NACCHO Aboriginal Health Alert :Income, literacy emerge as vital to changing health outcomes


“In remote areas, hospital admissi­ons were markedly higher than metropolitan areas for adults with heart failure, asthma and chronic obstructive pulmonary disease, and diabetes-related lower-limb amputation, perhaps reflecting the failure to properly manage chronic conditions. “It is known that indigenous people are about three times more likely to have diabetes, 10 times more likely to be admitted for diabetic foot complications and 30 times more likely to suffer diabe­t­es-related lower-limb amputation than non-indigenous people.”

The Australian has reported today

Income and literacy help determine the level of healthcare available to Australians, not just where people live and which doctor they see.

A draft report on variations in healthcare, considered by health ministers on Friday, details for the first time the massive disparities in service delivery across the nation. Some rates reflect the poorer health of a particular community, while others show greater access to doctors and facilities; some suggest a combination of issues that has skewed treatment options.

As revealed by The Weekend Australian , one of the most glaring irregularities was the prescription rate for ADHD drugs in the Taree-Gloucester region of NSW, 75 times higher than for children in the lowest-prescribed area.

The draft was prepared by the Australian Commission on Safety and Quality in Health Care, with help from the National Health Performance Authority and three specially formed advisory groups. It provides the evidence for further investigation and what ministers expect will be a debate over approp­riate levels of servicing.

The draft confirms that people with lower socio-economic status have greater health needs and poorer outcomes, espec­ially indig­enous Australians, for whom there was not even reliable data. “Given the importance of improv­ing the health and wellbeing of indigenous people, unwarranted variation is unaccept­able,” it states. “It is vital that efforts to address unwarranted variation prioritise this population’s needs and concerns.”

About 60 per cent of Australians have low health literacy, affect­ing their capacity to make decisions and act to manage their health.

While in some areas a lack of access to services may exacerbate a person’s underlying health problems, in other areas the type of ­services available may dictate treat­ment.

“For example, one reason for the variation in the dispensing of psychotropic medicines may be a lack of access to affordable, access­ible mental health services in rural or disadvantaged areas, with limited availability of psychosocial interventions as alternatives to medical treatments,” the report says

Health overuse hotspots revealed

Drugs for ADHD are prescribed to children most regularly in the country town of Taree and anti­biotics are dished out like lollies in Sydney’s west, while the residents of Western Australia’s Bunbury have the highest rate of knee arthroscopies in Australia.

A comprehensive report, ­obtained by The Weekend Australian, gives an unprecedented snapshot of the health system, laying bare over-servicing in some regions, while patients struggle to receive adequate medical attention in other areas.

The startling statistics reveal wide variances in medical treatments across the nation: the rate of prescribing drugs for attention deficit and hyperactivity disorder to children varies by 75 times ­between the Taree-Gloucester region and the area of Australia with the least prescriptions.

For the first time, the report, considered by the nation’s health ministers yesterday, pulls ­together government data across a range of medical treatments ­administered across the nation. It shows that how much access to drugs, medical tests and surgery ­depends on where you live and which professional you see.

In the western Sydney suburb of Mount Druitt, residents have greater access to CAT scans than anywhere else, even though ­experts warn against routine scanning.

Men in the New ­England and northwest region of NSW are more likely to have their ­prostate removed after a cancer scare, perhaps due to other treatment options being unavailable, while the rate of ­antipsychotic drug use in Vic­toria’s Yarra suggests some older people with mild dementia are being medicated unnecessarily.

While socioeconomic factors and the city-rural divide may ­explain some variation, in some areas it may be due to inappropriate clinical decision-making or misinformed patients.

The report, which is in draft form, stops short of laying blame, instead providing the evidence for further investigation into whether patients are at risk — from too little or too much healthcare — or resources are being used unwisely.

The variations are skewed by a lack of data from indigenous communities — a damning finding in itself — but even with the outliers removed, there is up to eight times difference in the rate of healthcare practices in some areas. For example, more than 500,000 drug prescriptions for ADHD were dispensed across Australia in 2013-14.

Under analysis, NSW stands out, having eight of the 12 areas with the highest prescription rate, a finding the draft report says warrants further attention.

While antibiotic resistance is a serious problem, creating superbugs that complicate healthcare, Australia still has one of the highest rates of antibiotic use in the world. More than 30 million prescriptions were charged to the Pharmaceutical Benefits Scheme in 2013-14.

According to the report, only Western Australia appears able to keep rates down — the highest rate for any area in that state is still lower than the national average — and it is unclear whether western Sydney has more people in need or simply more willing doctors.

In 2013-14, more than 314,000 computed tomography (CT) scans of the lumbar spine were billed to the Medicare Benefits Schedule, and the draft points to variations “suggesting overuse of this investigation”. There are also variations in fibre-optic colonoscopies, and prostate biopsies for men aged 40 and over.

Even surgery rates differ ­greatly. Hospital admissions for knee arthroscopies varied by 4.2 times, once outliers were removed, and the draft suggests “many of these people will have degenerative disease in their knees and will not benefit from this intervention”. There was also three times the difference in rates of MBS-funded cataract surgery, once the outliers were removed, and significant variation in rates of tonsillectomies for children.

Women living in regional areas were up to five times more likely to undergo a hysterectomy or endometrial ablation than those living in metropolitan areas, and the draft recommends patients be given more information on their options, the risks and benefits.

In 2012-13 there were 8496 radical prostatectomy admissions to hospital, which represents 150 ­admissions per 100,000 men aged 40 and over. Yet rates ranged from 69 to 282 per 100,000, and the draft suggests the lack of specialist surgeons might be the cause.

The final report, or atlas, is being prepared by the Australian Commission on Safety and Quality and Health Care and the ­National Health Performance Agency, aided by numerous clinical experts and health groups.

Stakeholders will be briefed ahead of its release, expected this month, and health ministers yesterday asked their national advisory council to work on a response.

In a joint statement, the ministers said the project “may help serve as a catalyst for debates about what constitutes ‘best care’ in the Australian health system”.

Anne Duggan, chair of the Atlas Advisory Group, last night said she hoped that reporting on variations at a local level would lead to changes that directly benefit patients.

“It is clear there is unwanted variation,” Professor Duggan told The Weekend Australian.

“Now we ask the question, ‘well, what does right look like?’ as we try to improve the equity and the appropriateness and the quality of care for all Australians.”


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