Better Cardiac Care measures. for Aboriginal and Torres Strait Islander people

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1 Better Cardiac Care measures for Aboriginal and Torres Strait Islander people

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3 Better Cardiac Care measures for Aboriginal and Torres Strait Islander people First national report 215 Australian Institute of Health and Welfare Canberra Cat. no. IHW 156

4 The Australian Institute of Health and Welfare is a major national agency which provides reliable, regular and relevant information and statistics on Australia s health and welfare. The Institute s mission is authoritative information and statistics to promote better health and wellbeing. Australian Institute of Health and Welfare 215 This product, excluding the AIHW logo, Commonwealth Coat of Arms and any material owned by a third party or protected by a trademark, has been released under a Creative Commons BY 3. (CC-BY 3.) licence. Excluded material owned by third parties may include, for example, design and layout, images obtained under licence from third parties and signatures. We have made all reasonable efforts to identify and label material owned by third parties. You may distribute, remix and build upon this work. However, you must attribute the AIHW as the copyright holder of the work in compliance with our attribution policy available at < The full terms and conditions of this licence are available at < A complete list of the Institute s publications is available from the Institute s website < ISBN (PDF) ISBN (Print) Suggested citation Australian Institute of Health and Welfare 215. Better Cardiac Care measures for Aboriginal and Torres Strait Islander people: first national report 215. Cat. no. IHW 156. Canberra: AIHW. Australian Institute of Health and Welfare Board Chair Dr Mukesh C Haikerwal AO Acting Director Ms Kerry Flanagan PSM Any enquiries about copyright or comments on this publication should be directed to: Digital and Media Communications Unit Australian Institute of Health and Welfare GPO Box 57 Canberra ACT 261 Tel: (2) info@aihw.gov.au Published by the Australian Institute of Health and Welfare This publication is printed in accordance with ISO 141 (Environmental Management Systems) and ISO 91 (Quality Management Systems). The paper is sourced from sustainably managed certified forests. Please note that there is the potential for minor revisions of data in this report. Please check the online version at < for any amendments.

5 Contents Acknowledgments... v Abbreviations... vi Symbols... vii Summary... viii Key findings... viii 1 Introduction Better Cardiac Care project Reporting on the Better Cardiac Care measures Structure of this report Results Priority area 1: Early cardiovascular risk assessment and management Measure 1.1: Annual health assessments Measure 1.3: Primary care practitioner follow-up Priority area 2: Timely diagnosis of heart disease and heart failure Measure 2.1: Cardiac-related diagnosis Priority area 3: Guideline-based therapy for acute coronary syndrome Measure 3.1: STEMI patients treated by PCI Measure 3.3: Acute coronary syndrome patients who received diagnostic angiography or definitive revascularisation... 3 Measure 3.5: Mortality rates for people admitted to hospital with acute myocardial infarction Priority area 4: Optimisation of health status and provision of ongoing preventive care Measure 4.2: Medicare chronic disease management Priority area 5: Strengthen the diagnosis, notification and follow-up of rheumatic heart disease Measure 5.1: Incidence of acute rheumatic fever Measure 5.2: Recurrent acute rheumatic fever Measure 5.3: Benzathine penicillin doses... 5 Summary measures: hospitalisation and mortality Measure 6.1: Hospitalisations for cardiac conditions Measure 6.2: Cardiac mortality iii

6 3 Data development requirements Data development relevant to Better Cardiac Care currently underway Modifications required to existing collections... 6 Data linkage of existing collections... 6 Next steps Appendix A: Technical specifications Appendix B: Data sources AIHW National Hospital Morbidity Database AIHW National Mortality Database ABS population data ABS Australian Aboriginal and Torres Strait Islander Health Survey MBS database Rheumatic Heart Disease registers Appendix C: Things to consider when interpreting the data Appendix D: List of persons consulted Glossary References List of tables List of figures iv

7 Acknowledgments This report was prepared by Helen Johnstone, Michelle Harvey and Indrani Pieris-Caldwell of the Indigenous Community and Health Services Reporting Unit at the Australian Institute of Health and Welfare (AIHW). It is based on the measures developed by the Better Cardiac Care for Aboriginal and Torres Strait Islander People Forum, an initiative of the Australian Health Ministers Advisory Council. The Department of Health funded the preparation of the report. The authors gratefully acknowledge the advice and guidance offered by Fadwa Al-Yaman during the production of this report. The AIHW would like to thank the data providers, including the Australian and state and territory health departments; the Northern Territory, Queensland and Western Australian Rheumatic Heart Disease registers; and the Australian Bureau of Statistics. State and territory health departments provided valuable comments on the draft as did members of the National Aboriginal and Torres Strait Islander Health Standing Committee (NATSIHSC) (see Appendix D for a list of NATSIHSC members and jurisdiction contacts for the Better Cardiac Care for Aboriginal and Torres Strait Islander People Forum). v

8 Abbreviations AATSIHS ABS ACS ACT AHMAC AIHW AMI ARF CABG ESSENCE GPMP ICD-1 ICD-1-AM MBS NATSIHSC NHMD nkpi NMD NSTEACS NSW PCI Qld RHD RHDR SA STEMI Australian Aboriginal and Torres Strait Islander Health Survey Australian Bureau of Statistics acute coronary syndrome Australian Capital Territory Australian Health Ministers Advisory Council Australian Institute of Health and Welfare acute myocardial infarction acute rheumatic fever coronary artery bypass graft Essential Service Standards for Equitable National Cardiovascular Care for Aboriginal and Torres Strait Islander people General Practitioner Management Plan International statistical classification of diseases and related health problems, 1th revision International statistical classification of diseases and related health problems, 1th revision, Australian modification Medicare Benefits Schedule National Aboriginal and Torres Strait Islander Health Standing Committee National Hospital Morbidity Database national key performance indicator National Mortality Database non-st elevation acute coronary syndrome New South Wales percutaneous coronary intervention Queensland rheumatic heart disease Rheumatic Heart Disease Register South Australia ST-elevation myocardial infarction vi

9 Tas Vic WA Tasmania Victoria Western Australia Symbols > greater than greater than or equal to < less than n.a. not available vii

10 Summary Aboriginal and Torres Strait Islander people have higher rates of cardiac conditions, and lower access to health services aimed at preventing and treating these conditions, than non- Indigenous Australians. The Better Cardiac Care for Aboriginal and Torres Strait Islander People a project supported by the Australian Health Ministers Advisory Council aims to reduce mortality and morbidity from cardiac conditions by increasing access to services, better managing risk factors and treatment, and by improving the coordination of care. This is the first national report on the 21 Better Cardiac Care measures that were developed to monitor the success of the project. It includes information for 4 full measures and 8 part measures for which national data were available, and outlines the data development work that is required to report on all 21 measures. Key findings The indicators provide examples of higher rates of mortality and morbidity from cardiac conditions for Aboriginal and Torres Strait Islander people, and lower rates of in-hospital treatment services, than for other Australians. The age-standardised mortality rate for cardiac conditions for Indigenous Australians in was 212 per 1, compared with 133 per 1, for non-indigenous Australians. The age-standardised proportion of people who presented to a hospital with a severe heart attack (that is, a STEMI), and had a procedure to open a blocked or narrowed artery (that is, a PCI) in was 46% for Indigenous Australians and 7% for non- Indigenous Australians. Access to cardiac prevention and treatment services for Indigenous Australians varied by state and by region. For example, the proportion of Indigenous people who presented to a hospital with a STEMI and had a PCI in ranged from 21% in the Northern Territory to 62% in Western Australia, and from 29% in Very remote areas to 64% in Major cities. Over time, mortality from cardiac conditions for Indigenous Australians decreased significantly and access to cardiac care improved. The age-standardised mortality rate for cardiac conditions for Indigenous Australians decreased by 41% between 1998 and 212, from 347 to 215 per 1,. The age-standardised proportion of Indigenous people who presented to a hospital with a STEMI and had a PCI increased from 25% in 24 5 to 46% in There are 17 Better Cardiac Care measures that require further data development to enable full reporting. The required improvements include linkage between data sets for information on post-hospital care and mortality, more details on hospital treatment, better coverage of Rheumatic Heart Disease registers, and new data collections on services provided by general practitioners and cardiologists. viii

11 Table S1: Summary of Better Cardiac Care results for Indigenous Australians Age-standardised rate Indigenous Measure Crude rate Indigenous Indigenous Non-Indigenous Change over time NSW Vic Qld WA SA Tas ACT NT 1.1 Annual health assessments, (%) Primary care practitioner follow-up (i) Blood pressure check, (%) 87 n.a. n.a. n.a (ii) Discussed quitting smoking, (%) 4 n.a. n.a. n.a Cardiac-related diagnostic items, (%) (a) 3 (a) (a) (a) ST-elevation myocardial infarction patients treated with percutaneous coronary intervention, (%) (a) 62 (a) (a) (a) Acute coronary syndrome patients who received diagnostic angiography or definitive revascularisation, (%) (a) 44 (a) (a) (a) People admitted to hospital with acute myocardial infarction who died in hospital, (%) n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 4.2 (i) People with cardiac disease with Team Care Arrangements, (%) (a) 16 (a) (ii) People with cardiac disease with a GP Management Plan, (%) (a) 18 (a) (iii) People with cardiac disease with Allied Health Services, (%) (a) 2 (a) (a) (a) (a) (a) (a) (a) 5.1 New and recurrent cases of acute rheumatic fever, (no. per 1,) X n.a. n.a n.a. n.a. n.a Recurrent acute rheumatic fever, (%) n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a Benzathine penicillin doses, 213 (% receiving >8% of doses) n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a Hospitalisations for cardiac conditions, (no. per 1,) (a) 15 (a) (a) (a) (i) Deaths from cardiac conditions, (no. per 1,) n.a n.a. n.a. 132 (ii) In-hospital deaths for patients admitted with cardiac conditions, (no. per 1,) n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. (a) Data for New South Wales are combined with data for the Australian Capital Territory, and data for Victoria are combined with data for Tasmania. = improved over time for Indigenous Australians; X = worsened over time for Indigenous Australians; = no change over time for Indigenous Australians. Notes 1. Data by state and territory for measures 2.1, 4.2 and 6.1 are age standardised, whereas state and territory data for the remaining measures are crude rates. 2. Data for the Indigenous/non-Indigenous comparison for measure 5.1 are not age standardised. 3. Change over time is measured over the following years: 24 5 to for measures 1.1 and 1.3; 24 5 and for measures 3.1, 3.3 and 6.1; 24 7 and for measure 3.5; 25 6 and for measure 4.2; 21 and 213 for measures 5.1 and 5.2; 1998 and 212 for measure 6.2. Sources: ABS Aboriginal and Torres Strait Islander Health Survey; AIHW analysis of Medical Benefits Schedule data; AIHW analysis of NT Rheumatic Heart Disease Program data; AIHW National Hospital Morbidity Database; AIHW National Mortality Database. ix

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13 1 Introduction Heart and circulatory conditions contribute most to the disease burden of Aboriginal and Torres Strait Islander people and are major contributors to the gap in life expectancy between Indigenous and other Australians (Vos et al. 29). Research evidence shows that, as well as having higher rates of cardiac conditions, Aboriginal and Torres Strait Islander people have poorer access to health services aimed at preventing and treating cardiac conditions (Clark et al. 212; Mathur et al. 26; Walters et al. 28). The Better Cardiac Care for Aboriginal and Torres Strait Islander People project was an initiative of the Australian Health Ministers Advisory Council (AHMAC). It aims to reduce mortality and morbidity from cardiac conditions among Aboriginal and Torres Strait Islander people by increasing access to services, better managing risk factors and treatment and by improving the coordination of care. A related project, the Essential Service Standards for Equitable National Cardiovascular Care for Aboriginal and Torres Strait Islander people (ESSENCE), has produced standards on the essential services and care for Aboriginal and Torres Strait Islander people with cardiovascular disease. These standards were developed by a national steering committee of experts in Aboriginal and Torres Strait Islander cardiovascular care. Measures for these standards (some of which overlap the Better Cardiac Care measures) are being developed by project staff at the Wardliparingga Unit at the South Australian Health and Medical Research Institute. The aim of the ESSENCE measures is to assess performance against the ESSENCE standards and associated improvements in cardiovascular health outcomes. It is expected that implementing these ESSENCE measures will drive change in practice across the continuum of care. Better Cardiac Care project The Better Cardiac Care for Aboriginal and Torres Strait Islander People Forum, a joint initiative of Australian, state and territory governments, was held in March 214 and involved representatives from both the Department of Health and state and territory health departments. The forum s role was to identify national priorities for action and high-impact initiatives for implementation to improve cardiac outcomes for Aboriginal and Torres Strait Islander people. The post-forum report identified five priority areas for intervention and associated actions that health services should undertake to improve cardiac care for Aboriginal and Torres Strait Islander people (Better Cardiac Care Forum 214). These five priority areas and actions recommended by the forum are outlined in Table 1.1. Better Cardiac Care measures for Aboriginal and Torres Strait Islander people

14 Table 1.1: Priority areas and actions recommended by the Better Cardiac Care Forum (a) Priority area and action Responsibility Priority area 1: Primary preventive care Early cardiovascular risk assessment and management 1.1 Provide regular risk assessment and management of all identified risk factors Australian government 1.2 Implement electronic quality improvement systems, along with quality assurance processes, in all primary health services 1.3 Support strategies to reduce smoking rates in Aboriginal and Torres Strait Islander people All governments All governments Priority area 2: Clinical suspicion of disease Timely diagnosis of heart disease and heart failure 2.1 Develop or enhance regional cardiac service delivery plans, to improve the coordination of access to specialist physicians, and integrate the delivery of cardiac diagnostic services for Aboriginal and Torres Strait Islander people All governments Priority area 3: Acute episode Guideline-based therapy for acute coronary syndrome 3.1 Promote education in relation to the warning signs of heart disease and acute coronary syndrome for Aboriginal and Torres Strait Islander people 3.2 Establish coordinated regional systems of care from point of first clinical contact to definitive care for patients presenting with acute coronary syndrome 3.3 Implement nationally consistent systems to monitor timing and rates of reperfusion and revascularisation in Aboriginal and Torres Strait Islander people with acute coronary syndrome 3.4 Develop a standard national clinical audit tool for acute coronary syndrome, which includes evaluation of pre, in- and post-hospital care State/territory governments State/territory governments State/territory governments State/territory governments Priority area 4: Ongoing care Optimisation of health status and ongoing preventive care 4.1 Ensure all patients admitted with cardiac conditions receive culturally appropriate cardiac education and commence cardiac rehabilitation while in hospital 4.2 Ensure all patients admitted with cardiac conditions are automatically referred to the most appropriate primary health-care service able to provide or coordinate multidisciplinary secondary prevention services 4.3 Deliver ongoing community-based, multidisciplinary chronic disease follow-up and specialist physician review as required for all Aboriginal and Torres Strait Islander people with cardiac disease 4.4 Expand the delivery of innovative cardiac rehabilitation and secondary prevention services that are appropriate for Aboriginal and Torres Strait Islander people State/territory governments State/territory governments All governments All governments Priority area 5: Rheumatic heart disease Strengthen the diagnosis, notification and follow-up of rheumatic heart disease 5.1 Make rheumatic heart disease and acute rheumatic fever notifiable conditions in all jurisdictions 5.2 Consider the creation of a single national rheumatic heart disease/acute rheumatic fever register 5.2 Explore options to link data from the rheumatic heart disease registry to the Patient Controlled Electronic Health Record or equivalent 5.4 Increase clinicians awareness and capacity to diagnose and manage acute rheumatic fever and rheumatic heart disease, in line with the current Australian guidelines for the prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease, particularly in high-risk or endemic communities 5.5 Establish dedicated centres for Aboriginal and Torres Strait Islander heart surgery and rheumatic heart surgery where appropriate, to enable centralisation of expertise and the development of culturally appropriate specialist support services All governments All governments All governments All governments All governments (a) The AHMAC agreed to these priority areas and actions in June Better Cardiac Care measures for Aboriginal and Torres Strait Islander people 215

15 The forum also developed a set of 21 Better Cardiac Care measures that were designed to ensure implementation and ongoing monitoring of these actions (Table 1.2). The Australian Institute of Health and Welfare (AIHW) was funded to prepare this first report on these 21 measures. Reporting on the Better Cardiac Care measures The report includes data for 4 full measures and 8 part measures for which national data are currently available. Measures were reported in full where data were available, or partially where there were data available that closely approximated the original agreed measure. The report also outlines the data development work that is likely to be required to fully report on all 21 measures. The measures, their reporting status, main data sources and estimated data development time frames are summarised in Table 1.2. Table 1.2: Summary of Better Cardiac Care measures: reporting status, data sources and data development time frame Measure Data source Time frame Priority area 1: Early cardiovascular risk assessment and management 1.1 Number/proportion of people who received an MBS Health Assessment within the previous 12 months* MBS 1.2 Number/per 1, people 2 years of age without cardiac disease with cardiovascular risk assessment and stratification in the last 2 years Short term 1.3 Proportion of people with risk factors for cardiac disease with evidence of primary care practitioner follow-up AATSIHS Long term Priority area 2: Timely diagnosis of heart disease and heart failure 2.1 Number/proportion of clients with Medicare-listed diagnostic items claimed in the previous 12 months* MBS 2.2 Number/proportion of people who received diagnostic services within 3 days of referral Long term 2.3 Proportion of people with suspected/confirmed cardiac disease reviewed by a cardiologist within the previous 12 months Long term Priority area 3: Guideline-based therapy for acute coronary syndrome 3.1 Proportion of people with STEMI: (a) treated by primary PCI; (b) treated with fibrinolysis* NHMD Med term 3.2 Proportion of people with STEMI who are not provided any reperfusion therapy NHMD Med term 3.3 Proportion of people with ACS who received diagnostic angiography or definitive revascularisation procedure within the index admission/within 3 days* NHMD Med term 3.4 Proportion of people diagnosed with ACS discharged from hospital on appropriate secondary prevention medicines Med term 3.5 In-hospital, 3-day and 12-month mortality rates for people admitted to hospital with a primary diagnosis of acute myocardial infarction* NHMD Short term Priority area 4: Optimisation of health status and provision of ongoing preventative care 4.1 Number/proportion of patients reviewed by a primary health-care professional within 1 week of discharge from hospital Short term 4.2 Number/proportion of patients with cardiac disease who received follow-up Medicare items within 3 months of hospital discharge MBS Short term 4.3 Number/proportion of patients with cardiac disease reviewed by a specialist physician within 3/12 months of discharge Short term 4.4 Number/proportion of patients with coronary heart disease discharged on prevention medications and remaining on it at 3, 6 and 12 months Med term (continued) Better Cardiac Care measures for Aboriginal and Torres Strait Islander people

16 Table 1.2 (continued): Summary of Better Cardiac Care measures: reporting status, data sources and data development time frame Measure Data source Time frame Priority area 5: Strengthen the diagnosis, notification and follow-up of rheumatic heart disease 5.1 Annual incidence of all acute rheumatic fever episodes RHDR Med term 5.2 Proportion of all acute rheumatic fever episodes that are recurrent RHDR Med term 5.3 Median proportion of scheduled benzathine penicillin doses given to patients with confirmed acute rheumatic fever or rheumatic heart disease in the preceding 12 months RHDR Med term 5.4 Proportion of people with moderate or severe rheumatic heart disease who received an echocardiogram in the previous 12 months Long term Summary measures: Hospitalisation and mortality 6.1 Age-standardised rates of hospitalisation for a cardiac condition NHMD 6.2 Age-standardised rates of cardiac mortality NMD Green shading indicates national data are available to report on the full measure Blue shading indicates that national data are available to report on part of the measures Orange shading indicates that no data are available for national reporting * Indicates those measures for which AHMAC requested annual reporting (1.1, 2.1, 3.1, 3.3, and 3.5). AATSIHS = Aboriginal and Torres Strait Islander Health Survey; ACS = acute coronary syndrome; MBS = Medicare Benefit Schedule; NHMD = National Hospital Morbidity Database; NMD = National Mortality Database; PCI = percutaneous coronary intervention; RHDRs = Rheumatic Heart Disease registers; STEMI = ST-elevation myocardial infarction. Structure of this report Chapter 2 of this report includes the results for 12 measures for which national data were available, structured around the 5 priority areas. Each measure is reported on separately, including a description of the full measure and why it is important. Where available, the relevant data are presented at the national, state and regional levels; by age and sex; by Indigenous status; and by trends over time. Data presented at the national level for Indigenous Australians are crude rates, whereas data presented by Indigenous status are age standardised. A list of things to consider in interpreting the data for each measure is included to assist users understand any data issues and limitations. In some cases, the original indicators were modified to enable reporting. Appendix A outlines the original indicators and how these were modified. It also provides the technical specifications for all the measures reported. Information on the data sources used in this report is provided at Appendix B. Appendix C includes more information about the data issues and limitations listed under the things to consider heading for each indicator. Chapter 3 of the report provides consolidated information on the data development work required to fully report on all 21 Better Cardiac Care measures. 14 Better Cardiac Care measures for Aboriginal and Torres Strait Islander people 215

17 2 Results Priority area 1: Early cardiovascular risk assessment and management The first priority area of the Better Cardiac Care project is early cardiovascular risk assessment and management. It is based on the premise that all Aboriginal and Torres Strait Islander people without known cardiac disease should receive a cardiovascular risk assessment each year, appropriate management and follow-up of identified risk factors, and lifestyle modification advice appropriate to their absolute cardiovascular risk level as per current guidelines (NACCHO/RACGP 212). Primary prevention in the form of early and consistent risk factor identification and management will improve not only long-term outcomes for Aboriginal and Torres Strait Islander people (and reduce the population burden of chronic cardiac disease) but also the appropriate delivery of care by the health-care system. Three measures were agreed in this priority area: measure 1.1, on health assessments, is a national measure; measure 1.2, on cardiovascular disease risk assessment, and measure 1.3, on early management strategies, are service level measures. Data were available to fully report on measure 1.1 and to partly report on measure 1.3. Measure agreed at Better Cardiac Care Forum 1.1 Number and proportion of regular Aboriginal and Torres Strait Islander clients of health services who received an MBS Health Assessment within the previous 12 months 1.3 Proportion of those Aboriginal and Torres Strait Islander people identified as having elevated risk of cardiac disease in the previous 2 years, with documented evidence of primary care practitioner follow-up, including the proportion commenced on anti-hypertensive and lipid-lowering therapy and proportion of smokers offered an evidence-based smoking cessation intervention Measure reported Data were reported for Aboriginal and Torres Strait Islanders aged 25 and over with an MBS Health Assessment. Persons aged under 25 were excluded due to the small numbers. No data on primary care practitioner follow-up were available so AATSIHS data were provided as a proxy. The measure reported was: (i) proportion of Indigenous people aged 18 and over living in non-remote areas without a current and long-term circulatory condition who were at high risk of cardiac disease who had their blood pressure checked in the last 2 years (ii) proportion of Indigenous people aged 18 and over without a current and long-term circulatory condition who were at high risk of cardiac disease and were current smokers who saw a doctor/health professional or specialist in the previous 12 months and discussed quitting smoking. Better Cardiac Care measures for Aboriginal and Torres Strait Islander people

18 Measure 1.1: Annual health assessments Proportion of people aged 25 and over who received a Medicare Benefits Schedule (MBS) Health Assessment within the previous 12 months. Why it is important Health assessments are intended to increase preventative health opportunities, detect chronic disease risk factors, better manage existing chronic disease and reduce inequities in access to primary care for Aboriginal and Torres Strait Islander people. Early detection and management of the risk factors for cardiac disease (smoking, physical inactivity, poor diet, high blood pressure) have the potential to reduce the incidence of cardiac disease and to lessen its severity. All Aboriginal and Torres Strait Islander people are eligible for an annual Indigenous-specific health assessment, listed as item 715 on the MBS. Both Indigenous and non-indigenous people may also have a general MBS Health Assessment. Results Nationally: Just over one-quarter (26% or 81,86) of Indigenous people aged 25 and over had an MBS Health Assessment in (crude rate). Indigenous status: After adjusting for the age differences in the populations, Indigenous Australians aged 25 and over were 7 times as likely to have had an MBS Health Assessment as non-indigenous Australians (27% compared with 4%) (Figure 1.1a). This higher figure reflects the creation of a specific MBS item for Indigenous people to address the health issue disadvantages they face. Time trend: In the 1 years from 24 5 to , the age-standardised proportion of Indigenous people aged 25 and over who had an MBS Health Assessment increased from 4% to 27% (Figure 1.1b). Over the same period, the proportion for non-indigenous people increased from 2% to 4%. For Indigenous people, there was a particularly large increase from 28 9 (Figure 1.1b) which coincided with the introduction of the Australian Government s Indigenous Chronic Disease Package. Age and sex The proportion of Indigenous Australians who had an MBS Health Assessment increased with age, from 19% for those aged to 37% for those aged 65 and over. For each age group, Indigenous females were more likely than Indigenous males to have had an MBS Health Assessment (Figure 1.1c). Rates were higher for Indigenous than for non-indigenous males and females in all age groups. Jurisdiction: The proportion of Indigenous people aged 25 and over who had an MBS Health Assessment was highest in Queensland and the Northern Territory (both 3%), followed by Western Australia (27%). The proportion was lowest in Tasmania (1%) (Figure 1.1d). Region: Uptake of MBS Health Assessments was highest in Inner and outer regional areas (29%) and lowest in Major cities (19%) (Figure 1.1e). Things to consider The MBS data reflect billing practices and not necessarily services provided. The general health assessments data were adjusted for Indigenous under-identification. General health assessments for non-indigenous Australians are not directly comparable with Indigenous-specific health assessments. 16 Better Cardiac Care measures for Aboriginal and Torres Strait Islander people 215

19 Indigenous Non-Indigenous Indigenous Source: AIHW analysis of MBS data. Indigenous status Non-Indigenous Figure 1.1a: Age-standardised proportion of people who had an MBS Health Assessment, by Indigenous status, Year Source: AIHW analysis of MBS data. Figure 1.1b: Trends in age-standardised proportion of people who had an MBS Health Assessment, by Indigenous status Indigenous Non-Indigenous 5 4 Male Female 5 4 Male Female Age group (years) Age group (years) Source: AIHW analysis of MBS data. Figure 1.1c: Proportion of people who had an MBS Health Assessment, by Indigenous status, age and sex, NSW Vic Qld WA SA Tas ACT NT Jurisdiction Major cities Inner and outer regional Region Remote and very remote Source: AIHW analysis of MBS data. Figure 1.1d: Proportion of Indigenous people who had an MBS Health Assessment, by state and territory, Source: AIHW analysis of MBS data. Figure 1.1e: Proportion of Indigenous people who had an MBS Health Assessment, by region, Better Cardiac Care measures for Aboriginal and Torres Strait Islander people

20 Measure 1.3: Primary care practitioner follow-up (i) Proportion of Indigenous people aged 18 and over living in non-remote areas without a current and long-term circulatory condition who were at high risk of cardiac disease who had their blood pressure checked in the previous 2 years. (ii) Proportion of Indigenous people aged 18 and over without a current and long-term circulatory condition who were at high risk of cardiac disease and were current smokers who saw a doctor/health professional or specialist in the previous 12 months and discussed quitting smoking. Why it is important Active follow-up and management of risk factors for cardiac disease through regular monitoring, supporting smoking cessation and providing access to essential medicines are essential for maintaining health and reducing risk. Box 1: At high risk of cardiac disease Indigenous people were classified as being at high risk of cardiac disease based on having one or more of the following: self-reported type 2 diabetes, self-reported hypertensive disease or measured high blood pressure (systolic or diastolic blood pressure >14/9 mmhg), self-reported high cholesterol, or current smoker (includes those who smoked daily, at least weekly, or less than weekly). Results 1.3 (i) Blood pressure check Nationally: In , in non-remote areas, 87% of Indigenous people without a circulatory condition who were at high risk of cardiac disease had their blood pressure checked in the last 2 years. Age and sex: The proportion of Indigenous Australians at high risk of cardiac disease who had their blood pressure checked in the last 2 years increased with age from 79% for those aged to 98% for those aged 55 and over (Figure 1.3a). Jurisdiction: The proportion of Indigenous people at high risk of cardiac disease who had their blood pressure checked in the last 2 years was highest in the Northern Territory (91%), followed by South Australia (89%) (Figure 1.3b). Region: The proportion of Indigenous people at high risk of cardiac disease who had their blood pressure checked in the last 2 years was highest in Inner regional areas (9%) (Figure 1.3c). 18 Better Cardiac Care measures for Aboriginal and Torres Strait Islander people 215

21 Male Female Age group (years) Source: ABS AATSIHS. Figure 1.3a: Proportion of Indigenous people at high risk of cardiac disease who had their blood pressure checked in the last 2 years, by age and sex, NSW Vic Qld WA SA Tas ACT NT 2 Major cities Inner regional Outer regional Jurisdiction Region Source: ABS AATSIHS. Figure 1.3b: Proportion of Indigenous people at high risk of cardiac disease who had their blood pressure checked in the last 2 years, by state and territory, Source: ABS AATSIHS. Figure 1.3c: Proportion of Indigenous people at high risk of cardiac disease who had their blood pressure checked in the last 2 years, by region, Better Cardiac Care measures for Aboriginal and Torres Strait Islander people

22 1.3 (ii) Discussed quitting smoking Nationally: In , 4% of Indigenous people at high risk of cardiac disease who were current smokers and saw a doctor/health professional or specialist in the previous 12 months and discussed quitting smoking. Age and sex: The proportion of Indigenous Australians at high risk of cardiac disease who discussed quitting smoking with their doctor/health professional or specialist in the previous 12 months increased with age from 33% for those aged to 51% for those aged (Figure 1.3d). Jurisdiction: The Northern Territory had the lowest proportion of Indigenous people at high risk of cardiac disease who discussed quitting smoking with their doctor/health professional or specialist in the previous 12 months (28%) (Figure 1.3e). Region: The proportion of Indigenous people at high risk of cardiac disease who discussed quitting smoking with their doctor/health professional or specialist in the previous 12 months decreased with remoteness, from 5% in Major cities to 27% in Very remote areas (Figure 1.3f). Things to consider The data provided are proxy measures for primary care practitioner follow-up. 2 Better Cardiac Care measures for Aboriginal and Torres Strait Islander people 215

23 Male Female Age group (years) Source: ABS AATSIHS. Figure 1.3d: Proportion of Indigenous people at high risk of cardiac disease who discussed quitting smoking, by age and sex, NSW Vic Qld WA SA Tas ACT NT Jurisdiction 4 2 Major cities Inner regional Outer regional Region Remote Very remote Source: ABS AATSIHS. Figure 1.3e: Proportion of Indigenous people at high risk of cardiac disease who discussed quitting smoking, by state and territory, Source: ABS AATSIHS. Figure 1.3f: Proportion of Indigenous people at high risk of cardiac disease who discussed quitting smoking, by region, Better Cardiac Care measures for Aboriginal and Torres Strait Islander people

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25 Priority area 2: Timely diagnosis of heart disease and heart failure The second priority area of the Better Cardiac Care project is timely diagnosis of heart disease and heart failure. It is based on the premise that all Aboriginal and Torres Strait Islander people suspected to have heart disease or heart failure should receive the appropriate initial diagnostic service (for example, stress testing or coronary angiography for ischaemic heart disease, echocardiography for heart failure and rheumatic heart disease, or other investigations as clinically indicated) as close to the patient s home as possible, and within acceptable time frames according to the level of risk and the patient s condition. Of the 3 measures recommended for this priority area, only measure 2.1 on Medicare-listed diagnostic items claimed in the previous 12 months is reported here. Measure agreed at Better Cardiac Care Forum 2.1 Number and proportion of regular Aboriginal and Torres Strait Islander clients of health services who had relevant Medicare-listed diagnostic items claimed in the previous 12 months, by region, compared with other Australians Measure reported Same as agreed measure. Better Cardiac Care measures for Aboriginal and Torres Strait Islander people

26 Measure 2.1: Cardiac-related diagnosis Number and proportion of Aboriginal and Torres Strait Islander people who had relevant Medicare diagnostic items claimed in the previous 12 months, in comparison with other Australians. Why it is important The level of access to diagnostic cardiac services in Australia varies considerably across regions and settings. This means that there is variation in the extent to which health-care professionals can provide appropriate treatment and follow-up. Data indicate that Aboriginal and Torres Strait Islander people have lower rates of angiography and other diagnostic services than other Australians, and that their access to these services is highly variable across Australia (AIHW 213a). Results Nationally: In , around 15,636 or 2% of Indigenous people had cardiac-related Medicare-listed diagnostic items claimed. There were 3 groups of these procedures: 6,255 or 1% of Indigenous people had electrocardiogram (ECG) monitoring, 12,822 or 2% had echocardiography and 933 or.1% had cardiac catheterisation (with or without PCI). Indigenous status: The age-standardised proportions were slightly lower for Indigenous Australians than for non-indigenous Australians, with a rate ratio of.9 for each of the 3 procedure groups: ECG monitoring (1.5% compared with 1.7%, respectively), echocardiography (2.9% compared with 3.2%) and cardiac catheterisation (.26% compared with.29%) (Figure 2.1a). Time trend: Between 24 5 and , the age-standardised proportion of Indigenous people who had Medicare-listed diagnostic items claimed increased from 1% to 4%. Over the same period, the proportion for non-indigenous people remained fairly stable around 3 4% (Figure 2.1b). Age and sex: The proportion of Indigenous Australians who had Medicare-listed cardiac-related diagnostic items claimed increased with age from.5% for those aged under 25 to 11% for those aged 65 and over (Figure 2.1c). Proportions were similar for Indigenous males and females. Jurisdiction: The age-standardised proportion of Indigenous people who had Medicare-listed diagnostic items claimed was similar in all jurisdictions for both Indigenous and non-indigenous Australians (Figure 2.1d). Region: For both Indigenous and non-indigenous Australians, the age-standardised proportion who had claimed Medicare-listed diagnostic items was lower in Remote and very remote areas compared with other areas (Figure 2.1e). Things to consider The MBS data reflect billing practices and not necessarily services provided. People may access these interventions (especially PCI) in public hospitals that are not captured in these data. The MBS data were adjusted for Indigenous under-identification. 24 Better Cardiac Care measures for Aboriginal and Torres Strait Islander people 215

27 6 4 Indigenous Non-Indigenous 8 6 Indigenous Non-Indigenous ECG monitoring Echocardiography Cardiac catheterisation +/ PCI Type of procedure Year Source: AIHW analysis of MBS data. Figure 2.1a: Age-standardised proportion of people who had Medicare-listed diagnostic items claimed, by Indigenous status, Source: AIHW analysis of MBS data. Figure 2.1b: Trends in age-standardised proportion of people who had Medicare-listed diagnostic items claimed, by Indigenous status Indigenous Non-Indigenous 2 Male Female 2 Male Female < < Age group (years) Age group (years) Source: AIHW analysis of MBS data. Figure 2.1c: Proportion of people who had Medicare-listed diagnostic items claimed, by Indigenous status, age and sex, Indigenous Non-Indigenous 8 Indigenous Non-Indigenous NSW/ ACT Vic/ Tas Qld WA SA NT Jurisdiction Major cities Inner and outer regional Region Remote and very remote Source: AIHW analysis of MBS data. Figure 2.1d: Age-standardised proportion of people who had Medicare-listed diagnostic items claimed, by Indigenous status, state and territory, Source: AIHW analysis of MBS data. Figure 2.1e: Age-standardised proportion of people who had Medicare-listed diagnostic items claimed, by Indigenous status and region, Better Cardiac Care measures for Aboriginal and Torres Strait Islander people

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29 Priority area 3: Guideline-based therapy for acute coronary syndrome The third priority area of the Better Cardiac Care project is guideline-based therapy for acute coronary syndrome. It is based on the premise that all Aboriginal and Torres Strait Islander people with ACS, a broad spectrum of acute clinical presentations ranging from unstable angina to acute myocardial infarction, receive guideline-based therapy. Data for 3 of the 5 measures identified in this priority area are reported. Measure agreed at Better Cardiac Care Forum 3.1 Proportion of people with STEMI who present within 12 hours of symptom onset and are eligible to receive emergency reperfusion therapy who are (a) treated by primary PCI, (b) treated with fibrinolysis 3.3 Proportion of people with ACS who received diagnostic angiography or a definitive revascularisation procedure (PCI or coronary artery bypass graft) within the index admission and 3 days of the index admission, by Aboriginal and Torres Strait Islander status 3.5 In-hospital, 3-day and 12-month mortality rates for people admitted to hospital with a primary diagnosis of acute myocardial infarction, by Aboriginal and Torres Strait Islander status Measure reported Data were not available to assess whether patients with a presented to emergency within 12 hours of symptom onset, nor on whether patients were eligible for reperfusion; hence, data on all people presenting with STEMI were reported. No data were available on whether patients were treated with fibrinolysis so this was not reported. People aged under 18 were excluded due to the small numbers. Data were reported on estimates of people with ACS who received diagnostic angiography or a definitive revascularisation procedure within their period of care (contiguous episodes of care separated only by a transfer within or between hospitals). This was estimated by excluding hospitalisations ending in transfer to another acute hospital, so that only the last hospitalisation was counted. Data were not available on whether these were received within 3 days of index admission. People aged under 18 were excluded due to the small numbers. Data were reported on in-hospital mortality for people aged 35 and over who were admitted to hospital with a principal diagnosis of acute myocardial infarction. No national data were available on 3-day and 12-month mortality following hospitalisation. Better Cardiac Care measures for Aboriginal and Torres Strait Islander people

30 Measure 3.1: STEMI patients treated by PCI Proportion of people aged 18 and over with a ST-elevation myocardial infarction (STEMI) who are treated by percutaneous coronary intervention (PCI) by Aboriginal and Torres Strait Islander status. Why it is important One of the most effective treatments for people presenting to hospitals with a STEMI (that is, a severe heart attack) is to unblock the affected artery by PCI (that is, a procedure such as stent that opens blocked or narrowed coronary arteries) (Pie rard 27). Across all states and territories, Aboriginal and Torres Strait Islander people have lower rates of access to reperfusion and revascularisation services, despite higher rates of hospitalisation and a higher proportion of Indigenous patients with ACS being high-risk (Gausia et al. 214). Results Nationally: Half (crude rate of 5%) of Indigenous people aged 18 and over with a STEMI were treated by PCI during the period Indigenous status: After adjusting for the age differences in the populations, 46% of Indigenous Australians with a STEMI were treated by PCI compared with 7% of non-indigenous Australians (rate ratio of.7) (Figure 3.1a). Time trend: Between 24 5 and , the age-standardised proportion of Indigenous people with a STEMI who were treated by PCI almost doubled, from 25% to 46%. Over the same period, the equivalent proportion for non-indigenous people increased from 52% to 71% (Figure 3.1b). Age and sex: Indigenous males and females with a STEMI in all age groups were less likely than their non-indigenous counterparts to be treated by PCI. For both Indigenous and non-indigenous Australians, the proportion of people with a STEMI who were treated by PCI was lowest for those aged 65 and over (Figure 3.1c). Jurisdiction: The proportion of Indigenous people aged 18 and over with a STEMI who were treated by PCI was lowest in the Northern Territory (21%) and highest in Western Australia (62%) (Figure 3.1d). Region: The proportion of Indigenous people with a STEMI who were treated by PCI decreased with remoteness, from 64% in Major cities to 29% in Very remote areas (Figure 3.1e). Things to consider The NHMD includes data on hospitalisations and not people, so the number of people is an estimate only. Hospitalisations ending in transfer to another acute hospital were excluded so that only the last hospitalisation episode is counted. Analysis by NSW Health using linked hospital data showed that this method appears to overestimate the percentage of STEMI patients who receive PCI. There is some under-identification of Indigenous people in the NHMD. Eligibility for reperfusion therapy cannot be determined from the NHMD. PCIs are also performed in a non-admitted patient setting but these are not captured in the NHMD. 28 Better Cardiac Care measures for Aboriginal and Torres Strait Islander people 215

31 Source: AIHW NHMD. Indigenous Indigenous status Non-Indigenous Figure 3.1a: Age-standardised proportion of people with a STEMI treated by PCI, by Indigenous status, Year Indigenous Non-Indigenous Note: Includes NSW, Vic, Qld, WA, SA and NT combined. Source: AIHW NHMD. Figure 3.1b: Trends in age-standardised proportion of people with a STEMI treated by PCI, by Indigenous status Indigenous Non-Indigenous 1 8 Male Female 1 8 Male Female Age group (years) Age group (years) Source: AIHW NHMD. Figure 3.1c: Proportion of people with a STEMI treated by PCI, by Indigenous status, age and sex, NSW/ ACT Vic/ Tas Qld WA SA NT Jurisdiction Note: Data were reported by patient s place of usual residence. Source: AIHW NHMD. Figure 3.1d: Proportion of Indigenous people with a STEMI treated by PCI, by state and territory, Major cities Inner regional Outer regional Region Remote Note: Includes NSW, Vic, Qld, WA, SA and NT combined. Source: AIHW NHMD. Very remote Figure 3.1e: Proportion of Indigenous people with a STEMI treated by PCI, by region, Better Cardiac Care measures for Aboriginal and Torres Strait Islander people