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Comparison of the uptake of health assessment items for Aboriginal and Torres Strait Islander people and other Australians: Implications for policy

Comparison of the uptake of health assessment items for Aboriginal and Torres Strait Islander... Background: Health Assessment (HA) items were introduced in 1999 for Aboriginal and Torres Strait Islander people aged at least 55 years and all Australians aged over 75 years. In 2004 a new item was introduced for HAs among adult Aboriginal and Torres Strait Islander people aged 15–54 years. The new item has been applauded as a major policy innovation however this enthusiasm has been tempered with concern about potential barriers to its uptake. In this study we aim to determine whether there are disparities in uptake of HA items for Aboriginal and Torres Strait Islander people compared to other Australians. Method: The analysis was based on Health Insurance Commission data. Indigenous status was ascertained based on the item number used. Logistic regression was used to compare uptake of HA items for older people among Aboriginal and Torres Strait Islander people compared to other Australians. Adjustments were made for dual eligibility. Uptake of the HA items for older people was compared to the uptake of the new item for Aboriginal and Torres Strait Islander people aged 15–44 years. Results: Our analyses suggest a significant and persistent disparity in the uptake of items for older patients among Aboriginal and Torres Strait Islander people compared to other Australians. A similar disparity appears to exist in the uptake of the new adult Aboriginal and Torres Strait Islander HA item. Conclusion: Further engagement of primary care providers and the community around the uptake of the new HA items may be required to ensure that the anticipated health benefits eventuate. tion and preventive care in primary care settings. The HA The introduction of Medical Benefits Scheme (MBS) item items provide reimbursement for doctors to evaluate numbers to reimburse health assessments (HAs) repre- patient's physical, psychological and social function in sented a major shift in support for access to health promo- order to optimise health care and education. HA items Page 1 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 Table 1: MBS Health Assessment item numbers Health Assessment All Australians 75+ yrs Aboriginal and Torres Strait Islander people 55+yrs At consulting room 700 704 Not at consulting rooms, hospitals or residential aged care facilities 702 706 were first introduced for older patients in 1999. [1] The indigenous rural and remote communities in Queensland items included HAs conducted at consulting rooms and where Well Persons Health Checks were conducted. [11] not at consulting rooms, hospitals or residential aged care If the new item results in increased HAs, it has the poten- facilities (referred to hereafter as non-consulting room tial to greatly reduce the burden of disease among indige- items). [1] Aboriginal and Torres Strait Islander people nous Australians; it has rightly been applauded as an aged at least 55 years and all Australians aged over 75 example of innovative policy in indigenous health. [9] years are eligible for these items. The item numbers for However this enthusiasm has been tempered with con- Aboriginal and Torres Strait Islander people and all Aus- cerns that the potential health benefits of the new item tralians are shown in table 1. will not be realised because of low uptake. [9] The uptake of the HA items and other items introduced as In this study we aim to establish whether there are likely part of the Enhanced Primary Care (EPC) program from to be barriers to the uptake of the new HA item by com- 1999–2001 has been rigorously evaluated. HA items had paring the uptake of the HA items for older people among the highest uptake of the Enhanced Primary Care items Aboriginal and Torres Strait Islander people and the rest of with around 18% of the eligible population using them. the community. We also examine differences in uptake [2,3] No information was available on baseline levels for over time and differences between States and Territories. the provision of HAs but the evaluation did suggest that Finally we compare uptake of the HA items for older peo- there was an increase in the use of HAs in case study prac- ple to the uptake of the new items for Aboriginal and tices and that reimbursement was an incentive to com- Torres Strait Islander people aged 15–44 years in the first pleting HAs in about one third of practices. Health three quarters after their introduction. It would be benefits associated with HA among older patients were expected that structural barriers to the introduction of relatively small [4,5] and the evaluation suggested that HAs should have decreased over since 1999 because of the further uptake was required to have significant impact on introduction of the HA items. Accordingly it might be the health of the target populations. [3] This was particu- expected that the uptake of the new item might be more larly true of the items for Aboriginal and Torres Strait rapid than the uptake of the items for older Australians. Islander people which were used at a significantly lower rate than the items for the general population. [6] It was Data suggested that this effect may have occurred either because Data on the use of item numbers (700, 702, 704, 706) by year and by State and Territory were obtained from the Aboriginal and Torres Strait Islander people might be more likely to have pre-existing care plans or because Abo- Health Insurance Commission statistical reports. [12] riginal and Torres Strait Islander people were more likely Data on the HA items was available from the last quarter to use services (e.g. hospitals) where Medicare was not in 1999 but this was not used in the general comparison used. [7] In either case it would be expected that the dis- because a full years data was not available. The extract parity should decrease over time as people required new included annual data from 2000–2004. health assessments and Medicare use among indigenous people increased. [8] Data on the use of item numbers (700, 704, 710) in the first three quarters of their introduction was also obtained In May 2004, a new item (item 710) was introduced for from the Health Insurance Commission statistical reports. HAs among adult Aboriginal and Torres Strait Islander [12] These data are available by State and Territory but fig- people aged 15–54 years. [8,9] Adult HAs could have sig- ures for the whole of Australia were used because of low nificant health benefits for indigenous people because of numbers. For items 702 and 704 the first three quarters the early age of onset of chronic disease and higher rates data was for the last quarter of 1999 and the first two quar- of infectious disease in this community compared to ters of 2000. For item 710 the data was from the last three other Australians. [10] For example, the rate of sexually quarters of 2004. It should be noted that the first quarter transmitted infection was halved at two year follow-up in data may not include data for the whole quarter. Page 2 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 Table 2: Logistic Regression for use of Consulting room HA items by Indigenous status and Year controlling for State/ 10.0% Territory 8.0% Variable Observed service Dual eligibility 6.0% use adjustment non-Indigenous Indigenous 4.0% OR (95% CI) OR (95% CI) 2.0% Indigenous status 0.37 (0.36–0.38) 0.51 (0.50–0.53) Linear trend for year 1.12 (1.12–1.12) 1.12 (1.12–1.12) 0.0% Indigenous status * year 1.11(1.10–1.14) 1.03(1.01–1.06) 2000 2001 2002 2003 2004 Year Tr status and Year Figure 1 ends in use of Consulting Room HA items by Indigenous Trends in use of Consulting Room HA items by Indigenous data to estimate the number of people who did not. Year status and Year. was coded to enable linear trends in uptake to be tested. Indigenous status was coded dichotomously based on whether the items were only available to Aboriginal and Torres Strait Islander people or available to all Australians. In addition to the other eligibility requirements, only one The 12.2% of Aboriginal and Torres Strait Islander people claim could be made per person in a 12 month period. aged at least 75 years would be eligible for the general Accordingly quarterly and annual data reports should population items as well as the Aboriginal and Torres only contain one observation per person. Data are availa- Strait Islander specific items. All analyses were conducted ble for smaller geographic areas than State and Territory, twice to explore whether dual eligibility could have an such as general practice divisions, however low numbers impact on the results. The first set of analyses was based and a high level of suppressed data made small area anal- on observed service use. Service use among Aboriginal ysis problematic. and Torres Strait Islander people would be underesti- mated in these analyses if people with dual eligibility were Population estimates for the Aboriginal and Torres Strait using general population items. The data were also ana- Islander population aged at least 55 years and aged 15–44 lysed assuming that Aboriginal and Torres Strait Islander years by State and Territory were obtained for the Austral- people aged at least 75 years accessed HAs through general ian Bureau of Statistics (ABS) projections from the 2001 population items at the same rate as the rest of commu- census for the years 2001 to 2004. [13] Population projec- nity. These instances of service use were then attributed to tions for the years 1999 and 2000 were obtained from Aboriginal and Torres Strait Islander people rather than to series developed from the 1996 census. [14] The projec- other Australians. Service use among Aboriginal and tions provide a low and high series of population esti- Torres Strait Islander people would be overestimated in mates. In this study the series used had little impact on the these analyses because some of the people using the Abo- results. The low series is reported because it yields the riginal and Torres Strait Islander items are likely to be aged most conservative estimates of the difference between at least 75 years and therefore would be counted twice. Aboriginal and Torres Strait Islander people and the rest of Some overestimation would also be expected to occur the community. Population estimates for the general pop- because the observed rate of service use among Aboriginal ulation aged at least 75 years were obtained using ABS and Torres Strait Islander people aged over 75 years is time series data. [15] likely to be less than that for the general population. Analysis Differences in rates of consulting room and non-consult- A logistic regression was conducted to analyse differences ing room service use for Aboriginal and Torres Strait in the uptake of consulting room (700, 704) and non- Islander people and the rest of the community were calcu- consulting room (702, 706) HA items according to Indig- lated for each State and Territory. enous status and year taking into account variation due to State and Territory. Consulting room and non-consulting A logistic regression was conducted to compare the uptake room items were analysed separately because there is geo- of older all Australian (700), older Aboriginal and Torres graphic variation in their use which may be potential Strait Islander (704) and adult Aboriginal and Torres source of confounding. The dependent variable was coded Strait Islander people (710) HA items. The HA item for dichotomously using service use data to estimate the adult Aboriginal and Torres Strait Islander people (710) number of people who used the service and population was used as the reference category for comparisons. Page 3 of 7 (page number not for citation purposes) % service use Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 Table 3: Per cent use of Consulting room HA items by Indigenous status and State/Territory State 75+ yrs non- 55+ yrs Indigenous Total Difference % (95% Difference % (95% Indigenous CI) CI)-dual eligibility adjustment NSW Count 156433 1316 157749 % 7.7% 2.7% 7.5% 5.0 (5.0–5.1) 4.2 (4.1–4.2) VIC Count 111742 566 112308 % 7.5% 5.8% 7.5% 2.0 (1.9–2.1) 0.8 (0.7–0.9) QLD Count 92970 1359 94329 % 9.4% 3.3% 9.1% 6.2 (6.1–6.3) 5.0 (4.9–5.0) SA Count 25788 159 25947 % 4.8% 1.8% 4.7% 3.0 (2.9–3.1) 2.4 (2.3–2.5) WA Count 27620 758 28378 % 5.7% 3.4% 5.6% 2.2 (2.4–2.5) 1.6 (1.5–1.7) TAS Count 5529 15 5544 % 3.6% .3% 3.5% 3.4 (3.3–3.5) 3.0 (2.9–3.1) ACT Count 2496 14 2510 % 4.0% 1.8% 4.0% 2.2 (2.1–2.4) 1.8 (1.6–2.0) NT Count 197 486 683 % 1.9% 2.5% 2.1% -0.6 (-0.8–-0.3) -0.9 (-1.1–-0.6) Table 4: Logistic Regression for use of non-Consulting room HA items by Indigenous status and Year controlling for State/ 9.0% Territory 8.0% 7.0% Variable Observed service Dual eligibility 6.0% use adjustment 5.0% non-Indigenous 4.0% Indigenous 3.0% OR (95% CI) OR (95% CI) 2.0% Indigenous status 0.22 (0.21–0.23) 0.34 (0.33–0.35) 1.0% Linear trend for year 1.22 (1.21–1.22) 1.22 (1.21–1.22) 0.0% Indigenous status * year 0.85 (0.82–0.88) 0.88 (0.86–0.90) 2000 2001 2002 2003 2004 Year Trends in use of non nous status and Year Figure 2 -Consulting Room HA items by Indige- Trends in use of non-Consulting Room HA items by Indige- Quarter was coded to enable linear and quadratic trends nous status and Year. in uptake to be tested. The dependent variable was coded dichotomously using service use data to estimate the number of people who used the service and population data to estimate the number of people who did not. Torres Strait Islander people than the rest of the commu- Results nity (see figure 1). Disparities remained in all years. Comparison of the uptake of HA items for older people among Aboriginal and Torres Strait Islander people and Table 3 shows the per cent use of consulting room HA other Australians items by State and Territory and Indigenous status. Per- The result of the logistic regression for use of consulting centage uptake generally increased with the size of the eli- room HA items (see table 2) suggested that Aboriginal gible population with New South Wales (NSW), and Torres Strait Islander people (3.0%) were significantly Queensland (QLD) and Victoria (VIC) having the highest less likely to have HAs than the rest of the community rates and the Northern Territory (NT) having the lowest. (7.4%). There was a significant linear increase in use of In all States and Territories, with the exception of the NT, the HA items, with use increasing from 5.1% in 2000 to use was significantly lower among Aboriginal and Torres 8.4% in 2004. There was also a significant interaction Strait Islander people. In the NT the pattern was reversed between Indigenous status and year with use of the HA with Aboriginal and Torres Strait Islander people being items increasing slightly more rapidly for Aboriginal and more likely than the rest of the community to use the HA Page 4 of 7 (page number not for citation purposes) % service use Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 Table 5: Per cent use of non-Consulting room HA items by Indigenous status and State/Territory State 75+ yrs non- 55+ yrs Indigenous Total Difference % (95% CI) Difference % (95% CI)-dual Indigenous eligibility adjustment NSW Count 132055 658 132713 % 6.5% 1.4% 6.4% 5.2 (5.2–5.3)% 4.5 (4.4–4.5)% VIC Count 94610 228 94838 % 6.4% 2.3% 6.3% 4.2 (4.1–4.2)% 3.2 (3.2–3.3)% QLD Count 50911 505 51416 % 5.2% 1.2% 5.0% 4.1 (4.0–4.1)% 3.27 (3.2–3.3)% SA Count 62203 176 62379 % 11.5% 2.0% 11.3% 9.5 (9.4–9.6)% 8.1 (8.0–8.2)% WA Count 25725 189 25914 % 5.4% 0.8% 5.1% 4.5 (4.5–4.6)% 3.8 (3.7–3.8)% TAS Count 15906 29 15935.0 % 10.4% 0.5% 10.1% 9.9 (9.8–10.1)% 8.8 (8.7–9.0)% ACT Count 2979 4 2983.00 % 4.8% 0.5% 4.8% 4.3 (4.1–4.5)% 3.9 (3.7–4.1)% NT Count 40 264 304 % 0.3% 1.4% 0.9% -1.0 (-1.2–-0.9)% -1.0 (-1.2–-0.9)% Table 6: Logistic Regression for uptake of Consulting room HA items. All differences remained significant if it was items in the first 3 quarters after their introduction assumed that Aboriginal and Torres Strait Islander people aged at least 75 years used services at the same rate as the Variable OR (95% CI) rest of the community. Linear trend-quarters 2.15 (2.02–2.29) The result of the logistic regression for use of non-consult- Quadratic trend-quarters 0.63 (0.60–0.66) 75+ yrs Non-Indigenous HA 2.6 (2.49–2.67) ing room HA items (see table 4) suggested that Aboriginal 55+ yrs Indigenous HA 0.70 (0.61–0.80) and Torres Strait Islander people (1.3%) were significantly 15–44 yrs Indigenous HA Reference less likely to have HAs than the rest of the community (6.7%). There was a significant linear increase in use of the HA items, with use increasing from 3.4% in 2000 to 8.2% in 2004. There was also a significant interaction between Indigenous status and year with use of the HA Uptake of Aboriginal and Torres Strait Islander adult HA items staying stable among Aboriginal and Torres Strait item compared to uptake of HA items for older people Islander people while increasing in the rest of the commu- The logistic regression for the uptake of consulting room nity (see figure 2). HA items in the first three quarters of their introduction suggested that uptake of the HA items for adult Aboriginal Table 5 shows the per cent use of non-consulting room and Torres Strait Islander people (710) was lower than for HA items by State and Territory and Indigenous status. the uptake of the general population item (700) but was Use of the HA was relatively low in all jurisdictions. Rates higher than uptake of the item for older Aboriginal and of use were much higher in South Australia (SA) and Tas- Torres Strait Islander people (704, see table 6). Both linear mania (Tas) than in other States and Territories. NT had and quadratic trends were significant because rates of use the lowest take up rate overall. In all States and Territories increased substantially after the first quarter and then sta- with the exception of the NT use of non-consulting room bilised in the second and third (see table 7). HA items was significantly lower among Aboriginal and Torres Strait Islander people. In the NT the trend was Discussion reversed with Aboriginal and Torres Strait Islander people Uptake of HA items was relatively low overall and there being more likely the rest of the community to use the HA was significant and persistent disparity in the uptake of items. All differences remained significant when it was HA items for older people among Aboriginal and Torres assumed that Aboriginal and Torres Strait Islander people Strait Islander people compared to the rest of the commu- aged at least 75 years used services at the same rate as the nity. There were significant differences between the rest of the community. jurisdictions in the overall uptake of items. For consulting Page 5 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 Table 7: Per cent use of Consulting room HA items in the first 3 quarters after their introduction HA Quarter 1 Quarter 2 Quarter 3 %-95%CI %-95%CI %-95%CI 75+ yrs non-Indigenous 0.63 (0.62–0.64) 1.74 (1.73–1.76) 1.73 (1.72–1.75) 55+ yrs Indigenous 0.16 (0.14–0.19) 0.48 (0.44–0.52) 0.51 (0.47–0.55) 15–44 yrs Indigenous 0.23 (0.23–0.24) 0.71 (0.69–0.72) 0.69 (0.67–0.7) room items there appeared to be a relationship between The EPC evaluation found that awareness of HA items was overall State or Territory population and uptake although high among doctors but that lack of awareness of the this was unrelated to other factors such as population den- items among consumers and allied health workers was a sity. [16] There was no clear pattern for non-consulting barrier to their uptake. [3] Consumer awareness may be room items. NT was the only jurisdiction where Aborigi- particularly important in the use of Aboriginal and Torres nal and Torres Strait Islander people used HA items more Strait Islander items where client identification is an issue. than non-Aboriginal people. This appeared to occur Uptake of HA items was facilitated in practices where because of low uptake among non-indigenous Australians practice nurses rather than the doctor undertook the infor- rather than higher uptake among Aboriginal and Torres mation gathering components. [2] The provision of addi- Strait Islander people. tional assistance to conduct HAs may be particularly important in Aboriginal and Torres Strait Islander health The comparison of the uptake of the HA items in the first services where the ratio of walk-in to appointment-based three quarters of their use suggested that the uptake of the consultations is far higher than in main stream services, new adult Aboriginal and Torres Strait Islander item was making it difficult for doctors to block out the time lower than the uptake of the HA item for older members required for HAs. Even greater barriers may exist in com- of the general population. This suggests that additional munities were there is no full-time doctor. Others barriers attention to the causes of barriers to the uptake of HAs include racism and problems with cross-cultural commu- among Aboriginal and Torres Strait Islander people may nication. [10] Barriers associated with cultural appropri- be necessary to achieve the potential benefits associated ateness may be addressed by initiatives such as the with these items. development of a guide to conducting health assessments in Aboriginal and Torres Strait islander people. [9] How- In the evaluation of the EPC program it was suggested that ever a multifaceted approach is likely to be required. [2,9] disparities in the uptake of HAs for older people could either be a function of Aboriginal and Torres Strait In any analysis of health services data where clinical data Islander people having pre-existing care plans or the result is absent it is difficult to determine appropriate levels of of Aboriginal and Torres Strait Islander patients being HA use. However it does not seem clinically plausible that more likely to see doctors who were ineligible to use Aboriginal and Torres Strait Islander people should be less Medicare. [2] Differences due to both causes would be in need of HAs than comparable other Australians. Amel- expected to decrease over time. Any variation in uptake iorating this situation may require not only further pro- due to difference in levels of pre-existing HAs would be motion of the items with doctors but further engagement reduced over time as HAs were renewed. Since the original of local primary health infrastructure and the community. evaluation an exemption under section 19(2) of the [2,5] The evaluation of the HA items and previous initia- National Health Act has enabled salaried doctors in tives to promote health checks[11] in Aboriginal and approved services to bill through Medicare. This has Torres Strait islander communities are valuable resources resulted in increased rates of Medicare use at Aboriginal in developing approaches to ensure that the potential and Torres Strait Islander services. There was some evi- health benefit deriving from the new and existing items dence of a slightly faster rate of increase in use among are delivered. Aboriginal and Torres Strait Islander people for consulting room items though rates appeared stable for non-consult- Statement of Competing cnterests ing room items. The persistence of the disparity suggests The author(s) declare that they have no competing neither explanation accounts for a large part of the differ- interests. ence in HA uptake between older Aboriginal and Torres Strait Islander people and other Australians. Page 6 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 16. Australian Bureau of Statistics (ABS): National Regional Profile. Authors' contributions Canberra: ABS; 2004. ABS catalogue no. 1379.0.55.001. Margaret Kelaher conceptualised the paper and conducted the analysis. David Dunt, Ian Anderson and David Tho- mas collaborated in drafting the paper. Acknowledgements Margaret Kelaher is funded by an NHMRC career development award and VicHealth. David Thomas is supported by NHMRC Population Health Capacity Building Grant No. 236235. Core funding for Onemda VicHealth Koori Health Unit is provided by the Victorian Health Promotion Founda- tion and the Commonwealth Department of Health and Ageing. Our thanks to Sophie Couzos for her comments on an earlier draft of this paper. References 1. Australian Department of Health and Ageing: Medicare Benefits Schedule Book Operating from 1 November 2004. Canberra: Commonwealth of Australia; 2004. 2. Wilkinson D, Mott K, Price K, Morey S, Beilby J, Best J, McElroy H, Pluck S, Eley V: Evaluation of the Enhanced Primary Care Med- ical Benefits Schedule Items and the General Practice Edu- cation, Support and Community Linkages Program. Final Report. Canberra: Australian Department of Health and Ageing; 3. Wilkinson D, McElroy H, Beilby J, Mott K, Price K, Morey S, Best J: Variation in levels of uptake of enhanced primary care item numbers between rural and urban settings, November 1999 to October 2001. Aust Health Rev 2002, 25(6):123-30. 4. Byles JE: A thorough going over: Evidence for health assess- ments for older persons. Aust N Z J Public Health 2000, 24(2):117-123. 5. Byles JE, Tavener M, O'Connell RL, Nair BR, Higginbotham NH, Jack- son CL, Mckernon ME, Francis L, Heller RF, Newbury JW, Marley JE, Goodger BG: Randomised control trial of health assessments for older Australian veterans and war widows. Med J Aust 2004, 181(4):186-190. 6. Wilkinson D, McElroy H, Beilby J, Mott K, Price K, Morey S, Best J: Uptake of health assessments, care plans and case confer- ences by general practitioners through the Enhanced Pri- mary Care program between November 1999 and October 2001. Aust Health Rev 2002, 25(4):1-11. 7. Australian Institute of Health and Welfare (AIHW): Expenditures on health services for Aboriginal and Torres Strait Islander people 1998–99. Canberra: AIHW and Commonwealth Depart- ment of Health and Aged Care; 2001. AIHW cat no. IHW 8. Department of Health and Ageing: New Medicare Checks for Indigenous Australians. [http://www.health.gov.au/internet/ wcms/publishing.nsf/Content/health-mediarel-yr2004-ta- abb052.htm]. 9. Mayers NR, Couzos S: Towards equity through an adult health check for Aboriginal and Torres Strait Islander people. Med J Aust 2004, 181(10):531-532. 10. Trewin D, Madden R: The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2003. Can- berra: Australian Institute of Heath and Welfare (AIHW) and Austral- ian Bureau of Statistics; 2004. ABS Catalogue no. 4704.0 AIHW Catalogue no. IHW11 ISSN 1441–2004 11. Miller G, McDermott R, McCulloch B, Leonard D, Arabena K, Muller Publish with Bio Med Central and every R: The Well Person's Health Check: A population screening scientist can read your work free of charge program in indigenous communities in north Queensland. "BioMed Central will be the most significant development for Aust Health Rev 2004, 25(6):1-11. 12. Health Insurance Commission: Medicare. [http://www.hic.gov.au/ disseminating the results of biomedical researc h in our lifetime." providers/health_statistics/statistical_reporting/medicare.htm.]. Sir Paul Nurse, Cancer Research UK accessed March 2005 13. Australian Bureau of Statistics (ABS): Experimental Estimates Your research papers will be: and Projections, Aboriginal and Torres Strait Islander available free of charge to the entire biomedical community Australians. Canberra: ABS; 2004. ABS catalogue no. 3238.0 14. Australian Bureau of Statistics (ABS): Experimental Projections of peer reviewed and published immediately upon acceptance the Aboriginal and Torres Strait Islander Population. Can- cited in PubMed and archived on PubMed Central berra: ABS. ABS catalogue no. 3231.0 yours — you keep the copyright 15. Australian Bureau of Statistics (ABS): Population by Age and Sex, Australian States and Territories. Canberra: ABS; 2004. Time BioMedcentral Submit your manuscript here: Series Spreadsheet 3201.0 http://www.biomedcentral.com/info/publishing_adv.asp Page 7 of 7 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Comparison of the uptake of health assessment items for Aboriginal and Torres Strait Islander people and other Australians: Implications for policy

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Springer Journals
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Copyright © 2005 by Kelaher et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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1743-8462
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Abstract

Background: Health Assessment (HA) items were introduced in 1999 for Aboriginal and Torres Strait Islander people aged at least 55 years and all Australians aged over 75 years. In 2004 a new item was introduced for HAs among adult Aboriginal and Torres Strait Islander people aged 15–54 years. The new item has been applauded as a major policy innovation however this enthusiasm has been tempered with concern about potential barriers to its uptake. In this study we aim to determine whether there are disparities in uptake of HA items for Aboriginal and Torres Strait Islander people compared to other Australians. Method: The analysis was based on Health Insurance Commission data. Indigenous status was ascertained based on the item number used. Logistic regression was used to compare uptake of HA items for older people among Aboriginal and Torres Strait Islander people compared to other Australians. Adjustments were made for dual eligibility. Uptake of the HA items for older people was compared to the uptake of the new item for Aboriginal and Torres Strait Islander people aged 15–44 years. Results: Our analyses suggest a significant and persistent disparity in the uptake of items for older patients among Aboriginal and Torres Strait Islander people compared to other Australians. A similar disparity appears to exist in the uptake of the new adult Aboriginal and Torres Strait Islander HA item. Conclusion: Further engagement of primary care providers and the community around the uptake of the new HA items may be required to ensure that the anticipated health benefits eventuate. tion and preventive care in primary care settings. The HA The introduction of Medical Benefits Scheme (MBS) item items provide reimbursement for doctors to evaluate numbers to reimburse health assessments (HAs) repre- patient's physical, psychological and social function in sented a major shift in support for access to health promo- order to optimise health care and education. HA items Page 1 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 Table 1: MBS Health Assessment item numbers Health Assessment All Australians 75+ yrs Aboriginal and Torres Strait Islander people 55+yrs At consulting room 700 704 Not at consulting rooms, hospitals or residential aged care facilities 702 706 were first introduced for older patients in 1999. [1] The indigenous rural and remote communities in Queensland items included HAs conducted at consulting rooms and where Well Persons Health Checks were conducted. [11] not at consulting rooms, hospitals or residential aged care If the new item results in increased HAs, it has the poten- facilities (referred to hereafter as non-consulting room tial to greatly reduce the burden of disease among indige- items). [1] Aboriginal and Torres Strait Islander people nous Australians; it has rightly been applauded as an aged at least 55 years and all Australians aged over 75 example of innovative policy in indigenous health. [9] years are eligible for these items. The item numbers for However this enthusiasm has been tempered with con- Aboriginal and Torres Strait Islander people and all Aus- cerns that the potential health benefits of the new item tralians are shown in table 1. will not be realised because of low uptake. [9] The uptake of the HA items and other items introduced as In this study we aim to establish whether there are likely part of the Enhanced Primary Care (EPC) program from to be barriers to the uptake of the new HA item by com- 1999–2001 has been rigorously evaluated. HA items had paring the uptake of the HA items for older people among the highest uptake of the Enhanced Primary Care items Aboriginal and Torres Strait Islander people and the rest of with around 18% of the eligible population using them. the community. We also examine differences in uptake [2,3] No information was available on baseline levels for over time and differences between States and Territories. the provision of HAs but the evaluation did suggest that Finally we compare uptake of the HA items for older peo- there was an increase in the use of HAs in case study prac- ple to the uptake of the new items for Aboriginal and tices and that reimbursement was an incentive to com- Torres Strait Islander people aged 15–44 years in the first pleting HAs in about one third of practices. Health three quarters after their introduction. It would be benefits associated with HA among older patients were expected that structural barriers to the introduction of relatively small [4,5] and the evaluation suggested that HAs should have decreased over since 1999 because of the further uptake was required to have significant impact on introduction of the HA items. Accordingly it might be the health of the target populations. [3] This was particu- expected that the uptake of the new item might be more larly true of the items for Aboriginal and Torres Strait rapid than the uptake of the items for older Australians. Islander people which were used at a significantly lower rate than the items for the general population. [6] It was Data suggested that this effect may have occurred either because Data on the use of item numbers (700, 702, 704, 706) by year and by State and Territory were obtained from the Aboriginal and Torres Strait Islander people might be more likely to have pre-existing care plans or because Abo- Health Insurance Commission statistical reports. [12] riginal and Torres Strait Islander people were more likely Data on the HA items was available from the last quarter to use services (e.g. hospitals) where Medicare was not in 1999 but this was not used in the general comparison used. [7] In either case it would be expected that the dis- because a full years data was not available. The extract parity should decrease over time as people required new included annual data from 2000–2004. health assessments and Medicare use among indigenous people increased. [8] Data on the use of item numbers (700, 704, 710) in the first three quarters of their introduction was also obtained In May 2004, a new item (item 710) was introduced for from the Health Insurance Commission statistical reports. HAs among adult Aboriginal and Torres Strait Islander [12] These data are available by State and Territory but fig- people aged 15–54 years. [8,9] Adult HAs could have sig- ures for the whole of Australia were used because of low nificant health benefits for indigenous people because of numbers. For items 702 and 704 the first three quarters the early age of onset of chronic disease and higher rates data was for the last quarter of 1999 and the first two quar- of infectious disease in this community compared to ters of 2000. For item 710 the data was from the last three other Australians. [10] For example, the rate of sexually quarters of 2004. It should be noted that the first quarter transmitted infection was halved at two year follow-up in data may not include data for the whole quarter. Page 2 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 Table 2: Logistic Regression for use of Consulting room HA items by Indigenous status and Year controlling for State/ 10.0% Territory 8.0% Variable Observed service Dual eligibility 6.0% use adjustment non-Indigenous Indigenous 4.0% OR (95% CI) OR (95% CI) 2.0% Indigenous status 0.37 (0.36–0.38) 0.51 (0.50–0.53) Linear trend for year 1.12 (1.12–1.12) 1.12 (1.12–1.12) 0.0% Indigenous status * year 1.11(1.10–1.14) 1.03(1.01–1.06) 2000 2001 2002 2003 2004 Year Tr status and Year Figure 1 ends in use of Consulting Room HA items by Indigenous Trends in use of Consulting Room HA items by Indigenous data to estimate the number of people who did not. Year status and Year. was coded to enable linear trends in uptake to be tested. Indigenous status was coded dichotomously based on whether the items were only available to Aboriginal and Torres Strait Islander people or available to all Australians. In addition to the other eligibility requirements, only one The 12.2% of Aboriginal and Torres Strait Islander people claim could be made per person in a 12 month period. aged at least 75 years would be eligible for the general Accordingly quarterly and annual data reports should population items as well as the Aboriginal and Torres only contain one observation per person. Data are availa- Strait Islander specific items. All analyses were conducted ble for smaller geographic areas than State and Territory, twice to explore whether dual eligibility could have an such as general practice divisions, however low numbers impact on the results. The first set of analyses was based and a high level of suppressed data made small area anal- on observed service use. Service use among Aboriginal ysis problematic. and Torres Strait Islander people would be underesti- mated in these analyses if people with dual eligibility were Population estimates for the Aboriginal and Torres Strait using general population items. The data were also ana- Islander population aged at least 55 years and aged 15–44 lysed assuming that Aboriginal and Torres Strait Islander years by State and Territory were obtained for the Austral- people aged at least 75 years accessed HAs through general ian Bureau of Statistics (ABS) projections from the 2001 population items at the same rate as the rest of commu- census for the years 2001 to 2004. [13] Population projec- nity. These instances of service use were then attributed to tions for the years 1999 and 2000 were obtained from Aboriginal and Torres Strait Islander people rather than to series developed from the 1996 census. [14] The projec- other Australians. Service use among Aboriginal and tions provide a low and high series of population esti- Torres Strait Islander people would be overestimated in mates. In this study the series used had little impact on the these analyses because some of the people using the Abo- results. The low series is reported because it yields the riginal and Torres Strait Islander items are likely to be aged most conservative estimates of the difference between at least 75 years and therefore would be counted twice. Aboriginal and Torres Strait Islander people and the rest of Some overestimation would also be expected to occur the community. Population estimates for the general pop- because the observed rate of service use among Aboriginal ulation aged at least 75 years were obtained using ABS and Torres Strait Islander people aged over 75 years is time series data. [15] likely to be less than that for the general population. Analysis Differences in rates of consulting room and non-consult- A logistic regression was conducted to analyse differences ing room service use for Aboriginal and Torres Strait in the uptake of consulting room (700, 704) and non- Islander people and the rest of the community were calcu- consulting room (702, 706) HA items according to Indig- lated for each State and Territory. enous status and year taking into account variation due to State and Territory. Consulting room and non-consulting A logistic regression was conducted to compare the uptake room items were analysed separately because there is geo- of older all Australian (700), older Aboriginal and Torres graphic variation in their use which may be potential Strait Islander (704) and adult Aboriginal and Torres source of confounding. The dependent variable was coded Strait Islander people (710) HA items. The HA item for dichotomously using service use data to estimate the adult Aboriginal and Torres Strait Islander people (710) number of people who used the service and population was used as the reference category for comparisons. Page 3 of 7 (page number not for citation purposes) % service use Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 Table 3: Per cent use of Consulting room HA items by Indigenous status and State/Territory State 75+ yrs non- 55+ yrs Indigenous Total Difference % (95% Difference % (95% Indigenous CI) CI)-dual eligibility adjustment NSW Count 156433 1316 157749 % 7.7% 2.7% 7.5% 5.0 (5.0–5.1) 4.2 (4.1–4.2) VIC Count 111742 566 112308 % 7.5% 5.8% 7.5% 2.0 (1.9–2.1) 0.8 (0.7–0.9) QLD Count 92970 1359 94329 % 9.4% 3.3% 9.1% 6.2 (6.1–6.3) 5.0 (4.9–5.0) SA Count 25788 159 25947 % 4.8% 1.8% 4.7% 3.0 (2.9–3.1) 2.4 (2.3–2.5) WA Count 27620 758 28378 % 5.7% 3.4% 5.6% 2.2 (2.4–2.5) 1.6 (1.5–1.7) TAS Count 5529 15 5544 % 3.6% .3% 3.5% 3.4 (3.3–3.5) 3.0 (2.9–3.1) ACT Count 2496 14 2510 % 4.0% 1.8% 4.0% 2.2 (2.1–2.4) 1.8 (1.6–2.0) NT Count 197 486 683 % 1.9% 2.5% 2.1% -0.6 (-0.8–-0.3) -0.9 (-1.1–-0.6) Table 4: Logistic Regression for use of non-Consulting room HA items by Indigenous status and Year controlling for State/ 9.0% Territory 8.0% 7.0% Variable Observed service Dual eligibility 6.0% use adjustment 5.0% non-Indigenous 4.0% Indigenous 3.0% OR (95% CI) OR (95% CI) 2.0% Indigenous status 0.22 (0.21–0.23) 0.34 (0.33–0.35) 1.0% Linear trend for year 1.22 (1.21–1.22) 1.22 (1.21–1.22) 0.0% Indigenous status * year 0.85 (0.82–0.88) 0.88 (0.86–0.90) 2000 2001 2002 2003 2004 Year Trends in use of non nous status and Year Figure 2 -Consulting Room HA items by Indige- Trends in use of non-Consulting Room HA items by Indige- Quarter was coded to enable linear and quadratic trends nous status and Year. in uptake to be tested. The dependent variable was coded dichotomously using service use data to estimate the number of people who used the service and population data to estimate the number of people who did not. Torres Strait Islander people than the rest of the commu- Results nity (see figure 1). Disparities remained in all years. Comparison of the uptake of HA items for older people among Aboriginal and Torres Strait Islander people and Table 3 shows the per cent use of consulting room HA other Australians items by State and Territory and Indigenous status. Per- The result of the logistic regression for use of consulting centage uptake generally increased with the size of the eli- room HA items (see table 2) suggested that Aboriginal gible population with New South Wales (NSW), and Torres Strait Islander people (3.0%) were significantly Queensland (QLD) and Victoria (VIC) having the highest less likely to have HAs than the rest of the community rates and the Northern Territory (NT) having the lowest. (7.4%). There was a significant linear increase in use of In all States and Territories, with the exception of the NT, the HA items, with use increasing from 5.1% in 2000 to use was significantly lower among Aboriginal and Torres 8.4% in 2004. There was also a significant interaction Strait Islander people. In the NT the pattern was reversed between Indigenous status and year with use of the HA with Aboriginal and Torres Strait Islander people being items increasing slightly more rapidly for Aboriginal and more likely than the rest of the community to use the HA Page 4 of 7 (page number not for citation purposes) % service use Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 Table 5: Per cent use of non-Consulting room HA items by Indigenous status and State/Territory State 75+ yrs non- 55+ yrs Indigenous Total Difference % (95% CI) Difference % (95% CI)-dual Indigenous eligibility adjustment NSW Count 132055 658 132713 % 6.5% 1.4% 6.4% 5.2 (5.2–5.3)% 4.5 (4.4–4.5)% VIC Count 94610 228 94838 % 6.4% 2.3% 6.3% 4.2 (4.1–4.2)% 3.2 (3.2–3.3)% QLD Count 50911 505 51416 % 5.2% 1.2% 5.0% 4.1 (4.0–4.1)% 3.27 (3.2–3.3)% SA Count 62203 176 62379 % 11.5% 2.0% 11.3% 9.5 (9.4–9.6)% 8.1 (8.0–8.2)% WA Count 25725 189 25914 % 5.4% 0.8% 5.1% 4.5 (4.5–4.6)% 3.8 (3.7–3.8)% TAS Count 15906 29 15935.0 % 10.4% 0.5% 10.1% 9.9 (9.8–10.1)% 8.8 (8.7–9.0)% ACT Count 2979 4 2983.00 % 4.8% 0.5% 4.8% 4.3 (4.1–4.5)% 3.9 (3.7–4.1)% NT Count 40 264 304 % 0.3% 1.4% 0.9% -1.0 (-1.2–-0.9)% -1.0 (-1.2–-0.9)% Table 6: Logistic Regression for uptake of Consulting room HA items. All differences remained significant if it was items in the first 3 quarters after their introduction assumed that Aboriginal and Torres Strait Islander people aged at least 75 years used services at the same rate as the Variable OR (95% CI) rest of the community. Linear trend-quarters 2.15 (2.02–2.29) The result of the logistic regression for use of non-consult- Quadratic trend-quarters 0.63 (0.60–0.66) 75+ yrs Non-Indigenous HA 2.6 (2.49–2.67) ing room HA items (see table 4) suggested that Aboriginal 55+ yrs Indigenous HA 0.70 (0.61–0.80) and Torres Strait Islander people (1.3%) were significantly 15–44 yrs Indigenous HA Reference less likely to have HAs than the rest of the community (6.7%). There was a significant linear increase in use of the HA items, with use increasing from 3.4% in 2000 to 8.2% in 2004. There was also a significant interaction between Indigenous status and year with use of the HA Uptake of Aboriginal and Torres Strait Islander adult HA items staying stable among Aboriginal and Torres Strait item compared to uptake of HA items for older people Islander people while increasing in the rest of the commu- The logistic regression for the uptake of consulting room nity (see figure 2). HA items in the first three quarters of their introduction suggested that uptake of the HA items for adult Aboriginal Table 5 shows the per cent use of non-consulting room and Torres Strait Islander people (710) was lower than for HA items by State and Territory and Indigenous status. the uptake of the general population item (700) but was Use of the HA was relatively low in all jurisdictions. Rates higher than uptake of the item for older Aboriginal and of use were much higher in South Australia (SA) and Tas- Torres Strait Islander people (704, see table 6). Both linear mania (Tas) than in other States and Territories. NT had and quadratic trends were significant because rates of use the lowest take up rate overall. In all States and Territories increased substantially after the first quarter and then sta- with the exception of the NT use of non-consulting room bilised in the second and third (see table 7). HA items was significantly lower among Aboriginal and Torres Strait Islander people. In the NT the trend was Discussion reversed with Aboriginal and Torres Strait Islander people Uptake of HA items was relatively low overall and there being more likely the rest of the community to use the HA was significant and persistent disparity in the uptake of items. All differences remained significant when it was HA items for older people among Aboriginal and Torres assumed that Aboriginal and Torres Strait Islander people Strait Islander people compared to the rest of the commu- aged at least 75 years used services at the same rate as the nity. There were significant differences between the rest of the community. jurisdictions in the overall uptake of items. For consulting Page 5 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 Table 7: Per cent use of Consulting room HA items in the first 3 quarters after their introduction HA Quarter 1 Quarter 2 Quarter 3 %-95%CI %-95%CI %-95%CI 75+ yrs non-Indigenous 0.63 (0.62–0.64) 1.74 (1.73–1.76) 1.73 (1.72–1.75) 55+ yrs Indigenous 0.16 (0.14–0.19) 0.48 (0.44–0.52) 0.51 (0.47–0.55) 15–44 yrs Indigenous 0.23 (0.23–0.24) 0.71 (0.69–0.72) 0.69 (0.67–0.7) room items there appeared to be a relationship between The EPC evaluation found that awareness of HA items was overall State or Territory population and uptake although high among doctors but that lack of awareness of the this was unrelated to other factors such as population den- items among consumers and allied health workers was a sity. [16] There was no clear pattern for non-consulting barrier to their uptake. [3] Consumer awareness may be room items. NT was the only jurisdiction where Aborigi- particularly important in the use of Aboriginal and Torres nal and Torres Strait Islander people used HA items more Strait Islander items where client identification is an issue. than non-Aboriginal people. This appeared to occur Uptake of HA items was facilitated in practices where because of low uptake among non-indigenous Australians practice nurses rather than the doctor undertook the infor- rather than higher uptake among Aboriginal and Torres mation gathering components. [2] The provision of addi- Strait Islander people. tional assistance to conduct HAs may be particularly important in Aboriginal and Torres Strait Islander health The comparison of the uptake of the HA items in the first services where the ratio of walk-in to appointment-based three quarters of their use suggested that the uptake of the consultations is far higher than in main stream services, new adult Aboriginal and Torres Strait Islander item was making it difficult for doctors to block out the time lower than the uptake of the HA item for older members required for HAs. Even greater barriers may exist in com- of the general population. This suggests that additional munities were there is no full-time doctor. Others barriers attention to the causes of barriers to the uptake of HAs include racism and problems with cross-cultural commu- among Aboriginal and Torres Strait Islander people may nication. [10] Barriers associated with cultural appropri- be necessary to achieve the potential benefits associated ateness may be addressed by initiatives such as the with these items. development of a guide to conducting health assessments in Aboriginal and Torres Strait islander people. [9] How- In the evaluation of the EPC program it was suggested that ever a multifaceted approach is likely to be required. [2,9] disparities in the uptake of HAs for older people could either be a function of Aboriginal and Torres Strait In any analysis of health services data where clinical data Islander people having pre-existing care plans or the result is absent it is difficult to determine appropriate levels of of Aboriginal and Torres Strait Islander patients being HA use. However it does not seem clinically plausible that more likely to see doctors who were ineligible to use Aboriginal and Torres Strait Islander people should be less Medicare. [2] Differences due to both causes would be in need of HAs than comparable other Australians. Amel- expected to decrease over time. Any variation in uptake iorating this situation may require not only further pro- due to difference in levels of pre-existing HAs would be motion of the items with doctors but further engagement reduced over time as HAs were renewed. Since the original of local primary health infrastructure and the community. evaluation an exemption under section 19(2) of the [2,5] The evaluation of the HA items and previous initia- National Health Act has enabled salaried doctors in tives to promote health checks[11] in Aboriginal and approved services to bill through Medicare. This has Torres Strait islander communities are valuable resources resulted in increased rates of Medicare use at Aboriginal in developing approaches to ensure that the potential and Torres Strait Islander services. There was some evi- health benefit deriving from the new and existing items dence of a slightly faster rate of increase in use among are delivered. Aboriginal and Torres Strait Islander people for consulting room items though rates appeared stable for non-consult- Statement of Competing cnterests ing room items. The persistence of the disparity suggests The author(s) declare that they have no competing neither explanation accounts for a large part of the differ- interests. ence in HA uptake between older Aboriginal and Torres Strait Islander people and other Australians. Page 6 of 7 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:21 http://www.anzhealthpolicy.com/content/2/1/21 16. Australian Bureau of Statistics (ABS): National Regional Profile. Authors' contributions Canberra: ABS; 2004. ABS catalogue no. 1379.0.55.001. Margaret Kelaher conceptualised the paper and conducted the analysis. David Dunt, Ian Anderson and David Tho- mas collaborated in drafting the paper. Acknowledgements Margaret Kelaher is funded by an NHMRC career development award and VicHealth. David Thomas is supported by NHMRC Population Health Capacity Building Grant No. 236235. Core funding for Onemda VicHealth Koori Health Unit is provided by the Victorian Health Promotion Founda- tion and the Commonwealth Department of Health and Ageing. Our thanks to Sophie Couzos for her comments on an earlier draft of this paper. References 1. Australian Department of Health and Ageing: Medicare Benefits Schedule Book Operating from 1 November 2004. Canberra: Commonwealth of Australia; 2004. 2. Wilkinson D, Mott K, Price K, Morey S, Beilby J, Best J, McElroy H, Pluck S, Eley V: Evaluation of the Enhanced Primary Care Med- ical Benefits Schedule Items and the General Practice Edu- cation, Support and Community Linkages Program. Final Report. Canberra: Australian Department of Health and Ageing; 3. Wilkinson D, McElroy H, Beilby J, Mott K, Price K, Morey S, Best J: Variation in levels of uptake of enhanced primary care item numbers between rural and urban settings, November 1999 to October 2001. Aust Health Rev 2002, 25(6):123-30. 4. Byles JE: A thorough going over: Evidence for health assess- ments for older persons. Aust N Z J Public Health 2000, 24(2):117-123. 5. Byles JE, Tavener M, O'Connell RL, Nair BR, Higginbotham NH, Jack- son CL, Mckernon ME, Francis L, Heller RF, Newbury JW, Marley JE, Goodger BG: Randomised control trial of health assessments for older Australian veterans and war widows. Med J Aust 2004, 181(4):186-190. 6. Wilkinson D, McElroy H, Beilby J, Mott K, Price K, Morey S, Best J: Uptake of health assessments, care plans and case confer- ences by general practitioners through the Enhanced Pri- mary Care program between November 1999 and October 2001. Aust Health Rev 2002, 25(4):1-11. 7. Australian Institute of Health and Welfare (AIHW): Expenditures on health services for Aboriginal and Torres Strait Islander people 1998–99. Canberra: AIHW and Commonwealth Depart- ment of Health and Aged Care; 2001. AIHW cat no. IHW 8. Department of Health and Ageing: New Medicare Checks for Indigenous Australians. [http://www.health.gov.au/internet/ wcms/publishing.nsf/Content/health-mediarel-yr2004-ta- abb052.htm]. 9. Mayers NR, Couzos S: Towards equity through an adult health check for Aboriginal and Torres Strait Islander people. Med J Aust 2004, 181(10):531-532. 10. Trewin D, Madden R: The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2003. Can- berra: Australian Institute of Heath and Welfare (AIHW) and Austral- ian Bureau of Statistics; 2004. ABS Catalogue no. 4704.0 AIHW Catalogue no. IHW11 ISSN 1441–2004 11. Miller G, McDermott R, McCulloch B, Leonard D, Arabena K, Muller Publish with Bio Med Central and every R: The Well Person's Health Check: A population screening scientist can read your work free of charge program in indigenous communities in north Queensland. "BioMed Central will be the most significant development for Aust Health Rev 2004, 25(6):1-11. 12. Health Insurance Commission: Medicare. [http://www.hic.gov.au/ disseminating the results of biomedical researc h in our lifetime." providers/health_statistics/statistical_reporting/medicare.htm.]. Sir Paul Nurse, Cancer Research UK accessed March 2005 13. Australian Bureau of Statistics (ABS): Experimental Estimates Your research papers will be: and Projections, Aboriginal and Torres Strait Islander available free of charge to the entire biomedical community Australians. Canberra: ABS; 2004. ABS catalogue no. 3238.0 14. Australian Bureau of Statistics (ABS): Experimental Projections of peer reviewed and published immediately upon acceptance the Aboriginal and Torres Strait Islander Population. Can- cited in PubMed and archived on PubMed Central berra: ABS. ABS catalogue no. 3231.0 yours — you keep the copyright 15. Australian Bureau of Statistics (ABS): Population by Age and Sex, Australian States and Territories. Canberra: ABS; 2004. Time BioMedcentral Submit your manuscript here: Series Spreadsheet 3201.0 http://www.biomedcentral.com/info/publishing_adv.asp Page 7 of 7 (page number not for citation purposes)

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Australia and New Zealand Health PolicySpringer Journals

Published: Sep 9, 2005

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