Blood pressure control in Australian general practice: analysis using general practice records of 1.2 million patients from the MedicineInsight database

Application of the Australian Bureau of Statistics Socio-Economic Indexes for Areas in cardiovascular disease research: a scoping review identifying implications for research

Objective To scope how the Australian Bureau of Statistics Socio-Economic Indexes for Areas (SEIFA) has been applied to measure socio-economic status (SES) in peer-reviewed cardiovascular disease (CVD) research. Methods The Joanna Briggs Institute's scoping review methodology was used. Results The search retrieved 2788 unique citations, and 49 studies were included. Studies were heterogeneous in their approach to analysis using SEIFA. Not all studies provided information as to what version was used and how SEIFA was applied in analysis. Spatial unit of analysis varied between studies, with participant postcode most frequently applied. Study quality varied. Conclusions The use of SEIFA in Australian CVD peer-reviewed research is widespread, with variations in the application of SEIFA to measure SES as an exposure. There is a need to improve the reporting of how SEIFA is applied in the methods sections of research papers for greater transparency and to ensure accurate interpretation of CVD research.

Knowledge, attitudes, and behaviors related to dietary salt intake and the acceptability of salt substitute among the Australian culturally and linguistically diverse community: An online survey

The Australian culturally and linguistically diverse (CALD) communities may be at higher risk of salt intake than recommended given the use of a combination of discretionary sources and exposure to processed foods within a western country. This survey aimed to understand the knowledge, attitudes, and behaviors toward dietary salt and the acceptability of salt substitutes in the CALD communities. An online cross-sectional survey was conducted among adults who self-reported being a part of a CALD community, which was defined as non-Indigenous cultural groups in Australia having cultural or linguistic connections with their overseas place of birth, ancestry or ethnic origin, religion, preferred language or language spoken at home. A total of 218 respondents opened the survey link. A total of 196 completed the entire survey. The majority of respondents (162, 83%) were aware that high salt intake causes serious health problems. Altogether 134 (69%) respondents were aware that there is a recommended amount for daily salt consumption although only 59 (44%) knew precise recommendations as <5 g salt per day. Around one quarter of the respondents rarely or never looked for ‟low in salt'' or ‟reduced salt'' messages on food labels when shopping. Over half specified they always or often added salt during cooking or preparing foods in the household. Almost 4 in 5 CALD respondents were willing to reduce their salt intake for health and 3 in 4 were open to trying a salt substitute. Further research into the utility of a salt substitute intervention in the Australian CALD community is warranted.

Pharmaceutical management of type 2 diabetes among Indigenous Australians living in urban or rural locations: a comparative study using a national general practice database

INTRODUCTION

Type 2 diabetes is more prevalent among Aboriginal and Torres Strait Islander Peoples, especially those living in rural than urban areas. However, little is known about how diabetes is managed in different settings.

OBJECTIVE

To investigate differences in the prevalence of diabetes and the prescription of antidiabetic medications for Aboriginal and/or Torres Strait Islander Peoples living in urban or rural Australia.

DESIGN

Cross-sectional study using de-identified electronic medical records of 29,429 Aboriginal and/or Torres Strait Islander adults (60.4% females; mean age 45.2 ± 17.3 years) regularly attending 528 'mainstream' Australian general practices (MedicineInsight) in 2018.

FINDINGS

The prevalence of diabetes was 16.0%, and it was more frequent among those living in rural areas (22.0; 95% CI 19.3-24.4) than inner regional (17.6%; 95% CI 16.0-19.2) or major cities (15.8%; 95% CI 14.7-17.0; p < 0.001). The highest prevalence of diabetes was for males living in rural settings (25.0%). Of those with diabetes, 71.6% (95% CI 69.0-74.0) were prescribed antidiabetics, with a similar frequency in urban and rural areas (p = 0.291). After adjustment for sociodemographics, the only difference in diabetes management was a higher prescription of sulfonylureas in rural areas than in major cities (OR 1.39; 1.07-1.80).

DISCUSSION

The prevalence of diabetes was similar to other national data, although we found it was more frequent amongst Aboriginal and/or Torres Strait Islander males, especially those from rural areas.

CONCLUSION

Despite current recommendations, one-in-four Indigenous Australians with diabetes were not prescribed antidiabetics. The clinical significance of more frequent prescriptions of sulfonylureas in rural locations remains unclear.

The Cost of Uncontrolled Blood Pressure in Australian General Practice: A Modelling Study Using Electronic Health Records (MedicineInsight)

BACKGROUND

Hypertension is the most common condition seen in Australian general practice. Despite hypertension being amenable to lifestyle modifications and pharmacological treatment, only around half of these patients have controlled blood pressure levels (< 140/90 mmHg), placing them at an increased risk of cardiovascular disease.

OBJECTIVE

We aimed to estimate the health and acute hospitalisation costs of uncontrolled hypertension among patients attending general practice.

METHODS

We used population data and electronic health records from 634,000 patients aged 45-74 years who regularly attended an Australian general practice between 2016 and 2018 (MedicineInsight database). An existing worksheet-based costing model was adapted to calculate the potential cost savings for acute hospitalisation of primary cardiovascular disease events by reducing the risk of a cardiovascular event over the next 5 years through improved systolic blood pressure control. The model estimated the number of expected cardiovascular disease events and associated acute hospital costs under current levels of systolic blood pressure and compared this estimate with the expected number of cardiovascular disease events and costs under different levels of systolic blood pressure control.

RESULTS

The model estimated that across all Australians aged 45-74 years who visit their general practitioner (n = 8.67 million), 261,858 cardiovascular disease events can be expected over the next 5 years at current systolic blood pressure levels (mean 137.8 mmHg, standard deviation = 12.3 mmHg), with a cost of AUD$1813 million (in 2019-20). By reducing the systolic blood pressure of all patients with a systolic blood pressure greater than 139 mmHg to 139 mmHg, 25,845 cardiovascular disease events could be avoided with an associated reduction in acute hospital costs of AUD$179 million. If systolic blood pressure is lowered further to 129 mmHg for all those with systolic blood pressure greater than 129 mmHg, 56,169 cardiovascular disease events could be avoided with potential cost savings of AUD$389 million. Sensitivity analyses indicate that potential cost savings range from AUD$46 million to AUD$1406 million and AUD$117 million to AUD$2009 million for the two scenarios, respectively. Cost savings by practice range from AUD$16,479 for small practices to AUD$82,493 for large practices.

CONCLUSIONS

The aggregate cost effects of poor blood pressure control in primary care are high, but cost implications at the individual practice level are modest. The potential cost savings improve the potential to design cost-effective interventions, but such interventions may be best targeted at a population level rather than at individual practices.

Diabetes mellitus monitoring and control among adults in Australian general practice: a national retrospective cohort study

OBJECTIVES

This study investigated whether the monitoring and control of clinical parameters are better among patients with newly compared with past recorded diabetes diagnosis.

DESIGN

Retrospective cohort study.

SETTING

MedicineInsight, a national general practice database in Australia.

PARTICIPANTS

101 875 'regular' adults aged 18+ years with past recorded (2015-2016) and 9236 with newly recorded (2017) diabetes diagnosis.

MAIN OUTCOME MEASURES

Two different groups of outcomes were assessed in 2018. The first group of outcomes was the proportion of patients with clinical parameters (ie, glycated haemoglobin A1c (HbA1c), blood pressure (BP), total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol, triglycerides, estimated glomerular filtration rate and albumin-to-creatinine ratio) monitored at least once in 2018. The second group of outcomes were those related to diabetes control in 2018 (HbA1c ≤7.0%, (BP) ≤140/90 mm Hg, total cholesterol <4.0 mmol/L and LDL-C <2.0 mmol/L). Adjusted ORs (OR_adj) and adjusted probabilities (%) were obtained based on logistic regression models adjusted for practice variables and patients' socio-demographic and clinical characteristics.

RESULTS

The study included 111 111 patients (51.7% men; mean age 65.3±15.0 years) with recorded diabetes diagnosis (11.0% of all 1 007 714 adults in the database). HbA1c was monitored in 39.2% (95% CI 36.9% to 41.6%) of patients with newly recorded and 45.2% (95% CI 42.6% to 47.8%) with past recorded diabetes (OR_adj 0.78, 95% CI 0.73 to 0.82). HbA1c control was achieved by 78.4% (95% CI 76.7% to 80.0%) and 54.4% (95% CI 53.4% to 55.4%) of monitored patients with newly or past recorded diabetes, respectively (OR_adj 3.11, 95% CI 2.82 to 3.39). Less than 20% of patients with newly or past recorded diabetes had their HbA1c, BP and total cholesterol levels controlled (OR_adj 1.08, 95% CI 0.97 to 1.21).

CONCLUSIONS

The monitoring of clinical parameters was lower among patients with newly than past recorded diabetes. However, diabetes control was similarly low in both groups, with only one in five monitored patients achieving control of all clinical parameters.

General practice management of depression among patients with coronary heart disease in Australia

BACKGROUND

Incident depression is associated with coronary heart disease (CHD) and increased morbidity and mortality. Treatment of depression with antidepressants and psychotherapy can be beneficial for these patients to reduce the risk of further CHD events. Ongoing management of CHD and depression mainly occurs in the community, but little is known about the identification and care of patients with comorbid CHD and depression in general practice. This study explores the prescription of antidepressants for these patients by sociodemographic variables.

METHODS

This is an open cohort study with de-identified data based on electronic medical records of 880,900 regular patients aged 40 + years from a national general practice database in Australia (MedicineInsight). Data from 2011-2018 was used to classify patients as newly recorded CHD (CHD recorded in 2018 but not in previous years), previously recorded CHD (CHD recorded between 2011-2017) or no recorded history of CHD. Antidepressant prescribing in 2018 considered active ingredients and commercial brand names. The association between sociodemographic variables and antidepressant prescribing was tabulated according to the CHD status.

RESULTS

The proportion of current depression among patients with newly recorded CHD was 11.4% (95%CI 10.3-12.6), 10.5% among those with previously recorded CHD (95%CI 10.0-11.1) and 9.6% among those with no recorded history of CHD (95%CI 9.2-10.1). Antidepressant prescribing was slightly higher among those with newly recorded CHD (76.4%; 95%CI 72.1-80.6) than among those with previously recorded CHD (71.6%; 95%CI 69.9-73.2) or no history of CHD (69.5%; 95%CI 68.6-70.4). Among males with newly recorded CHD and depression, antidepressant prescribing was more frequent in major cities or inner regional areas (~ 81%) than in outer/remote Australia (66.6%; 95% CI 52.8-80.4%).

CONCLUSIONS

Although antidepressant prescribing was slightly greater in those with newly recorded CHD compared to those with depression alone, its clinical significance is uncertain. Much larger differences in prescribing were seen by geographic location and could be addressed by innovations in clinical practice.

Predicted cardiovascular disease risk and prescribing of antihypertensive therapy among patients with hypertension in Australia using MedicineInsight

Hypertension guidelines recommend that absolute cardiovascular disease (CVD) risk guide the management of hypertensive patients. This study aimed to assess the proportion of patients with diagnosed hypertension with sufficient data to calculate absolute CVD risk and determine whether CVD risk is associated with prescribing of antihypertensive therapies. This was a cross-sectional study using a large national database of electronic medical records of patients attending general practice in 2018 (MedicineInsight). Of 571,492 patients aged 45-74 years without a history of CVD, 251,733 [40.6% (95% CI: 39.8-41.2)] had a recorded hypertension diagnosis. The proportion of patients with sufficient recorded data available to calculate CVD risk was higher for patients diagnosed with hypertension [51.0% (95% CI: 48.0-53.9)] than for patients without a diagnosis of hypertension [38.7% (95% CI: 36.5-41.0)]. Of those patients with sufficient data to calculate CVD risk, 29.3% (95% CI: 28.1-30.6) were at high risk clinically, 6.0% (95% CI: 5.8-6.3) were at high risk based on their CVD risk score, 12.8% (95% CI: 12.5-13.2) at moderate risk and 51.8% (95% CI: 50.8-52.9) at low risk. The overall prevalence of antihypertensive therapy was 60.9% (95% CI: 59.3-62.5). Prescribing was slightly lower in patients at high risk based on their CVD risk score [57.4% (95% CI: 55.4-59.4)] compared with those at low [63.3% (95% CI: 61.9-64.8)] or moderate risk [61.8% (95% CI: 60.2-63.4)] or at high risk clinically [64.1% (95% CI: 61.9-66.3)]. Guideline adherence is suboptimal, and many patients miss out on treatments that may prevent future CVD events.

Diabetes Mellitus Diagnosis and Screening in Australian General Practice: A National Study

Aims

To investigate the epidemiology of diabetes diagnosis and screening in Australian general practice.

Methods

Cross-sectional study using electronic health records of 1,522,622 patients aged 18+ years attending 544 Australian general practices (MedicineInsight database). The prevalence of diagnosed diabetes and diabetes screening was explored using all recorded diagnoses, laboratory results, and prescriptions between 2016 and 2018. Their relationship with patient sociodemographic and clinical characteristics was also investigated.

Results

Overall, 7.5% (95% CI 7.3, 7.8) of adults had diabetes diagnosis, 0.7% (95% CI 0.6, 0.7) prediabetes, and 0.3% (95% CI 0.3, 0.3) unrecorded diabetes/prediabetes (elevated glucose levels without a recorded diagnosis). Patients with unrecorded diabetes/prediabetes had clinical characteristics similar to those with recorded diabetes, except for a lower prevalence of overweight/obesity (55.5% and 69.9%, respectively). Dyslipidaemia was 1.8 times higher (36.2% vs. 19.7%), and hypertension was 15% more likely (38.6% vs. 33.8%) among patients with prediabetes than with diabetes. Diabetes screening (last three years) among people at high risk of diabetes was 55.2% (95% CI 52.7, 57.7), with lower rates among young or elderly males.

Conclusions

Unrecorded diabetes/prediabetes is infrequent in Australian general practice, but prediabetes diagnosis was also lower than expected. Diabetes screening among high-risk individuals can be improved, especially in men, to enhance earlier diabetes diagnosis and management.