[Show abstract][Hide abstract] ABSTRACT: Little is known about trends in risk factors and mortality for Aboriginal Australians with heart failure (HF). This population-based study evaluated trends in prevalence of risk factors, 30-day and 1-year all-cause mortality following first HF hospitalization among Aboriginal and non-Aboriginal Western Australians in the decade 2000-2009.
Linked-health data were used to identify patients (20-84 years), with a first-ever HF hospitalization. Trends in demographics, comorbidities, interventions and risk factors were evaluated. Logistic and Cox regression models were fitted to test and compare trends over time in 30-day and 1-year mortality.
Of 17,379 HF patients, 1,013 (5.8%) were Aboriginal. Compared with 2000-2002, the prevalence (as history) of myocardial infarction and hypertension increased more markedly in 2006-2009 in Aboriginal (versus non-Aboriginal) patients, while diabetes and chronic kidney disease remained disproportionately higher in Aboriginal patients. Risk factor trends, including the Charlson comorbidity index, increased over time in younger Aboriginal patients. Risk-adjusted 30-day mortality did not change over the decade in either group. Risk-adjusted 1-year mortality (in 30-day survivors) was non-significantly higher in Aboriginal patients in 2006-2008 compared with 2000-2002 (hazard ratio (HR) 1.44; 95% CI 0.85-2.41; p-trend = 0.47) whereas it decreased in non-Aboriginal patients (HR 0.87; 95% CI 0.78-0.97; p-trend = 0.01).
Between 2000 and 2009, the prevalence of HF antecedents increased and remained disproportionately higher in Aboriginal (versus non-Aboriginal) HF patients. Risk-adjusted 1-year mortality did not improve in Aboriginal patients over the period in contrast with non-Aboriginal patients. These findings highlight the need for better prevention and post-HF care in Aboriginal Australians.
International Journal for Equity in Health 12/2015; 14(1):66. DOI:10.1186/s12939-015-0197-4 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The epidemiology of atrial fibrillation (AF) among Indigenous minorities in affluent countries is poorly delineated, despite the high cardiovascular disease burden in these populations. We undertook a systematic scoping review examining the epidemiology of AF in the Indigenous populations of Australia, Canada, New Zealand (NZ) and the United States (US).
PubMed, Scopus, EMBASE and CINAHL-Plus databases were systematically searched in May 2014. Supplementary full-text searches of Google Scholar and government website searches were also undertaken.
Key findings from 27 publications with diverse aims and methods were included. Small studies from Canada and NZ suggest higher AF prevalence in Indigenous than other populations. However, this was not reflected in a large sample of US male military veterans. No data were identified on community-based incidence rates of AF in Indigenous populations. Australian and Canadian studies indicate higher first-ever and overall AF hospitalisation rates among Indigenous than other populations, at younger ages and with more comorbidity. Studies in stroke, heart failure and other clinical groups demonstrate AF as a common comorbidity, with AF possibly more prevalent at younger ages in Indigenous people. Indigenous patients have similar early post-hospitalisation adjusted mortality but higher 1-year risk-adjusted mortality than non-Indigenous patients.
No clear epidemiological pattern of AF frequency across the considered Indigenous populations emerges from the limited available evidence. AF should be included in key conditions reported in national surveillance reports, although Indigenous identifiers are required in administrative data from Canada and the US. Sufficiently powered, community-based studies of AF epidemiology in diverse Indigenous populations are needed.
[Show abstract][Hide abstract] ABSTRACT: People living in rural areas have poorer health than their urban counterparts with higher morbidity and mortality rates and lower life expectancy. Challenges attracting health professionals to work in rural locations in Australia and elsewhere have been well- documented. In response, the idea of a rural pipeline emerged in the medical literature as a career pathway for doctors, conceptualised as a career continuum starting at school and ending in a committed, appropriately trained and supported rural doctor. This article draws on the literature to consider how the concept of a rural pipeline can be used to enhance recruitment and retention of allied health professionals (AHPs) in Australia. The complexity of the issue is taken into account, acknowledging the diverse professional, organisational and social needs within and between AHPs and their different career pathways. With this in mind, the rural pipeline is adapted and extended to focus on AHPs who enter at any stage of their career to work in rural areas.
Barriers to recruitment and retention require multifaceted strategies to encourage and support AHPs at various stages along the pipeline to enter, and remain in, rural practice. Findings from the literature identify discrete themes within and between AHPs about factors influencing their rural recruitment and retention choices and include career stage at entry to rural practice, age, gender, social context, professional support, organisational environment and public-private practice mix in service delivery. These findings underscored the development of an extended rural pipeline adapted to specifically target AHPs. This flexible framework of entry to rural practice can be applied at any stage of their career and includes suggestions of strategies to support retention.
Evidence from studies of rural AHPs suggests a flexible approach to recruitment and retention is needed that takes into account the complexity of the issue. The extended rural pipeline adapted to AHPs avoids a one-size-fits-all approach. Instead, it offers a more nuanced approach that addresses the diversity within and between professions and reflects the different stages at which AHPs enter rural practice that can inform recruitment and retention strategies that better meet their needs.
Rural and remote health 07/2015; 15(3):3438. · 0.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The epidemiology of atrial fibrillation (AF) among Aboriginal Australians is poorly described. We compared risk factors, incidence rates and mortality outcomes for first-ever hospitalised AF among Aboriginal and non-Aboriginal Western Australians 20-84 years.
This retrospective cohort study used whole-of-state person-based linked hospital and deaths data. Incident hospital AF admissions (previous AF admission-free for 15 years) were identified and subsequent mortality determined. Disease-specific comorbidity histories were ascertained by 10-year look-back. Age-standardised incidence rates were estimated and the adjusted risk of 30-day and 1-year mortality calculated using regression methods.
Aboriginal patients accounted for 923 (2.5%) of 37 097 incident AF admissions during 2000-2009. Aboriginal patients were younger (mean age 54.8 vs 69.3 years), had lower proportions of primary field AF diagnoses and higher comorbidities than non-Aboriginal patients. The Aboriginal and non-Aboriginal age-standardised incidence rates per 100 000 for men 20-54 years were 197 and 55 (ratio=3.6), for women 20-54 years were 122 and 19 (ratio=6.4), for men 55-84 years were 1151 and 888 (ratio=1.3), and for women 55-84 years were 1050 and 571 (ratio=1.8). While 30-day mortality was similar, crude 1-year mortality risks in Aboriginal and non-Aboriginal patients were 20.6% and 16.3% (adjusted HR=1.24) and 14.4% and 9.9% in 30-day survivors (adjusted HR=1.58).
The incidence (particularly at young ages) and long-term mortality following hospitalised AF is significantly higher in Aboriginal people. Better control of the antecedent risk factors for AF, improved detection and management of AF itself and prevention of its complications are needed.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
[Show abstract][Hide abstract] ABSTRACT: Objectives The aim of the present study was to provide descriptive planning data for a hospital-based Aboriginal Health Liaison Officer (AHLO) program, specifically quantifying episodes of care and outcomes within 28 days after discharge. Methods A follow-up study of Aboriginal in-patient hospital episodes was undertaken using person-based linked administrative data from four South Metropolitan hospitals in Perth, Western Australia (2006-11). Outcomes included 28-day deaths, emergency department (ED) presentations and in-patient re-admissions. Results There were 8041 eligible index admissions among 5113 individuals, with episode volumes increasing by 31% over the study period. Among patients 25 years and older, the highest ranking comorbidities included injury (47%), drug and alcohol disorders (41%), heart disease (40%), infection (40%), mental illness (31%) and diabetes (31%). Most events (96%) ended in a regular discharge. Within 28 days, 24% of events resulted in ED presentations and 20% resulted in hospital re-admissions. Emergency readmissions (13%) were twice as likely as booked re-admissions (7%). Stratified analyses showed poorer outcomes for older people, and for emergency and tertiary hospital admissions. Conclusions Future planning must address the greater service volumes anticipated. The high prevalence of comorbidities requires intensive case management to address case complexity. These data will inform the refinement of the AHLO program to improve in-patient experiences and outcomes. What is known about the topic? The health gap between Aboriginal and non-Aboriginal Australians is well documented. Aboriginal people have significantly higher hospital utilisation rates, as well as higher rates of complications, comorbidities and discharges against medical advice (DAMA). Aboriginal patients receive most of their specialist services in hospital; however, detailed person-based analyses are limited and planning is often based on crude data. What does this paper add? This is the first analysis of linked data focusing on Aboriginal patient flows and volume and 28-day health system outcomes following hospital admission for all causes in a large metropolitan setting. Because the data were linked, admissions belonging to a single episode of care were combined, ensuring that transfers were not counted as re-admissions. Linkage also allowed follow up across time. The results highlight the main disease groups for which Aboriginal patients are admitted, how this varies by age and the high proportion of patients returning to (any) hospital within 28 days, either through EDs or as booked (pre-arranged) admissions. These data aid in the planning of hospital-based Aboriginal health liaison services. What are the implications for practitioners? The paper outlines the complexity with which many Aboriginal patients present to hospital and the risk of DAMA and re-admission. Clinical and organisational strategies can be put in place in hospitals to address these risks and ensure improved continuity of care with community-based primary health services. The Western Australian South Metropolitan Health Service is reviewing these data and will monitor the impact of the hospital-based AHLO program.
Australian health review: a publication of the Australian Hospital Association 02/2015; DOI:10.1071/AH14102 · 0.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: IntroductionAboriginal Australians have a substantially higher frequency of ischaemic heart disease (IHD) events than their non-Aboriginal counterparts, together with a higher prevalence of comorbidities. The pattern of health service provision for IHD suggests inequitable delivery of important diagnostic procedures. Published data on disparities in IHD management among Aboriginal Australians are conflicting, and the role of comorbidities has not been adequately delineated. We compared the profiles of Aboriginal and non-Aboriginal patients in the metropolitan area undergoing emergency IHD admissions at Western Australian metropolitan hospitals, and investigated the determinants of receiving coronary angiography.Methods
Person-linked administrative hospital and mortality records were used to identify 28-day survivors of IHD emergency admission events (n =20,816) commencing at metropolitan hospitals in 2005¿09. The outcome measure was receipt of angiography. The Aboriginal to non-Aboriginal risk ratio (RR) was estimated from a multivariable Poisson log-linear regression model with allowance for multiple IHD events in individuals. The subgroup of myocardial infarction (MI) events was modelled separately.ResultsCompared with their non-Aboriginal counterparts, Aboriginal IHD patients were younger and more likely to have comorbidities. In the age- and sex-adjusted model, Aboriginal patients were less likely than others to receive angiography (RRIHD 0.77, 95%CI 0.72-0.83; RRMI 0.81, 95%CI 0.75-0.87) but in the full multivariable model this disparity was accounted for by comorbidities as well as IHD category and MI subtype, and private health insurance (RRIHD 0.95, 95%CI 0.89-1.01; RRMI 0.94, 95% CI 0.88-1.01). When stratified by age groups, this disparity was not significant in the 25¿54 year age group (RRMI 0.95, 95% CI 0.88-1.02) but was significant in the 55¿84 year age group (RRMI 0.88, 95% CI 0.77-0.99).Conclusions
The disproportionate under-management of older Aboriginal IHD patients is of particular concern. Regardless of age, the disparity between Aboriginal and non-Aboriginal Australians in receiving angiography for acute IHD in a metropolitan setting is mediated substantially by comorbidities. This constellation of health problems is a `double-whammy¿ for Aboriginal people, predisposing them to IHD and also adversely impacting on their receipt of angiography. Further research should investigate how older age and comorbidities influence clinical decision making in this context.
International Journal for Equity in Health 10/2014; 13(1):93. DOI:10.1186/s12939-014-0093-3 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction
Secondary prevention drugs for cardiac disease have been demonstrated by clinical trials to be effective in reducing future cardiovascular and mortality events (WAMACH is the Western Australian Medication Adherence and Costs in Heart disease study). Hence, most countries have adopted health policies and guidelines for the use of these drugs, and included them in government subsidised drug lists to encourage their use. However, suboptimal prescribing and non-adherence to these drugs remains a universal problem. Our study will investigate trends in dispensing patterns of drugs for secondary prevention of cardiovascular events and will also identify factors influencing these patterns. It will also assess the clinical and economic consequences of non-adherence and the cost-effectiveness of using these drugs.
Methods and analysis
This population-based cohort study will use longitudinal data on almost 40 000 people aged 65 years or older who were hospitalised in Western Australia between 2003 and 2008 for coronary heart disease, heart failure or atrial fibrillation. Linking of several State and Federal government administrative data sets will provide person-based information on drugs dispensed precardiac and postcardiac event, reasons for hospital admission, emergency department visits, mortality and medical visits. Dispensed drug trends will be described, drug adherence measured and their association with future all-cause/cardiovascular events will be estimated. The cost-effectiveness of these long-term therapies for cardiac disease and the impact of adherence will be evaluated.
Ethics and dissemination
Human Research Ethics Committee (HREC) approvals have been obtained from the Department of Health (Western Australian #2011/62 and Federal) and the University of Western Australia (RA/4/1/1130), in addition to HREC approvals from all participating hospitals. Findings will be published in peer-reviewed medical journals and presented at local, national and international conferences. Results will also be disseminated to consumer groups.
BMJ Open 09/2014; 4(9):e006258. DOI:10.1136/bmjopen-2014-006258 · 2.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives We examined differentials in short-term (30-day mortality) and 1-year mortality (in 30-day survivors) following index (first-ever) hospitalisation for heart failure (HF), between rural and metropolitan patients resident in Western Australia.
Design A population-based cohort study.
Setting Hospitalised patients in Western Australia, Australia.
Participants Index patients aged 20–84 years with a first-ever hospitalisation for HF between 2000 and 2009 (with no prior admissions for HF in previous 10 years), identified using the Western Australia linked health data.
Main outcome measures 30-day and 1-year all-cause mortality (in 30-day survivors) following index admission for HF.
Results Of 17 379 index patients with HF identified, 25.9% (4499) were from rural areas. Rural patients were significantly younger at first HF hospitalisation than metropolitan patients. Aboriginal patients comprised 1.9% of metropolitan and 17.2% of rural patients. Despite some statistical differences, the prevalence of antecedents including ischaemic heart disease, hypertension, diabetes and chronic kidney disease was high (>20%) in both subpopulations. After adjusting for age only, patients from rural areas had a higher risk of 30-day death (OR 1.16 (95% CI 1.01 to 1.33)) and 1-year death in 30-day survivors (HR 1.11 (95% CI 1.01 to 1.23)). These relative risk estimates increased and remained significant after further progressive adjustments for Aboriginality, socioeconomic status, insurance status, emergency presentation, individual comorbidities and revascularisation with OR 1.25 (1.06 to 1.48) for 30-day mortality and HR 1.13 (1.02 to 1.27) for 1-year mortality. The addition of the weighted Charlson index to the 30-day model improved the ‘c’ statistic (under the receiver operating characteristic curve) from 0.656 (using a variation of administrative claims model) to 0.714.
Conclusions Remoteness and variable access to healthcare can cause important disparities in health outcomes. Rural patients with HF in Western Australia have poorer risk-adjusted outcomes compared with metropolitan patients. This finding has important implications for chronic disease management and provision of health services in rural Australia.
BMJ Open 05/2014; 4(5):e004724. DOI:10.1136/bmjopen-2013-004724 · 2.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Worldwide, the prevalence of stroke is poorly described in indigenous populations, despite high stroke burden. This paper reports the average point prevalence of hospitalized stroke and coexistent conditions (2007–2011) in indigenous and nonindigenous people in Western Australia, the largest and most sparsely populated Australian jurisdiction.Methods
Using state-wide linked hospital and mortality data, indigenous and nonindigenous prevalent stroke cases (aged 25–84 years) were identified after reviewing stroke admissions over a fixed 20-year look-back period. Prevalent cases were those alive at midyear of each study year. The 2007–2011 period prevalence was a weighted average of annual prevalence. Histories of 11 comorbidities were identified using the 20-year look-back period.ResultsIndigenous cases comprised 5% of the average 13 591 annual prevalent cases. Indigenous patients were more likely to be younger, female, and have unknown stroke type. Indigenous prevalence was higher at every age. The age-standardized prevalence in indigenous men (33·7 per 1000; 95% confidence interval 31·9–35·4) was 3.7 times greater than in nonindigenous men (9·1 per 1000; 95% confidence interval 9·0–9·2). The corresponding estimates for women were 27·1 per 1000 (25·7–28·4) and 6·1 per 1000 (6·0–6·2) (ratio = 4·4). The percentage with selected comorbid conditions was substantially higher for indigenous patients.Conclusions
The high stroke prevalence in indigenous Western Australians, coupled with clinical complexity from comorbid conditions, requires access to culturally appropriate medical, rehabilitation, and logistical support. Intensified primary and secondary prevention is needed to reduce the impact of stroke on indigenous people.
International Journal of Stroke 05/2014; 9 Suppl A100(A100). DOI:10.1111/ijs.12278 · 3.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Aboriginal people have a disproportionately higher incidence rate of ischaemic heart disease (IHD) than non-Aboriginal people. The findings on Aboriginal disparity in receiving coronary artery procedures are inconclusive. We describe the profile and transfers of IHD patients admitted to rural hospitals as emergency admissions and investigate determinants of transfers and coronary angiography.
Person-linked hospital and mortality records were used to identify 28-day survivors of IHD events commencing at rural hospitals in Western Australia. Outcome measures were receipt of coronary angiography, transfer to a metropolitan hospital, and coronary angiography if transferred to a metropolitan hospital.
Compared to non-Aboriginal patients, Aboriginal patients with IHD were more likely to be younger, have more co-morbidities, reside remotely, but less likely to have private insurance. After adjusting for demographic characteristics, Aboriginal people with MI were less likely to be transferred to a metropolitan hospital, and if transferred were less likely to receive coronary angiography. These disparities were not significant after adjusting for comorbidities and private insurance. In the full multivariate model age, comorbidities and private insurance were adversely associated with transfer to a metropolitan hospital and coronary angiography.
Disparity in receiving coronary angiography following emergency admission for IHD to rural hospitals is mediated through the lower likelihood of being transferred to metropolitan hospitals where this procedure is performed. The likelihood of a transfer is increased if the patient has private insurance, however, rural Aboriginal people have a lower rate of private insurance than their non-Aboriginal counterparts. Health practitioners and policy makers can continue to claim that they treat Aboriginal and non-Aboriginal people alike based upon clinical indications, as private insurance is acting as a filter to reduce rural residents accessing interventional cardiology. If health practitioners and policy makers are truly committed to reducing health disparities, they must reflect upon the broader systems in which disparity is perpetuated and work towards a systems improvement.
[Show abstract][Hide abstract] ABSTRACT: To compare the incidence of first heart failure (HF) hospitalisation, antecedent risk factors and 1-year mortality between Aboriginal and non-Aboriginal populations in Western Australia (2000-2009).
A population-based cohort aged 20-84years comprising Aboriginal (n=1013; mean 54±14years) and non-Aboriginal patients (n=16,366; mean 71±11years) with first HF hospitalisation was evaluated. Age and sex-specific incidence rates and HF antecedents were compared between subpopulations. Regression models were used to examine 30-day and 1-year (in 30-day survivors) mortality.
Aboriginal patients were younger, more likely to reside in rural/remote areas (76% vs 23%) and to be women (50.6% vs 41.7%, all p<0.001). Aboriginal (versus non-Aboriginal) HF incidence rates were 11-fold higher in men and 23-fold in women aged 20-39years, declining to about 2-fold in patients aged 70-84years. Ischaemic and rheumatic heart diseases were more common antecedents of HF in younger (<55years) Aboriginal versus non-Aboriginal patients (p<0.001). Hypertension, diabetes, chronic kidney disease, renal failure, chronic obstructive pulmonary disease, and a high Charlson comorbidity index (>=3) were also more prevalent in younger and older Aboriginal patients (p<0.001). Although 30-day mortality was similar in both subpopulations, Aboriginal patients aged <55years had a 1.9 risk-adjusted hazard ratio (HR) for 1-year mortality (p=0.015).
Aboriginal people had substantially higher age and sex-specific HF incidence rate and prevalence of HF antecedents than their non-Aboriginal counterparts. HR for 1-year mortality was also significantly worse at younger ages, highlighting the urgent need for enhanced primary and secondary prevention of HF in this population.
International journal of cardiology 02/2014; 173(1). DOI:10.1016/j.ijcard.2014.02.020 · 4.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the level of evidence-based drugs prescribing for acute coronary syndrome (ACS) at discharge from Western Australian (WA) hospitals and determine predictors of such prescribing in Aboriginal and non-Aboriginal patients.
All Aboriginal (2002-04) and a random sample of non-Aboriginal (2003) hospital admissions with a principal diagnosis of ACS were extracted from the WA Hospital Morbidity Data Collection (HMDC) of WA Data Linkage System. Clinical information, history of co-morbidities and drugs were collected from medical notes by trained data collectors. Evidence-based prescribing (EBP) was defined as prescribing of aspirin, statin, and beta-blocker or angiotensin converting enzyme (ACE) inhibitor/Angiotensin II antagonist (ARB).
Records for 1717 ACS patients discharged alive from hospitals were reviewed. The majority of patients (71%) had EBP and there was no significant difference between Aboriginal and non-Aboriginal patients (70% vs 71%, p=0.36). Conversely, a significantly higher proportion of Aboriginal patients had none of the drugs prescribed compared to non-Aboriginal patients (11% vs 7%, p<0.01). EBP for ACS was independently associated with male sex (OR 1.63, 95% CI 1.26 -2.11), previous admission for ACS (OR 1.83, 95% CI 1.39-2.42) and diabetes (OR 1.36, 95% CI 1.04-1.79). However, ACS patients living in regional and remote areas, attending district or private hospitals, or with a history of COPD were significantly less likely to have ACS drugs prescribed at discharge.
Opportunity exists to improve prescribing of recommended drugs for ACS patients at discharge from WA hospitals in both Aboriginal and non-Aboriginal patients. Attention regarding pharmaceutical management post-ACS is particularly required for patients from rural and remote areas, and those attending district and private hospitals.
Internal Medicine Journal 02/2014; 44(4). DOI:10.1111/imj.12375 · 1.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Administrative data are a valuable source of estimates of diabetes prevalence for groups such as coronary heart disease (CHD) patients. The primary aim of this study was to measure concordance between medical records and linked administrative health data for recording diabetes in CHD patients, and to assess temporal differences in concordance. Secondary aims were to determine the optimal lookback period for identifying diabetes in this patient group, whether concordance differed for Indigenous people, and to identify predictors of false positives and negatives in administrative data.
A population representative sample of 3943 CHD patients hospitalized in Western Australia in 1998 and 2002--04 were selected, and designated according to the International Classification of Diseases (ICD) version in use at the time (ICD-9 and ICD-10 respectively). Crude prevalence and concordance were compared for the two samples. Concordance measures were estimated from administrative data comparing diabetes status recorded on the selected CHD admission ('index admission') and on any hospitalization in the previous 1, 2, 5, 10 or 15 years, against hospital medical records. Potential modifiers of agreement were determined using chi-square tests and multivariable logistic regression models.
Identification of diabetes on the index CHD admission was underestimated more in the ICD-10 than ICD-9 sample (sensitivity 81.5% versus 91.1%, underestimation 15.1% versus 4.4% respectively). Sensitivity increased to 89.6% in the ICD-10 period using at least 10 years of hospitalization history. Sensitivity was higher and specificity lower in Indigenous patients, and followed a similar pattern of improving concordance with increasing lookback period. Characteristics associated with false negatives for diabetes on the index CHD hospital admission were elective admission, in-hospital death, principal diagnosis, and in the ICD-10 period only, fewer recorded comorbidities.
The accuracy of identifying diabetes status in CHD patients is improved in linked administrative health data by using at least 10 years of hospitalization history. Use of this method would reduce bias when measuring temporal trends in diabetes prevalence in this patient group. Concordance measures are as reliable in Indigenous as non-Indigenous patients.
BMC Medical Research Methodology 10/2013; 13(1):121. DOI:10.1186/1471-2288-13-121 · 2.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Discharge Against Medical Advice (DAMA) from hospital is associated with adverse outcomes and is considered an indicator of the responsiveness of hospitals to the needs of Aboriginal and Torres Strait Islander Australians, the indigenous people of Australia. We investigated demographic and clinical factors that predict DAMA in patients experiencing their first-ever inpatient admission for ischaemic heart disease (IHD). The study focuses particularly on the differences in the risk of DAMA in Aboriginal and non-Aboriginal patients while also investigating other factors in their own right.
A cross-sectional analytical study was undertaken using linked hospital and mortality data with complete coverage of Western Australia. Participants included all first-ever IHD inpatients (aged 25--79 years) admitted between 2005 and 2009, selected after a 15-year clearance period and who were discharged alive. The main outcome measure was DAMA as reflected in the hospital record.Multiple logistic regression was used to determine disparities in DAMA between Aboriginal and non-Aboriginal patients, adjusting for a range of demographic and clinical factors, including comorbidity based on 5-year hospitalization history. A series of additional models were run on subgroups of the cohort to refine the analysis. Ethics approval was granted by the WA Human Research and the WA Aboriginal Health Ethics Committees.
Aboriginal patients comprised 4.3% of the cohort of 37,304 IHD patients and 23% of the 224 DAMAs. Emergency admission (OR=5.9, 95% CI 2.9-12.2), alcohol admission history (alcohol-related OR=2.9, 95% CI 2.0-4.2) and Aboriginality (OR 2.3, 95% CI 1.5-3.5) were the strongest predictors of DAMA in the multivariate model. Patients living in rural areas while attending non-metropolitan hospitals had a 50% higher risk of DAMA than those living and hospitalised in metropolitan areas. There was consistency in the ORs for Aboriginality in the different multivariate models using restricted sub-cohorts and different Aboriginal identifiers. Sex, IHD diagnosis type and co-morbidity scores imparted different risks in Aboriginal versus non-Aboriginal patients.
Understanding the risks and reasons for DAMA is important for health system policy and proactive management of those at risk of DAMA. Improving care to prevent DAMA should target unplanned admissions, rural hospitals and young men, Aboriginal people and those with alcohol and mental health comorbidities.
BMC Health Services Research 08/2013; 13(1):330. DOI:10.1186/1472-6963-13-330 · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: South Africa is experiencing epidemiological transition, with the burden of chronic diseases increasing. Stroke is currently the second leading cause of death in South Africa; however, limited data are available on incidence, prevalence and resulting disability. Quantifying the epidemiological parameters and disease burden is important in the planning of health services. AIMS: To synthesize the data surrounding stroke in South Africa and calculate disability adjusted life years attributable to stroke in South Africa in 2008. METHODS: We undertook a systematic review to identify studies on the prevalence and mortality of stroke in South Africa. We used the DisMod program to calculate missing epidemiological parameters, in particular incidence and duration. Using these values, we calculated the burden of disease in years of life lost (YLL), years lived with disability (YLD) and disability adjusted life years (DALY). RESULTS: Data on prevalence and mortality of stroke in South Africa are scarce. We estimate there are 75 000 strokes in South Africa each year, with 25 000 of these fatal within the first month. The burden of disease due to stroke in South Africa was 564 000 DALYs. Of this, 17% is contributed by YLD (14-20% in sensitivity analysis). CONCLUSIONS: This study provides information on prevalence, incidence and disease burden of stroke at the national level in South Africa. The results of this analysis will enable further work on priority setting and health service planning for primary and secondary prevention of stroke in South Africa.
International Journal of Stroke 01/2013; 8(100). DOI:10.1111/j.1747-4949.2012.00955.x · 3.83 Impact Factor