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3.09 Discharge against medical advice

Why is it important?

Feedback on patient experiences, and community views of health care services and providers are important for shaping health services and policy. It is important to closely monitor consumer satisfaction, as it is believed to impact on health-related behaviours. For example, satisfied consumers may be more likely to cooperate with treatment, continue using services, maintain a relationship with a specific provider, and actively participate in their own treatment. Australia has a mixed history of systematically seeking feedback from the people whom health services are intended to benefit. A review of patient satisfaction and experience surveys found jurisdictions had adopted a range of methods for seeking feedback on patient experiences of hospitals and related services (Pearse 2005). Surveying the experiences of Aboriginal and Torres Strait Islander patients poses challenges that have been investigated by some jurisdictions.

The measure reported here is based on the extent to which Aboriginal and Torres Strait Islander people 'vote with their feet' (i.e. in discharging themselves from hospital against medical advice). The measure provides indirect evidence of the extent to which hospital services are responsive to Indigenous Australian patients' needs.

Findings

Between July 2011 and June 2013, there were 17,494 hospitalisations where Aboriginal and Torres Strait Islander people left hospital against medical advice or were discharged at their own risk. This represented around 5% of all hospitalisations for Aboriginal and Torres Strait Islander peoples compared with 0.5% for non-Indigenous Australians.

In the two years to June 2013, Indigenous Australians were discharged from hospital against medical advice at 8 times the rate of non-Indigenous Australians. Discharges from hospital against medical advice are most common for Aboriginal and Torres Strait Islander peoples aged 15–44 years. They are also more common for Indigenous people living in remote and very remote areas. The proportion of discharge against medical advice for Aboriginal and Torres Strait Islander peoples was highest in the NT (11% of all hospitalisations) and lowest in Tasmania, the ACT, and Victoria (around 1–2%).

Among Indigenous Australians who were discharged against medical advice, the most common principal diagnoses for hospitalisations were injury and poisoning (3,985 hospitalisations), followed by diseases of the respiratory system (2,154 hospitalisations). These two groups of diagnoses represented 35% of all hospitalisations for which Indigenous patients were discharged against medical advice. As a proportion of all hospitalisations of Indigenous Australians for each specific diagnoses group, discharge against medical advice was highest for injury and poisoning and external causes (7.4%), followed by endocrine, nutritional and metabolic disorders (including diabetes) (7.3%).

An analysis of the relative impact of a range of factors over the period July 2011 to June 2013 found that Indigenous status was the single most significant variable contributing to whether a patient would discharge themselves from hospital against medical advice, even after controlling for the other factors. Other factors that were significant in order of importance after Indigenous status were:

  • remoteness of hospital
  • sex
  • principal diagnosis
  • age
  • state of hospital
  • remoteness of usual residence
  • state/territory of usual residence.

Implications

The elevated levels of discharge against medical advice suggest that there are significant issues in the responsiveness of hospitals to the needs and perceptions of Aboriginal and Torres Strait Islander peoples (see measure 3.08). Mechanisms for obtaining feedback from Aboriginal and Torres Strait Islander patients will assist in responding and planning in relation to these rates of discharge against medical advice. The data suggest these issues are important for all age groups, although the issues are most evident for those aged 15–44 years.

There are several questions for health service researchers and health service managers to tackle in devising strategies to achieve more responsive and respectful service delivery. More needs to be known about the reasons for the high rates of discharge against medical advice across individual factors (such as personal circumstances, health and wellbeing, and cultural issues); community level factors (such as levels of trust or mistrust in system); and hospital level factors (such as staff attitudes, hospital policies and the environment). Historical issues, such as segregation and hospital being seen as a place to go to die are also factors to be investigated.

The experience of Aboriginal and Torres Strait Islander peoples of health services needs to be routinely evaluated but the mechanisms for doing this need to be better researched. Hospitals and health services that have implemented successful programs to reduce discharge against medical advice need to be studied and lessons disseminated.

Figure 3.09-1 Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and age group, July 2011–June 2013
hospitalisations ending in discharge against medical advice

Figure 3.09-1 shows the proportion of discharges from hospital which were against medical advice among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians between July 2011 and June 2013. Data is presented separately for the following age groups: 0-4 years, 5-14 years, 15-24 years, 25-34 years, 35-44 years, 45-54 years, 55-64 years, and 65 years and over. Refer to the findings section of this measure for a description of key results found in this figure.

Source: AIHW National Hospital Morbidity Database

Figure 3.09-2 Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and jurisdiction, July 2011–June 2013
hospitalisations ending in discharge against medical advice

Figure 3.09-2 shows the proportion of discharges from hospital which were against medical advice among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians between July 2011 and June 2013. Data is presented separately for each jurisdiction and Australia overall. Refer to the findings section of this measure for a description of key results found in this figure.

Note: proportions are age-standardised

Source: AIHW National Hospital Morbidity Database

Figure 3.09-3 Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and remoteness, July 2011–June 2013
hospitalisations ending in discharge against medical advice

Figure 3.09-3 shows the proportion of discharges from hospital which were against medical advice among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians between July 2011 and June 2013. Data is presented separately for major cities; inner regional areas; outer regional areas; remote areas; and very remote areas. Refer to the findings section of this measure for a description of key results found in this figure.

Note: proportions are age-standardised

Source: AIHW National Hospital Morbidity Database

Figure 3.09-4 Proportion of hospitalisations ending in discharge against medical advice, by Indigenous status and principal diagnosis, July 2011–June 2013
hospitalisations ending in discharge against medical advice

Figure 3.09-4 shows the proportion of discharges from hospital which were against medical advice among Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians between July 2011 and June 2013. Data is presented separately for the following principal diagnoses: injury and poisoning, symptoms and signs etc., endocrine etc., respiratory system, nervous system, digestive system, musculoskeletal system, circulatory system, genitourinary system, pregnancy and child birth, health status, other, and total. Refer to the findings section of this measure for a description of key results found in this figure.

Note: proportions are age-standardised

Source: AIHW National Hospital Morbidity Database