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Healthy Communities: GP care for patients with chronic conditions in 2009–2013 - Report - Introduction

Healthy Communities: GP care for patients with chronic conditions in 2009–2013

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Introduction

About this report

The National Health Performance Authority (the Authority) bases its performance reports on indicators agreed by the Council of Australian Governments (COAG). This report provides information on the following equity and effectiveness indicators:

  • Access to services by type of service compared to need
  • GP-type service use.

The report also provides contextual information relevant to the following indicators:

  • Specialist service utilisation
  • Allied health-type service use
  • Percentage of the population receiving primary mental health care.

This is the Authority’s first report on primary health care that presents information at the local level on how often and in what way GPs manage their patients’ health conditions, particularly chronic conditions.

Findings are broken down by 61 areas called Medicare Local catchments. The national network of Medicare Local organisations was established between 2011 and 2012 to work with GPs and other health professionals to improve the responsiveness, coordination and integration of local health services. These organisations are due to be replaced in 2015.

The report’s findings can be considered in the context of four broad themes:

  1. How frequently selected chronic conditions are found among people who visit a GP in a year
  2. How often GPs see patients with one chronic condition or two or more chronic conditions (multimorbidity)
  3. How often GPs actively manage patients for that chronic condition. In other words, how often a GP took steps to mitigate or monitor that condition, as opposed to another unrelated health problem
  4. What actions GPs took to manage that condition (such as prescribing a medication or providing a referral or counselling)

(See Measuring GP activity in this report).

Findings are presented around these themes for people who have a selected cardiovascular risk condition; depression and anxiety; and the musculoskeletal conditions, arthritis and chronic back pain. These conditions were selected because they are some of the most common among people in the community and are frequently seen in general practice (see about the patients).

In addition, the likelihood that people with these conditions experience complications or need to be hospitalised is reduced if these conditions are detected and managed early. Health outcomes are also improved with appropriate and ongoing GP care.6

The report offers insights into the extent to which GPs care for patients who have one or multiple chronic conditions, as many of these conditions require similar multidisciplinary approaches to prevention, treatment and management.1

While there is evidence that many aspects of care are well managed in Australia, there are gaps in the consistent delivery of appropriate care according to recommended guidelines. For example, studies have shown:

  • Only 41% of patients in Australia with selected cardiovascular risk conditions were taking statins despite current guidelines recommending almost all people at risk of cardiovascular disease, and who require treatment, take a statin8,11
  • Only 45% of patients with depression or anxiety were offered a treatment that could be beneficial9
  • Only 18% of patients with low back pain received an analgesic, and 45% received a referral for imaging despite guidelines recommending the use of analgesics and discouraging imaging to manage low back pain10,12.

Since people with chronic conditions consume a large amount of health and hospital services, improvements in their health and care are likely to increase the productivity and performance of Australia’s health system.

In this context, optimal management of people with chronic conditions are of mutual interest to primary health care networks and Local Hospital Networks.

The aim of this report is to deepen understanding of local populations and how GP care differs across local areas, and to help clinicians and health service managers target improvements in services relative to the health needs of people in their communities.

What we know about GP care for people with chronic conditions

The number of people in Australia with a chronic condition is increasing, as is the number and percentage who have multiple chronic conditions.4

Common chronic conditions among people in Australia include selected cardiovascular risk conditions such as hyperlipidaemia (12%), type 2 diabetes (6%) and ischaemic heart disease (5%).13, 14

One in six Australians have a diagnosed mental health condition including depression (10%) and anxiety (6%).13,14 Almost one in seven have a musculoskeletal condition including arthritis (12%) and chronic back pain (4%).14 Overall, one in two Australians are estimated to have at least one chronic condition and one in four have two or more chronic conditions (multimorbidity).15

Across local communities, there may be opportunities to improve prevention, treatment and management of chronic conditions. The Authority has reported marked differences in local rates of potentially avoidable hospitalisations and premature deaths from chronic conditions.2,3

For example:

  • In 2011–12, the rate of potentially avoidable hospitalisations for chronic conditions varied across local areas from 643 per 100,000 population in Northern Sydney to 2,237 per 100,000 population in Central and North West Queensland
  • The rate of potentially avoidable admissions for chronic conditions varied across similar metropolitan and regional communities
  • Potentially avoidable hospitalisations for cardiovascular conditions were particularly high.3

In Australia, the economic burden of chronic conditions is also significant. In 2008–09, the direct health care costs of three of the four most expensive groups of conditions (cardiovascular diseases, mental disorders and musculoskeletal conditions) was estimated to be $20 billion, or more than one-quarter (27%) of all health expenditure.4

What we don’t know

In Australia, there is limited information available at the local level on the reasons why people visit the GP and the health care they receive, which is intended to prevent, treat and manage chronic conditions.

There is also limited information on how GPs differ in the care they provide and the impact this has on rates of hospitalisations, morbidity and mortality.

This report is intended to start filling this gap in local-level information.

About the data

Data for this report were sourced from a continuous, national cross-sectional study of general practice activity called the Bettering the Evaluation and Care of Health (BEACH) program, which is conducted by the Family Medicine Research Centre (FMRC), the University of Sydney. Analysis of data was provided by FMRC.

The BEACH program comprises ever-changing, random samples of approximately 1,000 participating GPs per year, each of whom records information about encounters with 100 consecutive consenting patients. In this report, these encounters are called GP consultations.

The information in this report is about GP activity and the care GPs provide to their patients. The data does not include information on people who do not visit a GP or people with undiagnosed conditions. All of the data in this report are mapped to the geographic catchments where services were provided, rather than where people live.

Information on the management of chronic conditions by GPs and the actions GPs take (such as referral, prescription, counselling) are reported for the period from April 2009 to March 2013, and include 393,300 GP consultations.

The prevalence of conditions among patients are reported from a substudy within the BEACH program, the Supplementary and Nominal Data (SAND) for the period from July 2005 to June 2013, and include 25,855 patient consultations.

To report BEACH data at the local level, the Authority decided and FMRC applied methods and suppression rules to ensure the reliability, representativeness and confidentiality of the data.

To enable fairer comparisons, the Authority has allocated each local area to one of seven peer groups, based on socioeconomic status, remoteness, and distance to hospitals: three in metropolitan areas, two in regional areas, and two in rural areas. More information on these peer groups is available in the Appendix.

About the patients

Patients identified as having one or more selected chronic conditions include those patients, of any age, diagnosed with one or more of the following 18 commonly managed conditions, in order based on prevalence at GP consultation:

  • Hypertension
  • Osteoarthritis
  • Hyperlipidaemia
  • Depression
  • Gastro-oesophageal reflux disease
  • Anxiety
  • Asthma
  • Chronic back pain
  • Ischaemic heart disease
  • Type 2 diabetes
  • Cancer (malignant neoplasm)
  • Sleep disorder
  • Chronic obstructive pulmonary disease
  • Cerebrovascular disease/cerebrovascular accident
  • Congestive heart failure
  • Peripheral vascular disease
  • Rheumatoid arthritis
  • Type 1 diabetes.

The BEACH data were used to identify patients, of any age, with selected cardiovascular risk conditions based on clinical guidelines11 to support the management of:

  • Ischaemic heart disease – including acute myocardial infarction (AMI)
  • Cerebrovascular disease and stroke
  • Heart failure
  • Type 2 diabetes among people 60 years of age and older
  • Hyperlipidaemia.

Patients identified as having depression, anxiety or both of these conditions include patients, of any age, who have diagnosed depression, anxiety or both conditions, which is considered by the GP to be chronic.

Patients identified as having arthritis or chronic back pain include those patients, of any age, who have diagnosed osteoarthritis, rheumatoid arthritis and/or chronic back pain. Osteoarthritis and rheumatoid arthritis account for 86% of all arthritis problems managed in BEACH data.

About the measures

Patients with a chronic condition, included in this report, are those patients who visit the GP at least once in a year who are recorded by the GP as having a selected cardiovascular risk condition; depression, anxiety or both of these conditions; arthritis or chronic back pain or one or more of 18 selected chronic conditions per 100 people who visit the GP at least once in a year. Information is presented as a percentage.

This measure was weighted to the age and sex distribution of people who visited the GP at least once in a year, using Medicare Benefits Schedule data.

GP consultations with patients who have a chronic condition, is measured as the number of GP consultations that involved patients who have a specific chronic condition or one or more common chronic conditions per 100 GP consultations.

Information is presented as the percentage of GP consultations that occur with patients who have a condition, irrespective of whether the patient had that condition managed.

That is, people with a selected cardiovascular risk condition who, for example, had other problems managed but not the cardiovascular risk condition, are included in this measure. Therefore, this measure shows the percentage of consultations in which GPs have the opportunity to ‘check up’ on patients who have this condition, irrespective of the reason they visited.

GP management of chronic conditions is measured as the number of GP consultations in which the chronic condition or multiple chronic conditions are actively managed by the GP per 100 GP consultations. Information is presented as the percentage of GP consultations in which a specific chronic condition is actively managed, or for multimorbidity, when two or more chronic conditions of any kind are managed.

For example, people with a cardiovascular risk condition who had other problems managed, but not their cardiovascular risk condition are excluded in this measure.

GP actions in the management of chronic conditions is measured as the number of times a referral, prescription or GP counselling is provided to manage a specific chronic condition per 100 GP management occasions for the specific chronic condition. Information is presented as a percentage.

Measuring GP activity in this report

There are many people living in Australia with one or more chronic conditions, such as selected cardiovascular risk conditions, depression, anxiety, arthritis and chronic back pain.

Patients
Percentage of all people who visit a GP at least once in a year who have a chronic condition
Most people with a chronic condition visit a GP each year
Consultations
Percentage of all GP consultations with patients who have chronic conditions
Patients with chronic conditions tend to have more GP consultations than patients without
Management
Percentage of all GP consultations in which chronic conditions are actively managed
GPs may actively manage one or more chronic conditions during a single consultation
Actions
Percentage of GP management occasions in which patients with chronic conditions receive a prescription, referral or counselling
GPs may take clinical actions such as prescribing medications to manage these conditions

1. Institute for Health Metrics and Evaluation (IHME). The Global Burden of Disease:Generating Evidence, Guiding Policy [Internet]. Seattle, WA: IHME; 2013 [cited 2014 Oct 14]. Available from: http://www.healthdata.org/sites/default/files/files/policy_report/2013/GBD_GeneratingEvidence/IHME_GBD_GeneratingEvidence_FullReport.pdfExternal link, opens in a new window.

2. National Health Performance Authority. Healthy Communities: Avoidable deaths and life expectancies in 2009–2011 [Internet]. Sydney: National Health Performance Authority; 2013 [cited 2014 Oct 20]. Available from: Healthy Communities: Avoidable deaths and life expectancies in 2009–2011

3. National Health Performance Authority. Healthy Communities: Selected potentially avoidable hospitalisations in 2011–12 [Internet]. Sydney: National Health Performance Authority; 2013 [cited 2014 Sep 12]. Available from: Healthy Communities: Selected potentially avoidable hospitalisations in 2011–12

4. Australian Institute of Health and Welfare (AIHW). Australia’s Health 2014. Australia’s health series no. 14. Cat. no. AUS 178. Canberra: AIHW; 2014.

6. National Primary Health Care Strategic Framework. 2013 April [Internet]. [cited 2014 Oct 23]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/6084A04118674329CA257BF0001A349E/$File/NPHCframe.pdfExternal link, opens in a new window.

8. Webster RJ, Heeley EL, Peiris DP, Bayram C, Cass A, Patel AA. Gaps in cardiovascular disease risk management in Australian general practice. Med J Aust. 2009;191(6).

9. Andrews G, Sanderson K, Slade T, Issakidis C. Why does the burden of disease persist? Relating the burden of anxiety and depression to effectiveness of treatment. Bull World Health Organ.2000;78:446–54.

10. Williams CM, Maher CG, et al. Low back pain and best practice care: a survey of general practice physicians. Arch Intern Med. 2010;170:271–7.

11. National Health and Medical Research Council (NHMRC). Guidelines for the management of absolute cardiovascular disease risk [Internet]. NHMRC; 2012 [cited 2014 Oct 24]. Available from: https://www.nhmrc.gov.au/guidelines/publications/ext10

12. Airaksinen O, Brox JI, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 (Suppl. 2):S192–S300 DOI 10.1007/s00586-006-1072-1 page S194.

13. Australian Bureau of Statistics (ABS). Australian Health Survey [Internet]. Canberra:Commonwealth of Australia; 2012 Oct 10 [cited 2014 Oct 14]. Available from: http://www.abs.gov.au/australianhealthsurveyExternal link, opens in a new window.

14. Harrison CM, Britt HC, Miller GC, Henderson J. Prevalence of chronic conditions in Australia. PLoS ONE. 2013;8(7):e67494. DOI:10.1371/journal.pone.0067494.

15. Britt HC, Harrison CM, Miller GC, Knox SA. Prevalence and patterns of multimorbidity in Australia. Medical J Aust. 2008;189(2):72–7.

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