Indigenous Potentially Preventable Hospitalisations

A Geographic and Temporal Analysis

Published: 2020

Introduction

“We're a big country, you can’t possibly average out, in a meaningful way what happens from you know Cape York to Tasmania to Perth sort of thing, and I actually think communities are tired of being put into that basket, and part of the kind of the move towards self-management is about our data and what we need.” - response of an Indigenous knowledge broker to the relevance of the Indigenous Burden of Disease to the local, Indigenous context, and to community health services (Katz et al. 2017).

The impact of colonisation and settlement has been a major cause in the gap in health between the Aboriginal and Torres Strait Islander (now known as Indigenous) and the non-Indigenous population. Indigenous Australians currently experience poorer health status than non-Indigenous Australians with a burden of disease that was 2.3 times the rate of non-Indigenous Australians (Australian Institute of Health and Welfare, 2016). In reporting on their day-to-day health, Indigenous Australians were twice as likely as non-Indigenous Australians to report their health as fair or poor (Australian Bureau of Statistics, 2016). The Australian Health Ministers’ Advisory Council, 2017 report that 29% of Indigenous Australians aged 15 years and over had three or more long-term health conditions and had higher rates of chronic disease. Chronic diseases were responsible for 64% of the total disease burden for Indigenous Australians and 70% of the gap between Indigenous and non-Indigenous health in 2011 (Australian Institute of Health and Welfare, 2016). The Australian Health Ministers’ Advisory Council, 2017 report that for diseases like diabetes, rates were 3 times higher than the non-Indigenous rate and of those diagnosed with diabetes 61% had high blood sugar levels. Risk factors such as alcohol consumption, smoking, weight status and high blood pressure was highlighted as more prevalent among Indigenous Australians than non-Indigenous Australians. For example, Indigenous Australians aged 15 years and over reported that 42% were current smokers and 66% were overweight or obese. These figures represent Indigenous rates of 2.7 times higher for smoking and 1.6 times as likely to be obese compared to non-Indigenous Australians. These issues reflect that Indigenous person were more than twice as likely to be hospitalised (Australian Institute of Health and Welfare, 2019) and have a significant lower life expectancy with Indigenous males life expectancy estimated at 10.6 years lower than non-Indigenous males and 9.5 years lower for females (Australian Bureau of Statistics, 2013).

Connectedness to family and community, land and sea, culture and identity have been identified as integral to health from Indigenous perspectives (National Aboriginal Health Strategy Working Party, 1989). Since a large proportion of Indigenous Australians reside outside of the metropolitan area, their geographic location influence a range of factors such as their social and environmental context, ranging from cultural identification and social networks through to educational and employment opportunities (Australian Health Ministers’ Advisory Council, 2017). Remoteness of their residence also influence their health. The Australian Bureau of Statistics defines remoteness as one of five categories. These are Major Cities of Australia, Inner Regional Australia, Outer Regional Australia, Remote Australia and Very remote Australia (Australian Bureau of Statistics,2018).

Evidence from the Indigenous burden of disease study (Australian Institute of Health and Welfare, 2016) found that Remote areas had the highest rate of Indigenous burden in 2011 which was 2.4 times non-Indigenous Australians, followed by Very Remote areas which was 1.9 times the burden of non-Indigenous Australians. Inner regional areas had the lowest rate of total burden for Indigenous Australians, but rates were still 1.7 times higher than non-Indigenous Australians. The Australian Health Ministers’ Advisory Council, 2017 report that the gradient in burden of disease also persisted by range of disease. For example, Indigenous adults in Remote areas had higher rates of diabetes than in non-remote areas. Hospital separation rates were highest in Remote areas, lower in Very Remote areas and lowest in Major Cities. The associated direct health expenditure for Indigenous Australians was estimated at $8,515 per person in 2013-2014. His compared to $6,180 for non-Indigenous Australians, some 38% higher (Australian Institute of Health and Welfare,2018). These differences are suggested to likely reflect the higher underlying disease burden, the limited access to early detection, the management of common chronic conditions and the limited non-hospital alternatives and to some extent the higher costs of delivering health services in rural and remote areas (Australian Health Ministers’ Advisory Council, 2017).

Given the gap in health between Indigenous and non-Indigenous, there is still large geographic variations in Indigenous health across Australia – from large capital cities to small town camps.

The geographic distribution of Indigenous people across Australia

Given large variations in the distribution of the Indigenous people across the Australia, it is useful to break-down the Indigenous population by State and Territory and by Remoteness category to understand the geographical distributions in the Indigenous population. Using the estimated residential population for 2016 (Public Health Information Development Unit, 2020) the estimated population was 798,101 persons. Table 1 shows that over 60% of the Indigenous population live in New South Wales and Queensland. Western Australia has the next highest Indigenous population followed by the Northern Territory, Victoria, South Australia and Tasmania. Around 37% of the Indigenous population reside in the remoteness classification of Major Cities, 24% and 21% in the Inner and Outer regional category making up 45% of the Indigenous population. Around seven and 12% of the Indigenous population reside in Remote and Very Remote areas. This compares to around 73% of the non-Indigenous population who reside in Major Cities, 17% and eight percent in Inner and Outer regional areas, one percent in Remote and less than one percent in Very Remote areas. While only 12% of the Indigenous Australians lived in Very Remote areas, they made up 45% of those living in Very Remote areas.

The proportions of the Indigenous population also varied by remoteness across individual States or Territory (Table 1). The majority of Indigenous population residing in the Major Cities, Inner and Outer Regional areas classifications were in New South Wales and Queensland. Of the 19% of Indigenous people that reside in Remote and Very Remote areas, the majority were in Northern Territory, Western Australia, and Queensland. In the Very Remote areas, Indigenous people made up nearly 80% of the total population in the Northern Territory, followed by 41% in Queensland and 36% in Western Australia.

The number of Indigenous people by remoteness and the proportion (%) of the Indigenous population within each Remoteness category by State and Territory (Public Health Information Development Unit, 2020)
  Major Cities Inner Regional Outer Regional Remote Very Remote Total
New South Wales 122,852 (41%) 91,219 (49%) 41,814 (25%) 6,363 (12%) 3,436 (4%) 265,685 (33%)
Victoria 30,082 (10%) 20,090 (11%) 7,526 (5%) 69 (<1%) n.a 57,767 (7%)
Queensland 74,809 (25%) 47,127 (25%) 62,756 (38%) 12,853 (24%) 23,731 (25%) 221,276 (28%)
South Australia 21,957 (7%) 3,776 (2%) 10,309 (6%) 1,517 (3%) 4,708 (5%) 42,265 (5%)
Western Australia 40,055 (13%) 8,083 (4%) 14,137 (9%) 16,598 (31%) 21,639 (23%) 100,512 (13%)
Australian Capital Territory 7,453 (3%) 60 (<1%) n.a n.a n.a 7,513 (<1%)
Tasmania n.a 15,777 (8%) 11,882 (7%) 670 (1%) 208 (<1%) 28,537 (4%)
Northern Territory n.a n.a 17,456 (11%) 15,398 (29%) 41,693 (44%) 74,546 (9%)
Total 297,209 (37%) 186,131 (23%) 165,879 (21%) 53,467 (7%) 95,451 (12%) 798,101

n.a represents a remoteness category not available in the state or territory

Indigenous Potentially Preventable Hospitalisations (PPH)

Rates of PPH have increased over time across both Indigenous and non-Indigenous Australians (Table 2). Current data report that the rates of total Indigenous PPH were three times higher than non-Indigenous people and this trend was similar across the time series from 2013-2014. Rates of hospitalisation for Acute conditions and Chronic conditions were also comparable across all years with rates around 2.5 times and 3 or more times greater than the non-Indigenous population, respectively. Vaccine-preventable conditions also increased for all Australians with rates 4.4 higher in 2017-2018.

Table 2: Separations per 1,000 population for selected PPH by Indigenous status, all hospitals, 2013-14 to 2017-18 (Australian Institute of Health and Welfare, 2019).
  2013-14 2014-15 2015-16 2016-17 2017-18
Indigenous            
Total PPH 53.3 70.7 73.6 76.4 79.9
Acute conditions 24.7 28.2 30.1 31.1 31.5
Chronic conditions 23.5 34.8 35.6 37.0 38.0
Vaccine-preventable conditions 6.3 9.4 9.8 10.2 12.7
Non-indigenous            
Total PPH 16.3 24.3 25.4 26.2 26.7
Acute conditions 9.3 11.8 12.2 12.5 12.3
Chronic conditions 6.1 10.7 11.6 12.0 11.8
Vaccine-preventable conditions 0.9 1.6 1.8 2.0 2.9

The rates of PPH also vary by State and Territory (Table 3) giving a broad geographic perspective of the distribution of PPH admissions. Supplementary data (Australian Institute of Health and Welfare, 2017) taken from the Aboriginal and Torres Strait Islander Health Performance Framework (Australian Health Ministers’ Advisory Council, 2017) report the rates of total PPH (per 1,000 persons) ranged from 24.6 per 1,000 persons in Tasmania to 117.1 in the Northern Territory. The rate ratios (Indigenous divided by non-Indigenous Australians rates) were 1.2 times to 4.4 times the non-Indigenous population. The rates also varied by PPH category type. No rates for Tasmania were published for PPH category type. Rates for Vaccine-Preventable conditions ranged from 3.4 per 1,000 persons in New South Wales to 27.9 in the Northern Territory. Rate ratios ranged from 2.6 in New South Wales to 13.3 in the Northern Territory. Rates of Acute conditions were lowest in Victoria (16.9 per 1,000) and highest in the Northern Territory (44.1 per 1,000). Rate ratios for Acute condition were lowest in Victoria (1.6) and highest in Western Australia and the Northern Territory (3.5). Rates of Chronic Conditions were lowest in Victoria (23.6 per 1,000) and highest in the Northern Territory (52 per 1,000). Rate ratios were between 2.1 and 4.2, respectively.

Table 3: Rates per 1,000 persons of Indigenous and non-Indigenous PPH by location, excluding the Australian Capital Territory, and PPH category type for 2013-2015 (Australian Institute of Health and Welfare, 2017)
Location PPH category-type Indigenous Non-indigenous Ratio
New South Wales Total PPH 53.8 21.8 2.3
  Vaccine-preventable conditions 3.4 1.3 2.6
  Acute conditions 21.3 10.6 2.0
  Chronic conditions 29.6 10.1 2.9
Victoria Total PPH 44.0 23.1 1.8
  Vaccine-preventable conditions 4 1.5 2.7
  Acute conditions 16.9 10.6 1.6
  Chronic conditions 23.6 11.3 2.1
Queensland Total PPH 70.9 26.8 2.6
  Vaccine-preventable conditions 6.3 1.4 4.5
  Acute conditions 30.8 13.5 2.3
  Chronic conditions 35.1 12.1 2.9
Western Australia Total PPH 92.5 22.6 4.1
  Vaccine-preventable conditions 11.9 1 11.9
  Acute conditions 40.6 11.7 3.5
  Chronic conditions 42 10 4.2
South Australia Total PPH 73.7 24.1 3.1
  Vaccine-preventable conditions 9.6 1.7 5.6
  Acute conditions 29 11.9 2.4
  Chronic conditions 36.8 10.8 3.4
Northern Territory Total PPH 117.1 26.8 4.4
  Vaccine-preventable conditions 27.9 2.1 13.3
  Acute conditions 44.1 12.7 3.5
  Chronic conditions 52 12.3 4.2
Tasmania Total PPH 24.6 20.3 1.2

* PPH category types not reported for Tasmania

Within the Aboriginal and Torres Strait Islander Health Performance Framework (Australian Health Ministers’ Advisory Council, 2017) the PPH are also reported by remoteness for 2013-2015 (Australian Institute of Health and Welfare, 2017). The rates for all PPH were highest for Indigenous people living in Remote and Very Remote areas, and lowest in Inner Regional areas and Major Cities remoteness categories (Table 4). Rates were higher for Indigenous Australians at all remoteness levels compared to those for their non-Indigenous counterparts which were relatively equal across remoteness classifications.

Table 4: Potentially Preventable Hospital Rates and Rate Ratios of Indigenous to non-indigenous Australians by Remoteness for July 2013 -June 2015 (Australian Health Ministers’ Advisory Council, 2017)
Remoteness Area Potentially preventable hospitalisations rates for Indigenous Australians per 1,000 Potentially preventable hospitalisations rates for Non-Indigenous Australians per 1,000 Rate ratio of Indigenous to non-Indigenous Australians 2016 Indigenous ERP (persons)
Remote Areas 126 28 4.5 53,467
Very Remote Areas 109 29 3.8 95,415
Outer Regional 72 26 2.8 165,879
Inner Regional 49 24 2.0 186,131
Major Capital Cities 49 23 2.1 297,209

 

Table 5: The percentage of the 2016 Indigenous Potentially Preventable Hospitalisations (PPH) and population for 2014/15 to 2016/17 by remoteness category and state and Territory
  Major Cities Inner Regional Outer Regional Remote Very Remote
Percentage of category PPH (%)# Pop (%) PPH (%)# Pop (%) PPH (%)# Pop (%) PPH (%)# Pop (%) PPH (%)# Pop (%)
New South Wales 36 41 47 49 21 25 10 12 2 4
Victoria 9 10 10 11 4 5 >1 <1 n.a n.a
Queensland 28 25 32 25 41 38 23 24 17 25
South Australia 9 7 2 2 7 6 3 3 5 5
Western Australia 16 13 4 4 11 9 25 31 28 23
Tasmania n.a n.a 4 8 2 7 >1 1 >1 >0
Northern Territory n.a n.a n.a n.a 14 11 38 29 49 44

# data taken Public Health Information Development Unit, 2020.

Table 5 shows the percentage differences in PPH by remoteness and state and territory. The table provides a broad comparison contrasting the percentage of PPHs in the remoteness category against the population residing in the remoteness category for all states and the Northern Territory. We make the assumption of equal proportions, i.e. that there should be a 1:1 ratio between population and PPH admissions. This assumption seems to hold across the majority of Table. However, across the Northern Territory PPH percentages were always higher than the percentage of population, particularly in Very Remote Areas. This could indicate a less healthy Indigenous population or a lack of access to general practitioners, or perhaps both. Additionally, higher rates in less remote areas may also indicate a movement of Indigenous people to seek medical care such as in Queensland. Of note, are the rates in NSW which has much of the Indigenous population but its percentage of PPH is always less than the percentage of Indigenous population.

Expenditure on PPHs for Indigenous people was approximately $219 million in 2010–11 or $385 per Indigenous person. This compares to $174 per non-Indigenous Australian (Australian Institute of Health and Welfare, 2013). Chronic conditions had the highest level of per person expenditure at $202 per person compared to $98 per person for non-Indigenous Australians. Chronic obstructive pulmonary disease and diabetes complications were the highest contributors to these costs. Acute conditions were $163 per Indigenous Australian compared to $71 for non-Indigenous Australians. Expenditure on Vaccine-Preventable conditions was $21 per Indigenous Australians compared to $5 per non-Indigenous Australian.

Convulsions and Epilepsy, and Cellulitis conditions were ranked as top 5 PPH across all areas within the five regions where data was available (Australian Institute of Health and Welfare, 2017). Rates for Convulsions and Epilepsy varied from 3 per 1,000 people, which was far below the National average (5.7) in Victoria to 8.1 per 1,000 in the Northern Territory. Similar trends are found for Cellulitis. Rates of COPD when compared across all conditions were highest in NSW, Victoria and Queensland. COPD was not a Top 5 condition in Western Australia. Rates of Dental conditions were fairly comparable between Indigenous and Non-Indigenous people with NSW having lowest rates and Queensland the highest rates. Dental conditions were not reported as a Top 5 conditions in Western Australia and Northern Territory. Diabetes complications were not reported as a Top 5 PPH condition in NSW and the Northern Territory. Rates in Queensland were over four times higher than for non-Indigenous people. ENT infections were not reported as a Top 5 condition in Victoria and Queensland. NSW had rates less than the national average while Western Australia and Northern Territory were higher. Rates for Other Vaccine preventable conditions were nearly 17 times higher than non-Indigenous people in the Northern Territory.

Table 6: Top 5 Potentially Preventable Hospitalisations by Indigenous status for July 2013 to June 2015 by State and Territory (excluding South Australia, Australian Capital Territory and Tasmania) (Australian Institute of Health and Welfare, 2017).
  Australia New South Wales Victoria Queensland Western Australia Northern Territory
  Indigenous Non-Indigenous Indigenous Non-Indigenous Indigenous Non-Indigenous Indigenous Non-Indigenous Indigenous Non-Indigenous Indigenous Non-Indigenous
Convulsions and epilepsy 5.7 1.4 4.7 1.4 3 1.3 5.7 1.7 7.6 1.1 8.1 1.4
Cellulitis 7 2.2 5.2 2.2 3.3 1.8 7.9 3 10.5 1.8 11 3.6
Chronic Obstructive Pulmonary Disease 11.1 2.3 11.3 2.3 7.9 2.1 10.7 2.6 n.p n.p 16.1 3.6
Dental conditions 3.4 2.6 2.8 2.2 3 2.7 3.4 2.5 n.p n.p n.p n.p
Diabetes complications 6.6 1.6 n.p n.p 4.4 1.6 7.6 1.8 4.4 1.6 n.p n.p
ENT infections 3.2 1.6 2.6 1.6 n.p n.p n.p n.p 4.3 1.5 5.6 1.6
Other Vaccine Preventable 6.1 0.8 n.p n.p n.p n.p n.p n.p 9.2 0.6 21.9 1.3

n.p Not published as part of the ranking of Top 5 rates for PPH in the region.

Summary of the recent literature published on Potentially Preventable Hospitalisations for Indigenous Australians by State and Territory

The data on PPH demonstrate geographic variations in the magnitudes of their rates and type. This variation is also reflected in the literature on PPH where different evidence bases have been established in different areas of the country. This evidence base probably reflects the distribution of the Indigenous population in each State and Territory.

Potentially Preventable Hospitalisations for Indigenous Australians in New South Wales

New South Wales has around 33% (221,276) of the total Indigenous Population representing 3% of the total New South Wales population. Around 46% in reside in the Major Cities remoteness category, 34% in Inner Regional, 16% in Outer Regional, 2% in Remote and 1% in Very Remote areas.

Duncan et al. 2013 found from analysing presentations to the Sydney Children’s Hospital emergency department between 2002 to 2008 that Indigenous children aged 0-15 years presented more often than other Australians and were overrepresented in the emergency department population. Overall 44% of presentations by Indigenous children were coded potentially preventable and could have been avoided. Many presentations were in children less than one years old and reduced as age increased. Less than half (46%) of the children presented only once, 37% presented two to four times and 17% presented more than five times. The authors highlighted that the more frequent or multiple presenters to the emergency department did not represent children with a greater severity of illness or chronic disease and could be treated in a community setting.

Harrold et al. 2014 investigated 987,604 admissions for PPH conditions of which 3.7% were for Indigenous people over the 2003/04 to 2007/08 study period. The overall age-standardised rate of PPH admissions for Indigenous people was 76.5 per 1,000 persons compared with 27.3 per 1,000 persons for non-Indigenous people, a ratio of 2.80. Significantly higher rates of PPH admissions for Indigenous people were found for all PPH conditions with the exception of nutritional deficiencies (for which numbers were very small). After adjusting for geographic clustering, the magnitude of the Indigenous to non-Indigenous rate ratios decreased from 2.58 (95% CI 2.55– 2.60) to 2.16 (95% CI 2.14–2.19). This indicated that PPH admission rates in Indigenous people were 2.16 times higher than in non-Indigenous people of the same age group and sex who lived in the same Statistical Local Area (SLA) and that geographic clustering accounted for only some of the observed disparity in PPH rates. More specifically, the authors suggest that the higher rates of PPH admission among Indigenous people are not simply a function of their greater likelihood of living in rural and remote areas in New South Wales. The removal of the geographic elements highlighted that diabetes complications were responsible for the largest disparity, with the rate of these admissions for Indigenous people being more than five times higher than for non-Indigenous people of the same age group, sex and SLA of residence. The authors geographically highlighted more than 30 high rate, high disparity’ (high disparities of rates between Indigenous and non-Indigenous Australians) SLAs with the majority in regional areas, as well as three ‘low rate, low disparity’ SLAs.

Falster et al. 2016 investigated a state-wide cohort of children born in New South Wales from 2000 to 2012 reporting over 365,000 potentially avoidable hospitalisation. Rates for Indigenous children were 90.1 per 1,000 person-years and 44.9 per 1,000 person-years for non-Indigenous children. Rate differences and rate ratios (difference between Indigenous and non-Indigenous rates) declined with age, 94 per 1,000 person-years and 1.9 for children

Potentially Preventable Hospitalisations for Indigenous Australians in Queensland

Queensland has around 28% (221,276) of the total Indigenous Population representing 5% of the total Queensland population. Around 34% reside in the Major Cities remoteness category, 21% in Inner Regional, 28% in Outer Regional, 6% in Remote and 11% in Very Remote areas.

Harriss et al. 2018 investigated admissions to a regional north Queensland hospital with a local catchment area of 10 Statistical Local Areas, removing regional geographical differences. A total of 29,485 local residents generated 51,087 separations of which 5,488 (11%) were PPHs. Around 76% of all PPH were either chronic conditions or acute conditions associated with chronic conditions. Age-standardised PPH rates were 3.4 times higher for Indigenous than non-Indigenous people. Indigenous people made up 25% of these admissions and an estimated 37% of total cost of total PPHs. The median cost estimated for Diabetes complications for Indigenous persons was $11,546. This compared to $4,887 for non-Indigenous Australians. Although relatively low rates of Vaccine-Preventable PPHs were observed, the rate of these PPHs for Indigenous people was nearly eightfold higher than for non-Indigenous people. The authors suggest that the financial costs associated with PPH were substantially higher for Indigenous people, and justify investment in strategic, collaborative, evidence-based primary health interventions aimed at addressing health inequalities experienced in northern Queensland.

Another study (Caffery et al. 2017) highlighted the prevalence of dental conditions in Aboriginal population from all Queensland public and private hospital patients between 2011 and 2013. Indigenous infants and primary school children were significantly more likely to be hospitalised due to oral and dental conditions than their non-Indigenous counterparts. They found that were lower rates of hospitalisations for high school children but no significant difference in the rate of hospitalisation for adults.

Potentially Preventable Hospitalisations for Indigenous Australians in Western Australia

Western Australia has around 13% (221,276) of the total Indigenous Population representing 4% of the total Western Australian population. Around 40% reside in the Major Cities remoteness category, 8% in Inner Regional, 14% in Outer Regional, 17% in Remote and 22% in Very Remote areas.

Following on from the Grattan Institute report on PPH hotspots (Duckett and Griffiths, 2016), Gavidia et al. 2019 undertook a state-based hotspot analysis across Western Australia for the years 2010-11 to 2015-2016. The findings showed that areas with larger Indigenous populations were more likely to qualify as hotspots, especially for Acute conditions. This relationship did not hold for convulsions and epilepsy and dental conditions. When all 22 conditions were analysed together the Kimberley region was highlighted as a significant hotspot standing apart from the rest of Western Australia.

Western Australia has a long history in the investigation of dental conditions, especially reporting on the disparities between Indigenous and non-Indigenous children (Slack-Smith et al. 2011; Slack-Smith et al. 2013). Recent work by Kruger and Tennant, 2015 over a ten-year period between 1999-2000 to 2008-2009 found that Indigenous PPH admission rates for oral health conditions increased over time at a rate almost twice that of non-Aboriginal people. Alsharif et al. 2015 analysing a similar time period of hospitalisations for children under 15 years of age also showed this trend with the age-standardised rates of hospitalisation for Indigenous children in the last decade increasing to reach that of non-Indigenous children in 2009. The length of stay was also found to be longer for Indigenous children. Remoteness differences were also found with rural-living non-Indigenous children having 1.2 times the admission rate of rural-living Indigenous children. In contrast, Indigenous children living in major cities or regional areas had 2.6 times the admission rate of their Indigenous counterparts in rural or remote areas. Geographical access to health services was considered as the reason for this unequal distribution; it is evident by the fact that Indigenous children in metropolitan areas are also more likely to be admitted than Indigenous children in rural areas and all are less likely to have private health insurance cover which provides a role in health service delivery. The authors state that hospitalisations for ‘pulp and periapical’ conditions were mainly due to periapical abscess without sinus formation. It is not surprising that uninsured, Australian Indigenous male children aged < 9 years, and living in the most disadvantaged areas were more likely to be admitted for this condition. This can indicate that they only access dental care when conditions reached an advanced stage.

Of significance was research undertaken by Ha et al. 2019 in which a metric to understand the coverage or continuity of care was created for a cohort of people 45 years and over with diabetes mellitus. The measure was based on the maximum time interval between GP visits that afforded a protective effect against avoidable hospitalisations across complication cohorts. The metric of coverage or continuity of care was found to be lowest in Indigenous people.

Potentially Preventable Hospitalisations for Indigenous Australians in the Northern Territory

The Northern Territory has around 9% (74,546) of the total Indigenous population and this equates to 30% of the total Northern Territory population. Around 23% of the population reside in Outer Regional areas, 21% in Remote areas and 56% in Very Remote areas. Socioeconomic disadvantage is a major driver of ill-health with 25-30% of the NT health disparity explained by socioeconomic disadvantage (Zhao et al. 2013).

Early research by Li SQ et al. 2009 found that in the years 1998-99 to 2005-06, avoidable hospitalisations made up 15.6% of the total hospitalisations. Indigenous people made up 61% of these hospitalisations while only making up 28% of the population at the time of publication. Rates of avoidable hospitalisations were estimated at 11,090 per 100,000 population, nearly four times higher than then Australian rate of 2,848 per 100,000 population. Rates of Indigenous PPH exceeded the Australian rates for almost all conditions with the highest rate ratios for nutritional deficiencies (19.7), diabetes complications (6.8) and influenza and pneumonia (6.1).

Later studies have concentrated on populations with in remote communities reporting that there were gaps in screening and the recognition of elevated cardiovascular disease (Burgess et al. 2011) as well as high proportion of individuals who are at high risk of diabetes and had an accentuated cardiovascular risk profile (Arnold et al. 2016). Zhao et al. 2013b explored the relationship between primary health care utilisation and hospitalisations by linking 52,739 Indigenous residents from 54 remote primary care clinics and the five public hospitals for the years between 2007 and 2011. This population was characterised as having a high health need, high hospitalisation rate and poor access to primary health care utilisation. Across all conditions and demographic groups, they found a U-shape relationship between primary health care visits and hospitalisations. This result translates into an inverse association i.e. hospitalisations decrease as the number of primary care visits increase up to a certain (optimal) point (less than four primary health care visits) from which there was a positive association (i.e. hospitalisations increase as visits increase) with visits greater than four times or more. The data also showed that people who did not access their PHC service at all in the previous 12 months were more likely to be hospitalised. For specific conditions like diabetes and ischaemic heart disease (Angina), the minimum level of hospitalisation was calculated when there was 20–30 visits a year while for children with dental conditions, the number of visits was estimated at 5–8 per year.

Further analysis of the dataset (Zhao et al. 2015) reported a similar U-shaped curve for patients with diabetes where all-cause hospitalisations were minimised when primary health care visits were 7.9 per person-years (95% Confidence Interval 5.8-10). The authors propose that the effectiveness of a health system may hinge on a refined balance, rather than a straight-line relationship between primary health care and tertiary care in this area. Undertaking an investigation into chronic disease management, Zhao et al. 2014 also found a decrease in avoidable hospitalisation with increasing primary health care in 14,184 Indigenous residents, aged 15 years and over, who lived in remote communities and used a remote clinic or public hospital from 2002 to 2011. Compared to patients in the low primary care utilisation group, PPH rates in the medium (2-11 visits per year) and high primary care (12 visits or more per year) groups were 76% and 80% lower, respectively, for diabetes, 63% and 78% for ischaemic heart disease (Angina), 70% and 78% for hypertension. For chronic obstructive pulmonary disease (COPD), the reduction in the rate of PPH was the same for the both medium and high primary care groups (60%). In terms of cost-effectiveness, primary care for diabetes ranked as more cost-effective, followed by hypertension and ischaemic heart disease. Primary care for COPD was the least cost-effective of the five conditions. Primary care in remote Indigenous communities was shown to be associated with cost-savings to public hospitals and health benefits to individual patients. Investing $1 in high and medium level primary care in remote Indigenous communities could save between $3.95 and $11.75, respectively, in hospital costs, in addition to health benefits for individual patients.

Potentially Preventable Hospitalisations for Indigenous Australians in South Australia

South Australia has around 5% (21,957) of the total Indigenous Population and this represents around 2.5% of the total South Australian population. Around 52% reside in the Major Cities remoteness category, 9% in Inner Regional, 24% in Outer Regional, 4% in Remote and 11% in Very Remote areas.

Early research (Banham et al. 2010) on the South Australian residents in the years 2006 to 2008 identified that Indigenous people were part of a vulnerable population that were more likely to have more than one preventable admission. Research (Banham et al. 2017) on chronic PPH conditions for the years 2005-06 to 2010-11 across all the majority of South Australia identified a social gradient for Indigenous people by area disadvantage and remoteness, with the length of stay and financial cost increasing with increasing disadvantage and remoteness. This gradient also existed for the non-Indigenous population, however, the slope of this gradient was lower. Associated hospital costs were found to be 50% higher than that for non-Indigenous patients on average and to be more variable within the group of Indigenous patients. Disparities existed for Indigenous people with higher risks of chronic PPH hospitalisations with crude rates of 11.5 per 1,000 population compared to non-Indigenous 6.2 per 1,000 population. Diabetes complications were nearly 4 times (4.3 per 1,000 versus 1.3 per 1,000) the rates for non-Indigenous people. Of those that were hospitalised, Indigenous Australians were found to be younger than non-Indigenous people (median age of 48 years versus 70 years). Indigenous Australians were also found to have a higher number of admissions, 2.6 versus 1.9 per person, a longer total length of stay (11.7 versus 9.0 days) and higher average hospital costs ($A17,928 vs $A11,515 per ) when compared to non-Indigenous Australians. Of note is that residual data from the Anangu Pitjantjatjara Yankunytjatjara (APY) lands was removed as this area accesses over 95% of their hospital services at the Alice Springs Hospital in the Northern Territory. This removed around 2,000 Indigenous people (around 9% of South Australian Indigenous population) who resided in Very Remote Areas from the analysis.

Banham et al. 2019 investigating metropolitan emergency department presentations for ambulatory care sensitive conditions and GP-type issues between 2005-06 to 2010-11 found that adult Indigenous people had a greater presentation rate, 154.6 per 1,000 population when compared with 71.7 per 1,000 population for a comparative non-Indigenous population. Rates of presentations were higher for Acute conditions for Indigenous people (125.8 per 1,000 population compared to 51.6 per 1,000 population) and also for Chronic condition (41.6 per 1,000 population compared to 21.1 per 1,000 population). Rates for vaccine preventable conditions were similar for both Indigenous and and the comparator group (3.6 per 1,000 population v 3.3 per 1,000 population). Rates for GP-type presentations were also higher for Indigenous Australians with 308 presentations per 1,000 population versus 240 presentations per 1,000 population for the non-Indigenous group. These higher rates equated to an excess cost of $108,000 per 1,000 population for Acute conditions and $53,000 per 1,000 population for Chronic conditions. Indigenous people were also found to have had higher multiple attendances when compared to the comparator group. For example, a total of 5,095 Indigenous persons presented 23,825 times to the emergency department, 40% of these persons had one presentation, 16.7% presented twice, 16.9% had three or four presentations, and 26.4% had five or more presentations. This compares to the non-Indigenous comparison group were 346,844 persons had 898,399 presentations of which 52.6% had one presentation,19.8% had two presentations,15.3% had three or four presentations and 12.2% had five or more presentations.

Access to General Practitioner Services

Indigenous Australians currently experience poorer health status. Primary care can assist with the prevention of diseases through population health programmes such as vaccination programmes, more directed screening, early intervention and treatment of chronic conditions and rapid response to acute conditions. However, nearly 63% of the Indigenous population reside outside of the Major Cities remoteness category. Harriss et al. 2019 suggests that the relative paucity of primary and other community health services in regional and remote areas contributes significantly to high PPH rates, with local hospitals becoming the default service provider. Barriers to accessing care when needed vary between remote and non-remote areas and service types, suggesting that strategies need to be context-specific and adapted for local circumstances (Australian Health Ministers’ Advisory Council, 2017).

Overall GP services for the Australian population by State and Territory, and Remoteness

There are two major datasets that are accessed to review the access of General Practitioner by State and Territory and by Remoteness are reported by the Department of Health as Health Workforce Data (https://hwd.health.gov.au/).

The first is the National Health Workforce Dataset (NHWDS) which consists of de-identified registration and survey data for health practitioners from the fourteen health professions regulated by the Australian Health Practitioner Regulation Agency under the National Registration and Accreditation Scheme (Department of Health 2019). The Total Full-Time Equivalent of medical practitioners in the labour force and where their primary speciality was General Practice was calculated for 2018. This data was extracted from the Health Workforce Data portal (https://hwd.health.gov.au/webapi/jsf/login.xhtml). The indicator measures the workload of GPs based on the total self-reported hours in the medical workforce survey information of the NHWDS. It should be used as an estimate of GP workforce activity based on hours reported in the medical workforce survey and where geography is based on the location of their main job (Department of Health 2020).

The second is the GP Full-Time Equivalent and is available as GP primary care statistics for the calendar year (https://hwd.health.gov.au/index.html). The Department of Health (Department of Health 2020a) has moved to a new way of counting general practitioners and calculating their work effort providing primary care services. The new data methods reflect better the size of the general practice workforce and the actual workloads of general practitioners to more effectively address any maldistribution of primary care services. The new data methods are specific to health workforce planning activities. The new methods are different from other methods previously used by the Department and include a broader range of primary care Medicare Benefits Schedule (MBS) items. The indicator is described as measuring the workload of GPs delivering services taking into account provider geography, demographics and patient demographic information. Based on MBS, NHWDS, and Bettering the Evaluation and Care of Health information (BEACH) national study. MBS items are based on a GP’s scope of practice as agreed by Commonwealth Medical Advisors and GPs. It is suggested to be used for workforce specific method for GP workforce activity based on a broad range of services and provider and patient demographics. Geography is based on the exact location of the service delivery.

There is geographic variation in the Full-Time equivalents and GP Full-Time Equivalents per 100,000 persons by state and territory and remoteness defining. These two indicators show different trends in GP workforce activity. For the Full-Time equivalents derived from the NHWDS, the variation in rates across most states remoteness categories can be explained by a U or J shaped distribution, i.e. high in metropolitan areas, declining in regional areas and rising in remote areas. The exception is for rates in South Australia and the Northern Territory. The trend for GP Full-Time Equivalent indicator shows that rates decline across all remoteness categories across all states and the Northern Territory. Values are not published for Remote and Very Remote areas of New South Wales, Victoria, South Australia and Tasmania.

Table 7: Number of GPs, Full-Time Equivalent(FTE) (extracted from the National Health Workforce Dataset) and GP Full-Time Equivalent (extracted from Medicare Benefits Scheme) per 100,000 persons by State and Territory and Remoteness.
Major Cities Inner Regional Outer Regional Remote Very Remote
New South Wales FTE 96 85 72 115 125
GP full time equivalent 120 114 84 np np
Victoria
FTE 93 78 71 94
  GP full time equivalent 112 110 np np
Queensland
FTE 114 92 102 123 178
GP full time equivalent 126 118 111 72 83
South Australia
FTE 105 121 45 179 69
GP full time equivalent 118 103 98 np np
Western Australia
FTE 93 89 97 152 218
  GP full time equivalent 108 100 96 71 58
Tasmania
FTE   130 75 116 203
  GP full time equivalent   112 92 np np
Northern Territory
FTE 106 185 156
GP full time equivalent 107 83 59
Australian Capital Territory
FTE 107
  GP full time equivalent 89

Assessing Indigenous Australians access to General Practitioners through the Medicare Benefits scheme

Although not all care delivered through Indigenous primary health care can be claimed through Medicare, Medicare claims data do show a clear trend in services claimed which reduces by remoteness. These included rates of service claims for GP, allied health and specialist services, however, rates of claims for nurses and Aboriginal Health Worker services increased by remoteness mostly due to the types of services available in remoter areas (Australian Health Ministers’ Advisory Council, 2017).

The access to GPs can be broadly assessed by the number of services claimed through Medicare. The Australian Health Ministers’ Advisory Council, 2017 report that 2015-16 Indigenous Australians made nearly 8.7 million claims of which 4.2 million were for GP services. Between 2003-04 to 2015-2016 the rate of GP Medicare items claimed by Indigenous Australians increased by 39% and is now higher (6,623 per 1,000) than the non-Indigenous rate (5,840 per 1,000). It should be noted that not all care delivered through Indigenous primary health care services can be claimed through Medicare. Indigenous Australians were also more likely than non-Indigenous Australians to have long or complex GP consultations. Additionally, service claims for specialist and psychologist items were lower for Indigenous Australians.

The rates of Medicare service claims for GP, allied health and specialist services for both Indigenous and non-Indigenous Australians reduced by remoteness. Table 8 shows the age-standardised rate was higher in Major cities and declined steadily to lower rates in Very Remote Areas for Total Non-referred GP services claimed. This was the case for both Indigenous and non-Indigenous people. Against this gradient, rates of claims for practice nurse/Aboriginal Health Worker (AHW) services increased by remoteness for Indigenous Australians. This may reflect the types of services available in remote areas (Australian Health Ministers’ Advisory Council, 2017).

After hours care

The Australian Health Ministers’ Advisory Council, 2017 report that an important component of comprehensive primary health care services is the capacity for patients to access services after hours. In the absence of after-hours primary health care, patients with more urgent needs may delay seeking care. The Medicare Benefits Schedule (MBS) includes after-hours items that provide increased benefit rates to medical practitioners. Indigenous peoples have a lower rate of MBS after-hours services claimed than non-Indigenous Australians, a rate of 390 per 1,000 population compared to a rate of 474 per 1,000 population, a rate ratio of 0.8. The claims for after-hours services ranged from 170 per 1,000 population in remote areas to 636 per 1,000 in major cities (Table 8). Indigenous rates were 1.5 times as high as non-Indigenous rates in very remote areas. Rates of Indigenous presentations to after hours care were lowest in the NT (154 per 1,000). This is compared to rates from non-Indigenous people who reside in the Northern Territory of 455 per 1,000. A ratio of nearly 3 times lower. Indigenous presentation rates were highest in South Australia with 689 per 1,000, this compared to 514 per 1,000 for non-Indigenous people in South Australia.

Indigenous Health Checks

The Medicare Items for annual health checks are designed to promote early detection, diagnosis and management of many conditions associated with PPHs (Harriss et al. 2018). The Australian Health Ministers’ Advisory Council, 2017 report that MBS health assessment items have increased with the rate more than tripling between 2009 and 2016. In 2015-16, health assessments were undertaken on 26% of the Indigenous population between 0-14 years, 25% of the population between 15-54 years and 38% of the population between 55 years and over. In Indigenous primary health care organisation, 33% of Indigenous children aged 0-4 years, who were regular clients and had an MBS health assessment in the prior 12 months. The rates of people who had an MBS health check in the prior 24 months were 44% in those clients aged 25-54 years and 52% in those aged 55 years and over. Table 8 shows that the rates of health checks by remoteness were higher in Outer regional and Remote areas. The rate of health checks in Very Remote Areas was below the Australian average for Indigenous Australians. However, it must be noted that not all care delivered in remote areas through organisation such as Indigenous primary health care services can be claimed through Medicare.

Table 8: Age Standardised rate per 1,000 for Indigenous and non-Indigenous for non-referred GP (total), practice nurse/Aboriginal Health Worker (AHW) Indigenous Health Check, GP management Plan, co-ordinated team care arrangement and practice nurse, 2015-16 (Australian Health Ministers’ Advisory Council, 2017).
Major Cities Inner Regional Outer Regional Remote Very Remote Australia
Non-referred GP (total) Indigenous rate 7,641 7,073 6,386 5,461 4,343 6,623
Non-Indigenous rate 5,988 5,664 5,407 4,306 3,773 5,840
Practice nurse/AHW
Indigenous rate 327 412 436 754 775 464
Non-Indigenous rate 49 80 78 70 26 57
After Hours
Indigenous rate 636 279 318 180 170 390
Non-Indigenous rate 563 247 273 145 111 474
Indigenous Health Check
Indigenous rate 234 287 364 359 270 289
GP Management Plan (GPMP)
Indigenous rate 129 133 127 140 119 129
Non-Indigenous rate 86 90 83 66 41 86
Co-ordinated Team Care
Indigenous rate 112 113 110 124 103 112
Arrangements (TCA)
Non-Indigenous rate 72 74 65 49 28 72

Access to General Practitioners for chronic disease management

Chronic diseases are the leading causes of illness, disability and death among Indigenous peoples and estimated to be responsible for 70% of the health gap (AIHW, 2016f)- see AHMC). Effective management of chronic disease can delay the progression of disease, improve quality of life, increase life expectancy, and decrease the need for high cost interventions leading to net savings.

The Australian Health Ministers’ Advisory Council, 2017 report that a key measure of the quality of chronic disease management is whether a patient has a documented patient specific care plan. A care plan is a written action plan containing strategies for delivering care that address an individual’s specific needs, particularly patients with chronic conditions and/or complex care needs. Development of a care plan can also help encourage the patient to take informed responsibility for their care, including actions to help achieve the treatment goals.

GPs are encouraged to develop care plans through a number of items under the Medicare Benefits Schedule (MBS) these are, an MBS item related to the development of a GP Management Plan (GPM) and an item for a Team Care Arrangements (TCA) where planning involves a broader team, and items for where GPs contribute to care plans developed by another service provider or to a review of those plans. The Australian Health Ministers’ Advisory Council, 2017 report in the period 2009–10 to 2015–16, rates of services claimed by Indigenous Australians have almost doubled for GPMPs (from 70 to 129 per 1,000) and more than doubled for TCAs (from 55 to 112 per 1,000). Table 8 shows that these rates did not vary substantially over all the remoteness categories with the lowest rates (119 per 1,000 persons) in Very Remote areas and the highest (140 per 1,000) in Remote areas. Similarly, the lowest rates (103 per 1,000) for team care arrangements were in Very Remote areas and higher in Remote areas (124 per 1,000).

Indigenous primary health care organisations

Primary health care organisations play a critical role in helping Indigenous Australians. Access can be either through mainstream measured through the MBS or Indigenous primary health care organisations who are funded by the Australian and state and territory governments. These primary care organisations provide services with culture the most prominent characteristic underpinning all of the other seven characteristics which were identified as accessible of health services, community participation, continuous quality improvement, culturally appropriate and skilled workforce, flexible approach to care, holistic health care, and self-determination and empowerment. These findings were used to develop a new Indigenous PHC Service Delivery Model, which clearly demonstrates some of the unique characteristics of Indigenous specific models. (Harfield et al. 2018). These number of Commonwealth-funded Indigenous Primary Health Care organisations have increased from 108 in 1999–2000 to 203 in 2014–15. During this time period that the episodes of care for clients of these organisations have almost tripled (from 1.2 million to 3.5 million) and equivalent full-time staff have tripled. In 2018, the number of organisations increased to 247 organisations. The AIHW report (AIHW, 2019) that information on organisations funded by the Australian Government under its Indigenous Australians’ health programme (IAHP) is available through two data collections, the Online Services Report (OSR) and the national Key Performance Indicators (nKPIs). Information from the nKPI and OSR collections helps monitor progress against the Council of Australian Governments (COAG) Closing the Gap targets, and supports the national health goals set out in the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan 2013–2023.

The nKPI data collection reports the number of Indigenous regular client population of by state and territory and remoteness. The nKPI client population count reflects the Indigenous regular client population of primary health care organisations that are required to report against the nKPIs. A regular client is defined as a person who has an active medical record- that is, a client who attended the primary health care organisation on at least 3 separate occasions in the previous 2 years. This requires that the organisation report valid data against these nKPI indicators. In 2018 the number of organisations reporting valid data was 233 (Australian Institute of Health and Welfare, 2018g). It is important to note that the organisation count is based on the number of data submissions. For example, multiple assets are received from the Northern Territory government and these are counted as separate organisations. Table 9 shows the distribution of the nKPI client population, estimated residential population and number of organisations contributing nKPI data (Australian Institute of Health and Welfare 2019c).

Importantly, the nKPI figures need to be treated cautiously, as clients attending more than 1 organisation can be counted more than once. The calculation of the percentage of clients accessing the services by Remoteness category should also be treated with caution. This is due to the differences in how the nKPI and ERP populations are identified as Indigenous. Indigenous status in the Census is based on self-identification alone, while primary health care organisations may also consider community recognition and descent. However, while quality of the data is an issue, the data can act as a valuable comparator comparing accessibility to care by Indigenous Australians across Australia. The nKPI client population represented 25% of the Indigenous population in Vic/Tas, around 48% in Queensland and Western Australia and 114% in the Northern Territory. The number of Indigenous regular clients was highest in Major cities followed by organisations in the Very Remote classification while the lowest number were in areas classified as Remote. Remote areas, however, had a higher proportion of the Indigenous population accessing these organisations across most states. The largest number of organisations in major cities were in New South Wales/ACT. The Northern Territory had the most organisations (71) with most situated in Very remote areas (56). In 2017, the size of these organisations varies by state and territory and remoteness (Australian Institute of Health and Welfare 2018a). The average number of clients at each organisation was highest in major cities (3,200) and lowest in Very Remote areas (990). Half the organisation in Very Remote areas had fewer than 600 Indigenous regular clients while half the organisations in Major cities had more than 2,300 Indigenous regular clients.

Table 9: The nKPI client population count, percentage of population who are clients (in Brackets), Estimated Resident Population (ERP) and number of organisations by State and Territory for June 2018 (Australian Institute of Health and Welfare 2019c).
State/Territory Classification Major Cities Inner Regional Outer Regional Remote Very Remote Total
NSW/ACT NKPI population 24,823 (19%) 36,440 (40%) 17,526 (43%) 4,793 (66%) 173 (7%) 83,758 (31%)
  ERP 130,612 91,618 41,229 7,311 2,428 273,198
  Number of organisations 13 23 13 4 3 56
Vic/Tas NKPI population 5,813 (19%) 9,576 (27%) 6,396 (32%)     21,785 (25%)
  ERP 30,312 36,094 19,898     86,304
  Number of organisations 5 12 13   2 32
Qld NKPI population 41,428 (55%) 16,083 (33%) 27,126 (45%) 8,951 (67%) 14,297 (61%) 107,885 (49%)
  ERP 75,148 49,149 60,402 13,281 23,296 221,276
  Number of organisations 6 7 9 6 10 38
WA NKPI population 8,246 (20%) 2,373 (31%) 11,198 (79%) 15,478 (113%) 11,039 (45%) 48,334 (48%)
  ERP 40,433 7,722 14,172 13,634 24,551 100,512
  Number of organisations 1 1 5 6 7 20
SA NKPI population 2,640 (12%) 1,185 (26%) 4,581 (48%) 1,206 (71%) 6,519 (144%) 16,131 (38%)
  ERP 21,940 4,582 9,520 1,687 4,536 42,265
  Number of organisations 1 2 7 1 5 16
NT NKPI population .. .. 7,909 (45%) 30,769 (182%) 46,674 (116%) 85,352 (114%)
  ERP .. .. 17,465 16,932 40,149 74,546
  Number of organisations     1 14 56 71
Australia Total NKPI population 82,950 (28%) 65,657 (35%) 74,763 (46%) 61,197 (116%) 78,705 (83%) 363,245 (46%)
  Total ERP 298,445 189,165 162,686 52,845 94,960 798,101
  Total Number of organisations 26 45 48 31 83 233

Emergency Department

The Australian Health Ministers’ Advisory Council, 2017 report in the period 2014–15 to 2015–16, there were about 875,300 emergency department presentations mainly to large public hospitals located in major cities by Indigenous people. The number represents 6% of all presentations for 3% of the total Australian population. Around 59% (513,600) of these episodes occurred after hours. This proportion was similar for non-Indigenous patients (56%). For Aboriginal and Torres Strait Islander patients, around 55% (281,700) of emergency department presentations provided after-hours were classified as semi-urgent or non-urgent (triage categories 4 and 5) as were 50% of non-Indigenous after-hours emergency department episodes of care.

Pharmaceutical Benefits Scheme (PBS)

The Australian Health Ministers’ Advisory Council, 2017 report that affordable access to medicines is important for many acute and chronic illnesses. For chronic illnesses such as diabetes, hypertension, heart disease and renal failure, multiple medications may be required for many years to avoid complications. In 2013–14, total expenditure on pharmaceuticals per Indigenous person was around two-thirds less than the amount spent per non-Indigenous person ($579 compared with $857 person). Average expenditure per person for mainstream PBS benefits was $112 for Indigenous Australians and $338 for non-Indigenous Australians. Data suggests that the gap in spending between Indigenous and non-Indigenous is closing with average PBS expenditure per person increasing from 23% in 2011-12 to 33% in 2013-14 of the amounts spent for non-Indigenous persons.

Differences in expenditure on mainstream PBS benefits between Indigenous and non-Indigenous was apparent in non-remote i.e. major city areas. In 2013-14, the benefits paid were $131 per person in major cities, $137 for inner and outer regional areas and $305 for remote and very remote areas. The difference in per person expenditure between Remote and Very remote areas and other categories was the payment of for Section 100 items. Here, under the National Health Act 1953 Indigenous primary health care services can provide PBS medicines to address access problems in remote areas.

Identifying the geographical variation in the supply of General Practitioners

Several methods have been used to investigate the geographic variation in the supply of General Practitioners across Australia. The Access Relative to Need (ARN) index (Australian Institute of Health and Welfare 2014) reported that at the national level, the average access to GPs relative to need decreased with remoteness for the Indigenous population. This was due to both the worsening access to GPs and the increasing predicted need for primary health care based on variations in the Indigenous population’s demographic structure. While this trend of decreasing access with increasing remoteness also occurred for non-Indigenous people, it was less pronounced. This trend poses issues in GP access in Remote and Very Remote areas in the Northern Territory and Western Australia where over 75% of the Northern Territory Indigenous population and 37% of the Western Australian Indigenous population reside. Furthermore, Indigenous people living in Remote or Very Remote areas of the Northern Territory are widely dispersed in small communities that have few services, whereas this situation compares to non-Indigenous people in these areas who were more likely to live in towns (Taylor 2012).

Building on the ARN index, a report (Australian Institute of Health and Welfare 2015a) analysed the spatial variation in Indigenous people’s access to primary care focusing on the physical access to Indigenous-specific primary health care services and access to GPs and hospitals. Rates of Indigenous specific services were found to be highest in Remote and Very remote areas which reflected that these areas had the highest proportion of Indigenous people needing to travel more than 1 hour to access the nearest service. The report geographically identified at the Australian Bureau of Statistics Statistical Area Level 2 (SA2) geography 40 areas with no Indigenous specific services within 1 hours drive and with poor access in general to GP services including Royal Flying Doctor Services. The majority of these service gap areas had populations fewer than 600 Indigenous people. Six areas had populations between 600 and 1,200 people while four areas had populations greater than 1,200 Indigenous people. These areas were clustered in the central and south-eastern Queensland and western and south-western Western Australia regions with 16 and 12 SA2s respectively. The report also highlighted that 61% of these areas had high rates of PPHs.

The Geographically-adjusted Index of Relative Supply (GIRS) provides another indicative measure to assess the extent to which Indigenous people live in areas with lower relative levels of GP, nurse, pharmacy and dental service supply across small geographic areas (Australian Institute of Health and Welfare, 2016p). Once again using the SA2 geography, the majority of SA2s with higher scores were found in the Major Cities remoteness category with the number declining with increasing remoteness. Table 10 highlights the number of SA2s with GIRS scores between 0-1, a score that indicated a high probability of workforce supply challenges. Many of the areas identified with workforce supply challenges were in Very Remote and Remote areas. However, for SA2s identified with GP workforce supply challenges, there was variation within these categories with ten of the 47 Remote SA2s and two of the 50 Very Remote SA2s reporting GIRS scores of 6-8. The GIRS is unable to include important factors such as adequacy of services, the extent to which services are financially and culturally accessible and the extent to which services in an area meet the needs of the population.

Table 10: The number of Statistical Area Level (SA2) regions and residing Indigenous and non-Indigenous populations with Geographically-adjusted Index of Relative Supply scores of 0-1 by practitioner type (AIHW, 2016p).
Number of SA2s Indigenous population Non-indigenous population
GP 39 46,199 108,321
Nurse 17 17,350 73,349
GP 43 76,803 132,602

Australian Institute of Health and Welfare, 2016a looked specifically at access based on Indigenous people live within one hour of one of the 203 primary health care service organisations (138 being Aboriginal Community Controlled Health Services) that supply Indigenous-specific comprehensive primary health care activities. The report demonstrated that access to services varied substantially within remoteness areas and within states and territories. The number of clients attending these service organisations reflected the distribution of the Indigenous population in those areas. However, in a small number of SA2s in the Kimberley, Arnhem Land, north eastern Northern Territory and Cape York, there were small numbers of clients relative to large Indigenous populations. Access was identified as poor across a wide spectrum of areas with a range of issues. Access was highlighted as poor in the central parts of the Northern Territory where a relatively large number of Indigenous Australians live more than one hour from the locations. In the western part of Western Australia, in the areas surrounding Carnarvon, and the central and western Queensland (predominately rural and outback areas) where a relatively small number of Indigenous Australian live more than 1 hour from a primary care centre. Additionally, the areas surrounding Perth and Adelaide, which have many small SA2s with relatively large Indigenous populations.

Detailed notes on Potentially Preventable Hospitalisations

The created atlas shows the geographic and temporal variation in the rates of PPH by category and conditions. By providing a range of thresholds we can easily investigate the sensitivity in the differences between geographic areas, both between (geographic) and within (temporal) Indigenous Areas (IARE) compared to the Australian average for Indigenous PPH hospitalisations. Rates will vary by geographic area, category or condition and over time. We must also highlight that when specific conditions are investigated, the number of admissions by IARE may be small. Thus, we suggest that you use these data with caution.

Because the Indigenous population is distributed across the Australian continent, many publications report PPHs by the Australian Bureau of Statistics definition of remoteness. Compared with non-Indigenous Australians, hospitalisation rates for selected potentially preventable conditions were 4.6 times higher for Indigenous Australians living in remote areas, 3.7 times higher in very remote areas, 2.7 times higher in outer regional areas, 2.2 times higher in major cities and 2.0 times higher in inner regional areas (Australian Health Ministers’ Advisory Council 2017).

Analysing the temporal trend of the Total Separations PPH category provides an overview of the distribution of the overall rate of Indigenous PPH admissions. It is worth noting that the Total Separations PPH category across the IAREs will be made up of different combinations of Acute, Chronic and Vaccine-Preventable conditions and Same-Day and Overnight hospital separations. This suggests that, once this complexity is unpacked, different strategies will need to be implemented to effect change.

Seven IAREs, with five in the Northern Territory, were the hottest in Australia with rates consistently over four times the Australian average for Indigenous PPH hospitalisations (now referred to as the Australian average). This increased to 47 IAREs when the threshold was reduced to two times the Australian average. Forty seven percent of these IAREs were in the Northern Territory, 32% in WA and 15% in Queensland. A total of 88 IAREs were deemed “Hot” for Total Separations PPH category when compared to the 50% more than the Australian average threshold. Forty one percent of these were in the Northern Territory, 28% in Western Australia, 22% in Queensland. Table 2 shows the list of IAREs as the thresholds decrease from the highest threshold, the four times greater than the Australian average to the 50% more than the Australian average threshold. The IAREs are shown once against their cut-off thresholds, i.e. IAREs in the four times greater threshold are “Hot” for this threshold and below. Investigating the geographic and temporal variation of IAREs across Australia for this threshold can be here. The map shows that many of the “Hot” areas are in remote and rural IAREs. Only the metropolitan cities of Perth and Darwin had IAREs that were identified as “Hot”. The Total Separations PPH category is made-up of combinations of Acute, Chronic and Vaccine-preventable PPHs. For the 88 IAREs identified as “Hot” for the 50% more than the Australian average threshold, 44% of these IAREs were reported as “Hot” across the three PPH categories. A further 25% of IAREs were reported as “Hot” for the two PPH categories; Chronic and Acute PPHs.

Acute PPHs were reported as “Hot” in seven IAREs, the majority in the Northern Territory for the four times the Australian average threshold. Reducing the threshold to two times the Australian average identified 41 IAREs that were classified as “Hot”. Forty four percent of these were in Western Australia, 26% in Queensland, and 22% in the Northern Territory. A total of 82 IAREs were reported as “Hot” for the 50% more than the Australian average with 37% in the Northern Territory, 27% in Western Australia and 26% in Queensland. Around 48% of these IAREs where the rates of Acute PPH were higher than the 50% more than the Australian average threshold were also classified as “Hot” for both Chronic and Vaccine-preventable PPHs, 28% were reported as “Hot” for Chronic PPHs and around 16% of these IAREs were classified as “Hot” for Acute PPHs only (i.e. no other PPH category above the threshold).

Chronic PPHs were classified as “Hot” in five IAREs, the majority in the Northern Territory for the four times the Australian average threshold. Reducing the threshold to two times the Australian average identified 38 IAREs as “Hot”. Fifty percent were in the Northern Territory, 23% in Western Australia and 18% in Queensland. A total of 75 IAREs were reported as “Hot” for the 50% or more than the Australian average with 43% in the Northern Territory, 25% in Western Australia and 19% in Queensland. Around 52% of these IAREs where the rates of Chronic PPH were consistently higher than the 50% more than the Australian average threshold were also hot for both Acute and Vaccine-preventable PPHs, 31% were reported as “Hot” for Acute PPHs and around 4% were identified as “Hot" for Chronic PPHs only (i.e. no other PPH category above the threshold).

Vaccine-Preventable PPHs were reported as “Hot” in 13 IAREs, the majority in the Northern Territory for the four times the Australian average threshold. Reducing the threshold to the two times the Australian average threshold identified 58 IAREs as “Hot”. Sixty seven percent were in the Northern Territory, 29% in Western Australia and 2% in Queensland. A total of 66 IAREs were reported as “Hot” for the 50% more than the Australian average threshold with 61% in the Northern Territory, 33% in Western Australia and 3% in Queensland. Around 59% of these IAREs where the rates of Vaccine-Preventable PPH were consistently higher than the 50% more than the Australian average threshold were also hot for both Acute and Chronic PPHs, 15% were identified as “Hot” for Chronic PPHs and around 15% were reported as “Hot” for Vaccine-Preventable conditions only (i.e. no other PPH category above the threshold).

The geographic and temporal variation for these thresholds by category for Australia can be viewed in the Indigenous PPH atlas.

Alternatively, highlighting IAREs which have been deemed “Cold” provides an understanding of where primary care issues may not exist.

A total of 53 IAREs were deemed “Cold” when compared to the 50% less than the Australian average threshold for Total Separations PPH category. Table 10 provides a list of IAREs from the 50% less to the 30% less categories. The IAREs are shown once against their cut-off thresholds, i.e. IAREs in the 50% less than the Australian average threshold are identified as “Cold” for this threshold and above. Ten IAREs in the Northern Territory are identified as “Cold”, however, these IAREs have very low admission numbers for their corresponding populations and must be treated with caution. These are, NT: Amoonguna - Santa Teresa – Titjikala, NT: Ampilatwatja and Outstations, NT: Apatula (Finke) and Homelands, NT: Atitjere - Akarnenehe – Engawala, NT: Kaltukatjara and Outstations, NT: Mutitjulu - Uluru – Imanpa, NT: Urapuntja, NT: Douglas-Daly, NT: Elsey – Roper and NT: Anindilyakwa (Groote). The geographical and temporal variation of these IAREs can be viewed here.

A total of 44 and 39 IAREs were identified as “Cold” for total separations in the Acute and Chronic PPH categories when compared to the 50% less than the Australian average threshold. Around 60% of these IAREs where rates of PPH were consistently lower than the 50% less than the Australian average threshold were “Cold” for both Acute and Chronic PPHs. In comparison, 112 IAREs were identified as “Cold” for total separations for Vaccine-preventable PPHs. The geographic and temporal variation for these thresholds by category for Australia can be viewed here.

The list of PPHs for an IARE can also be investigated singularly using a heat map graph. These graphs show a visual representation of the heat of an IARE by threshold, category and condition. The heat maps can be accessed by following the instructions in the Heat map graphs by IARE section.

Table 11: Indigenous Areas (IARE) that were deemed “Hot” by rate thresholds from 50% more to four times greater than the Australian average for Total Indigenous Hospital Separations in the All PPH category.
Magnitude of threshold greater than the Australian Average for Indigenous PPH Hospitalisations Indigenous Areas (IARE)
Four times Qld: Cloncurry – McKinlay, SA: Eyre, NT: Anmatjere, NT: Willowra, NT: Yuelamu, NT: Yuendumu and Outstations, NT: Tennant Creek Town
Three times Qld: Cherbourg, Qld: Murgon, NT: Alice Springs exc. Town Camps, NT: Alice Springs Town Camps
Two and a half times Qld: Mareeba, WA: Argyle – Warmun, WA: Great Sandy Desert, WA: Halls Creek – Surrounds, WA: Kalumburu, WA: Kununurra, WA: North Kimberley, WA: Wyndham, WA: Fitzroy River, WA: Outer Derby - West Kimberley, NT: Nhulunbuy - Gunyangara
Two times NSW: Moree Plains, Qld: Cairns - Far North Coast, Qld: Murweh, Qld: Palm Island, SA: Ceduna, WA: Broome, WA: Carnegie South - Mount Magnet, WA: Meekathara – Karalundi, WA: Halls Creek, WA: Derby – Mowanjum, WA: Fitzroy Crossing, NT: Papunya and Outstations, NT: Walungurru and Outstations, NT: Coconut Grove – Ludmilla, NT: Marrara - Winnellie – Berrimah, NT: Nightcliff - Rapid Creek, NT: Borroloola, NT: Katherine Town, NT: Ngukurr, NT: Gapuwiyak and Outstations, NT: Laynhapuy - Gumatj Homelands, NT: Marthakal Homelands – Galiwinku, NT: Numbulwar and Outstations, NT: Ramingining - Milingimbi and Outstations, NT: Barkly
90% Qld: Wujal Wujal and Outstations, Qld: Carpentaria - Burke – Mornington, SA: Coober Pedy – Umoona, WA: Kalgoorlie - Ningia Mia, WA: Wiluna, WA: Port Hedland, NT: Hermannsburg, NT: Darwin - Inner Suburbs, NT: Gulf, NT: Lajamanu, NT: Yirrkala, NT: Alpurrurulam
80% Qld: Boulia - Diamantina – Winton, NT: Nyirripi and Tanami Outstations, NT: West MacDonnell Ranges, NT: Ali Curung
70% Qld: Lockhart River, Qld: Central Capricorn, Qld: Bulloo - Quilpie – Barcoo, Qld: Paroo, WA: Carnarvon – Mungullah, WA: Kalgoorlie - Dundas – Goldfields, NT: Wutunugurra - Canteen Creek
60% NSW: Tenterfield - Jubullum Village, NSW: Bourke, Qld: Herberton – Ravenshoe, Qld: Cape York, Qld: Hope Vale, SA: Berri – Barmera, SA: Port Augusta, WA: Narrogin - Wagin – Katanning, NT: Haasts Bluff - Mount Liebig (Watiyawanu), NT: Daguragu - Kalkarindji and Outstations, NT: Walangeri, NT: Elliott
50% Qld: Cooktown, Qld: Mapoon - Napranum – Weipa, WA: Menzies – Leonora, WA: Warburton, WA: Fremantle, WA: South Perth - Victoria Park

Note: The IAREs are shown once against their cut-off thresholds, i.e. IAREs in the four times greater threshold are hot for this threshold and below.

Table 12: Population Health Areas that were deemed “Cold” by rate thresholds from 50% less to 30% less than the Australian average for Total Indigenous Hospital Separations in the All PPH category.
Magnitude of threshold greater than the Australian Average for Indigenous PPH Hospitalisations  
50% NSW: Upper Hunter, NSW: Gloucester – Dungog, NSW: Lake Macquarie, NSW: Singleton, NSW: Central Murray, NSW: Mudgee, NSW: Southern Tablelands, NSW: Baulkham Hills, NSW: Camden, NSW: Hawkesbury, NSW: Hornsby - Ku-ring-gai, NSW: Hunters Hill – Ryde, NSW: Hurstville – Kogarah, NSW: Northern Beaches, NSW: Rockdale, NSW: Sutherland Shire, NSW: Sydney - Inner West, NSW: Sydney - Lower North, Vic: Melbourne – East, Vic: Melton, Vic: Yarra Ranges, Vic: Macedon Ranges – Moorabool, Vic: South Gippsland - Bass Coast, Vic: South-West Central Victoria, Vic: Wallan – Seymour, Qld: Noosa, Qld: Nebo – Clermont, SA: Adelaide Hills - Mount Barker, SA: Barossa, SA: South-East, WA: Joondalup, WA: Serpentine – Jarrahdale, WA: Yanchep - Two Rocks ,WA: Busselton, Tas: Central Coast – Devonport, Tas: Central Tasmania, Tas: Greater Hobart, Tas: Huon Valley, Tas: Kingborough, Tas: Meander Valley – Kentish, Tas: Tasmania - South-East Coast, Tas: Tasmania - West Coast, Tas: West Tamar – Latrobe, NT: Amoonguna - Santa Teresa – Titjikala, NT: Ampilatwatja and Outstations, NT: Apatula (Finke) and Homelands, NT: Atitjere - Akarnenehe – Engawala, NT: Kaltukatjara and Outstations, NT: Mutitjulu - Uluru – Imanpa, NT: Urapuntja, NT: Douglas-Daly, NT: Elsey – Roper, NT: Anindilyakwa (Groote)
40% NSW: Parkes, NSW: Cessnock, NSW: Gosford, NSW: Great Lakes, NSW: Newcastle, NSW: Port Macquarie – Hastings, NSW: Port Stephens, NSW: Lithgow – Oberon, NSW: Upper Murray, NSW: Shoalhaven, NSW: Snowy – Monaro, NSW: Canterbury – Bankstown, NSW: Kiama – Shellharbour, NSW: Wollongong, NSW: Woollahra – Waverley, Vic: Cardinia, Vic: Knox, Vic: Mornington Peninsula, Vic: Castlemaine – Kerang, Vic: Geelong – Queenscliff, Vic: Upper Goulburn Valley, Qld: Gold Coast, Qld: Toowoomba – South, Qld: Mackay – Surrounds, SA: Fleurieu - Kangaroo Island, SA: Holdfast Bay - West Torrens, SA: Anangu Pitjantjatjara, WA: Rockingham, Tas: Launceston, Tas: Tasmania - North-East Coast
30% NSW: Dubbo, NSW: Gunnedah, NSW: Liverpool Plains, NSW: Maitland, NSW: Wyong, NSW: Blayney – Cabonne, NSW: Young, NSW: Fairfield, NSW: Holroyd, NSW: Penrith, NSW: Randwick - La Perouse, NSW: Wollondilly, Vic: Brimbank, Vic: Maribyrnong - Moonee Valley, Vic: Melbourne - North-East, Vic: Wyndham – Altona, Vic: Wodonga, Qld: Maroochy, Qld: Mirani, Qld: Proserpine – Whitsunday, Qld: Townsville – Surrounds, SA: Onkaparinga, WA: Shark Bay - Coral Bay - Upper Gascoyne, WA: Kalamunda, WA: Wanneroo - North-East, WA: Mandurah, WA: Murray - Waroona - Boddington

Note: The IAREs are shown once against their cut-off thresholds, i.e. IAREs in the 50% less threshold are cold for this threshold and above.

Table 13: Indigenous Areas that were deemed “Hot” by rate thresholds from 50% more to four times greater than the Australian average for Total Indigenous Hospital Separations in the Acute PPH category.
Magnitude of threshold greater than the Australian Average for Indigenous PPH Hospitalisations Indigenous Areas (IARE)
Four times Qld: Cloncurry – McKinlay, SA: Eyre NT: Anmatjere, NT: Willowra, NT: Yuelamu, NT: Yuendumu and Outstations, NT: Tennant Creek Town
Three times Qld: Mareeba, Qld: Cherbourg, Qld: Murgon, WA: Kununurra, WA: Wyndham, WA: Outer Derby - West Kimberley, NT: Alice Springs exc. Town Camps, NT: Alice Springs Town Camps
Two and a half times Qld: Palm Island, SA: Ceduna, WA: Broome, WA: Argyle – Warmun, WA: Great Sandy Desert, WA: Halls Creek – Surrounds, WA: Kalumburu, WA: North Kimberley, WA: Derby – Mowanjum, WA: Fitzroy Crossing, WA: Fitzroy River
Two times Qld: Cairns - Far North Coast, Qld: Wujal Wujal and Outstations, Qld: Lockhart River, Qld: Carpentaria - Burke – Mornington, Qld: Central Capricorn, Qld: Bulloo - Quilpie – Barcoo, SA: Coober Pedy – Umoona, WA: Carnarvon – Mungullah, WA: Carnegie South - Mount Magnet, WA: Meekathara – Karalundi, WA: Wiluna, WA: Halls Creek, WA: Port Hedland, NT: Katherine Town, NT: Laynhapuy - Gumatj Homelands
90% Qld: Boulia - Diamantina – Winton, NT: Numbulwar and Outstations
80% WA: Kalgoorlie - Dundas – Goldfields, NT: West MacDonnell Ranges, NT: Alpurrurulam
70% NSW: Moree Plains, Qld: Herberton – Ravenshoe, Qld: Cape York, Qld: Mapoon - Napranum – Weipa, Qld: Paroo, SA: Port Augusta, WA: Roebourne – Wickham, NT: Haasts Bluff - Mount Liebig (Watiyawanu), NT: Hermannsburg, NT: Papunya and Outstations, NT: Lajamanu, NT: Ngukurr, NT: Nhulunbuy – Gunyangara, NT: Ali Curung
60% NSW: Bourke, Qld: Hope Vale, Qld: Mount Isa, Qld: Balonne, SA: Berri – Barmera, SA: Port Lincoln, NT: Nyirripi and Tanami Outstations, NT: Walungurru and Outstations, NT: Gulf, NT: Ramingining - Milingimbi and Outstations, NT: Elliott
50% Qld: Atherton, Qld: Murweh, SA: Murray Mallee, WA: East Pilbara, WA: Narrogin - Wagin – Katanning, NT: Darwin - Inner Suburbs, NT: Victoria River, NT: Walangeri, NT: Gapuwiyak and Outstations, NT: Marthakal Homelands – Galiwinku, NT: Barkly

Note: The IAREs are shown once against their cut-off thresholds, i.e. IAREs in the four times greater threshold are hot for this threshold and below.

Table 14: Indigenous Areas that were deemed “Cold” by rate thresholds from 50% less to 30% less than the Australian average for Total Indigenous Hospital Separations in the Acute PPH category.
Magnitude of threshold greater than the Australian Average for Indigenous PPH Hospitalisations  
50% NSW: Lake Macquarie, NSW: Port Macquarie – Hastings, NSW: Singleton, NSW: Baulkham Hills, NSW: Camden, NSW: Hawkesbury, NSW: Hornsby - Ku-ring-gai, NSW: Hunters Hill – Ryde, NSW: Northern Beaches, NSW: Rockdale, NSW: Sutherland Shire, NSW: Sydney - Lower North, NSW: Woollahra – Waverley, Vic: Melbourne – East, Vic: Melton, Vic: Castlemaine – Kerang, Vic: Macedon Ranges – Moorabool, Vic: South Gippsland - Bass Coast, Vic: Wallan – Seymour, Qld: Mackay – Surrounds, SA: Adelaide Hills - Mount Barker ,SA: Barossa, SA: Anangu Pitjantjatjara, WA: Shark Bay - Coral Bay - Upper Gascoyne, WA: Joondalup, WA: Rockingham, WA: Busselton, Tas: Central Coast – Devonport, Tas: Greater Hobart, Tas: Huon Valley, Tas: Kingborough,, Tas: Tasmania - North-East Coast, Tas: Tasmania - South-East Coast, Tas: Tasmania - West Coast, NT: Amoonguna - Santa Teresa – Titjikala, NT: Ampilatwatja and Outstations, NT: Apatula (Finke) and Homelands, NT: Atitjere - Akarnenehe – Engawala, NT: Kaltukatjara and Outstations, NT: Mutitjulu - Uluru – Imanpa, NT: Urapuntja, NT: Douglas-Daly, NT: Elsey – Roper, NT: Anindilyakwa (Groote)
40% NSW: Upper Hunter, NSW: Cessnock, NSW: Maitland, NSW: Port Stephens, NSW: Lithgow – Oberon, NSW: Shoalhaven, NSW: Southern Tablelands, NSW: Canterbury – Bankstown, NSW: Hurstville – Kogarah, NSW: Sydney - Inner West, Vic: Maroondah, Vic: Melbourne - North-East, Vic: Melbourne - Port Phillip, Vic: Wyndham – Altona, Vic: Yarra Ranges, Vic: Baw Baw, Vic: South-West Central Victoria, Qld: Noosa, Qld: Nebo – Clermont, SA: Onkaparinga, SA: South-East, SA: Unley - Burnside – Mitcham, WA: Serpentine – Jarrahdale, WA: Yanchep - Two Rocks, Tas: Central Tasmania, Tas: Launceston, Tas: Meander Valley – Kentish, Tas: West Tamar – Latrobe, ACT: Canberra - North
30% NSW: Parkes, NSW: Wellington, NSW: Liverpool Plains, NSW: Uralla – Walcha, NSW: Gloucester – Dungog, NSW: Gosford, NSW: Great Lakes, NSW: Newcastle, NSW: Wyong, NSW: Central Murray, NSW: Mudgee, NSW: Upper Murray, NSW: Snowy – Monaro, NSW: Fairfield, NSW: Holroyd, NSW: Kiama – Shellharbour, NSW: Penrith, NSW: Wollongong, Vic: Cranbourne - Narre Warren, Vic: Frankston, Vic: Knox, Vic: Mornington Peninsula, Vic: Geelong – Queenscliff, Qld: Gold Coast, Qld: Pine Rivers, Qld: Toowoomba – South, SA: Campbelltown – Norwood, SA: Holdfast Bay - West Torrens, WA: Kalamunda, WA: Mandurah, NT: Litchfield

Note: The IAREs are shown once against their cut-off thresholds, i.e. IAREs in the 50% less threshold are cold for this threshold and above.

Table 15: Indigenous Areas that were deemed “Hot” by rate thresholds from 50% more to four times greater than the Australian average for Total Indigenous Hospital Separations in the Chronic PPH category.
Magnitude of threshold greater than the Australian Average for Indigenous PPH Hospitalisations Indigenous Areas (IARE)
Four times SA: Eyre, NT: Anmatjere, NT: Willowra, NT: Yuelamu, NT: Yuendumu and Outstations
Three times WA: Halls Creek – Surrounds, NT: Coconut Grove – Ludmilla, NT: Tennant Creek Town
Two and a half times Qld: Cloncurry – McKinlay, Qld: Cherbourg, Qld: Murgon, SA: Ceduna, NT: Alice Springs exc. Town Camps, NT: Marrara - Winnellie – Berrimah, NT: Nhulunbuy – Gunyangara, NT: Numbulwar and Outstations, NT: Ramingining - Milingimbi and Outstations
Two times NSW: Moree Plains, Qld: Cairns - Far North Coast, Qld: Mareeba, Qld: Murweh, Qld: Paroo, WA: Broome, WA: Kalgoorlie - Dundas – Goldfields, WA: Kalgoorlie - Ningia Mia, WA: Halls Creek, WA: Kalumburu, WA: Kununurra, WA: Port Hedland, WA: Fitzroy River, NT: Alice Springs Town Camps, NT: Borroloola, NT: Gulf, NT: Ngukurr, NT: Gapuwiyak and Outstations, NT: Laynhapuy - Gumatj Homelands, NT: Marthakal Homelands – Galiwinku, NT: Yirrkala
90% NSW: Coonamble, Qld: Palm Island, WA: Great Sandy Desert, WA: North Kimberley, WA: Wyndham, WA: Outer Derby - West Kimberley, NT: Darwin - Inner Suburbs
80% NSW: Tenterfield - Jubullum Village, Qld: Herberton – Ravenshoe, Qld: Hope Vale, SA: Coober Pedy – Umoona, WA: Carnegie South - Mount Magnet, WA: Fitzroy Crossing, NT: Nyirripi and Tanami Outstations, NT: Katherine Town
70% Qld: Cooktown, Qld: Carpentaria - Burke – Mornington, SA: Murray Mallee, WA: Meekathara – Karalundi, WA: Narrogin - Wagin – Katanning, NT: Nightcliff - Rapid Creek
60% Qld: Lockhart River, SA: Port Augusta, WA: Derby – Mowanjum, NT: Maningrida and Outstations, NT: North-West Arnhem, NT: Tiwi Islands, NT: Barkly, NT: Wutunugurra - Canteen Creek
60% NSW: Bourke, Qld: Bulloo - Quilpie – Barcoo, SA: Berri – Barmera, WA: Argyle – Warmun, NT: Hermannsburg, NT: Walungurru and Outstations, NT: Lajamanu, NT: Ali Curung

Note: The IAREs are shown once against their cut-off thresholds, i.e. IAREs in the four times greater threshold are hot for this threshold and below.

Table 16: Indigenous Areas that were deemed “Cold” by rate thresholds from 50% less to 30% less than the Australian average for Total Indigenous Hospital Separations in the Chronic PPH category.
Magnitude of threshold greater than the Australian Average for Indigenous PPH Hospitalisations Indigenous Areas (IARE)
50% NSW: Great Lakes, NSW: Forbes, NSW: Southern Tablelands, NSW: Baulkham Hills, NSW: Camden, NSW: Hornsby - Ku-ring-gai, NSW: Hunters Hill – Ryde, NSW: Hurstville – Kogarah, NSW: Northern Beaches, NSW: Rockdale, NSW: Sutherland Shire, NSW: Sydney - Inner West, NSW: Sydney - Lower North, Vic: Yarra Ranges, Vic: South Gippsland - Bass Coast, Vic: South-West Central Victoria, Qld: Nebo – Clermont, SA: Barossa, WA: Joondalup, WA: Serpentine – Jarrahdale, WA: Yanchep - Two Rocks, Tas: Central Coast – Devonport, Tas: Central Tasmania, Tas: Huon Valley, Tas: Kingborough, Tas: Meander Valley – Kentish, Tas: Tasmania - South-East Coast, Tas: Tasmania - West Coast, Tas: West Tamar – Latrobe, NT: Amoonguna - Santa Teresa – Titjikala, NT: Ampilatwatja and Outstations, NT: Apatula (Finke) and Homelands, NT: Atitjere - Akarnenehe – Engawala, NT: Kaltukatjara and Outstations, NT: Mutitjulu - Uluru – Imanpa, NT: Urapuntja, NT: Douglas-Daly, NT: Elsey – Roper, NT: Anindilyakwa (Groote)
40% NSW: Gosford, NSW: Lake Macquarie, NSW: Port Stephens, NSW: Lithgow – Oberon, NSW: Mudgee, NSW: Snowy – Monaro, NSW: Hawkesbury, NSW: Kiama – Shellharbour, NSW: Wollongong, Vic: Cardinia, Vic: Melbourne – East, Vic: Melton, Vic: Mornington Peninsula, Vic: Whitehorse, Vic: Geelong – Queenscliff, Vic: Macedon Ranges – Moorabool, Vic: Wallan – Seymour, Qld: Caloundra, Qld: Gold Coast, Qld: Maroochy, Qld: Noosa, Qld: Kalakawal - Top Western Islands, Qld: Meriam - Eastern Islands, SA: Adelaide Hills - Mount Barker, SA: Fleurieu - Kangaroo Island, SA: Tea Tree Gully, WA: Busselton, Tas: Greater Hobart, ACT: Canberra – South
30% NSW: Dubbo, NSW: Parkes, NSW: Warrumbungle Shire, NSW: Newcastle, NSW: Singleton, NSW: Blayney – Cabonne, NSW: Central Murray, NSW: Orange, NSW: Upper Murray, NSW: Young, NSW: Shoalhaven, NSW: Auburn, NSW: Fairfield, NSW: Holroyd, NSW: Leichhardt, NSW: Penrith, NSW: Randwick - La Perouse, NSW: Wollondilly, NSW: Woollahra – Waverley, Vic: Craigieburn – Sunbury, Vic: Melbourne - North-East, Vic: Ballarat, Qld: Gatton – Laidley, Qld: Toowoomba – South, Qld: Flinders - Richmond – Dalrymple, Qld: Mirani, Qld: Townsville – Surrounds, SA: Holdfast Bay - West Torrens, SA: South-East, WA: Kalamunda, WA: Rockingham, Tas: Launceston

Note: The IAREs are shown once against their cut-off thresholds, i.e. IAREs in the 50% less threshold are cold for this threshold and above.

Table 17: Indigenous Areas that were deemed “Hot” by rate thresholds from 50% more to four times greater than the Australian average for Total Separations in the Vaccine-preventable PPH category.
Magnitude of threshold greater than the Australian Average for Indigenous PPH Hospitalisations Indigenous Areas (IARE)
Four times SA: Eyre, NT: Alice Springs exc. Town Camps, NT: Alice Springs Town Camps, NT: Anmatjere, NT: Papunya and Outstations, NT: Willowra, NT: Yuelamu, NT: Yuendumu and Outstations, NT: Marrara - Winnellie – Berrimah, NT: Marthakal Homelands – Galiwinku ,NT: Nhulunbuy – Gunyangara, NT: Yirrkala, NT: Tennant Creek Town
Three times WA: Menzies – Leonora, WA: Warburton, WA: Argyle – Warmun, WA: Kununurra, NT: Hermannsburg, NT: Walungurru and Outstations ,NT: Darwin - Inner Suburbs, NT: Nightcliff - Rapid Creek, NT: Daguragu - Kalkarindji and Outstations, NT: Lajamanu, NT: Gapuwiyak and Outstations, NT: Laynhapuy - Gumatj Homelands, NT: Ramingining - Milingimbi and Outstations, NT: Ali Curung, NT: Barkly, NT: Elliott
Two and a half times WA: Broome, WA: Kalgoorlie - Ningia Mia, WA: Kalumburu, WA: North Kimberley, WA: Fitzroy Crossing, WA: Fitzroy River, NT: Haasts Bluff - Mount Liebig (Watiyawanu), NT: Coconut Grove – Ludmilla, NT: Maningrida and Outstations, NT: North-West Arnhem, NT: Tiwi Islands, NT: Borroloola, NT: Katherine Town, NT: Victoria River
Two times Qld: Northern Peninsula Area, WA: Laverton – Ngaanyatjarraku, WA: Great Sandy Desert, WA: Wyndham, WA: Bayswater, WA: Fremantle, WA: South Perth – Victoria Park WA: Derby – Mowanjum, NT: West MacDonnell Ranges, NT: Thamarrurr inc. Wadeye, NT: Gulf, NT: Ngukurr, NT: Walangeri, NT: Alpurrurulam, NT: Wutunugurra - Canteen Creek
90% SA: Ceduna, WA: Meekathara - Karalundi
80% WA: Central West Coast
70% WA: Halls Creek, WA: Outer Derby - West Kimberley
60%  
50% Qld: Cloncurry – McKinlay, WA: Port Hedland, NT: Numbulwar and Outstations

Note: The IAREs are shown once against their cut-off thresholds, i.e. IAREs in the four times greater threshold are hot for this threshold and below.

Table 18: Indigenous Areas that were deemed “Cold” by rate thresholds from 50% less to 20% less than the Australian average for Total Separations in the Vaccine-preventable PPH category.
Magnitude of threshold greater than the Australian Average for Indigenous PPH Hospitalisations Indigenous Areas (IARE)
50% NSW: Narromine, NSW: Parkes, NSW: Warren, NSW: Warrumbungle Shire , NSW: Gunnedah, NSW: Liverpool Plains, NSW: Moree, NSW: Muswellbrook, NSW: Narrabri, NSW: Uralla – Walcha, NSW: Ballina – Bagotville, NSW: Cessnock, NSW: Coffs Harbour – Nambucca, NSW: Gloucester – Dungog, NSW: Great Lakes, NSW: Lake Macquarie, NSW: Newcastle, NSW: Port Macquarie – Hastings, NSW: Port Stephens, NSW: Singleton, NSW: Tweed, NSW: Wyong, NSW: Central Murray, NSW: Cowra, NSW: Deniliquin – Murray, NSW: Forbes, NSW: Griffith – Leeton, NSW: Gundagai - Junee – Harden, NSW: Mudgee, NSW: Narrandera, NSW: Tumut, NSW: Upper Murray, NSW: Bega Valley, NSW: Eurobodalla, NSW: Shoalhaven, NSW: Snowy – Monaro, NSW: Southern Tablelands, NSW: Botany Bay, NSW: Camden, NSW: Hawkesbury, NSW: Hornsby - Ku-ring-gai, NSW: Hurstville – Kogarah, NSW: Northern Beaches, NSW: Penrith, NSW: Rockdale, NSW: Sydney - Inner West, NSW: Wollongong, Vic: Cardinia, Vic: Craigieburn – Sunbury, Vic: Knox, Vic: Melton, Vic: Yarra Ranges, Vic: Campaspe - Shepparton – Moira, Vic: Castlemaine – Kerang, Vic: Geelong – Queenscliff, Vic: Macedon Ranges – Moorabool, Vic: South Gippsland - Bass Coast, Vic: South-West Central Victoria, Vic: Wallan – Seymour, Vic: Wodonga, Qld: Gold Coast, Qld: Noosa, Qld: Redland, Qld: Herberton – Ravenshoe, Qld: Nebo – Clermont, Qld: Bulloo - Quilpie – Barcoo, Qld: Maranoa - Roma – Mitchell, Qld: Southern Downs, Qld: Western Downs, Qld: Mackay, Qld: Mackay – Surrounds, Qld: Mirani, Qld: Proserpine – Whitsunday, Qld: Sarina, SA: Adelaide Hills - Mount Barker, SA: Barossa, SA: Campbelltown – Norwood, SA: Fleurieu - Kangaroo Island, SA: Loxton - Waikerie - Mid Murray, SA: Renmark Paringa, SA: South-East, WA: Irwin – Morawa, WA: Joondalup, WA: Serpentine – Jarrahdale, WA: Swan, WA: Yanchep - Two Rocks, WA: Harvey and Surrounds, WA: Kojonup – Gnowangerup ,WA: Manjimup - Denmark – Plantagenet, WA: Moora – Chittering, WA: Murray - Waroona – Boddington, WA: South-West, Tas: Central Coast – Devonport, Tas: Central Tasmania, Tas: Greater Hobart, Tas: Kingborough, Tas: Launceston, Tas: Meander Valley – Kentish, Tas: Tasmania - North-East Coast, Tas: Tasmania - South-East Coast, Tas: Tasmania - West Coast, Tas: West Tamar – Latrobe, NT: Amoonguna - Santa Teresa – Titjikala, NT: Ampilatwatja and Outstations, NT: Apatula (Finke) and Homelands, NT: Atitjere - Akarnenehe -Engawala, NT: Kaltukatjara and Outstations, NT: Mutitjulu - Uluru – Imanpa, NT: Urapuntja, NT: Douglas-Daly, NT: Elsey – Roper, NT: Anindilyakwa (Groote)
40% NSW: Upper Hunter, NSW: Coonamble, NSW: Clarence Valley, NSW: Taree, NSW: Blayney – Cabonne, NSW: Cootamundra, NSW: Baulkham Hills, NSW: Sutherland Shire, NSW: Wollondilly, Vic: Frankston, Vic: Moreland – Broadmeadows, Vic: Gippsland, Qld: Caboolture, Qld: Gatton – Laidley, Qld: Logan, Qld: Dalby, Qld: Toowoomba – North, Qld: Toowoomba – South, Qld: Charters Towers, SA: Flinders, WA: Mundaring - Swan View, WA: Rockingham, WA: Albany, Tas: Huon Valley
30% NSW: Bogan, NSW: Dubbo, NSW: Gosford, NSW: Kempsey, NSW: Bathurst, NSW: Carrathool – Murrumbidgee, NSW: Orange, NSW: Fairfield, NSW: Hunters Hill – Ryde, NSW: Kiama – Shellharbour, Vic: Wyndham – Altona, Vic: Upper Goulburn Valley, Vic: Wimmera, Qld: Beaudesert – Boonah, Qld: Caloundra, Qld: Esk – Kilcoy, Qld: Maroochy, Qld: Pine Rivers, Qld: Innisfail – Johnstone, Qld: North Burnett, Qld: Rockhampton – Yeppoon, Qld: Goondiwindi – Stanthorpe, Qld: Murweh, WA: Shark Bay - Coral Bay - Upper Gascoyne, WA: Campion, WA: Mandurah, ACT: Canberra – South

Note: The IAREs are shown once against their cut-off thresholds, i.e. IAREs in the 50% less threshold are cold for this threshold and above.

References

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Authored by PHIDU