Incomplete recording of Indigenous identification status under-estimates the prevalence of Indigenous population attending Australian general practices: a cross sectional study

Australian Aboriginal and Torres Strait Islander (hereafter Indigenous) peoples face major health disadvantage across a wide range of health conditions; including cancer, diabetes, and sexually transmissible infections (STIs) [1‐3]. Reducing the persisting disparity of Indigenous peoples’ health is a key commitment of national health strategies and the Closing the Gap (CTG) framework [1, 4].

In Australia, more than half of the Indigenous population access healthcare through mainstream primary care services [5]. Recording of a patients’ Indigenous status in practice records is important to ensure optimal health care and evaluate the effectiveness of clinical practices services and programs [6] recommended for Indigenous patients. For example, Indigenous adults are recommended to have annual health checks (Medicare Benefits Schedule (MBS) items 715 or 10,987) which provide preventive health strategies such as STI screening and detection of chronic disease risk factors [7]; and the CTG Pharmaceutical benefits scheme (PBS) co-payment reduces out-of-pocket costs of medicines for Indigenous people [8]. Additionally, for health services, recognition of patients’ as Indigenous is required for health services to claim incentive payments, such as Medicare Australia’s Practice Incentive Program (PIP) Indigenous Health Incentives [9], which can support delivery of quality services. Finally, complete Indigenous status in patient files provides a more accurate picture for monitoring disease prevalence, to identify risk and plan effective services and programs [6].

National guidelines for the collection of Indigenous identification status in health data sets recommend the use of a standard verbal or written question (Fig. 1); and that service providers make completion of Indigenous status a mandatory requirement for new patient registrations [6]. The Royal Australian College of General Practitioners (RACGP) [10, 11] recommends at least 75% of patient records be complete for cultural background where clinically relevant to achieve practice accreditation, including Indigenous status recording [10]. A number of general practice audits have shown that a large proportion of patient records did not have an Indigenous status completed [12‐15]. However to our knowledge no studies have compared the estimates of Indigenous population composition in general practice with other data sources, to provide an indication of how incomplete recording may under-estimate the true prevalence of the Indigenous population attending the clinics.

This study was completed in the context of the Australian Chlamydia Control Effectiveness Pilot (ACCEPt), a randomised controlled trial to determine if annual chlamydia testing for 16 to 29 year olds in general practice can reduce chlamydia prevalence. We took the opportunity to assess the completeness of Indigenous identification status recording (Aboriginal, Torres Strait Islander, both Aboriginal and Torres Strait Islander or neither) in general practice clinics, and examined factors associated with clinicians having greater than 75% completion in patient records. We also used a reference of patient self-reported Indigenous status to measure agreement of Indigenous status recording across administrative data sources, including complete and incomplete general practice medical records.

The study population included 95 general practice clinics located in NSW (28.4%), QLD (26.3%), Victoria (41.1%) and SA (4.2%). Clinics were located in major cities (9.7%), inner regional (72.6%), and outer regional or remote towns (17.7%). From the patient information management systems, we extracted records for 109,970 (clinic range: 60–12,120) patients aged 16–29 years old attending clinics in 2011.

This study found that almost half (44%) of patient records in the 95 general practice clinics had unknown or missing Indigenous identification status recorded. Using all patient records, the median proportion per clinic of patients identified as Indigenous was 0.9%, much lower than the 1.8% from the patient survey at the same clinics and the 1.7% in the clinic postcodes according to the ABS census data. The gaps in recording of Indigenous identification status are concerning but consistent with other studies [3, 14, 15]. However, to our knowledge this is the first study that assesses how incompleteness may bias the actual prevalence of Indigenous population attending general practice clinics through comparison with patient self-reported Indigenous status and population data.

We found that only 5.6% of GPs surveyed always asked patients about their Indigenous identification status, and these GPs were over four times more likely to have complete patient records. Additionally, GPs from regional and remote areas had poorer completeness, despite larger proportions of Indigenous populations residing in these areas [22]. This finding differs to a previous study which showed regional and remote areas to have more complete records [13], and may have been influenced by better recording at the major city clinics included in our study. Health policy and GP training initiatives for Indigenous status recording in general practice should be strengthened in an effort to improve completeness, targeting the areas with known poorer recording. However, the success of such initiatives would require a thorough understanding of the barriers and facilitators to recording from the perspectives of both clinic staff and Indigenous people, including staff cultural awareness [23] and application in existing clinic systems [15, 23], appropriate ways to ask and explain why Indigenous status is being recorded [15] and willingness of patients to disclose due to fear of racial discrimination, social or historical factors [24].

In addition to delivering culturally safe care, Indigenous identification status is useful for disease monitoring and surveillance. Our study also showed that when complete case analysis was used for general practice records, there were poorer correlations with patient self-report than when all patient records were used; and the estimated median proportion of Indigenous people increased from 0.9% in all records to 3.4% in the complete case analysis. Therefore, population disease estimates relying on general practice data, which exclude the records with missing or unknown Indigenous status, are likely to bias and possibly over-estimate rates among Indigenous people. A Western Australian study using data linkage between an infectious disease surveillance database and established health administrative databases to improve accuracy of Indigenous identification status, found that rates of chlamydia and syphilis among Indigenous people had been overestimated by up to 30%, compared to the pre-linked rates which excluded cases of unknown Indigenous status [25].

There are a few potential limitations to consider in our analysis. First, the study was conducted in selected general practices and towns in four Australian States and may not be representative of clinics across Australia, particularly those in major cities. However, it remains important since Indigenous populations reside in these regional and remote areas [16] and across health care indices rates are higher for Indigenous populations in regional areas [2]. Second, there is a reported undercount of Indigenous status for both Indigenous and non-Indigenous people in the 2011 census [22]; and further the ABS data focused on the entire postcode, and was compared to records for only patients who had attended the general practice that year, some of whom may have travelled from other postcodes. A study by Kong et al. showed that 74.8% of 16–29 year old Australians, attend a general practice at least once each year [26]. However annual health care attendance would have only influenced our study if variations in attendance between Indigenous and non-Indigenous people exist.

In conclusion, around half the patient records in this study had missing or unknown Indigenous identification status, highlighting that further efforts are needed to improve completeness of Indigenous identification status in general practices. Complete and accurate recording of Indigenous identification status in patient records may allow health care providers to better address the healthcare needs of Indigenous people; and may enable better health policy decisions addressing the needs of Indigenous people.