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A comparison of Indigenous and non-Indigenous Australians admitted to intensive care units reveals a “disturbing” difference in mortality outcomes.
A new study has found Aboriginal and Torres Strait Islander Australians are more likely to die within 12 months following an intensive care unit (ICU) admission than the general population.
Analysis recently published in The Medical Journal of Australia also shows the median age of Indigenous patients being admitted to ICUs is about 15 years younger than for non-Indigenous ICU patients.
In many countries, rates of ill health are higher for indigenous peoples, and life expectancy is lower.
Despite hospital and ICU admissions for Indigenous Australians being 1.3 times higher than for non-Indigenous people, the initial mortality outcomes are similar (here, here and here). However, once discharged from ICU, the mortality outcomes for Indigenous people become significantly poorer after adjusting for age and other baseline differences.
“While illness severity scores are similar this does not account for the younger age, and once this is considered, Indigenous patients have a higher level of disturbed physiology at ICU admission,” article author Dr Paul Secombe told InSight+.
How it was conducted
The study, headed by Adjunct Clinical Professor David Pilcher of Monash University, was based on retrospective data from Australian ICUs from 1 January 2017 to 31 December 2019.
Of the 330 712 admissions included in the study, 3.4% of those admissions were of Indigenous people, the largest proportion of which were located in the Northern Territory. The median age of Indigenous patients was lower, at 51.2 years compared with non-Indigenous patients at 66.5 years.
The proportion of elective ICU admissions was smaller for Indigenous patients than for non-Indigenous patients (21.6% v 41.1% respectively). A larger proportion of Indigenous patients experienced chronic renal failure, (8.2% v 2.9%), chronic liver dysfunction (2.8% v 1.5%), sepsis (11.6% v 7.2%), respiratory illness (16.6% v 14.7%), and trauma (7.6% v 4.6%).
Of the 1793 Indigenous patients who died within 12 months of ICU admission, the median time to death was 22 days. For non-Indigenous patients, 50 108 died with 12 months of admission, with a median time to death of 26 days. With the data unadjusted, the mortality risk was similar across both demographics. However, when the data were adjusted for age, admission diagnosis, illness severity, hospital type, jurisdiction, remoteness and socio-economic status, the mortality risk for Indigenous patients increased significantly.
Disturbing findings
One of the article’s authors describes the findings of higher adjusted mortality rates as “disturbing”.
“While we are unable to prove this empirically, our interpretation … may be that Indigenous patients have a delayed presentation that results in more disturbed physiology. This would be consistent with other research that has demonstrated poor engagement with health care systems as a result of both systemic racism and a lack of culturally appropriate care”.
Given the in-hospital mortality rates for Indigenous and non-Indigenous patients remained similar (here and here), the research findings suggest that the 12-month mortality rates are influenced by complex pre- and post-hospitalisation factors such as socio‐economic disadvantage, remoteness, and chronic disease trajectory.
“It is almost certainly the case that an ICU admission is a marker of a heightened disease trajectory,” Dr Secombe said.
“We need to close the 15-year gap in physiology. We also need to acknowledge that heightened surveillance and follow-up of patients who have experienced an admission for critical illness is important, and especially so for Indigenous patients.
Given the lack of national data on longer term outcomes for critically ill patients (here and here), the article authors urge further investigation into the pre-and post-ICU admission factors that could be contributing to these findings.
“Prevention of the development of chronic disease and improved management of chronic disease when it has developed must be the cornerstone of making any dent in these outcomes,” he said.
“This means engaging with Indigenous communities, offering culturally appropriate care, and ensuring there is equity in health care. This needs bravery from policy makers with increased investment.”
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