3.04 Early detection and early treatment
Why is it important?
Early detection is the discovery of a disease or condition at an early stage of its development or onset, usually before symptoms occur. Early detection may occur for individual patients, where clinically indicated, or for all members of a population through screening programmes. In Australia, primary health care providers, including Aboriginal and Torres Strait Islander health services and GPs, have a key role in early detection and early treatment programmes. Early detection and treatment programmes are most effective when there are systematic approaches to ensuring assessment and screening occurs regularly and at recommended intervals.
Medicare Benefits Schedule (MBS) health assessment items for Aboriginal and Torres Strait Islander peoples aim to encourage early detection, diagnosis and intervention for common and treatable conditions that cause morbidity and early mortality.
Breast, bowel and cervical cancer screening programmes are designed to detect cancer early (breast and bowel cancer) or prevent its occurrence in the first place (bowel and cervical cancer). National programmes for breast and cervical screening were implemented in Australia in the early 1990s, advising two-yearly screening for women aged 50–69 and 20–69 years respectively. The national programme for bowel cancer screening was first implemented in 2006. Lowered mortality rates for each of these cancers have been attributed, at least in part, to these programmes (DoHA 2009; AIHW 2014l; AIHW 2014u). Research shows that biennial bowel cancer screening can save up to 500 lives annually (Pignone et al. 2011).
Participation by Aboriginal and Torres Strait Islander peoples in BreastScreen Australia, the National Cervical Screening Program, and the National Bowel Cancer Screening Program (NBCSP) has been at a lower rate than non-Indigenous participation (Reath et al. 2008; AIHW 2014u; AIHW 2014l).
Medicare health assessment items for Indigenous Australians aged 55 years and over were introduced in 1999, for those aged 15–54 years in 2004, and for those aged 0–14 years in 2006. Measures to increase takeup of health assessments by those aged 15 years and over were introduced in 2009–10. Trend analysis shows a statistically significant increase in health assessments for all ages between July 2009 and June 2014 (the rate has nearly tripled). There has been acceleration in the rate of change since 2009–10 (annual average change of 35 per 1,000, compared with 26 per 1,000 for the period 2006–07 to 2013–14).
In 2013–14, around 47,400 health assessments were undertaken for children aged 0–14 years, representing around 19% of children in the target group. There were about 80,600 health assessments provided for Indigenous Australians aged 15–54 years (21% of this population) and 22,300 for those aged 55 years and over (representing 33% of this population). Health assessments through Medicare are also available to all Australians aged 75 years and over, with 32% of this population having an assessment in 2013–14. In this period, there were also 4,440 MBS Healthy Kids Checks claimed for Indigenous children (available to all children in conjunction with their 4-year-old immunisation).
In 2012–13, Indigenous Australians aged 50 years and over with no current diagnosis for diabetes were 1.2 times as likely as non-Indigenous Australians to have been tested for diabetes/high sugar levels in the last three years (67% compared with 55%).
According to the latest available data on screening for breast cancer (2011–12), 33% of Indigenous women aged 50–69 years had participated in screening compared with 55% of other Australian women. Rates for Indigenous women were highest in Qld (43%) and lowest in the NT (26%). In the period 1999–2000 to 2011–12, there was a small (4%) significant increase in the proportion of Indigenous women screened. In the 2012–13 Health Survey, 79% of Indigenous women aged 50–69 years reported ever having a mammogram.
In the 2012–13 Health Survey, 58% of Aboriginal and Torres Strait Islander women aged 20–69 years reported having a pap smear test at least every two years. In 2011–12, 58% of all Australian women aged 20–69 years were recorded in the national cervical screening register (AIHW 2014l). Indigenous women aged 20–69 years living in very remote areas were more likely to report having a regular pap smear test than those in major cities (69% and 60% respectively).
In the latest available data on bowel cancer screening (2012–13), around 321,400 Australians (aged 50, 55 and 65) participated in the NBCSP with 2,018 (0.6%) identifying as Indigenous. Participants recorded as Indigenous were more likely to receive a positive (i.e. potentially abnormal) test result than non-Indigenous participants (11% and 7% respectively). For those who received a positive test result, rates of colonoscopy follow-up were lower for Indigenous than non-Indigenous participants (59% compared with 71%). Rates of follow-up with a primary health care practitioner were similar for both Indigenous and non-Indigenous participants (56% and 60% respectively) (AIHW 2014u). A recent analysis of the NBCSP suggests that factors contributing to the disparity in participation rates include enrolment via Medicare records, disadvantaging those who are not registered; distribution of screening kits by post, disadvantaging those without a fixed address; the nature of the test; cultural perceptions of cancer; and lack of information about bowel cancer and screening (Christou et al. 2010). In the 2012–13 Health Survey, for those aged 50–74 years, 18% of Indigenous males and 11% of Indigenous females reported having ever participated in bowel cancer screening tests. For Indigenous males aged 50 years and over, 64% reported having ever been tested for prostate cancer.
December 2013 national Key Performance Indicators data, from Australian Government-funded Indigenous primary health care organisations, show that 27% of Indigenous children aged 0–4 years who were regular clients of these organisations had received an MBS health assessment in the previous 12 months. For adults aged 25 years and over, 40% of eligible regular clients had received a health check in the previous 24 months. In addition, 32% of regular female clients had a cervical screening in the previous 2 years, 39% in the previous 3 years and 46% in the previous 5 years. The NT and very remote areas had the highest proportions screened (AIHW 2014w).
Early detection and early treatment through primary health care has significant benefits for those at risk of disease. Identification of Indigenous patients is the first step in providing access to Aboriginal and Torres Strait Islander-specific health initiatives, including the additional MBS, Pharmaceutical Benefits Scheme (PBS), and immunisation programmes.
The Australian Government provides GP health assessments for Aboriginal and Torres Strait Islander peoples under the MBS, along with follow-on care and incentive payments for improved chronic disease management and cheaper medicines through the PBS. The Practice Incentives Programme—Indigenous Health Incentive aims to support general practices and Indigenous health services to provide better health care for Indigenous patients including identifying the Indigenous status of patients and best practice management of chronic disease.
The Indigenous Australians' Health Programme commenced 1 July 2014, (consolidating existing primary health care base funding, child and maternal health programmes, Stronger Futures in the Northern Territory and the Aboriginal and Torres Strait Islander Chronic Disease Fund) to focus on local health needs and better support efforts to achieve health equality between Indigenous and non-Indigenous Australians. Chronic disease activities provided through the Indigenous Australians' Health Programme include nationwide tobacco reduction and healthy lifestyle promotion activities; a care coordination and outreach workforce based in Medicare Locals and Aboriginal Community Controlled Health Organisations; and GP, specialist and allied-health outreach services serving urban, rural and remote communities. All of these services can be used to assist with early detection and treatment of chronic diseases for Indigenous Australians.
Uptake of health assessments by Indigenous Australians across all age groups has increased significantly since July 2009 (now reaching 19%–33% of the population in these age-groups). There has also been an increase in chronic disease management items and other aspects of primary health care (see measures 3.05 and 3.14).
Given the lower rate of participation of Indigenous Australians in the breast, bowel and cervical cancer screening programmes better ways of encouraging regular screening are needed (Christou et al. 2010).
In the 2014–15 Budget, the Australian Government committed to the roll-out of a biennial bowel screening interval for all Australians aged 50–74 years of age from 2015 to 2020. Following the successful Aboriginal and Torres Strait Islander community pilots in 2008–2011, further funding (over three years) has been allocated to pilot the offer of bowel cancer screening to eligible Indigenous Australians aged 50–74 years through integration with existing primary health care/chronic disease prevention mechanisms. The pilot will provide bowel cancer information, risk assessment, and offer of faecal occult blood test screening to individuals across Australia through Indigenous health clinics and medical services.
Cervical screening will remain vital for many decades, as the current HPV vaccines are not effective against all types of the virus that cause cervical cancer. A barrier to reporting on cervical screening is that pathology request forms do not currently include provision for Indigenous status to be recorded in all jurisdictions.
Figure 3.04-1 shows the rate (per 1,000 persons) of Aboriginal and Torres Strait Islander peoples receiving Medicare Benefits Schedule health checks/assessments, by age group. Data is presented for age groups 0-14 years, 15-54 years, and 55 years an over. Data is presented annually for the period 2006-07 to 2013-14. The figure shows that rates have increased over time, with an acceleration in the rate of change since 2009-10.
Source: AIHW analysis of Medicare Australia data
Figure 3.04-2 shows the rate (per 1,000 persons) receiving Medicare Benefits Schedule Health Assessments in 2013–14. Data is presented for Aboriginal and Torres Strait Islander peoples aged 55 years and over; and all Australians aged 75 years and for each jurisdiction and Australia as a whole.
Source: AIHW analysis of Medicare Australia data
Figure 3.04-3 shows participation rates for BreastScreen Australia among Aboriginal and Torres Strait Islander women and non-Indigenous Australian women aged 50 to 69 years in 2011-12. Data is presented separately for each jurisdiction, and Australia as a whole. For all jurisdictions, participation rates for Aboriginal and Torres Strait Islander women are lower than for other women.
Source: AIHW analysis of BreastScreen Australia data