Patterns of health workforce turnover and retention in Aboriginal Community Controlled Health Services in remote communities of the Northern Territory and Western Australia, 2017-2019.

BACKGROUND: Aboriginal Community Controlled Health Services (ACCHSs) in Australia aim to optimise access to comprehensive and culturally safe primary health care (PHC) for Aboriginal populations. Central to quality service provision is the retention of staff. However, there is lack of published research reporting patterns of staff turnover and retention specific to ACCHSs. This study quantified staff turnover and retention in regional and remote ACCHSs in the Northern Territory (NT) and Western Australia (WA), and examined correlations between turnover and retention metrics, and ACCHSs' geographical and demographic characteristics. METHODS: The study used 2017-2019 payroll data for health workers in 22 regional and remote PHC clinics managed by 11 ACCHSs. Primary outcome measures included annual turnover and 12-month stability rates, calculated at both clinic and organisation levels. RESULTS: There was a median of five client-facing (Aboriginal health practitioners, allied health professionals, doctors, nurses/midwives, and 'other health workers' combined) and two non-client-facing (administrative and physical) staff per remote clinic, at any timepoint. Mean annual turnover rates for staff were very high, with 151% turnover rates at the clinic level and 81% turnover rates at the organisation level. Mean annual turnover rates for client-facing staff were 164% and 75%, compared to 120% and 98% for non-client-facing staff, at clinic and organisational levels, respectively. Mean 12-month stability rates were low, with clinic-level stability rates of only 49% and organisation-level stability rates of 58%. Mean annual clinic-level turnover rates were 162% for non-Aboriginal staff and 81% for Aboriginal staff. Both workforce metrics were moderately to highly correlated with the relative remoteness of clinics, size of regular clients serviced, and average annual headcount of employees in each clinic (p values < 0.01). CONCLUSIONS: Participating ACCHSs in remote NT and WA have very high turnover and low retention of healthcare staff. Overall, clinic-level turnover rates increase as distance from regional centres increases and are lower for Aboriginal staff, suggesting that greater employment of Aboriginal staff could help stabilise staffing. Improved retention could reduce burden on ACCHSs' resources and may also support quality of service delivery due to improved cultural safety and continuity of care.

Determining the Optimal Methodology for Identifying Incident Stroke Deaths Using Administrative Datasets Within Australia.

BACKGROUND AND AIM: Quantifying stroke incidence and mortality is crucial for disease surveillance and health system planning. Administrative data offer a cost-effective alternative to "gold standard" population-based studies. However, the optimal methodology for establishing stroke deaths from administrative data remains unclear. We aimed to determine the optimal method for identifying stroke-related deaths in administrative datasets as the fatal component of stroke incidence, comparing counts derived using underlying and all causes of death (CoD). METHOD: Using whole-population multijurisdictional person-level linked data from hospital and death datasets from South Australia, the Northern Territory, and Western Australia, we identified first-ever stroke events between 2012 and 2015, using underlying CoD and all CoD to identify fatal stroke counts. We determined the 28-day case fatality for both counts and compared results with gold standard Australian population-based stroke incidence studies. RESULTS: The total number of incident stroke events was 16,150 using underlying CoD and 18,074 using all CoD. Case fatality was 24.7% and 32.7% using underlying and all CoD, respectively. Case fatality using underlying CoD was similar to that observed in four Australian "gold standard" population-based studies (20%-24%). CONCLUSIONS: Underlying CoD generates fatal incident stroke estimates more consistent with population-based studies than estimates based on stroke deaths identified from all-cause fields in death registers.

Risk of kidney disease following a pregnancy complicated by diabetes: a longitudinal, population-based data-linkage study among Aboriginal women in the Northern Territory, Australia.

AIMS/HYPOTHESIS: The aim of this work was to investigate the risk of developing chronic kidney disease (CKD) or end-stage kidney disease (ESKD) following a pregnancy complicated by gestational diabetes mellitus (GDM) or pre-existing diabetes among Aboriginal women in the Northern Territory (NT), Australia. METHODS: We undertook a longitudinal study of linked healthcare datasets. All Aboriginal women who gave birth between 2000 and 2016 were eligible for inclusion. Diabetes status in the index pregnancy was as recorded in the NT Perinatal Data Collection. Outcomes included any stage of CKD and ESKD as defined by ICD-10 coding in the NT Hospital Inpatient Activity dataset between 2000 and 2018. Risk was compared using Cox proportional hazards regression. RESULTS: Among 10,508 Aboriginal women, the mean age was 23.1 (SD 6.1) years; 731 (7.0%) had GDM and 239 (2.3%) had pre-existing diabetes in pregnancy. Median follow-up was 12.1 years. Compared with women with no diabetes during pregnancy, women with GDM had increased risk of CKD (9.2% vs 2.2%, adjusted HR 5.2 [95% CI 3.9, 7.1]) and ESKD (2.4% vs 0.4%, adjusted HR 10.8 [95% CI 5.6, 20.8]). Among women with pre-existing diabetes in pregnancy, 29.1% developed CKD (adjusted HR 10.9 [95% CI 7.7, 15.4]) and 9.9% developed ESKD (adjusted HR 28.0 [95% CI 13.4, 58.6]). CONCLUSIONS/INTERPRETATION: Aboriginal women in the NT with GDM or pre-existing diabetes during pregnancy are at high risk of developing CKD and ESKD. Pregnancy presents an important opportunity to identify kidney disease risk. Strategies to prevent kidney disease and address the social determinants of health are needed.

Incidence of Stroke in the Aboriginal and Non-Aboriginal Populations of Australia: A Data Linkage Study.

BACKGROUND: Most estimates of stroke incidence among Aboriginal and Torres Strait Islander (hereinafter Aboriginal) Australians are confined to single regions and include small sample sizes. We aimed to measure and compare stroke incidence in Aboriginal and non-Aboriginal residents across central and western Australia. METHODS: Whole-population multijurisdictional person-linked data from hospital and death datasets were used to identify stroke admissions and stroke-related deaths (2001-2015) in Western Australia, South Australia, and the Northern Territory. Fatal (including out-of-hospital deaths) and nonfatal incident (first-ever) strokes in patients aged 20-84 years were identified during the 4-year study period (2012-2015), using a 10-year lookback period to exclude people with prior stroke. Incidence rates per 100 000 population/year were estimated for Aboriginal and non-Aboriginal populations, age-standardized to the World Health Organization World Standard population. RESULTS: In a population of 3 223 711 people (3.7% Aboriginal), 11 740 incident (first-ever) strokes (20.6% regional/remote location of residence; 15.6% fatal) were identified from 2012 to 2015, 675 (5.7%) in Aboriginal people (73.6% regional/remote; 17.0% fatal). Median age of Aboriginal cases (54.5 years; 50.1% female) was 16 years younger than non-Aboriginal cases (70.3 years; 44.1% female; P<0.001), with significantly greater prevalence of comorbidities. Age-standardized stroke incidence in Aboriginal people (192/100 000 [95% CI, 177-208]) was 2.9-fold greater than in non-Aboriginal people (66/100 000 [95% CI, 65-68]) aged 20-84 years; fatal incidence was 4.2-fold greater (38/100 000 [95% CI, 31-46] versus 9/100 000 [95% CI, 9-10]). Disparities were particularly apparent at younger ages (20-54 years), where age-standardized stroke incidence was 4.3-fold greater in Aboriginal people (90/100 000 [95% CI, 81-100]) than non-Aboriginal people (21/100 000 [95% CI, 20-22]). CONCLUSIONS: Stroke occurred more commonly, and at younger ages, in Aboriginal than non-Aboriginal populations. Greater prevalence of baseline comorbidities was present in the younger Aboriginal population. Improved primary prevention is required. To optimize stroke prevention, interventions should include culturally appropriate community-based health promotion and integrated support for nonmetropolitan health services.

Suicides in Aboriginal and non-Aboriginal people following hospital admission for suicidal ideation and self-harm: A retrospective cohort data linkage study from the Northern Territory.

PURPOSE: This study aimed to explore risk factors for suicide in Aboriginal and non-Aboriginal people following hospital admission for suicidal ideation and self-harm in the Northern Territory, Australia to help clarify opportunities for improved care and intervention for these population groups. METHODS: Individuals with at least one hospital admission involving suicidal ideation and/or self-harm between 1 July 2001 and 31 December 2013 were retrospectively recruited and followed up using linked mortality records to 31 December 2014. Survival analyses stratified by Indigenous status identified socio-demographic and clinical characteristics from index hospital admissions associated with suicide. RESULTS: Just over half of the 4391 cohort members identified as Aboriginal (n = 2304; 52.4%). By 2014, 281 deaths were observed comprising 68 suicides, representing a 2.6% and 2.0% probability of suicide for Aboriginal and non-Aboriginal people, respectively. After adjusting for other characteristics, a higher risk of suicide was associated with male sex (Aboriginal adjusted hazard ratio: 4.14; 95% confidence interval: [1.76, 9.75]; non-Aboriginal adjusted hazard ratio: 5.96; 95% confidence interval: [1.98, 17.88]) and repeat hospital admissions involving self-harm (Aboriginal adjusted hazard ratio: 1.37; 95% confidence interval: [1.21, 1.55]; non-Aboriginal adjusted hazard ratio: 1.29; 95% confidence interval: [1.10, 1.51]). Severe mental disorders were associated with a four times higher risk of suicide (adjusted hazard ratio: 4.23; 95% confidence interval: [1.93, 9.27]) in Aboriginal people only. CONCLUSION: The findings highlight non-clinical risk factors for suicide that suggest the need for comprehensive psychosocial assessment tailored to Aboriginal and non-Aboriginal people hospitalised with suicidal ideation or self-harm. Implementing appropriate management and aftercare within a broader public health framework is needed to support recovery and reduce long-term suicide risk in the community, especially for Aboriginal people and males.

The extent of violence inflicted on adolescent Aboriginal girls in the Northern Territory.

BACKGROUND: Australian Aboriginal and Torres Strait Islander women are at very high risk of violence but there is little evidence about the age at which their higher exposure to violence commences. The aim of this study was to investigate violence inflicted on Aboriginal girls during childhood and adolescence, relative to Aboriginal boys and non-Aboriginal girls. METHODS: This was a retrospective cohort study using de-identified administrative data for NT residents aged 0-17 years. This study used linked hospital and child protection data to investigate hospitalization for injury caused by assault and substantiated child maltreatment involving violence (physical and sexual abuse). RESULTS: The incidence of assault hospitalization and substantiated physical/sexual abuse was much higher for Aboriginal than non-Aboriginal adolescents but similar for girls and boys to about age ten, then increased much more for Aboriginal girls than boys. In the 14-17 age-group, assault hospitalization incidence was 125% higher for Aboriginal girls than boys but 56% lower for non-Aboriginal girls than boys. 4.6% of Aboriginal girls were hospitalized (30.9% more than once) for assault between twelfth and eighteenth birthdays, compared to 3.4% of Aboriginal boys and 0.3% of non-Aboriginal girls. The incidence of assault hospitalization during adolescence was over three times higher for Aboriginal children who had substantiated child maltreatment during childhood. CONCLUSION: The very high levels of violence suffered by Aboriginal women commence in the pre-teen years. Non-Aboriginal girls are 'protected' from the rising levels of violence that boys experience as they progress through adolescence, but Aboriginal girls are not afforded such protection.

Opportunities for prevention: a data-linkage study to inform a public health response to youth offending in the Northern Territory, Australia.

BACKGROUND: Numerous studies have demonstrated a strong link between child maltreatment and subsequent youth offending, leading to calls for early intervention initiatives. However, there have been few whole-population studies into the dimensions of statutory child maltreatment responses that can inform these programs. The aim of this study was to investigate the sex-specific association between level and timing of child protection system (CPS) contact and youth offending. METHODS: This retrospective cohort study used linked individual-level records from multiple agencies, for 10,438Aboriginal children born in the Northern Territory between 1999 and 2006. The outcome measure was the first alleged offence. Key explanatory variables were level (no contact through to out-of-home care) and timing (0-4 years, 5-9 years, or both) of CPS contact. The Kaplan-Meier method was used to estimate cumulative incidence and a flexible parametric survival model to estimate hazard ratios (HR). RESULTS: Children with no record of CPS contact before age 10 had the lowest cumulative incidence of first alleged offence by age 18 (boys: 23.4% [95%CI:21.0-26.1]; girls: 6.6% [95%CI:5.3-8.2]) and those with a record of out-of-home care the highest CI (boys: 45.5% [95%CI:37.0-54.9]; girls: 18.6% [95%CI:13.0-26.2]). The association of CPS contact with the relative risk of a first alleged offence was greatest for children aged 10-13 years and decreased with age. Timing of CPS contact was also associated with increasing cumulative incidence. The relative risk for first alleged offence was generally higher for children with CPS contact, of any type, during both developmental phases including notifications during both phases (boys, HR at age 11: 8.9 [95%CI:4.2-17.2]; girls, HR at age 11: 13.7 [95%CI:3.8-48.9]) and substantiations during both phases (boys, HR at age 11: 17.0 [95%CI:9.6-30.0]; girls, HR at age 11: 54.1 [95%CI:18.1-162]). CONCLUSION: The increased risk of offending associated with level and timing of early CPS contact highlights opportunities for a differentiated public health response to improve life trajectories for children and to reduce youth crime. Although children with unsubstantiated notifications of maltreatment do not meet the criteria for a statutory CPS response, the higher risk of offending among these children supports their inclusion in targeted preventive interventions.

The link between hearing impairment and child maltreatment among Aboriginal children in the Northern Territory of Australia: is there an opportunity for a public health approach in child protection?

BACKGROUND: International studies provide evidence of an association between child disabilities, including hearing impairment (HI), and child maltreatment. There are high prevalences of ear disease with associated HI, and child maltreatment among Australian Aboriginal children, but the link between HI and child maltreatment is unknown. This study investigates the association between HI and child maltreatment for Aboriginal children living in the Northern Territory (NT) of Australia. METHODS: This was a retrospective cohort study of 3895 Aboriginal school-aged children (born between 1999 and 2008) living in remote NT communities. The study used linked individual-level information from health, education and child protection services. The outcome variables were child maltreatment notifications and substantiations. The key explanatory variable, HI, was based on audiometric assessment. The Kaplan-Meier estimator method was used in univariate analysis; Cox proportional hazards regression was used in multivariable analysis. RESULTS: A majority of the study cohort lived in very remote (94.5%) and most disadvantaged (93.1%) regions. Among all children in the study cohort, 56.1% had a record of either HI or unilateral hearing loss (UHL), and for those with a history of contact with child protection services (n = 2757), 56.7% had a record of HI/UHL (n = 1564). In the 1999-2003 birth cohort, by age 12 years, 53.5% of children with a record of moderate or worse HI had at least one maltreatment notification, compared to 47.3% of children with normal hearing. In the 2004-2008 cohort, the corresponding results were 83.4 and 71.7% respectively. In multivariable analysis, using the full cohort, children with moderate or worse HI had higher risk of any child maltreatment notification (adjusted Hazard Ratios (adjHR): 1.16, 95% CI:1.04-1.30), notification for neglect (adjHR:1.17, 95% CI:1.04-1.31) and substantiation (adjHR:1.20, 95% CI:1.04-1.40), than children with normal hearing. In the 2004-2008 birth cohort, children with moderate or worse HI had higher risk of a substantiated episode of physical abuse (adjHR:1.47, 95% CI:1.07-2.03) than children with normal hearing. CONCLUSION: Our findings demonstrate the urgent need for HI and child maltreatment prevention strategies through raised community awareness and inter-agency collaboration. Effective information-sharing between service providers is a critical first step to a public health approach in child protection.

The impact of hearing impairment on early academic achievement in Aboriginal children living in remote Australia: a data linkage study.

BACKGROUND: The prevalence of otitis media (OM) and related hearing loss has remained persistently high among some groups of Australian Aboriginal children who are also reported to have poor academic outcomes. The general literature remains inconclusive about the association between OM-related hearing loss and academic performance in primary school. This study aimed to investigate this association in Aboriginal children living in the Northern Territory (NT) of Australia. METHODS: A retrospective, observational cohort study was conducted for 2208 NT Aboriginal children, aged about 8 years, living in remote and very remote communities. The explanatory variable was audiometrically determined hearing level as recorded in the Remote Hearing Assessment dataset. The outcome variable consisted of scale scores in the five domains of the National Assessment Program - Literacy and Numeracy (NAPLAN) for Year 3. Other linked datasets used in the study included school attendance records, perinatal records and community level information on relative remoteness, socioeconomic disadvantage and housing crowdedness. Fixed effects linear regression models were used for statistical analyses. RESULTS: Compared with children with normal hearing and after controlling for a range of covariates, children with mild hearing impairment (HI) scored lower in Writing and Spelling by 15.0 points (95% CI: - 22.4 to - 7.6, p < 0.0005) and 5.0 points (95% CI: - 9.6 to - 0.3, p = 0.037), equivalent to 7.3 and 2.1% of the mean score, respectively. Children with moderate or worse HI scored lower in Writing and Numeracy by 13.4 points (95% CI, - 24.8 to - 1.9, p = 0.022) and 15.2 points (95% CI, - 27.6 to - 2.7, p = 0.017), both equivalent to 6.3% of the mean score the respective domain. Other factors associated with poorer NAPLAN results included being male, lower Year 2 school attendance, low birthweight, average household size> 5 persons, living in a very remote community and speaking English as a second language. CONCLUSIONS: OM-related HI was independently associated with poorer early year academic achievement in Aboriginal children living in remote NT communities. Interventions to improve academic outcomes for Aboriginal children must incorporate actions to address the negative impact associated with HI through early detection, effective treatment and ongoing support for affected children.

Impact of hearing impairment on early childhood development in Australian Aboriginal children: A data linkage study.

AIM: To investigate the association between hearing impairment (HI) and measures of early childhood development in Aboriginal children at age 5 years. METHODS: An observational cohort study (n = 1037) of children aged 4.0-7.3 years (median 5.4 years), living in remote Northern Territory (NT) communities, was conducted using multiple linked administrative datasets, including the NT Perinatal Data Register, Remote Hearing Assessment records (2007-2015) and Australian Early Development Censuses (AEDC, 2009, 2012 and 2015). Outcome measures were summary and domain-specific AEDC results using both dichotomous and continuous variables (domain scores). RESULTS: Compared with normal hearing children, after adjustment for selected confounding factors, those with moderate or worse HI had an adjusted odds ratio of 1.69 (95% confidence interval (CI), 1.03-2.77) for being developmentally vulnerable in two or more of the five AEDC domains. Children with mild HI and those with moderate to worse HI had lower domain score sum by -1.60 (95% CI, -3.02 to -0.18) and - 2.40 (95% CI, -4.50 to -0.30), respectively. There was also evidence for an association between HI and poorer outcomes in the 'language and cognitive skills', 'communication skills and general knowledge' and 'physical health and wellbeing' domains. CONCLUSIONS: Otitis media-related HI is associated with increased risk for poorer outcomes in early childhood development and this risk appears to increase with higher levels of HI. Prevention and early treatment of otitis media will reduce both the disease and the associated negative impact on early child development, especially the development of language, cognitive and communication skills and physical health and wellbeing.

Remote health workforce turnover and retention: what are the policy and practice priorities?

BACKGROUND: Residents of remote communities in Australia and other geographically large countries have comparatively poorer access to high-quality primary health care. To inform ongoing policy development and practice in relation to remote area health service delivery, particularly in remote Indigenous communities, this review synthesizes the key findings of (1) a comprehensive study of workforce turnover and retention in remote Northern Territory (NT) of Australia and (2) a narrative review of relevant international literature on remote and rural health workforce retention strategies. This synthesis provides a valuable summary of the current state of international knowledge about improving remote health workforce retention. MAIN TEXT: Annual turnover rates of NT remote area nurses (148%) and Aboriginal health practitioners (80%) are very high and 12-month stability rates low (48% and 76%, respectively). In remote NT, use of agency nurses has increased substantially. Primary care costs are high and proportional to staff turnover and remoteness. Effectiveness of care decreases with higher turnover and use of short-term staff, such that higher staff turnover is always less cost-effective. If staff turnover in remote clinics were halved, the potential savings would be approximately A$32 million per annum. Staff turnover and retention were affected by management style and effectiveness, and employment of Indigenous staff. Review of the international literature reveals three broad themes: Targeted enrolment into training and appropriate education designed to produce a competent, accessible, acceptable and 'fit-for-purpose' workforce; addressing broader health system issues that ensure a safe and supportive work environment; and providing ongoing individual and family support. Key educational initiatives include prioritising remote origin and Indigenous students for university entry; maximising training in remote areas; contextualising curricula; providing financial, pedagogical and pastoral support; and ensuring clear, supported career pathways and continuing professional development. Health system initiatives include ensuring adequate funding; providing adequate infrastructure including fit-for-purpose clinics, housing, transport and information technology; offering flexible employment arrangements whilst ensuring a good 'fit' between individual staff and the community (especially with regard to cultural skills); optimising co-ordination and management of services that empower staff and create positive practice environments; and prioritising community participation and employment of locals. Individual and family supports include offering tailored financial incentives, psychological support and 'time out'. CONCLUSION: Optimal remote health workforce stability and preventing excessive 'avoidable' turnover mandates alignment of government and health authority policies with both health service requirements and individual health professional and community needs. Supportive underpinning policies include: Strong intersectoral collaboration between the health and education sectors to ensure a fit-for-purpose workforce;A funding policy which mandates the development and implementation of an equitable, needs-based formula for funding remote health services;Policies that facilitate transition to community control, prioritise Indigenous training and employment, and mandate a culturally safe work context; andAn employment policy which provides flexibility of employment conditions in order to be able to offer individually customised retention packages There is considerable extant evidence from around the world about effective retention strategies that contribute to slowing excessive remote health workforce turnover, resulting in significant cost savings and improved continuity of care. The immediate problem comprises an 'implementation gap' in translating empirical research evidence into actions designed to resolve existing problems. If we wish to ameliorate the very high turnover of staff in remote areas, in order to provide an equitable service to populations with arguably the highest health needs, we need political and executive commitment to get the policy settings right and ensure the coordinated implementation of multiple strategies, including better linking existing strategies and 'filling the gaps' where necessary.

Does delay in planned diabetes care influence outcomes for aboriginal Australians? A study of quality in health care.

BACKGROUND: To examine the association between delay in planned diabetes care and quality of outcomes. METHODS: A retrospective analysis of primary care and inpatient records for 2567 Aboriginal patients, with diabetes, living in 49 remote communities in the Northern Territory of Australia. Poisson regression was used to estimate the association between delay from diagnosis to documented diabetes care plan and three outcome measures: mean HbA1c level, most recent blood pressure and number of diabetes-related hospital admissions. RESULTS: Compared with no delay (< 60 days), patients with delay had increased risk of elevated mean HbA1c: 60 days to < 2 years, incidence rate ratio (IRR), 1.2 (95% CI:1.07-1.39); 2 years to < 4 years, incidence rate ratio (IRR), 1.2 (95% CI:1.04-1.45); 4 years and over, incidence rate ratio (IRR), 1.3 (95% CI:1.12-1.52). There was no evidence of association between delay and optimal blood pressure control. Risk of diabetes-related admission increased with increased delay. Compared with no delay the IRRs for delay were: 60 days to < 2 years, 1.2 (95% CI:1.07-1.42); 2 to < 4 years, 1.3 (95% CI: 1.15-1.58): and 4 years and over, 2.6 (95% CI,2.28-3.08). CONCLUSION: The study found that a timely diabetes care plan was associated with better short-term blood glucose control and fewer diabetes-related admissions but not with improved blood pressure control. Delays may be a result of both patient and service-related factors.

What birthweight percentile is associated with optimal perinatal mortality and childhood education outcomes?

BACKGROUND: Small for gestational age, defined as birthweight <10th percentile for gestational age, is known to be associated with clinically meaningful impairments in health and development. The effects of variation within the normal range of birthweight percentile on perinatal mortality and childhood education remain less well defined. OBJECTIVE: We sought to quantify the association among birthweight percentile, perinatal mortality, and educational outcomes and to determine the optimal birthweight percentile for those outcomes in Aboriginal and non-Aboriginal Australian children. STUDY DESIGN: This was a retrospective cohort study. Perinatal data for all children born in the Northern Territory, Australia, from 1999 through 2008 were linked to measures of educational attainment at age 8-9 years. Multivariable analysis was used to determine the optimal birthweight percentile for low perinatal mortality and high reading and numeracy scores. RESULTS: The birth cohort contained 35,239 births (42% Aboriginal), of which 11,214 had linked and valid education records. Median birthweight percentile was 29.2 in Aboriginal infants and 44.0 in non-Aboriginal infants. The odds of perinatal mortality decreased by 4% with each 1-percentile increase birthweight percentile overall (adjusted odds ratio, 0.96; P = .000) and lowest mortality rates were at the 61st and 78th percentile in Aboriginal and non-Aboriginal infants, respectively. Although birthweights <10th percentile were associated with greatly increased odds of perinatal mortality, the increased risk extended well beyond this cut-off. Birthweight percentile was also positively correlated with scores in reading (P = .000) and numeracy (P = .000). In non-Aboriginal children, reading and numeracy scores peaked at the 66th percentile, but for Aboriginal children there was continuous benefit with increasing birthweight percentile. Birthweight percentile explained 1% of the variation in education outcomes, with much greater variation explained by other perinatal and sociodemographic factors. CONCLUSION: Birthweights between the 50th-93rd percentiles were most consistently associated with both low perinatal mortality and high reading and numeracy scores, suggesting that small for gestational age does not sufficiently capture the risks associated with variation in fetal growth. Our data indicate that the effect of birthweight percentile accounts for 1% of variation in perinatal and education outcomes.

Estimating the total prevalence and incidence of end-stage kidney disease among Aboriginal and non-Aboriginal populations in the Northern Territory of Australia, using multiple data sources.

BACKGROUND: Most estimates for End Stage Kidney Disease (ESKD) prevalence and incidence are based on renal replacement therapy (RRT) registers. However, not all people with ESKD will commence RRT and estimates based only on RRT registry data will underestimate the true burden of ESKD in the community. This study estimates the total number of Northern Territory (NT) residents with ESKD including: those receiving RRT, those diagnosed but not receiving RRT and an estimate of "undiagnosed" cases. METHODS: Four data sources were used to identify NT residents with a diagnosis of ESKD: public hospital admissions, Australia and New Zealand Dialysis and Transplant Registry registrations, death registrations and, for the Aboriginal population only, electronic primary care records. Three data sources contained information recorded between 1 July 2008 and 31 December 2013, death registration data extended to 31 December 2014 to capture 2013 prevalent cases. A capture-recapture method was used to estimate both diagnosed and undiagnosed cases by making use of probability patterns of overlapping multiple data sources. RESULTS: In 2013, the estimated ESKD prevalence in the NT Aboriginal population was 11.01 (95% confidence interval (CI) 10.24-11.78) per 1000, and 0.90 (95% CI 0.76-1.05) per 1000 in the NT non-Aboriginal population. The age-adjusted rates were 17.97 (95% CI 17.82-18.11) and 1.07 (95% CI 1.05-1.09) per 1000 in the NT Aboriginal and non-Aboriginal populations respectively. The proportion of individuals receiving RRT was 71.4% of Aboriginal and 75.5% of non-Aboriginal prevalent ESKD cases. The age-adjusted ESKD incidence was also greater for the Aboriginal (5.26 (95% CI 4.44-6.08) per 1000 population) than non-Aboriginal population (0.36 (95% CI 0.25-0.47) per 1000). CONCLUSION: This study provides comprehensive estimates of the burden of ESKD including those cases that are not identified in relevant health data sources. The results are important for informing strategies to reduce the total burden of ESKD and to manage the potential unmet demand, particularly from comparatively young Aboriginal patients who may be suitable for RRT but do not currently access the services for social, geographic or cultural reasons.

Progress in closing the gap in life expectancy at birth for Aboriginal people in the Northern Territory, 1967-2012.

OBJECTIVES: To compare long term changes in mortality and life expectancy at birth (LE) of Aboriginal people in the Northern Territory and of the overall Australian population; to determine the contributions of changes in mortality in specific age groups to changes in LE for each population. DESIGN, SETTING, PARTICIPANTS: Retrospective trend analysis of death and LE data for the NT Aboriginal and Australian populations, 1967-2012. MAIN OUTCOME MEASURES: LE estimates based on abridged life tables; mortality estimates (deaths per 100 000 population); and age decomposition of LE changes by sex and time period. RESULTS: Between 1967 and 2012, LE increased for both NT Aboriginal and all Australians; the difference in LE between the two populations declined by 4.6 years for females, but increased by one year for males. Between 1967-1971 and 1980-1984, LE of NT Aboriginal people increased rapidly, particularly through reduced infant mortality; from 1980-1984 to 1994-1998, there was little change; from 1994-1998 to 2008-2012, there were modest gains in older age groups. Decomposition by age group identified the persistent and substantial contribution of the 35-74-year age groups to the difference in LE between NT Aboriginal people and all Australians. CONCLUSIONS: Early gains in LE for NT Aboriginal people are consistent with improvements in nutrition, maternal and infant care, and infectious disease control. A rapid epidemiological transition followed, when LE gains in younger age groups plateaued and non-communicable diseases became more prevalent. Recent LE gains, across all adult age groups, are consistent with improved health service access and chronic disease management. If LE is to continue improving, socio-economic disadvantage and its associated risks must be reduced.

Patterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013-2015.

BACKGROUND: The geographical maldistribution of the health workforce is a persisting global issue linked to inequitable access to health services and poorer health outcomes for rural and remote populations. In the Northern Territory (NT), anecdotal reports suggest that the primary care workforce in remote Aboriginal communities is characterised by high turnover, low stability and high use of temporary staffing; however, there is a lack of reliable information to guide workforce policy improvements. This study quantifies current turnover and retention in remote NT communities and investigates correlations between turnover and retention metrics and health service/community characteristics. METHODS: This study used the NT Department of Health 2013-2015 payroll and financial datasets for resident health workforce in 53 remote primary care clinics. Main outcome measures include annual turnover rates, annual stability rates, 12-month survival probabilities and median survival. RESULTS: At any time point, the clinics had a median of 2.0 nurses, 0.6 Aboriginal health practitioners (AHPs), 2.2 other employees and 0.4 additional agency-employed nurses. Mean annual turnover rates for nurses and AHPs combined were extremely high, irrespective of whether turnover was defined as no longer working in any remote clinic (66%) or no longer working at a specific remote clinic (128%). Stability rates were low, and only 20% of nurses and AHPs remain working at a specific remote clinic 12 months after commencing. Half left within 4 months. Nurse and AHP turnover correlated with other workforce measures. However, there was little correlation between most workforce metrics and health service characteristics. CONCLUSIONS: NT Government-funded remote clinics are small, experience very high staff turnover and make considerable use of agency nurses. These staffing patterns, also found in remote settings elsewhere in Australia and globally, not only incur higher direct costs for service provision-and therefore may compromise long-term sustainability-but also are almost certainly contributing to sub-optimal continuity of care, compromised health outcomes and poorer levels of staff safety. To address these deficiencies, it is imperative that investments in implementing, adequately resourcing and evaluating staffing models which stabilise the remote primary care workforce occur as a matter of priority.

Frequent use of hospital inpatient services during a nine year period: a retrospective cohort study.

BACKGROUND: Frequent use (FU) of hospital services impacts on patients and health service expenditure. Studies examining FU in emergency departments and inpatient settings have found heterogeneity and the need to differentiate between potentially preventable FU and that associated with ongoing management of complex conditions. Psychosocial factors have often been reported as underpinning or exacerbating the phenomena. Most FU studies have been limited by time, to a single study site, or restricted to specific diagnoses or patient groups. This study provides a comprehensive description of adult patient characteristics, conditions and risk factors associated with FU, based on admissions to the five public hospitals in the Northern Territory (NT) of Australia over a nine year period. The study population is distinctive comprising both Aboriginal and non-Aboriginal patients. METHODS: Data on all inpatient episodes in NT public hospitals between 2005 and 2013 was analysed to identify patients with any FU (four or more episodes within any 12-month period) and measure FU duration (number of FU years) and intensity (mean number of episodes per FU year). Pregnancy, alcohol-related and mental health condition flags were assigned to patients with any episode with relevant diagnoses during the study period. Multivariate analysis was used to assess factors associated with any FU, FU duration and FU intensity, separately for Aboriginal and non-Aboriginal patients. RESULTS: Of people with any inpatient episodes during the study period, 13.6% were frequent users (Aboriginal 22%, non-Aboriginal 10%) accounting for 46.6% of all episodes. 73% of frequent users had only one FU year. Any FU and increased FU duration were more common among individuals who were: Aboriginal; older; female; and those with a pregnancy, alcohol or mental health flag. Having two or more alcohol-related episodes in the nine-year period was strongly associated with any FU for both Aboriginal (odds ratio 8.9, 95% CI. 8.20-9.66) and non-Aboriginal patients (11.5, 9.92-13.26). CONCLUSION: For many people, frequent inpatient treatment is necessary and unavoidable. This study suggests that damage arising from excessive alcohol consumption (either personal or by others) is the single most avoidable factor associated with FU, particularly for Aboriginal people.

Long-term trends in supply and sustainability of the health workforce in remote Aboriginal communities in the Northern Territory of Australia.

BACKGROUND: International evidence suggests that a key to improving health and attaining more equitable health outcomes for disadvantaged populations is a health system with a strong primary care sector. Longstanding problems with health workforce supply and turnover in remote Aboriginal communities in the Northern Territory (NT), Australia, jeopardise primary care delivery and the effort to overcome the substantial gaps in health outcomes for this population. This research describes temporal changes in workforce supply in government-operated clinics in remote NT communities through a period in which there has been a substantial increase in health funding. METHODS: Descriptive and Markov-switching dynamic regression analysis of NT Government Department of Health payroll and financial data for the resident health workforce in 54 remote clinics, 2004-2015. The workforce included registered Remote Area Nurses and Midwives (nurses), Aboriginal Health Practitioners (AHPs) and staff in administrative and logistic roles. MAIN OUTCOME MEASURES: total number of unique employees per year; average annual headcounts; average full-time equivalent (FTE) positions; agency employed nurse FTE estimates; high and low supply state estimates. RESULTS: Overall increases in workforce supply occurred between 2004 and 2015, especially for administrative and logistic positions. Supply of nurses and AHPs increased from an average 2.6 to 3.2 FTE per clinic, although supply of AHPs has declined since 2010. Each year almost twice as many individual NT government-employed nurses or AHPs are required for each FTE position. Following funding increases, some clinics doubled their nursing and AHP workforce and achieved relative stability in supply. However, most clinics increased staffing to a much smaller extent or not at all, typically experiencing a "fading" of supply following an initial increase associated with greater funding, and frequently cycling periods of higher and lower staffing levels. CONCLUSIONS: Overall increases in workforce supply in remote NT communities between 2004 and 2015 have been affected by continuing very high turnover of nurses and AHPs, and compounded by recent declines in AHP supply. Despite substantial increases in resourcing, an imperative remains to implement more robust health service models which better support the supply and retention of resident health staff.

Trends in cancer incidence and survival for Indigenous and non-Indigenous people in the Northern Territory.

OBJECTIVE: To assess trends in cancer incidence and survival for Indigenous and non-Indigenous Australians in the Northern Territory. DESIGN: Retrospective analysis of population-based cancer registration data. SETTING: New cancer diagnoses in the NT, 1991-2012. MAIN OUTCOME MEASURES: Age-adjusted incidence rates; rate ratios comparing incidence in NT Indigenous and non-Indigenous populations with that for other Australians; 5-year survival; multivariable Poisson regression of excess mortality. RESULTS: The incidence of most cancers in the NT non-Indigenous population was similar to that for other Australians. For the NT Indigenous population, the incidence of cancer at several sites was much higher (v other Australians: lung, 84% higher; head and neck, 325% higher; liver, 366% higher; cervix, 120% higher). With the exception of cervical cancer (65% decrease), incidence rates in the Indigenous population did not fall between 1991-1996 and 2007-2012. The incidence of several other cancers (breast, bowel, prostate, melanoma) was much lower in 1991-1996 than for other Australians, but had increased markedly by 2007-2012 (breast, 274% increase; bowel, 120% increase; prostate, 116% increase). Five-year survival was lower for NT Indigenous than for NT non-Indigenous patients, but had increased for both populations between 1991-2000 and 2001-2010. CONCLUSION: The incidence of several cancers that were formerly less common in NT Indigenous people has increased, without a concomitant reduction in the incidence of higher incidence cancers (several of which are smoking-related). The excess burden of cancer in this population will persist until lifestyle risks are mitigated, particularly by reducing the extraordinarily high prevalence of smoking.

A retrospective population-based study of induction of labour trends and associated factors among aboriginal and non-aboriginal mothers in the northern territory between 2001 and 2012.

BACKGROUND: Induction of labour (IOL) has become more common among many populations, but the trends and drivers of IOL in the Northern Territory (NT) of Australia are not known. This study investigated trends in IOL and associated factors among NT Aboriginal and non-Aboriginal mothers between 2001 and 2012. METHODS: A retrospective analysis of all NT resident women who birthed in the NT between 2001 and 2012 at ≥32 weeks gestation. Demographic, medical and obstetric data were obtained from the NT Midwives' Collection. The prevalence of IOL was calculated by Aboriginal status and parity of the mother and year of birth. The prevalence of each main indication for induction among women was compared for 2001-2003 and 2010-2012. Linear and logistic regression was used to test for association between predictive factors and IOL in bivariate and multivariate analysis, separately for Aboriginal and non-Aboriginal mothers. RESULTS: A total of 42,765 eligible births between 2001 and 2012 were included. IOL was less common for Aboriginal than non-Aboriginal mothers in 2001 (18.0 % and 25.1 %, respectively), but increased to be similar to non-Aboriginal mothers in 2012 (22.6 % and 24.8 %, respectively). Aboriginal primiparous mothers demonstrated the greatest increase in IOL. The most common indication for IOL for both groups was post-dates, which changed little over time. Medical and obstetric complications were more common for Aboriginal mothers except late-term pregnancy. Prevalence of diabetes in pregnancy increased considerably among both Aboriginal and non-Aboriginal mothers, but was responsible for only a small proportion of IOLs. Increasing prevalence of risk factors did not explain the increased IOL prevalence for Aboriginal mothers. CONCLUSIONS: IOL is now as common for Aboriginal as non-Aboriginal mothers, though their demographic, medical and obstetric profiles are markedly different. Medical indications did not explain the recent increase in IOL among Aboriginal mothers; changes in maternal or clinical decision-making may have been involved.