Identifying the cultural heritage of patients during clinical handover and in hospital medical records.

OBJECTIVE: To examine the frequency of and rationale for hospital doctors mentioning a patient's cultural heritage (ethnicity, national heritage, religion) during medical handovers and in medical records. DESIGN: Four-phase observational study, including the covert observation of clinical handovers in an acute care unit (ACU) and analysis of electronic medical records (EMRs) of ACU patients after their discharge to ward-based care. SETTING, PARTICIPANTS: 1018 patients and the doctors who cared for them at a tertiary hospital in Western Australia, May 2016 - February 2018. MAIN OUTCOME MEASURE: References to patients' cultural heritage by ACU doctors during clinical handover (written or verbal) and by ward-based doctors in hospital EMRs (written only), by geographic ethnic-national group. RESULTS: In 2727 ACU clinical handovers of 1018 patients, 142 cultural heritage identifications were made (ethnicity, 84; nationality, 41; religion, 17); the rate was highest for Aboriginal patients (370 [95% CI, 293-460] identifications per 1000 handovers). 14 505 EMR pages were reviewed; 380 cultural heritage identifications (ethnicity, 257; nationality, 119; religion, 4) were recorded. A rationale for identification was documented for 25 of 142 patients (18%) whose ethnic-national background was mentioned during handover or in their EMR. Multivariate analysis (adjusted for demographic, socio-economic and medical factors) indicated that being an Aboriginal Australian was the most significant factor for identifying ethnic-national background (handovers: adjusted odds ratio [aOR], 21.7; 95% CI, 7.94-59.4; hospital EMRs: aOR, 13.6; 95% CI, 5.03-36.5). 44 of 75 respondents to a post-study survey (59%) were aware that Aboriginal heritage was mentioned more frequently than other cultural backgrounds. CONCLUSIONS: Explicitly mentioning the cultural heritage of patients is inconsistent and seldom explained. After adjusting for other factors, Aboriginal patients were significantly more likely to be identified than patients with other backgrounds.

Time to clinical investigation for Indigenous and non-Indigenous Queensland women after a high grade abnormal Pap smear, 2000-2009.

OBJECTIVES: To investigate time to follow-up (clinical investigation) for Indigenous and non-Indigenous women in Queensland after a high grade abnormality (HGA) being detected by Pap smear. DESIGN, SETTING, PARTICIPANTS: Population-based retrospective cohort analysis of linked data from the Queensland Pap Smear Register (PSR), the Queensland Hospital Admitted Patient Data Collection, and the Queensland Cancer Registry. 34 980 women aged 20-68 years (including 1592 Indigenous women) with their first HGA Pap smear result recorded on the PSR (index smear) during 2000-2009 were included and followed to the end of 2010. MAIN OUTCOME MEASURES: Time from the index smear to clinical investigation (histology test or cancer diagnosis date), censored at 12 months. RESULTS: The proportion of women who had a clinical investigation within 2 months of a HGA finding was lower for Indigenous (34.1%; 95% CI, 31.8-36.4%) than for non-Indigenous women (46.5%; 95% CI, 46.0-47.0%; unadjusted incidence rate ratio [IRR], 0.65; 95% CI, 0.60-0.71). This difference remained after adjusting for place of residence, area-level disadvantage, and age group (adjusted IRR, 0.74; 95% CI, 0.68-0.81). However, Indigenous women who had not been followed up within 2 months were subsequently more likely to have a clinical investigation than non-Indigenous women (adjusted IRR for 2-4 month interval, 1.21; 95% CI, 1.08-1.36); by 6 months, a similar proportion of Indigenous (62.2%; 95% CI, 59.8-64.6%) and non-Indigenous women (62.8%; 95% CI, 62.2-63.3%) had been followed up. CONCLUSIONS: Prompt follow-up after a HGA Pap smear finding needs to improve for Indigenous women. Nevertheless, slow follow-up is a smaller contributor to their higher cervical cancer incidence and mortality than their lower participation in cervical screening.

Global diversity, population stratification, and selection of human copy-number variation.

In order to explore the diversity and selective signatures of duplication and deletion human copy-number variants (CNVs), we sequenced 236 individuals from 125 distinct human populations. We observed that duplications exhibit fundamentally different population genetic and selective signatures than deletions and are more likely to be stratified between human populations. Through reconstruction of the ancestral human genome, we identify megabases of DNA lost in different human lineages and pinpoint large duplications that introgressed from the extinct Denisova lineage now found at high frequency exclusively in Oceanic populations. We find that the proportion of CNV base pairs to single-nucleotide-variant base pairs is greater among non-Africans than it is among African populations, but we conclude that this difference is likely due to unique aspects of non-African population history as opposed to differences in CNV load.

The effect of Maori ethnicity misclassification on cervical screening coverage.

AIM: There is a large difference in the cervical screening coverage rate between Maori and European women in New Zealand. This paper examines the extent to which this difference is due to misclassification of ethnicity. METHODS: Data from Waitemata District Health Board's two Primary Health Organisations (PHOs) was used to identify the population of Waitemata domiciled women aged 25-69 years eligible for cervical screening. Their cervical screening status was obtained from the National Cervical Screening Programme register (NCPS-R). Data from Auckland and Waitemata DHBs was used to determine the women's ethnicity in the National Health Index (NHI). Women who had withdrawn from the NCSP-R, women who were deceased and women for whom an NHI ethnicity code could not be obtained were excluded from the analysis. Ethnicity codes from the three sources (PHO registers, NCSP-R and NHI) were compared to identify women classified as non-Maori in the NCSP-R but Maori in either of the other two data sources. The effect on Maori cervical screening coverage rates of not counting these women was assessed. RESULTS: Within the study population there was a total of 6718 women identified as Maori on the NCSP of whom 5242 had been screened within the last 3 years and 1476 who had not. In addition to these, there were 2075 women identified as Maori in either the PHO or NHI databases but not in the NCSP-R who had been screened within the preceding 3 years, and a further 2094 who had not been screened. There were also 797 women identified as Maori in the NHI or PHO datasets who were not on the NCSP-R (and therefore were not screened). If all screened women classified as Maori from any source were counted, Waitemata DHB's Maori screening coverage rate would rise from 49.3% to 68.8% (or to 61.0% and 63.2% respective if just PHO and NHI Maori were counted). CONCLUSION: Misclassification of ethnicity could explain (in absolute terms) up to 19.5% of the 35.0% difference in cervical screening coverage rate between Maori and non-Maori , non-Pacific, non-Asian coverage in Waitemata District. Misclassification is likely to have similar effects on coverage estimates throughout New Zealand. Without improving the accuracy of ethnicity data in the NCSP-R it will be impossible for the country to achieve the target coverage rate of 80% among Maori.

Ethnic counts on mortality and census data 2001-06: New Zealand census-mortality study update.

AIM: To provide an update for the assessment of discrepancies in ethnicity counts in the 2001 census and mortality data for the 2004-2006 period. METHODS: 2001 census anonymously and probabilistically linked to 5 years of subsequent mortality data (135,849 eligible mortality records), allowing a comparison of ethnicity recording for the years 2001-2004 and 2004-2006. RESULTS: Using a total definition of ethnicity, census and mortality counts agree reasonably well in 2004-06 and resemble comparisons in 2001-04, except at younger ages where counts for Pacific and Asian ethnicities are up to a third less for mortality data. Due to multiple ethnicities being more commonly recorded on census data, sole ethnicity counts are generally greater on mortality than census data, particularly for Maori ethnicity. CONCLUSION: Similar to 2001-2004, there is little bias in ethnic group counts between census and mortality data when using total ethnicity. Calculations of mortality rates by ethnicity using unlinked census and mortality data and a total definition of ethnicity should be unbiased. These results support ongoing use of the census definition of ethnicity on all health datasets.

The Gudaga Study: establishing an Aboriginal birth cohort in an urban community.

OBJECTIVE: This paper describes the establishment of the Gudaga Study, an Aboriginal birth cohort in south-west Sydney, and our approach to follow-up of participants. The Study describes the health, development, and services use of Aboriginal infants and their mothers. The research team works closely with the local Aboriginal community to implement the research. METHODS: All mothers in the maternity ward of an urban hospital were surveyed to identify mothers with an Aboriginal infant. These and some additional mothers identified through other networks were recruited to the study. RESULTS: The number of mothers were surveyed was 2,108. Mothers of Aboriginal infants were younger (25.3 years compared to 28.4 years, p<0.001), less likely to be married (16.1% cf. 58.4%, p<0.001) and to have completed school (63.2% cf. 77.8%, p=0.002) than mothers of non-Aboriginal infants. Of 155 identified mothers of Aboriginal infants, 136 were recruited and 23 through other networks. At 12 months, 85.5% of infants were followed up. CONCLUSIONS: This study, to our knowledge, is the first cohort study of this kind on the eastern seaboard of Australia. The study has strong community support and follow-up, contrary to views that Aboriginal people are reluctant to participate in research. These data have national and regional significance.

Measuring the gap: accuracy of the Western Australian hospital morbidity data in the identification of adult urban Aboriginal and Torres Strait Islander people.

OBJECTIVE: To assess the sensitivity of the recording of Aboriginality in the Western Australia Linked Data. METHODS: This was a follow-up study using record linkage. Demographic data was obtained from 993 adult, urban-dwelling Aboriginal Australian participants in the Perth Aboriginal Atherosclerosis Risk study (PAARS). These were linked to the Western Australian Linked Data (State-wide hospital admissions and discharges, and deaths) to provide the number of admissions and Indigenous status coding from 1980 to 2006. RESULTS: There were 14,413 admissions for PAARS participants in the study period. The sensitivity of coding of Indigenous status in hospital admissions data significantly improved over time, exceeding 0.9 in every year since 2002. Prior to 2002 sensitivity was around 0.8, but poorer for males, with some anomalous years. CONCLUSIONS: The coding of Indigenous status in the Western Australia Hospital Morbidity Database since 2002 has improved. The data from earlier decades must be approached with more caution. IMPLICATIONS: The improved accuracy of identification of Indigenous status in the Western Australia Hospital Morbidity Database allows comparative studies of adult Aboriginal and non-Aboriginal population health outcomes to be undertaken with confidence.

Matrilocal residence is ancestral in Austronesian societies.

The nature of social life in human prehistory is elusive, yet knowing how kinship systems evolve is critical for understanding population history and cultural diversity. Post-marital residence rules specify sex-specific dispersal and kin association, influencing the pattern of genetic markers across populations. Cultural phylogenetics allows us to practise 'virtual archaeology' on these aspects of social life that leave no trace in the archaeological record. Here we show that early Austronesian societies practised matrilocal post-marital residence. Using a Markov-chain Monte Carlo comparative method implemented in a Bayesian phylogenetic framework, we estimated the type of residence at each ancestral node in a sample of Austronesian language trees spanning 135 Pacific societies. Matrilocal residence has been hypothesized for proto-Oceanic society (ca 3500 BP), but we find strong evidence that matrilocality was predominant in earlier Austronesian societies ca 5000-4500 BP, at the root of the language family and its early branches. Our results illuminate the divergent patterns of mtDNA and Y-chromosome markers seen in the Pacific. The analysis of present-day cross-cultural data in this way allows us to directly address cultural evolutionary and life-history processes in prehistory.

Identification of Aboriginal infants at an urban hospital.

AIM: This study explored the accuracy of identification of Aboriginal infants at an urban hospital. METHODS: Data on the Aboriginal status of all infants who were delivered at the hospital to mothers who resided in the surrounding Local Government Area during 2002 were extracted from the Obstetrics Data Package (ODP). These data were supplemented with local health worker knowledge about the Aboriginal status of infants and compared with NSW Birth Register data held by the Australian Bureau of Statistics. RESULTS: There were 1739 deliveries at the hospital to mothers from the Local Government Area. Our study showed that 71.4% (n = 90) of Aboriginal and 77.5% (n = 1649) of non-Aboriginal infants identified through ODP were included in the Birth Register. The proportion of Aboriginal infants identified through the ODP was 5.2% and the Birth Register was 5.6%. The 90 Aboriginal infants included 38 with an Aboriginal mother, 34 with an Aboriginal father, and 18 with two Aboriginal parents. CONCLUSIONS: This was the first use of these data to examine the accuracy of identification of Aboriginal infants born at this facility. The study highlighted the importance of systematically seeking information on the Aboriginal status of both parents by antenatal services; of providing opportunities for timely feedback on the data quality to maternity service providers; and ensuring that the data are used to inform development of culturally appropriate services. As a result of this study, services have implemented strategies to routinely identify infants with an Aboriginal father as well as those with an Aboriginal mother.

Ethnicity, deprivation and mental health outcomes.

AIMS: To describe and measure differences between ethnic groups on standard measures of mental health outcome. METHODS: Clinical staff in eight New Zealand Health Districts collected consumer outcomes data at the start, end and review of episodes of care. Consumers were allocated to one of three ethnicity groupings -- Maori, Pacific Island and "All Other". RESULTS: There were large differences between the three ethnicity groupings on the measures. Maori and Pacific Island consumers appeared to demonstrate more psychotic phenomena and overall worse scores, and the All Other group, more depression. Changes in scores between start and end of episodes of care were proportionately similar across the three groups. Differences between ethnic groupings varied according to socio-economic deprivation level. CONCLUSIONS: Potential reasons for some of the effects observed are discussed, including differing pathways to care, clinician and selection bias, and differing models of mental health.

Asthma prevalence in Hispanic and Asian American ethnic subgroups: results from the California Healthy Kids Survey.

OBJECTIVES: Asthma prevalence for different ethnic groups in the United States, beyond white, black and Hispanic, is seldom reported. We compared the prevalence of asthma diagnosis among various Hispanic and Asian American ethnic subgroups using data collected from the school-based California Healthy Kids Survey. METHODS: The California Healthy Kids Survey was administered to 462 147 public school students in the seventh, ninth, and 11th grades throughout California during the 2001-2002 and 2002-2003 school years. Prevalence of lifetime asthma diagnosis was calculated for 11 Asian American Pacific Islander subgroups and 8 Hispanic subgroups. RESULTS: Asthma prevalence among Hispanic subgroups ranged from 13.2% for Mexican American students to 22.8% for Puerto Rican students and 23.0% among Cuban American students. Lifetime asthma diagnosis among the 11 Asian American Pacific Islander subgroups ranged from 10.9% among Korean American students to 23.8% among Filipino American students. CONCLUSIONS: The survey revealed substantial variation in asthma prevalence between the different Hispanic and Asian American Pacific Islander subgroups and that Pacific Islanders, Filipinos, Cubans, and Puerto Ricans are at elevated risk for asthma. Differences in the distributions of characteristics related to country of birth, residential history, generational status, and/or degree of acculturation might account for much of the observed differences in asthma prevalence between ethnic subgroups. Previous asthma prevalence estimates for Asians or Hispanics are in part a function of the particular ethnic composition of the population under investigation. We suggest that asthma studies that include a substantial number of Asian Pacific Islander and Hispanic persons use a more detailed categorization of race/ethnicity.

Asian American and Pacific Islander seafood consumption -- a community-based study in King County, Washington.

This paper describes and quantifies seafood consumption rates, and acquisition and preparation habits of 202 first- and second-generation Asian American and Pacific Islanders (AAPI) from 10 ethnic groups (Cambodian, Chinese, Filipino, Hmong, Japanese, Korean, Laotian, Mien, Samoan, and Vietnamese) in King County, Washington in 1997. Participants were all seafood consumers. Average and median seafood consumption rates were 117.2 and 89 g/day, respectively, based on the average body weight (62 kg) of participants. Shellfish comprised 45.9% and "all finfish" 43.3% of all seafood consumed. Consumption rates varied significantly between ethnic groups with Vietnamese (2.63 g/kg/day) and Japanese (2.18 g/kg/day) having the highest average consumption rates, and Mien (0.58 g/kg/day) and Hmong (0.59 g/kg/day) the lowest. The most frequently consumed finfish and invertebrates were salmon (93% of respondents), tuna (86%), shrimp (98%), crab (96%), and squid (82%). Fish fillets were eaten with the skin 55%, and the head, bones, eggs, and/or other organs 20% of the time. Crabmeat including the hepatopancreas (accumulates lipophilic chemicals such as organochlorine compounds) was consumed 43% of the time. This paper was a product of a Community-University Partnership. Community guidance in study design and data collection was essential for successful participation by the AAPI Community. Data reported here not only will provide risk assessors with AAPI-specific seafood consumption rates but with insights into cultural consumption/acquisition habits that may alter risk assessment assumptions for the AAPI Community.

Identification of Aboriginal and Torres Strait Islander women using an urban obstetric hospital.

OBJECTIVES: To determine the accuracy of routine identification of Aboriginal and Torres Strait Islander women confining at King George V (KGV) Hospital, located in Sydney, Australia. DESIGN: Interviewer-administered survey. PARTICIPANTS: Consecutive sample of women who delivered live, well infants from May to July 1999. MAIN OUTCOME MEASURE: Comparison of hospital documentation compared with confidential self-disclosure of Aboriginal or Torres Strait Islander status to a female Aboriginal health professional. RESULTS: Of 536 women in our sample, 29 (5%) self-disclosed as being Aboriginal or Torres Strait Islander. Only 10 of these were identified as Aboriginal or Torres Strait Islander in hospital records (p<0.001). While specificity as determined by us was 100%, sensitivity was low (34.5%). Those Aboriginal and Torres Strait Islander women referred by another organisation were significantly more likely than those who self-referred to the hospital to be correctly identified (p=0.011). Only 1% of non-Aboriginal women indicated they would have objected to an explicit question by staff about their Aboriginal or Torres Strait Islander status. CONCLUSIONS: Routine identification significantly under-represents Aboriginal or Torres Strait Islander women giving birth at an urban obstetric hospital. We recommend the development and use of a sensitive but also specific series of questions to ensure women always are given the opportunity to disclose their status, especially as few women appear to mind such questions.

High prevalence of hyperuricemia in adolescent Taiwan aborigines.

OBJECTIVE: To explore the prevalence and related factors of hyperuricemia among adolescent Taiwan aborigines in tribes with a high prevalence of adult gout, compared with adolescents of low prevalence aboriginal and non-aboriginal tribes. METHODS: The participants were aborigines and non-aborigines in Taiwan, age 12 to 15 years and free of gout. Each participant provided information on sex, age, and parents' tribal background as well as body weight and height. Serum samples were analyzed for biochemical markers. A logistic regression model was used to study factors related to hyperuricemia. RESULTS: In total 940 adolescents participated. The hyperuricemia rate in tribes with high gout prevalence (57.7%) was higher than in non-aborigines (48.2%) and in aboriginal tribes with low gout prevalence (34.0%). Factors statistically significantly related to hyperuricemia were tribe, sex, obesity, creatinine, and cholesterol levels in preliminary analysis. After adjustment by the logistic regression model, obese boys with higher creatinine were most likely to have hyperuricemia. Adolescents whose parents originated from tribes with high gout prevalence had a tendency to have hyperuricemia, and those aborigines from tribes with low gout prevalence had a low prevalence of hyperuricemia compared to non-aborigines. CONCLUSION: The prevalence of hyperuricemia in aboriginal adolescents mirrors the incidence of adult gout, implying a predisposition for adult gout in childhood, with genetic and/or environmental components presumably contributing to the differences between tribes; this may be of potential benefit to preventive efforts.

To be or not to be: recording Aboriginal identity on hospital records.

Accurate health information is a key component in the development of health improvement strategies. This paper provides a discussion of the challenges in improving hospital information systems in relation to indigenous patients. Based on interviews with both staff and patients of a major city hospital complex, a picture emerges of the need for bottom-up approaches to understanding perceptions of identity. Indigenous patients were found to be generally comfortable about identifying themselves on hospital records (if asked), but were often not clear why such questions were asked. On the other hand hospital staff were often uncomfortable about asking and were equally not always clear why such information was needed. Issues of accurate hospital record administration are discussed in relation to the attitudes and perceptions of both staff and patients.

High length-of-stay outliers under casemix funding of a remote rural community with a high proportion of aboriginal patients.

The diagnosis related groups (DRG) classification was designed primarily to categorize patients of acute short-stay hospitals in urban areas. As one might expect, many studies have shown it is a less effective predictor of the needs--and consequently the costs of care--of remote and socio-economically disadvantaged communities. One way of improving the equity of funding involves separating the cases in each DRG into inlier and outlier episodes, and making different resource allocations for each category. This paper summarises the outlier payment model used by the Health Department of Western Australia, with emphasis on high length of stay outliers. The model provides additional funds for high length of stay outliers, but funding levels are deliberately set below the actual estimated costs of care, on the assumption that some of the additional costs are a consequence of poor care management. All high length of stay outlier episodes in the East Pilbara Health Service in 1997-98 were examined. It was found that the outliers were predominantly Aboriginal patients from remote communities with higher than average needs for care as indicated by their greater tendency to have multiple conditions requiring treatment. The age distribution of high length of stay outliers was quite different from that found in most Australian hospitals, in that there was a higher proportion of young children. It is concluded that, although the ideas on which the funding model is based are sound, revisions of detail need to be considered to reduce the risk that the burden of cost containment will fall to a disproportionate degree on the most disadvantaged groups of patients.

Socioeconomic inequalities in health: how big is the problem and what can be done?

Socioeconomic factors shape the working day for many doctors in New Zealand. The occurrence and severity of most common conditions confronting doctors in day-to-day practice are linked to the socioeconomic conditions in which patients live and work. Poorer people are likely to have worse health than wealthier people; but it is also becoming clearer that it is not just the absolute level of poverty that affects people's health, but also the distribution of material resources in society. This article highlights important aspects of our current knowledge concerning the effects of socioeconomic factors on health, and makes practical suggestions for day-to-day practice. An essential first step is to identify and characterise the socioeconomic characteristics of patients. Information routinely collected by many general practitioners can be used to characterise the socioeconomic circumstances of individual patients and the practice population as a whole. Doctors can then take action at three levels to mitigate the risks associated with these socioeconomic factors: at a broad social level; at a community and practice level; and at an individual level.