per 1,000). For Indigenous Australians aged 45 and over, COPD was the leading cause of PPH, at a rate of 21 PPH per 1,000 for those aged 45–64 and 52 per 1,000 for those aged 65 and over (Table D3.07.6, Figure 3.07.4).
Figure 3.07.4: Rate of potentially preventable hospitalisations among Indigenous Australians for top 3 leading causes by Indigenous status and age group, Australia, July 2017 to June 2019
Source: Table D3.07.6. AIHW analysis of National Hospital Morbidity Database.
When grouping PPH conditions into acute, chronic and vaccine-preventable conditions:
- acute conditions accounted for 48% (44,470, 29 per 1,000) of all PPH for Indigenous Australians,
- chronic conditions accounted for 40% (36,508, 22 per 1,000) and
- vaccine-preventable conditions accounted for 14% (13,174, 7.9 per 1,000) (Table D3.07.12).
Note that the sum of the categories exceeds the total, as more than one potentially preventable condition can be diagnosed for each hospitalisation.
For Indigenous Australians, the leading causes of PPH due to acute conditions were: cellulitis, a skin infection usually caused by bacteria (22% of all PPH due to acute conditions, or 6.0 per 1,000 population); ear, nose and throat infections (18%, or 4.8 per 1,000); and convulsions and epilepsy (17%, or 4.7 per 1,000) (Table D3.07.12).
The leading causes of PPH due to chronic conditions among Indigenous Australians were: COPD (30% of all PPH due to chronic conditions, or 6.5 per 1,000); diabetes complications (21%, or 4.6 per 1,000); and congestive heart failure (11%, or 2.5 per 1,000) (Table D3.07.12).
The leading causes of hospitalisation due to vaccine-preventable conditions for Indigenous Australians were: chronic hepatitis B (53% of all PPH due to vaccine-preventable conditions, or 4.2 per 1,000); influenza (33%, or 2.6 per 1,000); and pneumonia (12%, or 1.0 per 1,000) (Table D3.07.12).
Comparisons with non-Indigenous Australians
From July 2017 to June 2019, after adjusting for differences in the age structure between the two populations, Indigenous Australians were hospitalised for potentially preventable conditions at a rate 2.8 times that for non-Indigenous Australians (Table D3.07.1).
By age group, the largest relative difference in the PPH rate for Indigenous and non-Indigenous Australians was in the 35–44 and 45–54 age groups (rate ratios of 4.6 and 4.9, respectively). The largest absolute gap in the rates between the two populations was in the 55–64 age group (a difference of 92 hospitalisations per 1,000 population), followed by the 65 and over age group (a difference of 87 per 1,000) (Table D3.07.1, Figure 3.07.1).
Across all states and territories, the PPH rate for Indigenous Australians was higher than non-Indigenous Australians, after adjusting for differences in the age structure between the two populations. This was greatest in the Northern Territory and Western Australia (both 3.9 times the non-Indigenous rate) and was more evident for females in these jurisdictions (ratios of 4.7 and 4.2, respectively). Within most jurisdictions (the exceptions being Victoria and Tasmania), the difference in PPH rates between Indigenous and non-Indigenous Australians was larger for females than males, based on rate ratios (Table D3.07.2).
Across remoteness areas, the relative difference in the rates between the two populations was highest in Remote areas (a ratio of 4.3) and Very remote areas (a ratio of 4.0) and lowest in Inner regional areas (a ratio of 2.1) and Major cities (a ratio of 2.2), based on age-standardised rates (Table D3.07.3, Figure 3.07.3).
Across all the 10 most common causes of PPH for Indigenous Australians, non-Indigenous Australians had lower PPH rates than Indigenous Australians (based on age-standardised rates). The smallest relative difference in the top 10 causes was for dental conditions, where the rate for Indigenous Australians was 1.4 times the non-Indigenous rate. This greatest difference was for chronic hepatitis, for which Indigenous Australians were 8 times as likely as non-Indigenous Australians to be hospitalised.
Although PPH rates were higher for Indigenous Australians for the top 10 conditions, on average, non-Indigenous Australians spent more time in hospital for these 10 conditions (4.1 bed days) compared with Indigenous Australians (3.4 days) (Table D3.07.5).
Looking at the top causes of PPH for Indigenous Australians by age group, the disparity in PPH rates was particularly high for Indigenous Australians aged 45–64, who were hospitalised at 9.1 times the rate of non-Indigenous Australians for COPD, and 9.0 times the rate for chronic hepatitis (Table D3.07.6, Figure 3.07.4).
Changes over time
From 2013–14 to 2018–19, based on age-standardised rates, PPH rates increased by 20% for Indigenous Australians. This was predominantly driven by increases in the PPH rate for Indigenous females, which were more than double the increase for Indigenous males (27% compared with 11%) over this period. The age-standardised rate for non-Indigenous Australians also increased, though to a lesser degree, resulting in the gap in rates between Indigenous and non-Indigenous Australians widening over the period, from a rate difference of 40 per 1,000 (in 2013–14) to 49 per 1,000 (in 2018–19).
In each year from 2013–14 to 2016–17, the age-standardised PPH rate for Indigenous Australians was 2.7 times as high as for non-Indigenous Australians; in 2017–18 it was 2.8 times, and in 2018–19 it was 2.9 times as high (Table D3.07.11, Figure 3.07.5).
Figure 3.07.5: Age-standardised rates of potentially preventable hospitalisations, by Indigenous status, Australia, 2013–14 to 2018–19
Note: Rate difference is the age-standardised rate (per 1,000) for Indigenous Australians minus the age-standardised rate (per 1,000) for non-Indigenous Australians. Rate ratio is the age-standardised rate for Indigenous Australians divided by the age-standardised rate for non-Indigenous Australians.
Source: Table D3.07.11. AIHW analysis of National Hospital Morbidity Database.
Looking at type of PPH, age-standardised rates for both acute and chronic conditions for Indigenous Australians increased between 2010–11 and 2018–19, by 23% and 19%, respectively (Table D3.07.9, Table D3.07.10). For vaccine-preventable conditions, the age-standardised rate of PPH hospitalisations of Indigenous Australians increased by 65% from 2013–14 to 2018–19 (Table D3.07.8). For vaccine-preventable conditions, data are presented for a shorter period due to changes in coding practices in 2013–14.
What do research and evaluations tell us?
Research shows that disparities exist in the PPH rates between Indigenous and non-Indigenous Australians, reflecting differences in utilisation of care as well as the underlying conditions and social determinants.
A study of Indigenous residents living in remote Northern Territory communities found that those who utilised primary health care at medium/high levels were less likely to be admitted to hospital (and to die) than those in the low utilisation group (Zhao et al. 2014). Higher levels of primary care utilisation for renal disease reduced avoidable hospitalisations by 82–85% and for ischaemic heart disease the reduction was 63–78%.
Research by Harrold and others (2014) found that the Indigenous Australian rate of PPH was 2.16 times as high as the rate for non-Indigenous Australians who lived in the same Statistical Local Area in New South Wales, after controlling for age and sex (Harrold et al. 2014). The disparity was greatest in rural and remote areas relative to major cities. The largest differences in PPH were for diabetes complications, COPD and rheumatic heart disease. Geospatial analysis of PPH data can help identify areas where greater effort is needed to target the determinants of disease and to better manage chronic disease through culturally appropriate primary health care (Harrold et al. 2014).
A study in New South Wales found that personal sociodemographic and health characteristics are major drivers of geographic variation in PPH rates, and explain more of the variation than general practitioner (GPs) supply (Falster M et al. 2015). These personal characteristics (which included age, sex, Indigenous status, highest level of education, annual household income, level of psychological distress and more) also explained a greater amount of the variation for chronic conditions than for acute or vaccine-preventable conditions.
A recent Australian study found that there are substantial inequalities in paediatric avoidable hospitalisations between Indigenous and non-Indigenous children, regardless of where they live. The avoidable hospitalisation rates were found to be almost double in Aboriginal compared with non-Aboriginal children aged less than 2. Respiratory and infectious conditions were the most common reason for hospitalisation for children of all ages in the study, with Indigenous children being more likely to be hospitalised for all conditions (Falster K et al. 2016).
All Indigenous Australians are eligible for an annual Indigenous-specific health check, as well as free follow-up care. The health check can help identify whether a person is at risk of developing illnesses or chronic conditions. An analysis by the AIHW of geographical variation in rates of Indigenous-specific health checks, PPH and potentially avoidable deaths, found that –somewhat counter-intuitively – areas with the highest rates of Indigenous health checks were often not those with the lowest rates of PPH and potentially avoidable deaths. However, the report notes that while the uptake of Indigenous health checks has increased (national rates tripled between 2010–11 and 2016–17), it is reasonable to expect some lag time as to when positive effects on health outcomes, such as reduced PPH, can be seen. How effective health checks are at preventing PPH will also depend on the extent to which recommended follow up care resulting from these health checks is completed. Preliminary analysis by the AIHW showed that areas where a relatively high proportion of health checks result in follow-up care also tend to be in areas with relatively high rates of PPH; this may be because more health checks are likely to result in follow-up care being recommended in areas with relatively poor health outcomes. Reasons for low PPH rates include effective local primary health care, people not being hospitalised when they should be, and Indigenous under-identification in hospital records. Reasons for high PPH rates include ineffective local primary health care, high prevalence of certain diseases or conditions and high rates of inter-hospital transfers. The importance of these factors is not well understood and further investigation is needed into how they impact on PPH rates for Indigenous Australians (AIHW 2019b).
Please refer to measure 1.24 Avoidable and preventable deaths for more information on relevant evaluations.
Implications
PPH rates have typically been seen as useful indicators of the effectiveness of, or access to community-based health services (Passey et al. 2015). The rates of PPH for Indigenous Australians are rising and are considerably higher than rates for non-Indigenous Australians, particularly in Remote and Very remote areas. A recent AIHW report highlights opportunities that exist to prevent hospitalisations through primary health care interventions including:
- reducing and managing risk factors for disease
- vaccination
- oral health checks
- lifestyle interventions
- management of chronic conditions
- antenatal care (AIHW 2020).
Several studies have found that improving patient-provider communication and collaboration makes it easier for people to navigate, understand and use information and services to take care of their health. This could include matching information to the patient’s needs and abilities, recognising the importance of asking questions, shared decision-making, and providing a range of avenues for communication (Hernandez et al. 2012; Øvretveit 2012).
For Indigenous children, there is scope to reduce PPH though targeted prevention, early intervention through primary health care and better access to treatment for common childhood conditions. Policy measures that aim to reduce disparities in social determinants (such as access to better housing) may also help to reduce the incidence of these conditions in Indigenous children.
Research has started to show that geographic variation in PPH may not be simply explained by the supply of GPs. PPH may be more a reflection of social determinants and individual health factors, particularly for chronic conditions, than access to GPs (Falster M et al. 2015). PPH may, therefore, indicate areas where primary health care could be more effective or where it may be underutilised. There is a need for improvements in efforts to address the social determinants of health beyond the Health sector.
The data in this measure has illustrated the increasing rate of PPH for Indigenous Australians, indicating that primary health care is not adequately meeting the need. Further research is needed using data linkage, at smaller levels of geography across Australia. This should include measures of social determinants, and primary care utilisation to explore areas of unmet health need or underutilised health care for Indigenous Australians.
Understanding the reasons for underutilisation of primary health care at the local level is important 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.
Aboriginal Community Controlled Health Services (ACCHSs) play an essential role in providing comprehensive, appropriate and culturally safe care for Indigenous Australians. The evaluations in measure 1.24 Avoidable and preventable deaths point to mainstream services being less effective than ACCHSs. Comprehensive, accessible and well-integrated care is needed, particularly in managing chronic conditions, in order to prevent hospitalisations and death from avoidable causes. Ensuring services are accessible and appropriate is therefore important to drive reductions in PPH and avoidable deaths.
The National Aboriginal and Torres Strait Islander Health Plan (the Health Plan), released in December 2021, is the overarching policy framework to drive progress against the Closing the Gap health targets and priority reforms. Implementation of the Health Plan aims to drive structural reform towards models of care that are prevention and early intervention focused, with greater integration of care systems and pathways across primary, secondary and tertiary care. It also emphasises the need for mainstream services to address racism and provide culturally safe and responsive care, and be accountable to Aboriginal and Torres Strait Islander people and communities.
The policy context is at Policies and strategies.
References
- AIHW (Australian Institute of Health and Welfare) 2019a. Potentially preventable hospitalisations in Australia by age groups and small geographic areas, 2017–18. Canberra: AIHW. Viewed, May 2020.
- AIHW 2019b. Regional variation in uptake of Indigenous health checks and in preventable hospitalisations and deaths. Cat. no. IHW 216. Canberra: AIHW.
- AIHW 2020. Disparities in potentially preventable hospitalisations across Australia: Exploring the data. Canberra: AIHW. Viewed, May 2020.
- Falster K, Banks E, Lujic S, Falster M, Lynch J, Zwi K et al. 2016. Inequalities in pediatric avoidable hospitalizations between Aboriginal and non-Aboriginal children in Australia: a population data linkage study. BMC pediatrics 16:169.
- Falster MO, Jorm LR, Douglas KA, Blyth FM, Elliott RF & Leyland AH 2015. Sociodemographic and health characteristics, rather than primary care supply, are major drivers of geographic variation in preventable hospitalizations in Australia. Medical care 53:436.
- Gibson O & Segal L 2009. Avoidable hospitalisation in Aboriginal and non-Aboriginal people in the Northern Territory. The Medical Journal of Australia 191:411.
- Harrold. TC, Randall. DA, Falster. MO, Sanja L & Louisa J 2014. The Contribution of Geography to Disparities in Preventable Hospitalisations between Indigenous and Non-Indigenous Australians. PloS one.
- Hernandez SE, Conrad DA, Marcus-Smith MS, Reed P & Watts C 2012. Patient-centered innovation in health care organizations: A conceptual framework and case study application. Health Care Management Review.
- 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.
- Øvretveit J 2012. Summary of 'Do changes to patient-provider relationships improve quality and save money?'. London: The Health Foundation.
- Page A, Ambrose S, Glover J & Hetzel D 2007. Atlas of Avoidable Hospitalisations in Australia: ambulatory care-sensitive conditions. Adelaide: PHIDU.
- Passey ME, Longman JM, Johnston JJ, Jorm L, Ewald D, Morgan GG et al. 2015. Diagnosing Potentially Preventable Hospitalisations (DaPPHne): protocol for a mixed-methods data-linkage study. BMJ Open 5:e009879.
- 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.