This study has demonstrated that Aboriginal people in NSW are significantly more likely to experience frequent avoidable admissions for ambulatory care sensitive chronic conditions compared with non-Aboriginal people. Aboriginal patients were 15% more likely to have a higher number of avoidable admissions for each financial year over the study period and were almost two times as likely to experience three or more avoidable admissions for each financial year compared to non-Aboriginal people. These findings remained significant after being adjusted for sociodemographic variables.
In our study the rates of both the number of avoidable admissions and whether or not an individual experienced three or more avoidable admissions per financial year remained consistently higher than non-Aboriginal people over the nine-year study period however there were no significant differences in yearly trends between Aboriginal and non-Aboriginal people. This finding demonstrates that Aboriginal people with chronic conditions are at a consistently higher risk of experiencing frequent avoidable admissions compared with non-Aboriginal people. Despite the “Closing the Gap” government strategy to reduce disadvantage among Aboriginal people in health, education and employment being in place since 2008,[24] there is no evidence of the gap being closed in the area of frequent avoidable admissions.
Our findings show that the heightened risk of frequent avoidable admissions is relevant to a small proportion of those Aboriginal people experiencing avoidable admissions. Over the study period an average of eleven percent of Aboriginal people experienced three or more avoidable admissions compared to just six percent in non-Aboriginal people. This is consistent with other research in the area of frequent admissions which reiterates the fact that a small proportion of patients account for a disproportionate share of avoidable admissions.[9, 15]
Research in the area of frequent avoidable admissions commonly aims to develop risk profiles or risk prediction tools to help identity those patients most at risk.[7, 9, 15] Our study showed that Aboriginal people experiencing avoidable admissions were more likely to be female, younger, single, have diabetes complications, asthma and COPD, live in moderately accessible to very remote locations, and to be more disadvantaged compared with non-Aboriginal people. Further research in identifying a risk profile for this vulnerable group of people would be helpful in creating appropriate community medical and prevention care.
The high risk of frequent avoidable admissions for Aboriginal people in part reflects the higher rate of chronic conditions in the Aboriginal population which accounts for most of the gap in life expectancy compared with non-Aboriginal people.[4] However it also highlights the health inequities and barriers that remain for Aboriginal people in terms of access to community health services. Cultural and locational factors can impede access to appropriate primary and community health care services for Aboriginal people.[25] National survey data shows that Aboriginal people report difficulties in accessing health services and experience discrimination and services not being culturally appropriate.[26] As our findings demonstrated, compared to non-Aboriginal people, Aboriginal people with avoidable admissions were more likely to live remotely. Aboriginal people who live in remote areas can face practical, logistical and financial barriers which impact on the timeliness and effectiveness of health care.[27] For some Aboriginal people there are also high rates of homelessness, food insecurity, lack of transport, complex comorbidities and alcohol misuse.[16, 28] These underlying risk factors and consequences of social disadvantage have enduring effects and may contribute significantly to the disproportionate burden of frequent avoidable admissions among Aboriginal people.
Our study highlights the need to strengthen services that intervene before a patient needs to be admitted to hospital. Effective management of chronic disease in the primary care setting can delay the progression of disease, improve quality of life, increase life expectancy, and decrease the need to be admitted to hospital.[2, 29] However there is little intervention research in the area of frequent avoidable admissions for Aboriginal people with chronic conditions. A Northern Territory cohort study of a community-led case management program using a culturally competent framework to support frequent attenders aimed to address causes of recurrent emergency department presentations among Aboriginal people with complex social and medical backgrounds. The program was able to significantly improve engagement with primary care and reduce emergency department presentations but not frequent hospital admissions.[16] A retrospective analysis of primary care and inpatient records for Aboriginal patients with diabetes, also in the Northern Territory, found that a timely diabetes care plan was associated with better short-term blood glucose control and fewer diabetes-related admissions.[30] Although such studies provide promising results for reducing frequent avoidable admissions in Aboriginal people, there is still a need for rigorous, well-evaluated and culturally-appropriate interventions to provide robust evidence of effective strategies to help reduce frequent avoidable admissions.
Interestingly, our study found that Aboriginal people in this study had a significantly shorter average length of stay compared with non-Aboriginal people. As discussed in our previous paper examining unplanned readmissions in this same cohort,[31] this finding may indicate that Aboriginal patients with chronic conditions in NSW are not receiving adequate health care or are at higher risk of discharge against medical advice resulting in poorer health outcomes and increased risk of readmission or frequent avoidable admissions.
Limitations
There are limitations to this study. Firstly, it is important to keep in mind that not all avoidable admissions may be avoidable. While many admissions could have been prevented through effective chronic disease management in the primary care setting, other admissions may reflect necessary admissions for seriously ill patients.[32] Secondly, national hospital records are likely to under-report Aboriginal status and it is likely that the true numbers of avoidable admissions and their frequency among Aboriginal people are higher than reported in this study.[33]