Exploring Leave Events for Aboriginal and Torres Strait Islander People From Australian Tertiary Services: A Systematic Literature Review


 Objective The primary objective of this systematic review was to identify contributing causes to leave events from health services for Australian patients. The second objective was to identify evidence based preventative measures for effectively reducing leave events, which could be implemented. Study design Articles published in Australia were included if they reported on Aboriginal and/or Torres Strait Islander people and other Australians who leave health services prior to being seen or discharged by a medical professional. Two researchers screened each abstract and independently reviewed full text articles. Study quality was assessed, and data were extracted with standardised tools.Data sources MEDLINE and Google Scholar were searched for relevant publications from May 27th to June 30th, 2020. The search returned 30 relevant records. Nine additional records were identified by manual search in Google Scholar. References of included articles were searched. From these articles, 11 met the inclusion criteria. Of these 5 were from New South Wales, 2 from Western Australia, 1 each from Queensland and Northern Territory, two were conducted nationally. Data synthesis Four studies used a retrospective cohort method, one included patient interviews,(1) Four cohort studies and two systematic reviews were included. Two government reports and one health policy document were included in this review. All studies were from Australia using mixed methods.Conclusions This review identified causes for, and evidence based preventative measures that have been or could be implemented to reduce Leave Events and describes additional terms and definitions used for Leave Events.

Australians. (3)(4)(5) Given the sovereign health rights of Aboriginal and Torres Strait Islander peoples, it was critical to ensure that this was captured in this review.
This systematic literature review sought to answer questions on the causes contributing to leave events, the evidence-based preventative measures that have been or could be implemented to reduce leave events and to describe any additional terms and de nitions used for Leave Events by states and territories in Australia.

Methods
This systematic literature review was conducted between 27 May and 30 June 2020. It included Australian studies published from January 2013. Publications were considered and included if they reported on primary research which focused on Aboriginal and Torres Strait Islander peoples and other Australians who leave health services, this included acute health services, Aboriginal community-controlled health and medical services, community services or primary care health services prior to being seen by a medical professional or having left against medical advice. Additionally, any other possible de nitions in relation to leave events used by Australian health and medical services that may not be already outlined in the search terms were included when found while conducting the search. Included papers were summarised using a qualitative synthesis and were independently reviewed by two authors (JC and SS) with a unanimous agreement as to which papers were to be included.
Search terms also included the many different terms that can be used to refer to Aboriginal and Torres Strait Islander peoples such as: Indigenous, First Australian, Murri, Koori, and Noongar (Table 1).
Data was obtained on the prevalence and incidence rate of leave events, or any similar terms for Aboriginal and Torres Strait Islander peoples who present to acute health service organisations, Aboriginal community-controlled health services, Aboriginal medical services, community services and primary care services. Causes that contribute to leave events for Aboriginal and/or Torres Strait Islander peoples and other Australians were identi ed. Any additional terms and de nitions used for leave events by states and territories not already listed was also searched.

Inclusion Criteria
Studies were included in the review if they addressed: Australian Aboriginal and/or Torres Strait Islander people across all ages ndings were from primary research (both quantitative and qualitative) the data sources (e.g. interview, survey, focus group, hospital databases) "leave events" causes for Aboriginal and/or Torres Strait Islander children (≤18 years of age) intervention-based studies that had been implemented to reduce Aboriginal and/or Torres Strait Islander people and other Australians who leave the health or medical service or have left against medical advice.

Exclusion Criteria
Studies were excluded if they: Did not focus on Australian or Aboriginal and Torres Strait Islander people Included routine discharge or negotiated/agreed discharge Included discharge for the day programs and instances of 'did not attend' Did not include the search terms in title or abstract.
Both quantitative and qualitative research designs were included in the search. Two methods were used to locate relevant studies: (a) a search of databases for primary papers using the OVID Medline and Google Scholar platforms (b) A hand search of references from identi ed studies. Once the search had been conducted, duplicates were removed and the title and abstract of the remaining articles were screened for inclusion. EndNote software was used to manage references.

Assessment of included papers
Included papers were assessed using the Mixed Methods Appraisal Tool (MMAT).(6) The MMAT has previously been shown to be a comprehensive tool for assessing mixed method studies and meets the accepted standards for validity and reliability. Where possible, a qualitative synthesis was conducted that was dependant on the assessment of individual qualitative based articles and a quantitative meta analyses for quantitative studies.

Search Results
The electronic database search returned 30 relevant records and 9 additional records were identi ed by a manual search in Google Scholar. Reference lists of the included articles were searched. After assessing the records for relevance, 29 references were saved, and full texts were obtained and reviewed for relevance to the research questions. Duplicates were removed, and titles and abstracts were reviewed to select studies. Preselected full-text studies were screened by two (JC and SS) reviewers independently, to identify studies according to inclusion criteria. This systematic literature review was reported in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analysis) reporting guidelines provided for systematic reviews and meta-analyses. (PRISMA Figure 1) Data was extracted, and study ndings and characteristics were synthesised in a narrative summary. From these articles, 11 met the inclusion criteria for the review. Of these 5 were based in New South Wales, 2 in Western Australia, 1 from Queensland, 1 from Northern Territory and 2 were conducted nationally. Included studies were appraised for quality using MMAT (Table 2).

Terminology
Terminology for leave events in Australia are used generally to specify when a person has left a health service prior to being seen by a health professional or have left against medical advice. However, there are many inconsistencies in the use of this terminology as each state and territory de ne leave events differently. Terminology for leave events can also vary depending on the location a person presents, for example to an emergency department compared to being admitted as a patient.
The Northern Territory use 'discharge/leave against medical advice within 48 hours' (DAMA/LAMA), 'discharge against medical advice' (DAMA), 'self-discharge', 'absconding', 'taking own leave' (TOL) and 'away without leave' (AWOL) for leave events. Tasmania and Victoria are the only states that use CODE Z which means left against medical advice. South Australia document leave events as 'inpatient discharge against medical advice' and 'left emergency department at own risk'. Queensland use a code for leave events but is different to TAS and VIC which is Code 07 'discharged at own risk'. Finally, Australian Capital Territory use 'patient who did not wait to be seen'.

Prevalence of 'leave events'
Leave events rates for Aboriginal and Torres Strait Islander people are seven times more than that of other Australians.(13) There are several contributing and interrelated factors as mentioned in the background of this review, associated with leave events that cause Aboriginal and Torres Strait Islander peoples to leave a healthcare facility before treatment or during treatment. Several recommendations from evidenced based studies could be implemented across Australian healthcare services to address this. (1,3,10,11,13) The Australian Institute of Health and Welfare collected national data using the National Hospital Morbidity Database for years 1998-99 to 2012-13 and found that leave events for Aboriginal and Torres Strait Islander patients have increased. (14) Hospitalisation for injury and poisoning had the highest rates of leave events for Aboriginal and Torres Strait Islander peoples compared to other Australians.(4) The greatest difference between Aboriginal and Torres Strait Islander peoples and other Australians was in endocrine, nutritional and metabolic disorders. Other contributing factors identi ed were Indigenous status and remoteness of hospitals. (4) While it is established that the prevalence and rate of leave events is higher among marginalised communities such as culturally and linguistically diverse (CALD), and children 0-16 years,(11) similar patterns are also seen in Aboriginal and Torres Strait Islander children. A retrospective cohort study by Gardner in 2016 indicated that urban Aboriginal children 0-16 years were more likely to be reported as discharged against medical advice than other Australian children. (15) In a study by Gardner et al., routinely collected medical data between January 2007 and December 2012 were analysed and the ndings showed that patients' medical records were incomplete and not being recorded by clinical staff. Although comprehensive quality routine data can help to identify service gaps experienced by patients and families, this was not possible due to the incomplete records. (7) Remote rehabilitation service uptake by male Aboriginal patients was studied by Munro in 2018. It is noted that 47% Aboriginal patients at a remote NSW drug and alcohol rehabilitation centre self-discharged without completing the program. (8) This nding is aligned with the study by Katzenellenbogen et al. (2013) that revealed leave events are more common among Aboriginal and Torres Strait Islander peoples in rural and remote areas. Munro's analysis of the patients' admissions from 2011 to 2016 showed that patients referred from the criminal justice system were more likely to self-discharge. (8) It is known that discharge against medical advice in adult general population leads to increased risks of re-admission,(3) but Munro could not establish the same pattern in remote Aboriginal male patients due to unavailability of follow-up data. (8) Causes of 'leave events' In a study conducted by Einsiedel et al factors that predicted leave events included: loneliness, taken by family, payday, attending court, the football, feeling better, staff mistreatment; staff speaking 'roughly' and waiting too long. Einsiedel et al also found that in the Northern Territory, Aboriginal and Torres Strait Islander people with medical conditions that appeared to "get better" before completing treatment and left the healthcare facility were documented to have been discharged against medical advice or recorded as 'non-compliant'.(1) However, most had little understanding of their illness and there was a lack of clear and culturally appropriate communication from health providers explaining the potential consequences of leaving before treatment is completed.(1) Findings from Einsiedel et al suggested that Aboriginal people who live in the Central Dessert continue to fear hospital settings and believe they are connected to death. Another issue identi ed was not being able to go back on Country so patients who have a terminal illness prefer to leave the hospital in order to be able to die on Country. (1) A systematic review by Shaw revealed that experiences of racism, distrust of the health system, a lack of culturally safe institutions, miscommunication and misunderstandings, feelings of isolation and loneliness, family and social obligations as well as remoteness of hospital from usual residence all contributed to leave events.(3) Shaw's review included a study by Katzenellenbogen that indicated acute healthcare settings are not effective at addressing the apprehensions of Aboriginal and Torres Strait Islander patients in order to maintain patient's engagement in their follow up treatment. (9) The cross-sectional analytical study undertaken by Katzenellenbogen in Western Australia showed the risks associated with leave events were unique to Aboriginal and Torres Strait Islander patients compared with other Australians, although, the study also identi ed that drug and alcohol dependency associated with leave events was a strong predictor for both Aboriginal and Torres Strait Islander patients and other Australians. The study found that Aboriginal and Torres Strait Islander patients leave events were unique due to culturally distinct personal and systemic factors associated with negative experiences from hospital and mainstream institutions. The study had consistent ndings with other studies in this review of leave events for Aboriginal and Torres Strait Islander patients that were associated with a lack of cultural safety and culturally appropriate care, personal and institutionalised racism, miscommunication, family and social commitments, isolation and loneliness.
In a retrospective cross-sectional study by Sealy et al in 2019, leave events among Aboriginal and Torres Strait Islander children compared with other Australian children 0-14 were analysed from a 5-year inpatient admissions dataset. The Bayesian multivariable logistic regression analysis was used to determine the predictors of leave events in admissions. This study did not assess the reasons of leave events for Aboriginal children but drew on other studies that stated it could be due to distrust in the health system, lack of cultural safety, staff attitudes, hospital policies and racism. The study also highlighted the probable under identi cation of Aboriginal or Torres Strait Islander status which may be due to fear of racist treatment and the historical practice of removal of children during hospital stays.(12) While many authors tried to discover predictors for leave events in Australian hospitals from medical datasets, (3,9,11,12) little evidence is available from robust qualitative exploration of Aboriginal patients' experience. A summary of causes is represented in Table 1.

Preventative Measures
The Aboriginal Health Policy Directorate 2018, Western Australia Department of Health found a number of preventative measures to reducing leave events outlined within this section.(2) These included the need for health systems to be responsive through effective cultural competency which could be achieved through increased cultural training of hospital staff on connection to country, kinship and family obligations. (16) It was found that to be effective this training must be mandatory and ongoing. Cultural training models need to be developed to address the individual service and community settings according to locally identi ed priorities. (16) Other preventative measures that were explored in the paper found that the implementation of a 'living document' such as a 'Cultural Security/Safety Policy/Framework', developed in collaboration with Aboriginal and Torres Strait Islander stakeholders, policy makers and communities can improve the appropriateness and safety of healthcare. Improving the hospital environment through policy changes to accommodate family members to stay with the patient during their admission was also recommended. (16) Pathways between hospital and community care providers need to be developed in collaboration with Aboriginal and Torres Strait Islander communities and community controlled Aboriginal Health Services to enable appropriate healthcare within their community. Culturally safe and appropriate environments during pre-admission processes for Aboriginal and Torres Strait Islander patients were also found to be important for patients to feel welcome and comfortable. The availability of an Aboriginal health Worker/Liaison O cer to address the concerns of culture early in their admission was also found to build a trusting environment.

Discussion
The purpose of this systematic literature review was to examine the causes that contribute to leave events from health care services and understand the current recommendations that may reduce rates of leave events for Aboriginal and Torres Strait Islander people and other Australians. This study established that there are numerous causes that contribute to Aboriginal and Torres Strait Islander patient leave events. (2,3,11) Many of the studies and reports repeated themes such as systematic and personal racism, distrust of hospitals and patients feeling misunderstood and unwelcome. Other themes such as the lack of cultural competency, cultural safety in hospital and cultural training among the health workforce were recurrent. Systemic and personal racism needs to be addressed if equity is to be achieved in the healthcare system.(17) Improving the cultural competence of health services and creating culturally safe environments will help address racism, and feelings of being unwelcome. (2) Health service policies and procedures continue to be developed from a western biomedical worldview, which reinforces colonial power structures, and invisible whiteness in the Australian healthcare system and continue to marginalise Aboriginal and Torres Strait Islander peoples. (17) A change in institutional policies to balance the inequitable power structures is needed. Genuine engagement of Aboriginal and Torres Strait Islander stakeholders can change the policy structures to ensure that Indigenous Knowledge is central, which will support systematic. (2) Limitations And Strengths There is di culty in ascertaining the exact factors on leave events for Aboriginal and Torres Strait Islander people in Australia due to the limited previous research. The evidence that currently exists is mainly through quantitative analysis of hospital data. A strength of this systematic review was that it was led by a First Nation researcher, ensuring the included studies were viewed through the lens of a First Nation perspective.

Conclusions
Higher prevalence and incidence rates of leave events among Aboriginal and Torres Islander patients in comparison to non-Aboriginal Australians indicate that there are unique individual and system factors driving the problematic issue. While attempts are made to understand the causes, most research efforts are focused on quantitative studies and a lack of robust qualitative exploration of the patients' experiences exists. The causes and preventative measures from the literature highlight the needs of effective cultural competency, culturally appropriate holistic models of healthcare and Aboriginal community-controlled health services involvement. Consistent terminology and appropriate terms to de ne leave events across states and territories within Australia will also ensure better data capture. Further research on how to improve treatment completion rates for Aboriginal and Torres Strait Islander patients could provide evidence on patient's experience and therefore practical strategies to reduce leave events. health service organisations.