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1.  Use of health services by remote dwelling Aboriginal infants in tropical northern Australia: a retrospective cohort study 
BMC Pediatrics  2012;12:19.
Australia is a wealthy developed country. However, there are significant disparities in health outcomes for Aboriginal infants compared with other Australian infants. Health outcomes tend to be worse for those living in remote areas. Little is known about the health service utilisation patterns of remote dwelling Aboriginal infants. This study describes health service utilisation patterns at the primary and referral level by remote dwelling Aboriginal infants from northern Australia.
Data on 413 infants were analysed. Following birth, one third of infants were admitted to the regional hospital neonatal nursery, primarily for preterm birth. Once home, most (98%) health service utilisation occurred at the remote primary health centre, infants presented to the centre about once a fortnight (mean 28 presentations per year, 95%CI 26.4-30.0). Half of the presentations were for new problems, most commonly for respiratory, skin and gastrointestinal symptoms. Remaining presentations were for reviews or routine health service provision. By one year of age 59% of infants were admitted to hospital at least once, the rate of hospitalisation per infant year was 1.1 (95%CI 0.9-1.2).
The hospitalisation rate is high and admissions commence early in life, visits to the remote primary health centre are frequent. Half of all presentations are for new problems. These findings have important implications for health service planning and delivery to remote dwelling Aboriginal families.
PMCID: PMC3384247  PMID: 22373262
2.  A retrospective population-based cohort study identifying target areas for prevention of acute lower respiratory infections in children 
BMC Public Health  2010;10:757.
Acute lower respiratory infections (ALRI) are a major cause of hospitalisation in young children. Many factors can lead to increased risk of ALRI in children and predispose a child to hospitalisation, but population attributable fractions for different risk factors and how these fractions differ between Indigenous and non-Indigenous children is unknown. This study investigates population attributable fractions of known infant and maternal risk factors for ALRI to inform prevention strategies that target high-risk groups or particular risk factors.
A retrospective population-based data linkage study of 245,249 singleton births in Western Australia. Population attributable fractions of known maternal and infant risk factors for hospitalisation with ALRI between 1996 and 2005 were calculated using multiple logistic regression.
The overall ALRI hospitalisation rate was 16.1/1,000 person-years for non-Aboriginal children and 93.0/1,000 for Aboriginal children. Male gender, being born in autumn, gestational age <33 weeks, and multiple previous pregnancies were significant risk factors for ALRI in both Aboriginal and non-Aboriginal children. In non-Aboriginal children, maternal smoking during pregnancy accounted for 6.3% (95%CI: 5.0, 7.6) of the population attributable fraction for ALRI, being born in autumn accounted for 12.3% (10.8, 13.8), being born to a mother with three or more previous pregnancies accounted for 15.4% (14.1, 17.0) and delivery by elective caesarean accounted for 4.1% (2.8, 5.3). In Aboriginal children, being born to a mother with three or more previous pregnancies accounted for 16.5% (11.8, 20.9), but remote location at birth accounted for 11.7% (8.5, 14.8), maternal age <20 years accounted for 11.2% (7.8, 14.5), and being in the most disadvantaged socio-economic group accounted for 18.4% (-6.5, 37.4) of the population attributable fraction.
The population attributable fractions estimated in this study should help in guiding public health interventions to prevent ALRI. A key risk factor for all children is maternal smoking during pregnancy, and multiple previous pregnancies and autumnal births are important high-risk groups. Specific key target areas are reducing elective caesareans in non-Aboriginal women and reducing teenage pregnancies and improving access to services and living conditions for the Aboriginal population.
PMCID: PMC3004840  PMID: 21138593
3.  Morbidity due to acute lower respiratory infection in children with birth defects: a total population-based linked data study 
BMC Pediatrics  2014;14:80.
Acute lower respiratory infections (ALRIs) are leading causes of hospitalisation in children. Birth defects occur in 5% of live births in Western Australia (WA). The association between birth defects and ALRI hospitalisation is unknown.
We conducted a retrospective cohort study of 245,249 singleton births in WA (1996-2005). Population-based hospitalisation data were linked to the WA Register of Developmental Anomalies to investigate ALRI hospitalisations in children with and without birth defects. We used negative binomial regression to estimate associations between birth defects and number of ALRI hospitalisations before age 2 years, adjusting for known risk factors.
Overall, 9% of non-Aboriginal children and 37% of Aboriginal children with birth defects had at least one ALRI admission before age 2 years. Aboriginal children (IRR 2.3, 95% CI: 1.9-2.8) and non-Aboriginal children (IRR 2.0, 95% CI: 1.8-2.2) with birth defects had higher rates of hospitalisation for an ALRI than children with no birth defects. Rates of ALRI hospitalisation varied by type of defect but were increased for all major birth defects categories, the highest rate being for children with Down syndrome (IRR 8.0, 95% CI: 5.6-11.5). The rate of ALRI hospitalisation was 3 times greater in children with multiple birth defects than in those with isolated defects.
Children with birth defects experience higher rates of hospitalisation for ALRIs before age 2 years than children with no birth defects. Optimal vaccination coverage and immunoprophylaxis for specific categories of birth defects would assist in reducing hospitalisation rates for ALRI.
PMCID: PMC3987821  PMID: 24661413
Acute lower respiratory infections; Birth defects; Aboriginal Australian children; Linked population health data; Hospitalisations
4.  Mortality in an Aboriginal Medical Service (Redfern) cohort 
Published estimates of Aboriginal mortality and life expectancy (LE) for the eastern Australian states are derived from demographic modelling techniques to estimate the population and extent of under-recording of Aboriginality in death registration. No reliable empirical information on Aboriginal mortality and LE exists for New South Wales (NSW), the most populous Australian state in which 29% of Aboriginal people reside.
This paper estimates mortality and LE in a large, mainly metropolitan cohort of Aboriginal clients from the Aboriginal Medical Service (AMS) Redfern, Sydney, NSW.
Identifying information from patient records accrued by the AMS Redfern since 1980 of definitely Aboriginal clients, without distinction between Aboriginal and Torres Strait Islander (n=24,035), was extracted and linked to the National Death Index (NDI) at the Australian Institute of Health and Welfare (AIHW). Age-specific mortality rates and LEs for each sex were estimated using the AMS patient population as the denominator, discounted for deaths. Directly age-standardised mortality and LEs were estimated for 1995–1999, 2000–2004 and 2005–2009, along with 95% confidence intervals. Comparisons were made with other estimates of Aboriginal mortality and LE and with the total Australian population.
Mortality declined in the AMS Redfern cohort over 1995–2009, and the decline occurred mostly in the ≤44 year age range. Male LE at birth was estimated to be 64.4 years (95%CI:62.6-66.1) in 1995–1999, 65.6 years (95%CI:64.1-67.1) in 2000–2004, and 67.6 years (95%CI:65.9-69.2) for 2005–2009. In females, these LE estimates were 69.6 (95%CI:68.0-71.2), 71.1 (95%CI:69.9-72.4), and 71.4 (95%CI:70.0-72.8) years. LE in the AMS cohort was 11 years lower for males and 12 years lower for females than corresponding all-Australia LEs for the same periods. These were similar to estimates for Australian Aboriginal people overall for the same period by the Aboriginal Burden of Disease for 2009, using the General Growth Balance (GGB) model approach, and by the Australian Bureau of Statistics (ABS) for 2005–2007. LE in the AMS cohort was somewhat lower than these estimates for NSW Aboriginal people, and higher than ABS 2005–2007 estimates for Aboriginal people from Northern Territory, South Australia, and Western Australia.
The AMS Redfern cohort has provided the first empirically based estimates of mortality and LE trends in a large sample of Aboriginal people from NSW.
PMCID: PMC3602118  PMID: 23391275
5.  Voting with their feet - predictors of discharge against medical advice in Aboriginal and non-Aboriginal ischaemic heart disease inpatients in Western Australia: an analytic study using data linkage 
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.
PMCID: PMC3765140  PMID: 23962275
Discharge against medical advice; Aboriginal health; Ischaemic Heart Disease; Linked data; Australia
6.  Trends in road injury hospitalisation rates for Aboriginal and non-Aboriginal people in Western Australia, 1971–97 
Injury Prevention  2002;8(3):211-215.
Objective: To examine trends in road injury hospitalisation rates for Aboriginal and non-Aboriginal people in Western Australia.
Methods: Data from the Western Australian Hospital Morbidity Data System for the years between 1971 and 1997 were analysed. Poisson regression models were fitted to determine whether the trends were significant.
Results: The rate of hospitalisation due to road injury for Aboriginal people (719.1 per 100 000 population per year) over the time period examined was almost twice as high as that for non-Aboriginal people (363.4 per 100 000 population per year). Overall, the results showed that while hospitalisations from road injury involving non-Aboriginal people have been decreasing by 6.7% per three year period since 1971, the rates of hospitalisation for Aboriginal people have been increasing by 2.6% per three year period. Both of these trends were statistically significant. The alarming increasing trend observed for Aboriginal people was more pronounced in males, those aged 0–14 years and over 45 years, and for those living in rural areas.
Conclusions: As the rates of road injury for Aboriginal people are higher than for non-Aboriginal people, and are also following an increasing trend, road safety issues involving Aboriginal people need to be addressed urgently by health and transport authorities.
PMCID: PMC1730892  PMID: 12226118
7.  Intestinal permeability and diarrhoeal disease in Aboriginal Australians 
Archives of Disease in Childhood  1999;81(4):304-308.
BACKGROUND—Northern Territory Aboriginal children hospitalised with acute gastroenteritis have high rates of acidosis, hypokalaemia, and dehydration.
AIMS—To determine whether Aboriginal children with and without diarrhoea have greater impairment in intestinal function than non-Aboriginal children, as assessed by increased permeability ratios.
METHODS—A descriptive study of 124 children (96 Aboriginal and 28 non-Aboriginal) hospitalised with and without diarrhoea. Intestinal permeability was assessed by the lactulose to rhamnose (L-R) ratio from a five hour urine collection.
RESULTS—In Aboriginal children, mean L-R ratios (95% confidence intervals) were 18.3 (17.1 to 19.6) with diarrhoea and 9.0 (7.3 to 11.0) without diarrhoea, and in non-Aboriginal children they were 5.9 (2.8 to 12.3) and 4.2 (3.3 to 5.2), respectively. In patients with diarrhoea, L-R ratios were significantly raised when accompanied by acidosis (mean, 22.8; 95% CI, 17.0 to 30.5), hypokalaemia (mean, 20.7; 95% CI, 15.4 to 27.9), and ⩾ 5% dehydration (mean, 24.3; 95% CI, 19.0 to 29.6) compared with none of these complications (mean, 7.0; 95% CI, 3.5 to 13.8).
CONCLUSION—The high incidence of acidosis, hypokalaemia, and dehydration in Aboriginal children admitted with diarrhoeal disease is related to underlying small intestinal mucosal damage.

PMCID: PMC1718109  PMID: 10490433
8.  Under-ascertainment of Aboriginality in records of cardiovascular disease in hospital morbidity and mortality data in Western Australia: a record linkage study 
Measuring the real burden of cardiovascular disease in Australian Aboriginals is complicated by under-identification of Aboriginality in administrative health data collections. Accurate data is essential to measure Australia's progress in its efforts to intervene to improve health outcomes of Australian Aboriginals. We estimated the under-ascertainment of Aboriginal status in linked morbidity and mortality databases in patients hospitalised with cardiovascular disease.
Persons with public hospital admissions for cardiovascular disease in Western Australia during 2000-2005 (and their 20-year admission history) or who subsequently died were identified from linkage data. The Aboriginal status flag in all records for a given individual was variously used to determine their ethnicity (index positive, and in all records both majority positive or ever positive) and stratified by region, age and gender. The index admission was the baseline comparator.
Index cases comprised 62,692 individuals who shared a total of 778,714 hospital admissions over 20 years, of which 19,809 subsequently died. There were 3,060 (4.9%) persons identified as Aboriginal on index admission. An additional 83 (2.7%) Aboriginal cases were identified through death records, increasing to 3.7% when cases with a positive Aboriginal identifier in the majority (≥50%) of previous hospital admissions over twenty years were added and by 20.8% when those with a positive flag in any record over 20 years were incorporated. These results equated to underestimating Aboriginal status in unlinked index admission by 2.6%, 3.5% and 17.2%, respectively. Deaths classified as Aboriginal in official records would underestimate total Aboriginal deaths by 26.8% (95% Confidence Interval 24.1 to 29.6%).
Combining Aboriginal determinations in morbidity and official death records increases ascertainment of unlinked cardiovascular morbidity in Western Australian Aboriginals. Under-identification of Aboriginal status is high in death records.
PMCID: PMC3024993  PMID: 21192809
9.  Enhanced reporting of deaths among Aboriginal and Torres Strait Islander peoples using linked administrative health datasets 
Aboriginal and Torres Strait Islander peoples are under-reported in administrative health datasets in NSW, Australia. Correct reporting of Aboriginal and Torres Strait Islander peoples is essential to measure the effectiveness of policies and programmes aimed at reducing the health disadvantage experienced by Aboriginal and Torres Strait Islander peoples. This study investigates the potential of record linkage to enhance reporting of deaths among Aboriginal and Torres Strait Islander peoples in NSW, Australia.
Australian Bureau of Statistics death registration data for 2007 were linked with four population health datasets relating to hospitalisations, emergency department attendances and births. Reporting of deaths was enhanced from linked records using two methods, and effects on patterns of demographic characteristics and mortality indicators were examined.
Reporting of deaths increased by 34.5% using an algorithm based on a weight of evidence of a person being Aboriginal or Torres Strait Islander, and by 56.6% using an approach based on 'at least one report' of a person being Aboriginal or Torres Strait Islander. The increase was relatively greater in older persons and those living in less geographically remote areas. Enhancement resulted in a reduction in the urban-remote differential in median age at death and increases in standardised mortality ratios particularly for chronic conditions.
Record linkage creates a statistical construct that helps to correct under-reporting of deaths and potential bias in mortality statistics for Aboriginal and Torres Strait Islander peoples.
PMCID: PMC3413579  PMID: 22747900
10.  Adjusting for under-identification of Aboriginal and/or Torres Strait Islander births in time series produced from birth records: Using record linkage of survey data and administrative data sources 
Statistical time series derived from administrative data sets form key indicators in measuring progress in addressing disadvantage in Aboriginal and Torres Strait Islander populations in Australia. However, inconsistencies in the reporting of Indigenous status can cause difficulties in producing reliable indicators. External data sources, such as survey data, provide a means of assessing the consistency of administrative data and may be used to adjust statistics based on administrative data sources.
We used record linkage between a large-scale survey (the Western Australian Aboriginal Child Health Survey), and two administrative data sources (the Western Australia (WA) Register of Births and the WA Midwives’ Notification System) to compare the degree of consistency in determining Indigenous status of children between the two sources. We then used a logistic regression model predicting probability of consistency between the two sources to estimate the probability of each record on the two administrative data sources being identified as being of Aboriginal and/or Torres Strait Islander origin in a survey. By summing these probabilities we produced model-adjusted time series of neonatal outcomes for Aboriginal and/or Torres Strait Islander births.
Compared to survey data, information based only on the two administrative data sources identified substantially fewer Aboriginal and/or Torres Strait Islander births. However, these births were not randomly distributed. Births of children identified as being of Aboriginal and/or Torres Strait Islander origin in the survey only were more likely to be living in urban areas, in less disadvantaged areas, and to have only one parent who identifies as being of Aboriginal and/or Torres Strait Islander origin, particularly the father. They were also more likely to have better health and wellbeing outcomes. Applying an adjustment model based on the linked survey data increased the estimated number of Aboriginal and/or Torres Strait Islander births in WA by around 25%, however this increase was accompanied by lower overall proportions of low birth weight and low gestational age babies.
Record linkage of survey data to administrative data sets is useful to validate the quality of recording of demographic information in administrative data sources, and such information can be used to adjust for differential identification in administrative data.
PMCID: PMC3493324  PMID: 22747850
11.  Absent otoacoustic emissions predict otitis media in young Aboriginal children: A birth cohort study in Aboriginal and non-Aboriginal children in an arid zone of Western Australia 
BMC Pediatrics  2008;8:32.
Otitis media (OM) is the most common paediatric illness for which antibiotics are prescribed. In Australian Aboriginal children OM is frequently asymptomatic and starts at a younger age, is more common and more likely to result in hearing loss than in non-Aboriginal children. Absent transient evoked otoacoustic emissions (TEOAEs) may predict subsequent risk of OM.
100 Aboriginal and 180 non-Aboriginal children in a semi-arid zone of Western Australia were followed regularly from birth to age 2 years. Tympanometry was conducted at routine field follow-up from age 3 months. Routine clinical examination by an ENT specialist was to be done 3 times and hearing assessment by an audiologist twice. TEOAEs were measured at ages <1 and 1–2 months. Cox proportional hazards model was used to investigate the association between absent TEOAEs and subsequent risk of OM.
At routine ENT specialist clinics, OM was detected in 55% of 184 examinations in Aboriginal children and 26% of 392 examinations in non-Aboriginal children; peak prevalence was 72% at age 5–9 months in Aboriginal children and 40% at 10–14 months in non-Aboriginal children. Moderate-severe hearing loss was present in 32% of 47 Aboriginal children and 7% of 120 non-Aboriginal children aged 12 months or more.
TEOAE responses were present in 90% (46/51) of Aboriginal children and 99% (120/121) of non-Aboriginal children aged <1 month and in 62% (21/34) and 93% (108/116), respectively, in Aboriginal and non-Aboriginal children at age 1–2 months. Aboriginal children who failed TEOAE at age 1–2 months were 2.6 times more likely to develop OM subsequently than those who passed.
Overall prevalence of type B tympanograms at field follow-up was 50% (n = 78) in Aboriginal children and 20% (n = 95) in non-Aboriginal children.
The burden of middle ear disease is high in all children, but particularly in Aboriginal children, one-third of whom suffer from moderate-severe hearing loss. In view of the frequently silent nature of OM, every opportunity must be taken to screen for OM. Measurement of TEOAEs at age 1–2 months to identify children at risk of developing OM should be evaluated in a routine health service setting.
PMCID: PMC2538518  PMID: 18755038
12.  Breastfeeding Duration and Residential Isolation amid Aboriginal Children in Western Australia 
Nutrients  2012;4(12):2020-2034.
Objectives: To examine factors that impact on breastfeeding duration among Western Australian Aboriginal children. We hypothesised that Aboriginal children living in remote locations in Western Australia were breastfed for longer than those living in metropolitan locations. Methods: A population-based cross-sectional survey was conducted from 2000 to 2002 in urban, rural and remote settings across Western Australia. Cross-tabulations and multivariate logistic regression analyses were performed, using survey weights to produce unbiased estimates for the population of Aboriginal children. Data on demographic, maternal and infant characteristics were collected from 3932 Aboriginal birth mothers about their children aged 0–17 years (representing 22,100 Aboriginal children in Western Australia). Results: 71% of Aboriginal children were breastfed for three months or more. Accounting for other factors, there was a strong gradient for breastfeeding duration by remoteness, with Aboriginal children living in areas of moderate isolation being 3.2 times more likely to be breastfed for three months or more (p < 0.001) compared to children in metropolitan Perth. Those in areas of extreme isolation were 8.6 times more likely to be breastfed for three months or longer (p < 0.001). Conclusions: Greater residential isolation a protective factor linked to longer breastfeeding duration for Aboriginal children in our West Australian cohort.
PMCID: PMC3546620  PMID: 23363997
breastfeeding duration; Australian Aboriginal children; isolation
13.  A review of life expectancy and infant mortality estimations for Australian Aboriginal people 
BMC Public Health  2014;14:1.
Significant variation exists in published Aboriginal mortality and life expectancy (LE) estimates due to differing and evolving methodologies required to correct for inadequate recording of Aboriginality in death data, under-counting of Aboriginal people in population censuses, and unexplained growth in the Aboriginal population attributed to changes in the propensity of individuals to identify as Aboriginal at population censuses.
The objective of this paper is to analyse variation in reported Australian Aboriginal mortality in terms of LE and infant mortality rates (IMR), compared with all Australians.
Published data for Aboriginal LE and IMR were obtained and analysed for data quality and method of estimation. Trends in reported LE and IMR estimates were assessed and compared with those in the entire Australian population.
LE estimates derived from different methodologies vary by as much as 7.2 years for the same comparison period. Indirect methods for estimating Aboriginal LE have produced LE estimates sensitive to small changes in underlying assumptions, some of which are subject to circular reasoning. Most indirect methods appear to under-estimate Aboriginal LE. Estimated LE gaps between Aboriginal people and the overall Australian population have varied between 11 and 20 years.
Latest mortality estimates, based on linking census and death data, are likely to over-estimate Aboriginal LE.
Temporal LE changes by each methodology indicate that Aboriginal LE has improved at rates similar to the Australian population overall. Consequently the gap in LE between Aboriginal people and the total Australian population appears to be unchanged since the early 1980s, and at the end of the first decade of the 21st century remains at least 11–12 years.
In contrast, focussing on the 1990–2010 period Aboriginal IMR declined steeply over 2001–08, from more than 12 to around 8 deaths per 1,000 live births, the same level as Australia overall in 1993–95. The IMR gap between Aboriginal people and the total Australian population, while still unacceptable, has declined considerably, from over 8 before 2000 to around 4 per 1,000 live births by 2008.
Regardless of estimation method used, mortality and LE gaps between Aboriginal and non-Aboriginal people are substantial, but remain difficult to estimate accurately.
PMCID: PMC3893414  PMID: 24383435
14.  Improving the accuracy of Aboriginal and non-Aboriginal disease notification rates using data linkage 
Routinely collected infectious disease surveillance data provide a valuable means to monitor the health of populations. Notifiable disease surveillance systems in Australia have consistently reported high levels of completeness for the demographic data fields of age and sex, but low levels of completeness for Aboriginality data. Significant amounts of missing data associated with case notifications can introduce bias in the estimation of disease rates by population subgroups. The aim of this analysis was to evaluate the use of data linkage to improve the accuracy of estimated notification rates for sexually transmitted infections (STIs) and blood borne viruses (BBVs) in Aboriginal and non-Aboriginal groups in Western Australia.
Probabilistic methods were used to link disease notification data received in Western Australia in 2004 with core population health datasets from the established Western Australian Data Linkage System. A comparative descriptive analysis of STI and BBV notification rates according to Aboriginality was conducted based on the original and supplemented notification datasets.
Using data linkage, the proportion of STI and BBV notifications with missing Aboriginality data was reduced by 74 per cent. Compared with excluding notifications with unknown Aboriginality data from the analysis, or apportioning notifications with unknown Aboriginality based on the proportion of cases with known Aboriginality, the rate ratios of chlamydia, syphilis and hepatitis C among Aboriginal relative to non-Aboriginal people decreased when Aboriginality data from data linkage was included.
Although there is still a high incidence of STIs and BBVs in Aboriginal people, incompleteness of Aboriginality data contributes to overestimation of the risk associated with Aboriginality for these diseases. Data linkage can be effectively used to improve the accuracy of estimated disease notification rates.
PMCID: PMC2429908  PMID: 18510777
15.  Pre-pregnancy predictors of hypertension in pregnancy among Aboriginal and Torres Strait Islander women in north Queensland, Australia; a prospective cohort study 
BMC Public Health  2013;13:138.
Compared to other Australian women, Indigenous women are frequently at greater risk for hypertensive disorders of pregnancy. We examined pre-pregnancy factors that may predict hypertension in pregnancy in a cohort of Aboriginal and Torres Strait Islander women in north Queensland.
Data on a cohort of 1009 Indigenous women of childbearing age (15–44 years) who participated in a 1998–2000 health screening program in north Queensland were combined with 1998–2008 Queensland hospitalisations data using probabilistic data linkage. Data on the women in the cohort who were hospitalised for birth (n = 220) were further combined with Queensland perinatal data which identified those diagnosed with hypertension in pregnancy.
Of 220 women who gave birth, 22 had hypertension in the pregnancy after their health check. The mean age of women with and without hypertension was similar (23.7 years and 23.9 years respectively) however Aboriginal women were more affected compared to Torres Strait Islanders. Pre-pregnancy adiposity and elevated blood pressure at the health screening program were predictors of a pregnancy affected by hypertension. After adjusting for age and ethnicity, each 1 cm increase in waist circumference showed a 4% increased risk for hypertension in pregnancy (PR 1.04; 95% CI; 1.02-1.06); each 1 point increase in BMI showed a 9% adjusted increase in risk (1.09; 1.04-1.14). For each 1 mmHg increase in baseline systolic blood pressure there was an age and ethnicity adjusted 6% increase in risk and each 1 mmHg increase in diastolic blood pressure showed a 7% increase in risk (1.06; 1.03-1.09 and 1.07; 1.03-1.11 respectively). Among those free of diabetes at baseline, the presence of the metabolic syndrome (International Diabetes Federation criteria) predicted over a three-fold increase in age-ethnicity-adjusted risk (3.5; 1.50-8.17).
Pre-pregnancy adiposity and features of the metabolic syndrome among these young Aboriginal and Torres Strait Islander women track strongly to increased risk of hypertension in pregnancy with associated risks to the health of babies.
PMCID: PMC3599805  PMID: 23410045
Indigenous; Pre-pregnancy; Hypertension; Preeclampsia
16.  One third of hospital costs for atherothrombotic disease are attributable to readmissions: a linked data analysis 
Cardiovascular disease is the most frequent cause of death in Australia, with an associated cost burden of 11% of Australian annual health expenditure of which 40% is for hospital admissions. We investigated health outcomes and the components of hospital expenditure in the two years after an atherothrombotic disease admission to a tertiary hospital in an Australian setting.
Using data linkage we analysed two years of hospitalisation data and death records of all men and women aged 35–84 years with an admission to a Western Australian tertiary hospital for atherothrombotic disease in 2007. Costs were identified by matching the Australian refined diagnostic related group on the admission records to the published schedules of public and private hospital costs for the period of interest, and converted to 2013 Australian dollars.
Of 6172 patients studied (74% coronary, 20% cerebrovascular, 6% peripheral), 783 (13%) died during follow-up and 174 of these were in hospital case-fatalities at index. Thirty-two percent of patients (n = 1965) accounted for 3172 readmissions to hospital with one in three having multiple hospitalisations. The hazard ratio of atherothrombotic disease readmission was 1.45 (95% CI 1.27, 1.66) in those with more than one vascular territory affected compared to those with only one territory affected after controlling for age, sex, comorbidity, admission type, procedures, and episode length of stay. The total index plus 2-year admission cost for atherothrombotic disease was calculated at $101 million; $71 million for index, and $30 million for readmissions.
Among patients hospitalised with atherothrombotic disease, the cost of related rehospitalisations within 24 months is almost a third of the total. Much of the readmission costs fell within the first year. Whether readmissions and cost associated with atherothrombotic disease can be lowered through secondary prevention measures requires further investigation.
PMCID: PMC4251605  PMID: 25102911
Cardiovascular disease; Coronary heart disease; Hospital; Peripheral vascular disease; Stroke; Linked data; Western Australia
17.  Impact of population ageing on the costs of hospitalisations for cardiovascular disease: a population-based data linkage study 
Cardiovascular disease (CVD) is the most costly disease in Australia. Measuring the impact of ageing on its costs is needed for planning future healthcare budget. The aim of this study was to measure the impact of changes in population age structure in Western Australia (WA) on the costs of hospitalisation for CVD.
All hospitalisation records for CVD occurring in WA in 1993/94 and 2003/04 inclusive were extracted from the WA Hospital Morbidity Data System (HMDS) via the WA Data Linkage System. Inflation adjusted hospitalisation costs using 2012 as the base year was assigned to all episodes of care using Australian Refined Diagnosis Related Group (AR-DRG) costing information. The component decomposition method was used to measure the contribution of ageing and other factors to the increase of hospitalisation costs for CVD.
Between 1993/94 and 2003/04, population ageing contributed 23% and 30% respectively of the increase in CVD hospitalisation costs for men and women. The impact of ageing on hospitalisation costs was far greater for chronic conditions than acute coronary syndrome (ACS) and stroke.
Given the impact of ageing on hospitalisation costs, and the disparity between chronic and acute conditions, disease-specific factors should be considered in planning for future healthcare expenditure.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-014-0554-9) contains supplementary material, which is available to authorized users.
PMCID: PMC4236486  PMID: 25392132
Cardiovascular disease; Health expenditures; Population ageing; Data linkage
18.  Hospital Admissions in Children with Down Syndrome: Experience of a Population-Based Cohort Followed from Birth 
PLoS ONE  2013;8(8):e70401.
Children with Down syndrome, the most common genetic cause of intellectual disability, are prone to multiple and varied health-related problems. This study describes patterns of hospitalisations for children and young people with Down syndrome in Western Australia.
Birth records were linked to the Western Australian population-based Intellectual Disability database to identify all children born with Down syndrome in Western Australia between 1 January, 1983 and 31 December, 1999. These records were linked to the Hospital Morbidity Data System to provide information on all hospitalisations up to 31 December, 2004. Hospitalisation data, coded using ICD-9CM or ICD-10 (v0.5) were grouped into clinically relevant categories using the primary diagnosis. Rates of hospital admission for all and specific diagnoses were expressed in 1000-person-years at-risk and median age at first admission and length of stay were calculated.
Of the 405 children, 395 had one or more hospital admissions, totalling 3786 admissions for all children and an estimated 39.5 person-years in hospital. On average, children were admitted 9.7 times, with an estimated rate of 757.2 admissions per 1000pyr (95% CI: 680, 843). A quarter of all admissions occurred in the first year of life. The average hospital length of stay was 3.8 days (95% CI: 3.7, 4.1). Upper respiratory tract conditions affected the most children (58.5%) and accounted for 12.1% of all admissions. Other disorders which affected a high percentage of children were ear/hearing conditions (50.6%), disorders of the oral cavity (38.0%) and lower respiratory tract conditions (37.5%). Overall, children with Down syndrome were hospitalised at a rate five times (95% CI = 4.3–6.2) that of the general population.
Children with Down syndrome are at increased risk of morbidity for varied causes underlining the importance of comprehensive and targeted primary care for this group.
PMCID: PMC3742744  PMID: 23967074
19.  Are prenatal, obstetric, and infant complications associated with postpartum psychosis among women with pre-conception psychiatric hospitalisations? 
To examine the associations of maternal and infant complications with postpartum hospitalisation for psychosis in women with a pre-conception history of psychiatric hospitalisation.
Population-based study.
Swedish medical birth register.
Primiparous women who gave birth between 1 January 1987 and 31 December 2001, and who had a pre-conception history of psychiatric hospitalisation but who were not hospitalised during pregnancy (n = 1842).
International Classification of Diseases (ICD) codes were used to identify prenatal, obstetric, postpartum maternal complications, and newborn health conditions. We used multivariable logistic regression to describe the associations between maternal and infant health conditions and the odds for postpartum hospitalisation for psychosis.
Main outcome measure
Psychiatric hospitalisation within 90 days of delivery.
Compared with women who did not have a postpartum psychiatric hospitalisation, hospitalised women were at 2.3 times higher odds (95% CI 1.0–4.9) of having non-psychiatric puerperium complications (e.g. infection, lactation problems or venous complications). No other maternal complications were associated with postpartum psychiatric hospitalisation. Although their infants were at no higher odds for health complications, the offspring of women who had a postpartum psychiatric hospitalisation were at 4.1 times higher odds (95% CI 1.3–12.6) of death within the first 365 days of life than those of women who were not hospitalised.
We found no prenatal indicators of postpartum risk for psychiatric hospitalisation among high-risk women, but they had higher odds of postpartum pregnancy-related medical problems and, rarely, offspring death.
PMCID: PMC4001727  PMID: 23194279
Infant mortality; maternal health; postpartum health; psychosis
20.  Acute bronchiolitis in infancy as risk factor for wheezing and reduced pulmonary function by seven years in Akershus County, Norway 
BMC Pediatrics  2005;5:31.
Acute viral bronchiolitis is one of the most common causes of hospitalisation during infancy in our region with respiratory syncytial virus (RSV) historically being the major causative agent. Many infants with early-life RSV bronchiolitis have sustained bronchial hyperreactivity for many years after hospitalisation and the reasons for this are probably multifactorial. The principal aim of the present study was to investigate if children hospitalised for any acute viral bronchiolitis during infancy in our region, and not only those due to RSV, had more episodes of subsequent wheezing up to age seven years and reduced lung function at that age compared to children not hospitalised for acute bronchiolitis during infancy. A secondary aim was to compare the hospitalised infants with proven RSV bronchiolitis (RS+) to the hospitalised infants with non-RSV bronchiolitis (RS-) according to the same endpoints.
57 infants hospitalised at least once with acute viral bronchiolitis during two consecutive winter seasons in 1993–1994 were examined at age seven years. An age-matched control group of 64 children, who had not been hospitalised for acute viral bronchiolitis during infancy, were recruited from a local primary school. Epidemiological and clinical data were collected retrospectively from hospital discharge records and through structured clinical interviews and physical examinations at the follow-up visit.
The children hospitalised for bronchiolitis during infancy had decreased lung function, more often wheezing episodes, current medication and follow-up for asthma at age seven years than did the age matched controls. They also had lower average birth weight and more often first order family members with asthma. We did not find significant differences between the RSV+ and RSV- groups.
Children hospitalised for early-life bronchiolitis are susceptible to recurrent wheezing and reduced pulmonary function by seven years compared to age-matched children not hospitalised for early-life bronchiolitis. We propose that prolonged bronchial hyperreactivity could follow early-life RSV negative as well as RSV positive bronchiolitis.
PMCID: PMC1199604  PMID: 16109158
21.  Rural–urban differentials in 30-day and 1-year mortality following first-ever heart failure hospitalisation in Western Australia: a population-based study using data linkage 
BMJ Open  2014;4(5):e004724.
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.
A population-based cohort study.
Hospitalised patients in Western Australia, Australia.
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.
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.
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.
PMCID: PMC4025448  PMID: 24793254
22.  Maternal and foetal outcomes among pregnant women hospitalised due to interpersonal violence: A population based study in Western Australia, 2002-2008 
Interpersonal violence is responsible for more ill-health and premature death in women under the age of 45 than other preventable health conditions, but findings concerning the effects of violence during pregnancy on both maternal and foetal health have been inconsistent.
A retrospective population-based cohort study was undertaken using linked data from the Hospital Morbidity Data Collection and the Western Australian Midwives' Notification System from 2002 to 2008. The aim was to determine the association between exposure to interpersonal violence during pregnancy and adverse maternal and foetal health outcomes at the population level.
A total of 468 pregnant women were hospitalised for an incident of interpersonal violence during the study period, and 3,744 randomly selected pregnant women were included as the comparison group. The majority of violent events were perpetrated by the pregnant women's partner or spouse. Pregnant Indigenous women were over-represented accounting for 67% of all hospitalisations due to violence and their risk of experiencing adverse maternal outcomes was significantly increased compared to non-Indigenous women (adjusted odds ratio 1.53, 95% CI 1.21 to 1.95, p = 0.01). Pregnant women hospitalised for an incident of interpersonal violence sustained almost double the risk for adverse maternal complications than the non-exposed group (95% CI 1.34 to 2.18, p < 0.001). The overall risk for adverse foetal complications for pregnant women exposed to violence was increased two-fold (95% CI 1.50 to 2.76, p < 0.001).
The risk of adverse health outcomes for both the mother and the baby increases if a pregnant woman is hospitalised for an incident of interpersonal violence during pregnancy.
PMCID: PMC3203083  PMID: 21989086
23.  Identifying barriers and improving communication between cancer service providers and Aboriginal patients and their families: the perspective of service providers 
Aboriginal Australians experience poorer outcomes from cancer compared to the non-Aboriginal population. Some progress has been made in understanding Aboriginal Australians’ perspectives about cancer and their experiences with cancer services. However, little is known of cancer service providers’ (CSPs) thoughts and perceptions regarding Aboriginal patients and their experiences providing optimal cancer care to Aboriginal people. Communication between Aboriginal patients and non-Aboriginal health service providers has been identified as an impediment to good Aboriginal health outcomes. This paper reports on CSPs’ views about the factors impairing communication and offers practical strategies for promoting effective communication with Aboriginal patients in Western Australia (WA).
A qualitative study involving in-depth interviews with 62 Aboriginal and non-Aboriginal CSPs from across WA was conducted between March 2006 - September 2007 and April-October 2011. CSPs were asked to share their experiences with Aboriginal patients and families experiencing cancer. Thematic analysis was carried out. Our analysis was primarily underpinned by the socio-ecological model, but concepts of Whiteness and privilege, and cultural security also guided our analysis.
CSPs’ lack of knowledge about the needs of Aboriginal people with cancer and Aboriginal patients’ limited understanding of the Western medical system were identified as the two major impediments to communication. For effective patient–provider communication, attention is needed to language, communication style, knowledge and use of medical terminology and cross-cultural differences in the concept of time. Aboriginal marginalization within mainstream society and Aboriginal people’s distrust of the health system were also key issues impacting on communication. Potential solutions to effective Aboriginal patient-provider communication included recruiting more Aboriginal staff, providing appropriate cultural training for CSPs, cancer education for Aboriginal stakeholders, continuity of care, avoiding use of medical jargon, accommodating patients’ psychosocial and logistical needs, and in-service coordination.
Individual CSPs identified challenges in cross-cultural communication and their willingness to accommodate culture-specific needs within the wider health care system including better communication with Aboriginal patients. However, participants’ comments indicated a lack of concerted effort at the system level to address Aboriginal disadvantage in cancer outcomes.
PMCID: PMC3835135  PMID: 24188503
Aboriginal; Indigenous; Cancer; Communication; Health service provider; Cancer service provider
24.  Cross vascular risk for first and recurrent hospitalised atherothrombosis determined retrospectively from linked data 
BMJ Open  2013;3(11):e003813.
To determine the sex-specific and age-specific risk ratios for the first-ever and recurrent hospitalisation for cerebrovascular, coronary and peripheral arterial disease in persons with other vascular history versus without other vascular history in Western Australia from 2005to 2007.
Cross-sectional linkage study.
Hospitalised population in a representative Australian State.
All persons aged 34–85 years between 1 January 2005 and 31 December 2007 were hospitalised with a principal diagnosis of atherothrombosis.
Data sources
Person-linked file of statutory-collected administrative morbidity and mortality records.
Main outcome measures
Sex-specific and age-specific risk ratios for the first-ever and recurrent hospitalisations for symptomatic atherothrombosis of the brain, coronary and periphery using a 15-year look-back period lead to the determining of prior events.
Over 3 years, 40 877 (66% men; 55% first-ever) were hospitalised for atherothrombosis. For each arterial territory, age-specific recurrent rates were higher than the corresponding first-ever rates, with the biggest difference seen in the youngest age groups. For all types of first-ever atherothrombosis, the rates were higher in those with other vascular history and the risk ratios declined with an advancing age (trend: all p<0.0001) and remained significantly >1 even for 75–84 years old. However, for recurrent events, the rates were marginally higher in those with other vascular history and no risk ratio age trend was apparent with several not significantly >1 (trend: all p>0.13).
This study of hospitalised atherothrombosis suggests first-events predominate and that the risk of further events in the same or other arterial territory is very high for all ages and both sexes, accentuating the necessity for an early and sustained active prevention.
PMCID: PMC3840350  PMID: 24259391
25.  Association between early bacterial carriage and otitis media in Aboriginal and non-Aboriginal children in a semi-arid area of Western Australia: a cohort study 
BMC Infectious Diseases  2012;12:366.
Streptococcus pneumoniae (Pnc), nontypeable Haemophilus influenzae (NTHi) and Moraxella catarrhalis (Mcat) are the most important bacterial pathogens associated with otitis media (OM). Previous studies have suggested that early upper respiratory tract (URT) bacterial carriage may increase risk of subsequent OM. We investigated associations between early onset of URT bacterial carriage and subsequent diagnosis of OM in Aboriginal and non-Aboriginal children living in the Kalgoorlie-Boulder region located in a semi-arid zone of Western Australia.
Aboriginal and non-Aboriginal children who had nasopharyngeal aspirates collected at age 1- < 3 months and at least one clinical examination for OM by an ear, nose and throat specialist before age 2 years were included in this analysis. Tympanometry to detect middle ear effusion was also performed at 2- to 6-monthly scheduled field visits from age 3 months. Multivariate regression models were used to investigate the relationship between early carriage and subsequent diagnosis of OM controlling for environmental factors.
Carriage rates of Pnc, NTHi and Mcat at age 1- < 3 months were 45%, 29% and 48%, respectively, in 66 Aboriginal children and 14%, 5% and 18% in 146 non-Aboriginal children. OM was diagnosed at least once in 71% of Aboriginal children and 43% of non-Aboriginal children. After controlling for age, sex, presence of other bacteria and environmental factors, early nasopharyngeal carriage of NTHi increased the risk of subsequent OM (odds ratio = 3.70, 95% CI 1.22-11.23) in Aboriginal children, while Mcat increased the risk of OM in non-Aboriginal children (odds ratio = 2.63, 95% CI 1.32-5.23). Early carriage of Pnc was not associated with increased risk of OM.
Early NTHi carriage in Aboriginal children and Mcat in non-Aboriginal children is associated with increased risk of OM independent of environmental factors. In addition to addressing environmental risk factors for carriage such as overcrowding and exposure to environmental tobacco smoke, early administration of pneumococcal-Haemophilus influenzae D protein conjugate vaccine to reduce bacterial carriage in infants, may be beneficial for Aboriginal children; such an approach is currently being evaluated in Australia.
PMCID: PMC3546895  PMID: 23256870
Otitis media; Aboriginal; Streptococcus pneumoniae; Haemophilus influenzae; Moraxella catarrhalis

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