HEALTH CONDITIONS AND ILLNESS

This section provides an overview of Indigenous peoples' experience of ill-health using burden of disease and injury estimates, self-reported prevalence data, visits to general practitioners and admissions to hospitals. This is followed by more detailed information on the specific causes of ill-health. For information on the prevalence of need for assistance with core activities among Aboriginal and Torres Strait Islander people, see Chapter 5.


Burden of disease and injury

The burden of disease and injury for Indigenous Australians was assessed using Disability Adjusted Life Years (DALYS) - the sum of years of life lost due to premature death and years lived with disability (Vos et al 2007). In 2003 it was estimated that the burden of disease and injury for Indigenous Australians was 95,976 DALYS. This was 3.6% of the burden of disease for the total Australian population.

Cardiovascular disease (18%) and mental disorders (16%) were the leading causes of the disease burden in the Indigenous population (table 7.4). Intentional and unintentional injuries accounted for a further 13% of the disease and injury burden.

7.4 DISABILITY ADJUSTED LIFE YEARS (DALYS), broad cause group, Indigenous persons - 2003
	DALYS	Proportion of total
Cause	no.	%
Cardiovascular disease	16 786	17.5
Mental disorders	14 860	15.5
Chronic respiratory disease	8 587	8.9
Diabetes	8 498	8.9
Cancers	7 817	8.1
Unintentional injuries	6 989	7.3
Intentional injuries	5 395	5.6
Other	27 044	28.2
All causes	95 976	100.0
Source: Vos et al 2007

Leading specific causes of the burden of disease

Ischaemic heart disease was the leading specific cause of the disease burden experienced by Indigenous males, accounting for 12% of the total Indigenous male burden. Type 2 diabetes, anxiety and depression, and suicide were the next three leading specific causes, together accounting for another 18% of the Indigenous male burden. For Indigenous females, the leading specific cause of the burden was anxiety and depression, accounting for 10% of the burden. Type 2 diabetes, ischaemic heart disease and asthma were the next three leading specific causes, accounting for a further 23% of the Indigenous female burden.

Comparison with the Australian burden of disease

Indigenous Australians suffer a burden of disease that is two-and-a-half times greater than the burden of disease in the total Australian population. This indicates a very large potential for health gain. Two-thirds of the difference in the burden of disease was due to mortality and one-third was due to disability which, in part, reflects a higher case fatality among Indigenous Australians. Non-communicable diseases, which include chronic illnesses such as cardiovascular disease, diabetes, mental disorders and chronic respiratory diseases were responsible for 70% of the observed difference in the burden of disease between the Indigenous and non-Indigenous population. If Indigenous Australians experienced the same burden rates as the total Australian population due to the 11 selected risk factors examined, 29% of the total Indigenous Australian burden of disease could be avoided. (Vos et al 2007).


Prevalence of long-term health conditions

Information about the self-reported prevalence of long-term health conditions is available from the 2004-05 NATSIHS, with comparable data for non-Indigenous people available from the 2004-05 National Health Survey (NHS). In the NATSIHS, respondents were asked whether they had any of a number of specific health conditions (e.g. asthma, cancer, arthritis, diabetes, etc.) or any other health conditions that had lasted, or were expected to last, for six months or more.

Around two-thirds of Indigenous people (65%) reported at least one long-term health condition in 2004-05 (ABS 2006c). Eye/sight problems (30%), asthma (15%), musculoskeletal conditions (including back conditions and arthritis) (13%) and heart and circulatory diseases (12%) were the most commonly reported long-term health conditions among Indigenous people (table 7.5).

The NATSIHS did not specifically ask about mental health or psychological problems in the context of long-term health conditions, but respondents in non-remote areas were shown a prompt listing that included mental health conditions when asked if they had any other long-term health conditions. Some 22% of Aboriginal and Torres Strait Islander people in non-remote areas indicated that they had a long-term mental or behavioural condition when responding to this question (AIHW forthcoming).

7.5 PREVALENCE OF SELECTED LONG-TERM HEALTH CONDITIONS AND AGE STANDARDISED RATE RATIOS - 2001 and 2004-05
	2001			2004-05
	Indigenous	Non-Indigenous	Rate ratio(a)	Indigenous	Non-Indigenous	Rate ratio(a)
Long-term health conditions(b)	%	%	rate	%	%	rate
Arthritis	8.1	13.7	1.2	9.1	15.4	1.2
Asthma	16.5	11.5	1.5	15.1	10.2	1.6
Back pain/problems n.e.c., disc disorders	15.2	20.9	1.0	13.1	16.2	1.2
Diabetes/high sugar levels	5.2	3.2	3.3	6.1	3.8	3.4
Ear/hearing problems	14.6	13.8	1.1	(c)12.2	(c)12.7	(c)1.0
Eye/sight problems	29.2	51.7	0.9	(c)30.2	(c)52.2	(c)0.9
Heart, circulatory problems/diseases	10.5	17.0	1.1	11.8	18.0	1.3
Kidney disease	1.2	0.3	5.3	1.8	0.3	10.0
Neoplasms/cancer	**0.8	1.7	0.7	0.8	2.0	0.7
Osteoporosis	*0.3	1.6	0.4	0.9	3.0	0.7
* estimate has a relative standard error of 25% to 50% and should be used with caution
** estimate has a relative standard error greater than 50% and is considered too unreliable for general use
(a) Rate ratios are the age standardised rates for Indigenous persons divided by the rates for non-Indigenous persons.
(b) ICD-10 based output classification.
(c) Difference between Indigenous and non-Indigenous data is not statistically significant.
Source: ABS 2001 NHS, 2001 NHS(I), 2004-05 NATSIHS, 2004-05 NHS

Indigenous people had a higher prevalence of most types of long-term health conditions compared with non-Indigenous people (table 7.5). The differences were greatest for kidney disease, (where the overall age standardised Indigenous rate was 10 times the non-Indigenous rate) and diabetes/high sugar levels (three times higher).

Between 2001 and 2004-05, there was a significant decrease in the proportion of Indigenous Australians reporting ear and hearing problems (from 15% to 12%) and a significant increase in the proportion of Indigenous Australians reporting kidney problems (from 1% to 2%).


Encounters with general practitioners

Information about encounters with general practitioners (GPs) is available from the 'Bettering the Evaluation and Care of Health' (BEACH) survey. Encounters can be direct consultations (the patient was seen by the GP) or indirect consultations (the patient was not seen by a GP but a clinical service was provided). Information is collected from a random sample of approximately 1,000 GPs from across Australia each year. A sample of 100 consecutive encounters is collected from each GP.

Over the period 2001-02 to 2005-06, there were 496,100 GP encounters recorded in the BEACH survey, of which 7,682 encounters (1.5%) were with patients who identified as Aboriginal and/or Torres Strait Islander. The number of GP encounters with Indigenous Australians in the BEACH survey is likely to be underestimated. This may be due to lower attendance in general practices where other services exist (e.g. Aboriginal Community Controlled Health Services), failure by GPs to record the Indigenous status of patients, or reluctance on the part of patients to identify as Indigenous (AIHW 2002a). However, other evidence, such as continuing lower levels of access to MBS-funded services (AHMAC 2006) suggests that Indigenous people are accessing primary health care services at a lower rate than non-Indigenous people. The reliability of the results of the BEACH survey has been tested in a sub-study in 2003 of about 9,000 patient encounters during the survey. The sub-study found that when the question on Indigenous status was asked of the patient within the context of a series of questions about origin and cultural background, 2.2% identified as Aboriginal or Torres Strait Islander - twice the rate recorded in the BEACH survey for that year (AIHW: Britt et al 2003).

Table 7.6 presents the number and age standardised rate of selected problems managed at GP encounters with Indigenous and other patients over the period 2001-02 to 2005-06. Respiratory problems were the most frequently managed problems at GP encounters with both Indigenous and other patients (around 20 per 100 encounters). Circulatory problems and endocrine and metabolic problems (including diabetes) were also frequently managed at encounters with Indigenous clients (20 and 19 per 100 encounters respectively).

The rate of GP encounters for non-gestational diabetes was three times higher for Indigenous patients than for other patients (10 compared with 3 per 100 encounters) (table 7.6). For most types of problems managed, however, GP encounter rates were similar for Indigenous and other Australians. Contrasting the problems identified in table 7.6 with hospitalisation rates for similar conditions (table 7.8) suggests a much higher use of hospital services by Indigenous people in comparison to GP services. It is impossible to know, however, how much of this difference is a reflection of under-identification of Indigenous people in BEACH data or to what extent it represents lower use of GP services by Indigenous Australians.

7.6 PROBLEMS MANAGED BY GENERAL PRACTITIONERS, by Indigenous status of patient - 2001-02 to 2005-06
		Number		Rate(a)
Problems managed(b)		Indigenous	Other	Indigenous	Other	Ratio
Respiratory		1 582	96 697	20.3	19.8	1.0
Circulatory		1 034	81 995	19.8	16.7	1.2
Endocrine and metabolic		1 139	55 339	18.6	11.3	1.6
	Diabetes - non-gestational(c)	587	15 017	10.2	3.1	3.3
Musculoskeletal		1 048	84 712	15.3	17.3	0.9
Skin		1 231	82 684	14.7	16.9	0.9
Psychological		983	56 822	12.0	11.6	1.0
Digestive		804	48 966	10.9	10.0	1.1
Pregnancy and family planning		485	21 157	4.7	4.4	1.1
Ear		395	19 708	4.1	4.0	1.0
Other		2 665	179 319	35.9	36.7	1.0
Total problems		11 366	727 399	156.4	148.8	1.1
(a) Per 100 encounters. Rates are directly age standardised using the total encounters over the period 2001-02 to 2005-06 as the standard.
(b) Classified according to ICPC-2 chapter codes (Classification Committee of the World Organization of Family Doctors (WICC) 1998).
(c) ICPC-2 codes T89-T90.
Source: BEACH survey of general practice, AGPSCC

Hospitalisations

Hospitalisation statistics are not a measure of prevalence or incidence of a disease, but can provide insights into the health of the population who use hospitals, through data on the number of, and reasons for, hospitalisations. The principal diagnosis is the main reason for the patient's episode of hospital care (see boxes 7.7 and 7.9, below).

7.7 HOSPITALISATIONS DATA Hospitalisation data provides a measure of a population’s use of hospital services. A number of qualifications need to be made about hospitalisation data with regard to Indigenous identification, which is incomplete in some jurisdictions. In this publication, hospital separations (hospitalisations) for 2005-06 are presented for New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory for public and most private hospitals, and have not been adjusted for under-identification. See also Box 7.9. All hospitalisations are presented by principal diagnosis or the diagnosis established to be the problem that was chiefly responsible for the patient’s episode of care in hospital. Disease categories are based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM Fifth Edition). Age standardised ratios have been used in this chapter as a measure of hospitalisation in the Indigenous population relative to other Australians. Ratios of this type illustrate differences between the rates of hospital admissions among Indigenous people and those of other Australians, taking into account differences in age distributions. They reflect differences between observed hospitalisations of Aboriginal and Torres Strait Islander people and those expected if they had the same hospitalisation rate as other Australians. All hospitalisation rates have been calculated using the average of the Indigenous and non-Indigenous Estimated Resident Population projections for the years 2005 and 2006 based on the 2001 Census. The data are presented by state of residence, rather than state of hospitalisation as this is more consistent with the population data used to calculate rates. State of residence is also likely to have a greater impact on health status than state of hospitalisation. Hospitalisations for which Indigenous status was not reported are included with the non-Indigenous hospitalisations under the ‘Other’ category. This is because a preliminary analysis of the data indicated that the demographic profile of patients for whom Indigenous status was not recorded was similar to that of ‘non-Indigenous’ patients. In 2005-06, there were approximately 128,900 hospitalisations for which the Indigenous status of the patient was not reported in New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory combined, compared with approximately 243,100 hospitalisations recorded for Indigenous people. In these six jurisdictions, the proportion of records where Indigenous status was not reported declined from approximately 11.8% of hospitalisations in 1997-98 to 1.8% of hospitalisations in 2005-06.

In 2005-06, in New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory combined, the most common diagnosis for hospitalisation of Indigenous Australians was for care involving dialysis which is used in the treatment of kidney failure. Indigenous Australians were also commonly hospitalised for injury (e.g. transport accidents, assault and suicide); pregnancy and childbirth (e.g. complications of labour and delivery); respiratory diseases (e.g. influenza and pneumonia); digestive diseases (e.g. diseases of the liver, intestines and oral cavity); mental and behavioural disorders (e.g. schizophrenia and psychoactive substance use) and circulatory diseases (e.g. ischaemic heart disease and cerebrovascular disease). 'Symptoms, signs and abnormal clinical and laboratory findings' was also a common diagnosis for Indigenous Australians and includes a broad range of conditions such as Sudden Infant Death Syndrome (SIDS), convulsions, fever of unknown origin, pain in throat and chest, and abdominal and pelvic pain (table 7.8).

Hospitalisation rates for Indigenous Australians were higher than for other Australians for many diagnoses (table 7.8). Indigenous Australians were hospitalised for care involving dialysis at 14 times the rate, and for endocrine, nutritional and metabolic diseases, which includes diabetes, at three times the rate for other Australians.

7.8 HOSPITALISATIONS OF INDIGENOUS PERSONS(a), by principal diagnosis - 2005-06
		Observed hospitalisations	Expected hospitalisations	Ratio(b)
Principal diagnoses (ICD-10-AM chapter)		no.	no.	rate
Factors influencing health status and contact with health services (Z00-Z99)		108 682	18 634	5.8
	Care involving dialysis (Z49)	100 153	7 392	13.5
	Other (Z00-Z48, Z50-Z99)	8 529	11 241	0.8
Injury, poisoning and certain other consequences of external causes (S00-T98)		18 843	9 383	2.0
Complications of pregnancy, childbirth and the puerperium (O00-O99)		18 012	11 548	1.6
Diseases of the respiratory system (J00-J99)		15 722	6 877	2.3
Diseases of the digestive system (K00-K93)		12 906	13 342	1.0
Symptoms, signs and abnormal clinical and laboratory findings, n.e.c. (R00-R99)		10 461	6 723	1.6
Mental and behavioural disorders (F00-F99)		10 083	5 318	1.9
Diseases of the circulatory system (I00-I99)		7 859	3 799	2.1
Diseases of the genitourinary system (N00-N99)		6 220	5 614	1.1
Diseases of the skin and subcutaneous tissue (L00-L99)		5 599	2 073	2.7
Certain infectious and parasitic diseases (A00-B99)		5 249	2 562	2.0
Endocrine, nutritional and metabolic diseases (E00-E89)		4 797	1 610	3.0
Other (C00-D48, G00-H95, M00-M99, P00-Q99)(c)		18 609	21 265	0.9
Total(d)		243 106	108 793	2.2
(a) Data are for NSW, Vic., Qld, WA, SA and NT combined. These six jurisdictions are considered to have adequate levels of Indigenous identification. Data exclude private hospitals in the NT.
(b) Ratio is observed hospitalisations divided by expected hospitalisations. Expected hospitalisations are calculated based on the age, sex and cause-specific rates of other Australians.
(c) Includes: diseases of the musculoskeletal system and connective tissue, neoplasms, diseases of the nervous system, certain conditions originating in the perinatal period, diseases of the ear and mastoid process, diseases of the eye and adnexa, diseases of the blood and blood-forming organs and certain disorders involving the immune system, and congenital malformations, deformations and chromosomal abnormalities.
(d) Includes hospitalisations for which no principal diagnosis was recorded.
Source: AIHW National Hospital Morbidity Database

7.9 IDENTIFICATION OF INDIGENOUS PERSONS IN HOSPITAL RECORDS Information on the number of hospitalisations of Indigenous people is limited by the accuracy with which Indigenous patients are identified in hospital records. Problems associated with identification result in an underestimation of morbidity patterns and hospitalisation use among Aboriginal and Torres Strait Islander persons. At present, it is not possible to ascertain the extent to which a change in hospitalisation rates for Indigenous people is due to differences in Indigenous identification or a genuine change in hospital use/ health status. Information on the quality of Indigenous identification in hospital data is provided annually to the Australian Institute of Health and Welfare by the states and territories. For several years, Queensland, South Australia, Western Australia and the Northern Territory reported that Indigenous status in their hospital separations data was of acceptable quality (AIHW 2007b). The AIHW, however, has recently completed an assessment of the level of Indigenous under-identification in hospital data in all states and territories. Results from this assessment indicate that New South Wales, Victoria, Queensland, Western Australia, South Australia and the Northern Territory have adequate Indigenous identification (20% or less overall under-identification of Indigenous patients) in their hospital separations data. These six states and territories have therefore been included in all analyses of Indigenous hospitalisations data in this report. From the AIHW study, it was possible to produce factors for the level of under-identification in hospital data for each jurisdiction. The use of these factors to adjust 2005-06 hospitalisations data resulted in an 11% increase in hospitalisations recorded for Indigenous people. Therefore, the adjusted age standardised hospitalisation rate for Indigenous Australians was 2.4 times the rate for other Australians instead of 2.2 times the rate.

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