To the best of the authors knowledge, this study is the first to demonstrate the clinical profile and outcomes of adult Indigenous Australians in comparison to non-Indigenous patients presenting to ED with respiratory disorders, especially from the TEHS region of the NT of Australia. The majority (84%) of respiratory related ED presentations were self-initiated and triaged as urgent (70%), although less than half (42%) required admission to a ward. LRTIs (41%) and exacerbation of airway disease (31%) were the most common reasons for ED presentation, and one-third (35%) of patients reported a comorbidity of which three-quarters (79%) identified existing airway disease. Re-presentation within the study months was noted for 8% of patients, and overall mortality through the follow-up period was 22%.
We identified multiple key findings in relation to the differences/similarities in presentation to ED and outcomes by Indigenous status: 1) The overall proportion of Indigenous presentations (44%) exceeds the proportion of the population which is Indigenous in the NT overall (30%) and in particular in the local area (9% of the Greater Darwin area population identify as Indigenous Australian); 2) A significantly lower proportion of Indigenous ED presentations were self-initiated (80% vs. 88%), and a greater proportion were transferred from other health centres (11% vs. 1%); 3) The proportion of presentations which resulted in ward admission did not differ by Indigenous status (44% vs. 41%); 4) A higher proportion of Indigenous patients’ presentations were observed to be secondary to exacerbation of airway disease (34% vs. 28%); 5) A significantly higher proportion of Indigenous patients presented multiple times in the study months (16% vs. 2%); and 6) The proportion of patients who were deceased through follow-up did not significantly differ by Indigenous status (22% for both).
AIHW data have reported that the NT population has the highest rate of ED presentations in comparison to other states and territories (presentation rate per 1000 persons = 559), and even more so among the NT Indigenous Australian population (presentation rate per 1000 persons = 988) [15]. There is limited published data in the literature specific to respiratory related ED admission in the Australian population, especially from the NT. The current study highlights the significant discrepancy in ED presentation rates between Indigenous and non-Indigenous Australians. Hence, we believe our study is of relevance in addressing this gap in knowledge.
Due to the vast geography and varied climate conditions of the Top End region which could significantly alter population movements between seasons, the exact catchment population of RDH ED and thus the proportion of Indigenous Australians served is difficult to ascertain – however, as the Indigenous Australian proportion of the greater Darwin region is about 9%, and for the NT overall is 30% we can assume it is between these limits [16]. Therefore, that the proportion of Indigenous Australian ED respiratory presentations was 40% indicates a significantly higher presence of respiratory disease, issues with access to management of respiratory disease in the ambulatory settings, or both among this population. Moreover, Indigenous patients with respiratory conditions tend to display multiple complex and quite advanced disease [17,18,19,20,21]. Hence, it is inevitable that these patients will need hospital admissions during exacerbation of the underlying respiratory disease. Moreover, currently there are no evidence based culturally specific chronic respiratory disease management guidelines for Indigenous people.
The differences noted in self-presentation, and health clinics transfer rates between Indigenous and non-Indigenous patients reflect on the availability and accessibility of pathways to care. Though this study was not designed to assess these factors, Indigenous Australians, both in the NT and across Australia face many barriers in accessing health care [22]. There is a complex interplay between the accessibility and usage patterns of various health services in this population, whether it be remote health services, General Practices (GPs) or Aboriginal Community Controlled Health Organisations (ACCHOs) which are influenced by remoteness, residence location, transport, “out-of-pocket” costs, perceived cultural and safety of various services. Furthermore, many of these primary care options lack healthcare professionals specialised in dealing with complex respiratory conditions. These determinants may have ramifications for both Indigenous and non-Indigenous patients for the thresholds for ED presentations. This is indeed reflected in our study finding, although self-initiation was the most common mode of ED presentations in both groups, a much higher proportion of Indigenous patients were transferred from other health clinics. The timeliness and regular utilisation of local health services for chronic disease management or unavailability of expertise in remote communities may delay presentation to local health clinics until the clinical condition deteriorates to the point it is inevitable that patient is transferred to tertiary care centres. Furthermore, we noted the proportion of self-initiated presentations rose for subsequent re-presentations to ED among Indigenous patients. This is likely an indication of the higher proportion of Indigenous patients who live remotely – their first presentation requiring transfer to tertiary care centres, and after discharge and for subsequent presentations the patients is ‘in the area’ already and thus more able to self-represent to ED irrespective of the need for ED presentations or not. Remote patients may have no local destination to go to, or face a lack of easy access to transport to travel back to respective communities. Hence, they may be more likely to be admitted to the ward irrespective of if the admission is warranted or not. This issue highlights the importance of implementing aftercare pathways following ED presentation or discharge from hospital, that may reduce recurrent presentations.
We also observed that non-Indigenous patients’ presentation to ED was typically self-initiated with most related to upper respiratory tract issues. The majority were assessed not to require admission to the ward. It may be reasonable to speculate that ED visits are on occasion utilised as non-emergency ‘GP’ consultations service.
Previously published reports have observed that respiratory related symptoms, particularly secondary to COPD are one of the most common reasons for self-initiated presentation to ED [23]. Although both Indigenous and non-Indigenous patients had the same prevalence of existing airway disease recorded, previously reported data from our centre indicate the rates of existing airway disease are likely higher in the Indigenous population [17]. The discrepancy in the final diagnosis of exacerbation of airway disease and reported existing airway disease supports this notion as in this study. It is plausible that the EMR available do not have recorded all the patients’ comorbidities. Furthermore, whether the patient is able to inform medical practitioners of their own medical history upon presentation is questionable and likely culturally determined. Additionally, the high prevalence of smoking among Indigenous patients may be underlying the higher proportion of airway exacerbations, and indeed respiratory disease in general, with 84% in the current study reporting as a current smoker compared to 50% of non-Indigenous patients. Previous reports from this region have ascertained the high prevalence of current and former smoking among Indigenous people [17, 24]. Again, further efforts are needed to engage with the Indigenous Australian population in this region in order to reduce smoking rates and improve health and life outcomes.
Previous reports from our centre have shown significantly lower lung function parameters [25,26,27], even among apparently healthy Indigenous Australian individuals [28], and a higher prevalence of complex multiple respiratory comorbidities [17, 20, 21, 29,30,31]. The current study portrays one aspect of the outcomes related to these epidemiological underpinnings in the population with a high relative prevalence of ED presentations, and a significantly higher proportion of multiple presentations. Almost 20% of Indigenous patients who presented to ED with respiratory issues, re-presented to ED with respiratory issues within the calendar month. In comparison, only 1% of non-Indigenous patients did so. Given the limitation of looking purely at presentations within a calendar month it is quite plausible that this is an underestimation of the true rate, which may be better estimated via a 30-day ‘look forward’ and ‘look backward’ approach from each patients’ first presentation.
The results of our study may be an indication for policy makers and stakeholders to explore strategies in reducing ED presentations, especially with chronic airway disease in this region. Implementation of strategies involving patient education by specialist acute care nurse practitioners or facilitating access to trained community care nurses may be helpful. Furthermore, improving communications between hospital physicians and primary care physicians along with education on self-management strategies may aid in avoiding recurrent ED presentation and subsequent hospital admissions [32,33,34]. The outcomes of few such programmes in reducing hospital admissions have been demonstrated in previous studies [35, 36]. In the authors opinion, for this region, patient education, better coordination of aftercare by strengthening communication and improved access to primary health care and community health clinics will be the key in reducing subsequent ED presentations. Moreover, primary care physicians are more than often at the helm in the diagnosis and ongoing management of chronic respiratory conditions, in particular for patients living in the regional and remote communities [37]. Emerging evidence in the recent past suggests that understanding the different clinical manifestations and health care needs along with adopting to culturally and clinically relevant strategies in the diagnosis and management of chronic health conditions may lead to reducing the health gap amongst Indigenous population [38,39,40,41,42].
Previously published reports have noted admission rates for acute and chronic respiratory conditions are higher for people living in the Top End, NT climate zone compared to NT Central Australia [10]. In our study we did not observe any significant difference in the ED presentation between wet and dry seasons. However, a larger sample size, seasonal population movements and migration may in the future change the outcomes observed in this study.
Nevertheless, our study complements other previous published date [3,4,5, 10, 43, 44] in documenting the clinical characteristics and outcomes for ED presentations among Indigenous patients presenting with respiratory disorders in a regional centre of the NT. The results of this study may be an avenue to explore possibilities of implementing programs or for further prospective studies that could help in reducing morbidity, mortality, decreasing health gap [45], preventing avoidable ED presentation and hospitalisation as well as to reduce health care cost and utilisation among both Indigenous and non-Indigenous population.
Limitations
Patients involved in this study were only those who presented to RDH ED during the two study months. Although this is the primary option for tertiary care in the Top End region, other ED options exist which may be more accessible for patients residing further from this urban centre. As one moves out away from this urban centre, the demographics significantly change, with a greater proportion of Indigenous residents, lesser access to primary health care and significant differences in lifestyle factors – therefore ED presentations to more minor regional hospitals may differ from those reported in the current study. This is partially noted in the current study by the higher proportion of ED presentations via health centre transfer for Indigenous patients. Furthermore, EMRs utilised in data collection may be incomplete – systems used at the study hospital and those used at varied primary care facilities may differ. Thus, the hospital EMRs rely on investigations from the treating team during the acute presentation, and on the patients’ ability to recall their medical history. For Indigenous patients presenting into this healthcare setting recounting medical information is significantly harder, as linguistic and cultural discrepancy are mounted on top of the poor health condition in which the patient is presenting. As noted previously, the use of calendar months as the timeframe of observation results in different available follow-up times for patients, and though it gives some indication of re-presentations to ED, the true rates are not entirely comparable between patient groups, and potentially underestimate the true population incidence. We also entirely relied on the ICD codes for respiratory conditions provided by the RDH health information service for the study participants. It is possible some patients were not identified by specific sub-codes or due to misclassification of the ICD codes.
