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Healthy Communities: GP care for patients with chronic conditions in 2009–2013 - Report - Key findings: GP care for patients with chronic conditions and multimorbidity

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

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Key findings: GP care for patients with chronic conditions and multimorbidity

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

GPs provide care for acute and episodic health conditions and help patients manage chronic conditions. Patients with two, or three or more chronic conditions, often have complex health needs that require ongoing management and coordination of more specialised care with other parts of the health care system.

Among all people who visit the GP at least once in a year, the percentage of people who had one or more chronic conditions ranged from 44% to 56% across local areas. The percentage was slightly higher in regional areas, particularly in lower-income regional areas than in metropolitan areas (Figure 1).

In comparison, the percentage of all GP consultations that involved patients who had one or more chronic conditions was only slightly higher (51% to 60%) across metropolitan and rural areas, and higher still (60% to 66%) across regional areas (Figure 2).

Across local areas, the percentage of GP consultations in which one or more chronic conditions were actively managed ranged from 34% of all GP consultations in Sydney North Shore & Beaches, to 50% of consultations in Hume (Vic/NSW).

  • Among metropolitan communities (Metro 1, 2 and 3 peer groups), the highest percentage of GP consultations in which one or more chronic conditions were actively managed was Southern Adelaide-Fleurieu-Kangaroo Island
  • Among regional communities (Regional 1 and 2) the highest percentage of GP consultations in which one or more chronic conditions were actively managed was Hume (Vic/NSW)
  • Among rural communities (Rural 1 and 2) the highest percentage of GP consultations in which one or more chronic conditions were actively managed was Townsville-Mackay (Qld)

(Figure 3b).

The findings also indicate that irrespective of variation in how often GPs saw patients with three or more chronic conditions (19% to 30% of consultations across peer groups), they actively managed three or more chronic conditions at about the same frequency (2% to 3% of consultations). This may indicate that in local areas with a higher proportion of patients with three or more chronic conditions, opportunities may exist to optimise care for these patients (Figures 2, 3a and 3b).

Figure 1: Percentage of people who visit the GP at least once in a year who had one, two or three or more common chronic conditions*, by Medicare Local catchment peer group, 2005–2013

Peer groups Number of chronic conditions (with 95% confidence interval)
One only Two only Three or more
Metro 1 21% (CI: 20%–23%) 11% (CI: 10%–12%) 16% (CI: 14%–18%)
Metro 2 20% (CI: 19%–22%) 11% (CI: 11%–12%) 18% (CI: 16%–19%)
Metro 3 19% (CI: 18%–21%) 11% (CI: 10%–13%) 19% (CI: 16%–21%)
Regional 1 20% (CI: 18%–22%) 12% (CI: 11%–13%) 19% (CI: 17%–22%)
Regional 2 20% (CI: 19%–22%) 13% (CI: 12%–14%) 23% (CI: 21%–25%)
Rural 1 20% (CI: 16%–23%) 10% (CI: 8%–13%) 20% (CI: 15%–25%)
Rural 2 19% (CI: 16%–22%) 10% (CI: 8%–13%) 15% (CI: 11%–19%)
Figure 2: Percentage of GP consultations with patients who had one, two or three or more common chronic conditions*, by Medicare Local catchment peer group, 2005–2013

Peer groups Number of chronic conditions
One only Two only Three or more
Metro 1 21% (CI: 19%–22%) 12% (CI: 11%–13%) 21% (CI: 18%–23%)
Metro 2 20% (CI: 19%–21%) 13% (CI: 12%–14%) 23% (CI: 21%–25%)
Metro 3 18% (CI: 17%–20%) 14% (CI: 13%–15%) 28% (CI: 25%–31%)
Regional 1 19% (CI: 17%–20%) 14% (CI: 13%–16%) 27% (CI: 24%–31%)
Regional 2 20% (CI: 19%–21%) 15% (CI: 14%–17%) 30% (CI: 28%–33%)
Rural 1 18% (CI: 15%–21%) 13% (CI: 11%–15%) 29% (CI: 23%–35%)
Rural 2 20% (CI: 17%–23%) 12% (CI: 10%–14%) 19% (CI: 14%–24%)
Figure 3a: Percentage of GP consultations in which one, two or three or more chronic conditions were managed, by Medicare Local catchment peer group, 2009–2013

Peer groups Number of chronic conditions
One only Two only Three or more
Metro 1 29% (CI: 28%–29%) 8% (CI: 7%–8%) 2% (CI: 2%–3%)
Metro 2 30% (CI: 29%–30%) 8% (CI: 7%–8%) 2% (CI: 2%–3%)
Metro 3 29% (CI: 28%–30%) 8% (CI: 7%–8%) 3% (CI: 2%–3%)
Regional 1 33% (CI: 32%–34%) 9% (CI: 8%–9%) 3% (CI: 2%–3%)
Regional 2 33% (CI: 32%–34%) 9% (CI: 9%–10%) 3% (CI: 3%–3%)
Rural 1 31% (CI: 29%–33%) 8% (CI: 7%–9%) 3% (CI: 2%–3%)
Rural 2 30% (CI: 28%–32%) 8% (CI: 7%–9%) 3% (CI: 2%–4%)
Figure 3b: Percentage of GP consultations in which one, two or three or more chronic conditions were managed, by Medicare Local catchment, 2009–2013

Medicare Local catchments grouped by peer group Number of chronic conditions
One only Two only Three or more
Metro 129% (CI: 28%–29%)8% (CI: 7%–8%)2% (CI: 2%–3%)
Northern Sydney31% (CI: 29%–33%)9% (CI: 7%–10%)2% (CI: 2%–3%)
Australian Capital Territory30% (CI: 28%–33%)8% (CI: 7%–9%)2% (CI: 1%–2%)
Inner West Sydney28% (CI: 27%–30%)9% (CI: 7%–10%)3% (CI: 2%–4%)
Inner NW Melbourne29% (CI: 28%–31%)8% (CI: 7%–9%)2% (CI: 2%–3%)
Inner East Melbourne29% (CI: 28%–31%)7% (CI: 6%–8%)2% (CI: 2%–3%)
Bayside (Vic)29% (CI: 27%–31%)7% (CI: 6%–8%)2% (CI: 1%–3%)
Eastern Sydney26% (CI: 24%–28%)8% (CI: 6%–9%)3% (CI: 2%–4%)
Sydney Nth Shore & Beaches27% (CI: 25%–28%)6% (CI: 5%–7%)2% (CI: 1%–2%)
Metro 230% (CI: 29%–30%)8% (CI: 7%–8%)2% (CI: 2%–3%)
Sthn Adelaide-Fleurieu-Kang. Is.34% (CI: 31%–36%)11% (CI: 10%–13%)4% (CI: 3%–5%)
Fremantle (WA)32% (CI: 31%–34%)8% (CI: 6%–10%)3% (CI: 2%–4%)
Eastern Melbourne30% (CI: 28%–33%)10% (CI: 8%–12%)3% (CI: 2%–4%)
Perth Central & East Metro31% (CI: 29%–33%)8% (CI: 7%–10%)3% (CI: 2%–3%)
South Western Melbourne29% (CI: 24%–33%)10% (CI: 6%–13%)2% (CI: 1%–3%)
Central Adelaide & Hills30% (CI: 28%–32%)8% (CI: 6%–9%)2% (CI: 2%–3%)
Gold Coast (Qld)30% (CI: 28%–32%)7% (CI: 6%–8%)2% (CI: 1%–3%)
Perth North Metro28% (CI: 27%–30%)8% (CI: 6%–9%)2% (CI: 1%–3%)
Greater Metro South Brisbane29% (CI: 27%–30%)7% (CI: 6%–8%)2% (CI: 2%–3%)
South Eastern Sydney29% (CI: 27%–31%)7% (CI: 5%–8%)2% (CI: 1%–3%)
Metro North Brisbane29% (CI: 27%–30%)7% (CI: 6%–8%)2% (CI: 1%–2%)
Bentley-Armadale (WA)28% (CI: 26%–31%)6% (CI: 4%–7%)1% (CI: 1%–2%)
Metro 329% (CI: 28%–30%)8% (CI: 7%–8%)3% (CI: 2%–3%)
Northern Adelaide33% (CI: 31%–35%)10% (CI: 8%–12%)3% (CI: 2%–4%)
Northern Melbourne31% (CI: 29%–33%)9% (CI: 7%–10%)3% (CI: 2%–4%)
South Western Sydney30% (CI: 28%–31%)8% (CI: 7%–9%)3% (CI: 2%–3%)
Macedon Ranges & NW Melbourne29% (CI: 26%–31%)7% (CI: 6%–9%)2% (CI: 1%–4%)
Western Sydney28% (CI: 27%–29%)8% (CI: 7%–9%)2% (CI: 2%–3%)
West Moreton-Oxley (Qld)28% (CI: 26%–30%)6% (CI: 5%–7%)2% (CI: 1%–2%)
South Eastern Melbourne28% (CI: 25%–30%)5% (CI: 4%–7%)2% (CI: 1%–3%)
Regional 133% (CI: 32%–34%)9% (CI: 8%–9%)3% (CI: 2%–3%)
Hunter (NSW)35% (CI: 34%–37%)10% (CI: 9%–11%)3% (CI: 3%–4%)
Frankston-Mornington Peninsula (Vic)34% (CI: 31%–36%)10% (CI: 8%–13%)3% (CI: 2%–4%)
Illawarra-Shoalhaven (NSW)33% (CI: 31%–35%)10% (CI: 8%–11%)4% (CI: 3%–5%)
Perth South Coastal35% (CI: 31%–39%)9% (CI: 6%–11%)2% (CI: 2%–3%)
Central Coast NSW32% (CI: 29%–35%)10% (CI: 7%–12%)3% (CI: 2%–4%)
Sunshine Coast (Qld)32% (CI: 30%–33%)8% (CI: 7%–9%)2% (CI: 2%–3%)
Nepean-Blue Mountains (NSW)31% (CI: 29%–33%)7% (CI: 5%–8%)2% (CI: 1%–2%)
Barwon (Vic)29% (CI: 27%–32%)7% (CI: 6%–9%)2% (CI: 1%–3%)
Regional 233% (CI: 32%–34%)9% (CI: 9%–10%)3% (CI: 3%–3%)
Hume (Vic/NSW)32% (CI: 29%–35%)13% (CI: 10%–15%)5% (CI: 3%–8%)
Loddon-Mallee-Murray (Vic/NSW)35% (CI: 32%–39%)10% (CI: 8%–12%)4% (CI: 2%–5%)
Wide Bay (Qld)35% (CI: 32%–38%)10% (CI: 9%–12%)4% (CI: 3%–5%)
Murrumbidgee (NSW)33% (CI: 30%–37%)10% (CI: 7%–13%)4% (CI: 2%–6%)
Gippsland (Vic)34% (CI: 32%–36%)10% (CI: 8%–12%)3% (CI: 2%–3%)
Tasmania34% (CI: 33%–36%)9% (CI: 8%–10%)3% (CI: 2%–4%)
Goulburn Valley (Vic)33% (CI: 29%–37%)10% (CI: 7%–12%)3% (CI: 2%–5%)
North Coast NSW33% (CI: 31%–35%)9% (CI: 8%–10%)3% (CI: 2%–4%)
Great South Coast (Vic)34% (CI: 31%–38%)8% (CI: 7%–10%)2% (CI: 1%–3%)
Southern NSW32% (CI: 29%–35%)10% (CI: 8%–11%)3% (CI: 2%–4%)
Darling Downs-SW Qld33% (CI: 31%–34%)9% (CI: 8%–11%)3% (CI: 2%–3%)
Grampians (Vic)33% (CI: 30%–36%)9% (CI: 7%–11%)2% (CI: 1%–3%)
South West WA33% (CI: 31%–35%)8% (CI: 7%–10%)2% (CI: 1%–3%)
Western NSW31% (CI: 28%–33%)8% (CI: 6%–10%)3% (CI: 2%–4%)
New England (NSW)30% (CI: 27%–33%)7% (CI: 6%–9%)2% (CI: 1%–3%)
Country South SANPNPNP
Rural 131% (CI: 29%–33%)8% (CI: 7%–9%)3% (CI: 2%–3%)
Townsville-Mackay (Qld)31% (CI: 29%–33%)8% (CI: 6%–10%)3% (CI: 2%–4%)
Central Qld30% (CI: 26%–33%)9% (CI: 6%–11%)NP
Country North SA31% (CI: 28%–33%)7% (CI: 6%–9%)2% (CI: 1%–3%)
Far West NSWNPNPNP
Lower Murray (Vic/NSW)NPNPNP
Rural 230% (CI: 28%–32%)8% (CI: 7%–9%)3% (CI: 2%–4%)
Far North Qld30% (CI: 28%–33%)8% (CI: 6%–9%)3% (CI: 2%–3%)
Northern Territory31% (CI: 28%–34%)7% (CI: 5%–10%)2% (CI: 1%–4%)
Central & NW QldNPNPNP
Goldfields-Midwest (WA)NPNPNP
Kimberley-Pilbara (WA)NPNPNP

95% confidence interval.

* Results comprise patients who are recorded by the GP as having been diagnosed with one or more of 18 common chronic conditions.

Data were weighted to the attending patient population using Department of Human Services, Medicare Benefits statistics, 12 months ending June 2013.

Results comprise all chronic conditions managed. See O’Halloran J, et al. Defining chronic conditions for primary care with ICPC-2. Fam Pract 2004;21(4).

NP Not available for publication.

Notes: Data are reported as whole numbers. However, for graphical display and ordering they are plotted unrounded. Data are collected from a national survey of GPs. Characteristics of participating GPs may differ from non-participating GPs in a Medicare Local catchment which may affect the generalisability of results. For data limitations and exclusions see this report’s Technical Supplement.

Sources: Customised analysis of BEACH dataset (April 2009–March 2013) and BEACH SAND substudy dataset (July 2005–June 2013) prepared for the National Health Performance Authority by the Family Medicine Research Centre, the University of Sydney.

GP management of three or more chronic conditions
Years of data: 2009–2013

During 2009–2013, the percentage of GP consultations in which three or more chronic conditions1 were managed varied across Medicare Local catchments and across peer groups, ranging from 5% in Hume (Vic/NSW) to 1% in Bentley-Armadale (WA).

Percentage of GP consultations in which three or more chronic conditions were managed, 2009–2013

The following image is a map of Australia showing the percentage of GP consultations in which three or more chronic conditions were managed for mddicare local catchments. Data can be found in the Fair comparisons section.

Results for Medicare Local catchments were ranked from highest to lowest and then split into five equal-sized groups.2

The following is a legend for the maps detailed on this page. The first row shows the various colour ranges, the second is the relevant colour's range value and the third indicates which end is highest and lowest.
NP
1.0%
2.0%
3.0%
4.0%
5.0%
Lowest group
Highest group
Medicare Local catchment boundary
506
Numbers on map are Medicare Local reference codes
The following are images of maps around major cities showing the percentage of GP consultations in which three or more chronic conditions were managed for mddicare local catchments. Data can be found in the Fair comparisons section.

i. Perth and
surrounding areas

ii. Adelaide and
surrounding areas

iii. Melbourne and
surrounding areas

iv. Canberra and
surrounding areas

v. Sydney and
surrounding areas

vi. Brisbane and
surrounding areas

1. Results comprise all chronic conditions managed in general practice defined in O’Halloran J, et al. Defining chronic conditions for primary care with ICPC-2. Fam Pract 2004;21(4):381–6.

2. Each Medicare Local catchment has been assigned to a group that represents one percentage point.

3. For more information on peer groups and the calculation of peer group results refer to this report’s Technical Supplement.

Notes: Data are reported as whole numbers. However, for graphical display and ordering they are plotted unrounded. Data are collected from a national survey of GPs. Characteristics of participating GPs may differ from non-participating GPs in a Medicare Local catchment which may affect the generalisability of results. For data limitations and exclusions see this report’s Technical Supplement.

Source: Customised analysis of BEACH data prepared for the National Health Performance Authority by the Family Medicine Research Centre, the University of Sydney, 2009–2013. Data can be downloaded from Explore the data.

NP Not available for publicaton.

More informatino can be found at http://www.myhealthycommunities.gov.au and in this report’s Technical Supplement.

Fair comparisons

To compare Medicare Locals more fairly, each Medicare Local catchment has been grouped into one of seven peer groups3, based on remoteness and socioeconomic status.
This allows:

  • Medicare Local catchments to be compared within the same metropolitan, regional or rural peer group, and
  • Medicare Local catchments to be compared with the average for their peer group.

It also allows variation to be seen across peer groups that may be associated with remoteness and socioeconomic status.

See the PDF ReportOpens in a new window. for a graphical representation of the table below.

Peer groups Map Ref. Percentage of GP Consultations
Metro 12% (CI: 2%–3%)
Inner West Sydney1023% (CI: 2%–4%)
Eastern Sydney1013% (CI: 2%–4%)
Inner NW Melbourne2012% (CI: 2%–3%)
Inner East Melbourne2062% (CI: 2%–3%)
Northern Sydney1072% (CI: 2%–3%)
Bayside2022% (CI: 1%–3%)
Australian Capital Territory8012% (CI: 1%–2%)
Sydney North Shore & Beaches1082% (CI: 1%–2%)
Metro 22% (CI: 2%–3%)
Sthn Adelaide-Fleurieu-Kang. Is.4034% (CI: 3%–5%)
Eastern Melbourne2073% (CI: 2%–4%)
Fremantle5033% (CI: 2%–4%)
Perth Central & East Metro5013% (CI: 2%–3%)
Greater Metro South Brisbane3022% (CI: 2%–3%)
South Western Melbourne2032% (CI: 1%–3%)
South Eastern Sydney1032% (CI: 1%–3%)
Central Adelaide & Hills4022% (CI: 2%–3%)
Perth North Metro5022% (CI: 1%–3%)
Gold Coast3032% (CI: 1%–3%)
Metro North Brisbane3012% (CI: 1%–2%)
Bentley-Armadale5041% (CI: 1%–2%)
Metro 33% (CI: 2%–3%)
Northern Adelaide4013% (CI: 2%–4%)
Northern Melbourne2053% (CI: 2%–4%)
South Western Sydney1043% (CI: 2%–3%)
Macedon Ranges & NW Melbourne2042% (CI: 1%–4%)
Western Sydney1052% (CI: 2%–3%)
South Eastern Melbourne2082% (CI: 1%–3%)
West Moreton-Oxley3052% (CI: 1%–2%)
Regional 13% (CI: 2%–3%)
Illawarra-Shoalhaven1104% (CI: 3%–5%)
Hunter1113% (CI: 3%–4%)
Frankston-Mornington Peninsula2093% (CI: 2%–4%)
Central Coast NSW1093% (CI: 2%–4%)
Perth South Coastal5052% (CI: 2%–3%)
Barwon2102% (CI: 1%–3%)
Sunshine Coast3042% (CI: 2%–3%)
Nepean-Blue Mountains1062% (CI: 1%–2%)
Regional 23% (CI: 3%–3%)
Hume2165% (CI: 3%–8%)
Murrumbidgee1164% (CI: 2%–6%)
Loddon-Mallee-Murray2144% (CI: 2%–5%)
Wide Bay3074% (CI: 3%–5%)
Southern NSW1173% (CI: 2%–4%)
Goulburn Valley2153% (CI: 2%–5%)
Tasmania6013% (CI: 2%–4%)
Western NSW1153% (CI: 2%–4%)
North Coast NSW1133% (CI: 2%–4%)
Darling Downs-SW Qld3063% (CI: 2%–3%)
Gippsland2173% (CI: 2%–3%)
Great South Coast2122% (CI: 1%–3%)
Grampians2112% (CI: 1%–3%)
South West WA5062% (CI: 1%–3%)
New England1142% (CI: 1%–3%)
Country South SA404NP
Rural 13% (CI: 2%–3%)
Townsville-Mackay3103% (CI: 2%–4%)
Country North SA4052% (CI: 1%–3%)
Far West NSW118NP
Lower Murray213NP
Central Qld308NP
Rural 23% (CI: 2%–4%)
Far North Qld3113% (CI: 2%–3%)
Northern Territory7012% (CI: 1%–4%)
Central & NW Qld309NP
Goldfields-Midwest507NP
Kimberley-Pilbara508NP

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.

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