Health Sciences

Early diagnosis research points to Indigenous health impacts of “cultural incompetence”

Evidence of why we need "culturally competent" health professionals and services may be found in preliminary research that shows different rates of unspecified diagnoses in major hospitals between Aboriginal and Torres Strait Islander and non-Indigenous patients.

Australian Catholic University's Senior Lecturer in Public Health, Dr Michael Taylor, told the Congress Lowitja 2014: Many mobs, one vision: creating a healthy future last week that the data was raw and could have a host of explanations but still it raised questions that "assumptions, rather than diagnoses, are perhaps being made" when hospitals treat Aboriginal and Torres Strait Islander people.

The research was presented to a conference workshop on cultural competency in hospitals – that is, their ability to meet the needs of Aboriginal patients and their communities amid Victorian research that found nearly one third of Aboriginal participants reported experiencing racism in health settings.

"I don't know what's the full story behind the figures, but it is notable that a group of people who are traditionally left behind in almost every respect of health, whether it's health outcomes or the services they receive, are suddenly ahead of non-Indigenous people in terms of specificity of certain diagnoses, such as renal failure, liver disease and alcohol abuse," Dr Taylor said.

With funding from the Lowitja Institute and using data from the Australian Institute of Health and Welfare, Dr Taylor has been working on a project to measure the incidence of adverse events in hospitals experienced by Indigenous patients.

In looking at nearly 5 million hospital admissions (almost 4 per cent involving Aboriginal and Torres Strait Islander people) across Australia, he admits he "almost accidentally" stumbled on the diagnosis issue when he put together the top 20 list of principal diagnoses of Aboriginal and Torres Strait islander people (see table below) and noted how many unspecified conditions there were, compared to non-Indigenous patients.

Top 20 principal diagnoses: Aboriginal and Torres Strait Islander people
#ICD codePrincipal diognosis% admissions
1O80Single spontaneous delivery
4.8%
2J18.9Pneumonia, unspecified
5.7%
3J44.0Chronic ebstructive pulmonary disease with acute lower respiratory infection
4.2%
4O82Single delivery by caesarean section
3.1%
5L02.4Cutaneous adscess, furuncle and carbuncle of limb
21.5%
6Z50.9Rehabilitation procedure
1.1%
7J22Unspecified acute lower respiratory infection
7.9%
8P07.32Other preterm infants
6.7%
9L03.11Cellulitis of other parts of limb
4.4%
10I21.4Acute subendocardial myocardial infarction
3.3%
11N39.0Urinary tract infection, site not specified
3.1%
12J21.9Acute bronchiolitis, unspecified
18.8%
13J45.9Asthma, unspecified
6.1%
14I50.0Congestive heart failure
2.5%
15F20.0Paranoid schizophrenia
8.1%
16F20.9Schizophrenia, unspecified
7.4%
17R07.4Chest pain, unspecified
3.7%
18A09.9Gastroenteritis and colitis of unspecified origin
4.4%
19K85.2Alcohol-induced acute pancreatitis
24.0%
20J44.1Chronis obstructive pulmonary disease with acute exacerbation, unspecified
4.6%

Digging into the data revealed that, for example, 55 per cent of diagnoses of coagulopathies in admissions for Aboriginal and Torres Strait Islander people were unspecified, versus only 46 per cent for non-Indigenous patients (see table below). More troubling, he said, was the difference for neurological conditions, with 51 per cent unspecified for Aboriginal and Torres Strait Islander patients against 33 per cent for non-Indigenous patients. Slight differences were also to be seen in cardiac arrhythmia, congestive heart failure and lymphoma.

Specified and unspecified coagulopathy
Aboriginal and Torres Strait Islander people
 All Australian hospitals (admissions per 1,000 population)Top 5 hospitals by number of admissions (admissions per 1,000 population)Top 10 hospitals by % indigenous people and > 2000 admissions (admissions per 1,000 population)
Overall rate of coagulopathy6.71.00.6
Rate of unspecified coagulopathy3.70.60.3
% unspecified55.3%61.1%54.9%

Specified and unspecified coagulopathy
Non-indigenous people
 All Australian hospitals (admissions per 1,000 population)Top 5 hospitals by number of admissions (admissions per 1,000 population)Top 10 hospitals by % indigenous people and > 2000 admissions (admissions per 1,000 population)
Overall rate of coagulopathy4.30.40.1
Rate of unspecified coagulopathy2.00.20.1
% unspecified46.2%56.8%54.0%

Other examples: neurological conditions (50.9% v 32.9%); slight difference in cardiac arrhythmia, congestive heart failure, lymphoma.

The patterns then "went into reverse" for certain other conditions, such as renal failure, liver disease, and alcohol abuse, where diagnoses for Aboriginal and Torres Strait Islander patients showed higher rates of specificity (see table).

Specified and unspecified renal failure
Aboriginal and Torres Strait Islander people
 All Australian hospitals (admissions per 1,000 population)Top 5 hospitals by number of admissions (admissions per 1,000 population)Top 10 hospitals by % indigenous people and > 2000 admissions (admissions per 1,000 population)
Overall rate of renal failure35.54.94.6
Rate of unspecified renal failure3.20.20.2
% unspecified9.1%3.4%4.2%

Specified and unspecified renal failure
Non-indigenous people
 All Australian hospitals (admissions per 1,000 population)Top 5 hospitals by number of admissions (admissions per 1,000 population)Top 10 hospitals by % indigenous people and > 2000 admissions (admissions per 1,000 population)
Overall rate of renal failure10.60.90.3
Rate of unspecified renal failure2.00.10.0
% unspecified19.2%12.2%12.7%

Other examples: slight: alcohol abuse (80.5% v 87.3%), slight difference in liver disease and rheumatoid arthritis/collagen vascular diseases.

"When it comes to renal failure, only 10 per cent of is unspecified in Aboriginal and Torres Strait Islander people, whereas for non-Indigenous patients it's closer to 20 per cent," Dr Taylor said.

"They could be just testing and diagnosing really thoroughly, but there is the possibility they're assuming rather than diagnosing: to say ‘you're an Aboriginal and Torres Strait Islander person, you have these symptoms, so it's going to be this.'"

Dr Taylor said there were many caveats about the use of the hospital data that was not designed and collected for research purposes but for payment of services. There can also be many other factors behind unspecified diagnosis: diagnosis may not be complete when the patient leaves hospital, complexity and co-morbidity can be a reason some conditions are unspecified, and/or it indicates gaps in testing and documentation.

"At this stage, we can see and say is there is most definitely a difference between the two populations," he said. "What is actually going on in the background will be exceptionally complicated, but this is yet another health difference for Aboriginal and Torres Strait Islander people that needs to be looked at urgently."

View Dr Taylor's full slide presentation.