What explains the regional variation in the use of general practitioners in Australia?

Hospitalisations for non-specific low back pain in people presenting to South Australian public hospital emergency departments

OBJECTIVE

The present study sought to investigate predictors of hospitalisation in adults diagnosed with non-specific low back pain (LBP) and/or sciatica from an ED.

METHODS

A 5-year, multicentre retrospective observational study was conducted across six public hospitals (metropolitan and regional) using data from electronic medical records. Patient presentations were identified using LBP diagnostic codes and key data extracted (patient demographics, clinical activity, discharge destination). Descriptive statistics and logistic regression were used to measure associations between identified variables and hospitalisation.

RESULTS

There were 11 709 ED presentations across the study period. People aged ≥65 years (odds ratio [OR] 2.84, 95% confidence interval [CI] 2.61-3.10) and those who arrived at the ED via ambulance (age-adjusted OR 2.68, 95% CI 2.44-2.95) were more likely to be hospitalised. People were also more likely to be hospitalised when triaged as more urgent, when blood tests or advanced spinal imaging were ordered, and when i.v./subcutaneous opioids or oral benzodiazepines were administered. Hospitalisation rates for LBP were lower in regional hospitals, in people residing in lower socioeconomic areas and in Indigenous Australians.

CONCLUSION

Certain patient characteristics and ED clinical activity are associated with hospitalisations for LBP. Understanding these factors will better inform the design and delivery of appropriate high-quality care.

Views on the Development and Use of a New Digital Adverse Drug Event Reporting Platform in Australia: A Qualitative Study

BACKGROUND

Reporting of adverse drug events (ADEs) to regulatory authorities remains low, particularly among consumers.

OBJECTIVES

To explore stakeholders' views on the development and use of a digital platform to improve ADE reporting by consumers to the regulatory authority in Australia, i.e., the Therapeutic Goods Administration.

METHODS

A qualitative study was conducted using semi-structured interviews, focus group discussions (FGDs), and co-design workshops with consumers, healthcare professionals (HCPs), and regulators. The interview recordings were transcribed verbatim, coded, and analysed thematically according to the Capability, Opportunity, Motivation, Behaviour model. Findings of the FGDs and co-design workshops were incorporated to enhance and complement the insights gathered from the interviews.

RESULTS

A total of 39 participants took part in the study (54 % consumers, 41 % HCPs, and 5 % regulators). Uncovered themes related to ADE reporting in general were: difficulty recognizing ADEs and health literacy, awareness about reporting ADEs (Capability); visibility of ADE reporting, professionals' views on consumer ADE reporting, consumer education (Opportunity); the common good, benefit to the reporter, identifying ADEs worth reporting, and concern about reporting (Motivation). Additional identified themes specific to a new digital platform were: physical abilities (Capability); features that facilitate intuitive use, convenience and accessibility, user experience, integration with existing systems, trust, sharing experiences with others (Opportunity); and concern about using a reporting platform, and feedback loop (Motivation).

CONCLUSIONS

A cross-section of attitudes and values were obtained regarding ADE reporting in general and a new ADE reporting digital platform for consumers in Australia, which will inform its development, implementation and evaluation.

Does use of GP and specialist services vary across areas and according to individual socioeconomic position? A multilevel analysis using linked data in Australia

OBJECTIVE

Timely access to primary care and supporting specialist care relative to need is essential for health equity. However, use of services can vary according to an individual's socioeconomic circumstances or where they live. This study aimed to quantify individual socioeconomic variation in general practitioner (GP) and specialist use in New South Wales (NSW), accounting for area-level variation in use.

DESIGN

Outcomes were GP use and quality-of-care and specialist use. Multilevel logistic regression was used to estimate: (1) median ORs (MORs) to quantify small area variation in outcomes, which gives the median increased risk of moving to an area of higher risk of an outcome, and (2) ORs to quantify associations between outcomes and individual education level, our main exposure variable. Analyses were adjusted for individual sociodemographic and health characteristics and performed separately by remoteness categories.

SETTING

Baseline data (2006-2009) from the 45 and Up Study, NSW, Australia, linked to Medicare Benefits Schedule and death data (to December 2012).

PARTICIPANTS

267 153 adults aged 45 years and older.

RESULTS

GP (MOR=1.32-1.35) and specialist use (1.16-1.18) varied between areas, accounting for individual characteristics. For a given level of need and accounting for area variation, low education-level individuals were more likely to be frequent users of GP services (no school certificate vs university, OR=1.63-1.91, depending on remoteness category) and have continuity of care (OR=1.14-1.24), but were less likely to see a specialist (OR=0.85-0.95).

CONCLUSION

GP and specialist use varied across small areas in NSW, independent of individual characteristics. Use of GP care was equitable, but specialist care was not. Failure to address inequitable specialist use may undermine equity gains within the primary care system. Policies should also focus on local variation.

An assessment of the spatial distribution of bulk billing-only GP services in Australia in relation to area-based socio-economic status

BACKGROUND

The accessibility to affordable primary healthcare services contributes to population health and health equity. A key aspect to accessibility is the geographical distribution of primary healthcare services. Limited studies have assessed the nationwide spatial distribution of bulk billing-only medical practices or 'no-fee' services. The aim of this study was to provide a nationwide approximation of bulk billing-only services and evaluate the socio-demographic status and population characteristics in relation to the distribution of bulk billing-only GP services.

METHODS

The methodology in this study used Geographic Information System (GIS) technology to map the locations of all bulk bulking-only medical practices collected in mid-2020 and linked this with population data. The population data and practice locations were analysed at the level of Statistical Areas Level 2 (SA2) regions and used the most recent Census data.

RESULTS

The study sample included (n =2095) bulk billing-only medical practice locations. The nationwide average Population-to-Practice (PtP) ratio was 1 practice to 8529 people for regions with access to bulk billing-only practice, and 57.4% of the Australian population lives within an SA2 that has access to at least one bulk billing-only medical practices. No significant associations were identified between practice distribution and area socio-economic status.

CONCLUSION

The study identified areas with low access to affordable GP services, with many SA2 regions having no access to bulk billing-only practices. Findings also indicate that there was no association between area socio-economic status and the distribution of bulk billing-only services.

Association of individual-socioeconomic variation in quality-of-primary care with area-level service organisation: A multilevel analysis using linked data

RATIONALE, AIMS AND OBJECTIVES

Ensuring equitable access to primary care (PC) contributes to reducing differences in health related to people's socioeconomic circumstances. However, there is limited data on system-level factors associated with equitable access to high-quality PC. We examine whether individual-level socioeconomic variation in general practitioner (GP) quality-of-care varies by area-level organisation of PC services.

METHODS

Baseline data (2006-2009) from the Sax Institute's 45 and Up Study, involving 267,153 adults in New South Wales, Australia, were linked to Medicare Benefits Schedule claims and death data (to December 2012). Small area-level measures of PC service organisation were GPs per capita, bulk-billing (i.e., no copayment) rates, out-of-pocket costs (OPCs), rates of after-hours and chronic disease care planning/coordination services. Using multilevel logistic regression with cross-level interaction terms we quantified the relationship between area-level PC service characteristics and individual-level socioeconomic variation in need-adjusted quality-of-care (continuity-of-care, long-consultations, and care planning), separately by remoteness.

RESULTS

In major cities, more bulk-billing and chronic disease services and fewer OPCs within areas were associated with an increased odds of continuity-of-care-more so among people of high- than low education (e.g., bulk-billing interaction with university vs. no school certificate 1.006 [1.000, 1.011]). While more bulk-billing, after-hours services and fewer OPCs were associated with long consultations and care planning across all education levels, in regional locations alone, more after-hours services were associated with larger increases in the odds of long consultations among people with low- than high education (0.970 [0.951, 0.989]). Area GP availability was not associated with outcomes.

CONCLUSIONS

In major cities, PC initiatives at the local level, such as bulk-billing and after-hours access, were not associated with a relative benefit for low- compared with high-education individuals. In regional locations, policies supporting after-hours access may improve access to long consultations, more so for people with low- compared with high-education.

Systematic population-wide ecological analysis of regional variability in disease prevalence

The prevalence of diseases often varies substantially from region to region. Besides basic demographic properties, the factors that drive the variability of each prevalence are to a large extent unknown. Here we show how regional prevalence variations in 115 different diseases relate to demographic, socio-economic, environmental factors and migratory background, as well as access to different types of health services such as primary, specialized and hospital healthcare. We have collected regional data for these risk factors at different levels of resolution; from large regions of care (Versorgungsregion) down to a 250 by 250 m square grid. Using multivariate regression analysis, we quantify the explanatory power of each independent variable in relation to the regional variation of the disease prevalence. We find that for certain diseases, such as acute heart conditions, diseases of the inner ear, mental and behavioral disorders due to substance abuse, up to 80% of the variance can be explained with these risk factors. For other diagnostic blocks, such as blood related diseases, injuries and poisoning however, the explanatory power is close to zero. We find that the time needed to travel from the inhabited center to the relevant hospital ward often contributes significantly to the disease risk, in particular for diabetes mellitus. Our results show that variations in disease burden across different regions can for many diseases be related to variations in demographic and socio-economic factors. Furthermore, our results highlight the relative importance of access to health care facilities in the treatment of chronic diseases like diabetes.

Primary and Secondary Care Related Quality Indicators for Dementia Care Among Australian Aged Care Users: National Trends, Risk Factors, and Variation

Background: Studies related to clinical quality indicators (CQIs) in dementia have focused on hospitalizations, medication management, and safety. Less attention has been paid to indicators related to primary and secondary care. Objective: To evaluate the incidence of primary and secondary care CQIs for Australians with dementia using government-subsidized aged care. The examined CQIs were: comprehensive medication reviews, 75+ health assessments, comprehensive geriatric assessments, chronic disease management plans, general practitioner (GP) mental health treatment plans, and psychiatrist attendances. Methods: Retrospective cohort study (2011–2016) of 255,458 individuals. National trend analyses estimated incidence rates and 95% confidence intervals (CI) using Poisson or negative binomial regression. Associations were assessed using backward stepwise multivariate Poisson or negative binomial regression model, as appropriate. Funnel plots examined geographic and PRAC facility variation. Results: CQI incidence increased in all CQIs but medication reviews. For the overall cohort, 75+ health assessments increased from 1.07/1000 person-days to 1.16/1000 person-days (adjusted incidence rate ratio (aIRR) = 1.03, 95% CI 1.02–1.03).Comprehensive geriatric assessments increased from 0.24 to 0.37/1000 person-days (aIRR = 1.12, 95% CI 1.10–1.14). GP mental health treatment plans increased from 1.30 to 2.1/1000 person-days (aIRR = 1.13, 95% CI 1.12–1.15). Psychiatric attendances increased from 0.09 to 0.11/1000 person-days (aIRR = 1.05, 95% CI 1.03–1.07). Being female, older, having fewer comorbidities, and living outside a major city were associated with lower likelihood of using the services. Large geographical and facility variation was observed (0–92%). Conclusion: Better use of primary and secondary care services to address needs of individuals with dementia is urgently needed.