Govt wants kids to have cut-price health checks

The Federal Government wants children to have cut-price health checks after confirming it will rip almost $145 million out of general practice by abolishing a Medicare program that last year provided comprehensive pre-school health assessments for 154,000 children.

But Health Minister Sussan Ley said parents would still be able to get their GP to conduct a similar Medicare-funded health check of their child, though at a fraction of the cost to the taxpayer.

The Minister was forced to make the clarification after an announcement in the Federal Budget that $144.6 million would be taken out of general practice over the next four years by “removing the current duplication” Medicare-funded health checks and child health assessments provided by the states and territories.

AMA President Associate Professor Brian Owler voiced concern about the cut, saying it was “very unclear” whether or not there was duplication occurring.

The measure was also heavily criticised by health groups angered by what appeared to be a decision to axe comprehensive health checks for children aged three to five years, introduced by the former Labor Government in 2008.

But Ms Ley rushed to assure parents that they could still get Medicare-funded health checks for their children.

“Parents needing to access the pre-school health check for their child in order to access income support will still be able to do so through a GP or the various state-based nurse infant and children checks, as is currently the case,” the Minister said. “The only change in the Budget is to the Medicare items GPs can bill taxpayers and patients for undertaking the check.”

The Government has moved to scrap Labor’s “Healthy Kids Check”, which costs Medicare $268.80 per visit, and instead allow GPs to bill for the check as a standard GP item costing $105.55 for an equivalent amount of time.

“Instead of GPs billing a special Medicare item worth hundreds of dollars per visit, they will instead be able to deliver the pre-school health check for three- and four-year-olds through a standard GP item worth about half that,” Ms Ley said.

The Government said an increase in the number of people using the Healthy Kids Check in recent years had sent the cost spiralling.

It reported that the number of assessments had jumped from 40,031 in 2008-09 to 153,725 last financial year, driving the annual cost from $1.8 million to $20 million.

While lamenting the cost of the program, Ms Ley simultaneously criticised it for not being comprehensive enough.

“Currently, only half of Australia’s 300,000-plus four-year-olds have accessed a pre-school health check at the more expensive billing rates,” the Minister said, adding there was no evidence show Labor’s program provided health checks superior to standard GP and state infant check services.

But a study published in the Medical Journal of Australia last year did not support this conclusion.

It found the program was effective in detecting problems with speech, toileting, hearing, vision and behaviour in about 20 per cent of children, and directly led to changes in the clinical management of between 3 and 11 per cent of such children.

The study’s authors said their results suggested “GPs are identifying important child health concerns during the Healthy Kids Checks, using appropriate clinical judgement for the management of some conditions, and referring when concerned”.

They added that GPs were also using the checks as an opportunity to identify other health problems.

The authors admitted to having no knowledge of the cost-effectiveness of the program, “although, given that its timing coincides with vaccination at four years of age, the incremental cost is likely small”.

It followed a study published in the MJA in 2010 which found that although the evidence behind the Healthy Kids Check at that stage was “not compelling”, it had the potential to play a important role in monitoring child development by filling a gap between maternal and child health nurse screening and examinations of selected children by school nursing services.

Adrian Rollins

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Updated TGA Business Services information

2015 Health Budget – at a glance

Main measures

· Medicare rebate freeze to mid-2018

· public hospital funding wound back

· MBS review

· e-health records re-boot – $485m

· Emergency response capacity – $98m

· Cancer screening and medication – $628m

· National Drugs Campaign and Ice Action strategy – $20m

· Boosting immunisation coverage – $188m

· Developing tropical health expertise – $23.8m

Cuts

· Slashing health programs and funds – $962.8m

· $5000 cap on FBT exemption for hospital doctors – $295m

· Child dental benefits – $125.6m

· GP child health assessments – $144.6m

· PBS price and safety net changes – $257.3m

· Health Dept and TGA cuts – $113.1m

· Consolidating health work force scholarships – $72.5m

· Adult public dental services – $45m

The nKPI data collection: data quality issues working paper

The AIHW collects data against a set of national Key Performance Indicators (nKPIs) from primary health care organisations that provide health care to Aboriginal and Torres Strait Islander Australians. The nKPI data are collected every 6 months, reported back to organisations at the individual service level and compiled for national reporting purposes. The raw data received from health organisations are carefully checked to identify any data quality issues and are corrected, in consultation with services, through an ‘exception reporting’ process before the data are used in any type of reporting.This working paper identifies the most common data quality issues that lead to the issuing of exception reports, and suggests a number of options to improve the data collection process that will reduce the number of exception reports issued.

Specialist patients up for thousands as rebate freeze bites

Patients undergoing heart surgery and other specialist treatments face a major hike in out-of-pocket expenses in the next three years that could leave them thousands of dollars poorer if the Federal Government persists with its Medicare rebate freeze, an AMA analysis has found.

Figures prepared by the AMA show the freeze will save the Government almost $2 billion by mid-2018, with more than half of this coming from medical specialists, their patients and health insurers as the value of the Medicare rebate declines and the cost of providing care rises.

The Government has kept the rebate freeze, first announced in last year’s Budget, as a device to encourage the AMA and other medical groups to assist in identifying efficiencies and savings through the Medicare Benefits Schedule review initiated last month.

Health Minister Sussan Ley has described the freeze as a regrettable necessity, though indicating that, “as an article of good faith, I am open to a future review of the current indexation pause as work progresses to identify waste and inefficiencies in the system”.

But the AMA analysis shows it will come at an enormous cost to patients, as the Government dumps a bigger share of health care cost onto households and practitioners.

The AMA estimates the freeze will have caused a $127 million shortfall in Medicare funding this year alone, rising to almost $364 million next financial year, $604.1 million in 2016-17, and almost $850 million in 2017-18. Even without any increase in the number of services provided, the rebate freeze will cumulatively rip $1.94 billion out of the system over four years.

Its effect in general practice has been likened to a “co-payment by stealth”, after University of Sydney research suggested GPs may have to charge non-concession patients more than $8 a visit to make up for the money withheld from the system as a result of the rebate freeze.

AMA President Associate Professor Brian Owler said patients would bear the brunt of the funding shortfall.

“We know that doctors’ costs are going to keep rising. The costs for their practice staff is going to keep rising. The costs to lease their premises and to provide quality practice as a GP or a specialist is going to keep rising,” A/Professor Owler said. “If the rebates don’t rise, those costs have to be passed on in out-of-pocket expenses – we will see less bulk-billing, and there is the possibility of seeing a co-payment by stealth, as has been alluded to by some.”

The AMA President said the effect on patients in need of specialist care would be even more profound, warning that, “the out-of-pocket expenses for specialists are going to be most severely hit”.

Under current arrangements, the Medicare rebate only covers a proportion of the cost of specialist care, and private health funds commit to covering an extra 25 per cent of the MBS fee, plus a loading on top of that for doctors who participate in “gap cover” schemes.

In the past, the health funds have indexed their cover in tandem with increases in the Medicare rebate – and have on occasion increased their cover even when rebates have been held flat.

But A/Professor Owler is among those fearful that insurers will be reluctant increase their cover without any lift in the rebate. If this occurs, many specialists may opt-out of gap cover schemes, which would mean private health cover would revert to the bare minimum 25 per cent of the Medicare rebate, with patients left to pick up the tab.

“I think there is a real issue for private health insurers,” he said. “If they choose to index independently of the MBS, they are going to have to pass on higher private health insurance premiums to people, or, if they choose not to index, there is a real chance that out-of-pocket expenses for specialist costs are going to rise significantly.”

The AMA has prepared resources for doctors and patients to help explain the Medicare rebate indexation freeze and its impact, including a patient guide and clinical examples. The resources are available at: article/medicare-indexation-freeze-support-materials-…

Adrian Rollins

Budget breakdowns

Organ and Tissue Donation

Despite programs to encourage more donors there has been a decline in the rate of organ donations over the past two years according to ShareLife.

The Australian Government hope to improve organ and tissue donation rates by providing $10.2 million over the next two years. The funding will go towards delivering clinical education to hospitals, developing a new Australian Organ Matching System and enhancing the Australian Organ Donor Register.

Currently around 1500 people are on Australian organ transplant waiting lists at any time. One organ and tissue donor can transform the lives of 10 or more people.

The Government will also continue to provide minimum wage for up to nine week to employers of people who have taken leave to donate organs as part of the Supporting Leave for Living Organ Donors Programme. The aim of the Programme is to help alleviate the financial stress that can be experienced by living organ donors by reimbursing employers for payments or leave credits provided to their employees for leave taken to donate an organ and recover from the procedure. The Government announced that the Programme will continue for the next two years.

Tropical health

The Government will provide $15.3 million over four years to invest in research into exotic disease threats to Australia and the region.

The National Health and Medical Research Council will receive 6.8 million to support research into tropical diseases, build collaboration and capacity in the health and medical research workforce, and promote the translation of this research into health policy and practice.

The Government will also provide $8.5 million to establish an Australian Tropical medicine Commercialisation grants program to support Australian researchers to commercialise therapeutics and diagnostics in tropical medicine.

National Drugs Campaign

The Government will provide $20 million over two years to renew the National Drugs Campaign. The Campaign aims to reduce young Australians’ motivation to use illicit drugs by increasing their knowledge about the potential negative consequences of drug use. It is a media campaign to promote the avoidance and cessation of illicit drug use.

The campaign will focus on raising awareness to young people and their parents about the harm caused by illicit drug use, in particular methamphetamine also known as ice.

Royal Flying Doctor Service

The Government has committed additional funding to support the Royal Flying Doctors Service to deliver emergency and primary health care services to people in rural and remote communities of Australia.

The Service will receive an extra $20 million as part of the Government’s commitment to rural and remote communities.

Kirsty Waterford

Govt accused of ‘cruel hoax’ on dental

The Federal Government has been accused of playing a “cruel hoax” on patients after confirming $200 million had been provided for public dental services in the Budget.

In a pre-Budget release, Health Minister Sussan Ley announced a one-off allocation of $155 million for a 12-month National Partnership Agreement on Adult Public Dental Services, supplemented by a child dental benefit scheme that would take to the total value of the package to more than $200 million.

But the Budget papers show the Government has actually cut $125.6 million from funding for child dental services over the next four years by lowering the rate at which it is indexed.

Ms Ley said the provision of public dental services would be considered as part of reforms of federal-state relations, and the funding would ensure care continued to be provided while those discussions were held.

“Real progress has been made in recent years towards improving access to dental services, and the Abbott Government is determined to ensure Australia continues to improve as a nation, which is why we must take hold of this once-in-a-generation opportunity for constructive reform,” the Minister said. “We want to see dental incorporated into our plans for a better integrated health system where services work in co-operation, not isolation.”

But Shadow Health Minister Catherine King condemned the Minister’s statement as “no more than a cruel hoax”.

Ms King said that, far from investing in public dental services, the Government had cut hundreds of millions of dollars out.

In last year’s Budget, the Government announced it would save $390 million over four years by deferring the starting date of the National Partnership Agreement for adult public dental services by a year, and in last year’s Budget, $200 million had been allocated for such services in 2015-16.

But this was trimmed back to just $155 million in the latest Budget, disappointing health advocates concerned about poor oral health, particularly among vulnerable and disadvantaged groups.

Ms King said the figures showed that the Government had actually cut money from public dental health, rather than investing in it.

Dental health problems are widespread in the community. The Australian Institute of Health and Welfare has reported that more than half of 12-year-old children have tooth decay, and it is untreated in about 30 per cent of adults.

Ms Ley said the failure of people to care for their teeth not only harmed the health of their mouth, but placed a significant burden on the health system.

Adrian Rollins

The ghosts of Budgets past

While listening to the Secretary of the Department of Health in the Health Budget lock-up in Canberra on Tuesday night, I was more than a little surprised that the sales pitch to Australia’s health leaders was that the centrepiece of the 2015 Health Budget was the Review of the Medicare Benefits Schedule (MBS) – a measure that had been announced some months earlier with supposedly no Budget revenue implications.

I was even more surprised when the Secretary inferred that the MBS Review would deliver further considerable savings to the Government. Health Minister, Susan Ley, has since clarified that this was not the Government’s intention.

It is not purely about a savings measure, it is about making sure that we have a modern MBS that actually reflects modern medical practice, and it actually maintains access for patient services.

Nevertheless, given the damage caused to the Government from last year’s Budget co-payment proposals and public hospital funding cuts – misguided measures that brought misery to the Government for the best part of a year – the general expectation was that the Government would play some strong suits in health policy.

That was not the case. Instead, we saw a range of modest (but welcome) announcements that remain completely overshadowed by the lingering negative effects of the Medicare patient rebate freeze and public hospital funding cuts – the ghosts of Budgets past.

The Budget unfortunately does not go anywhere near addressing the concerns of the AMA from last year’s Budget.

There is no indication that the public hospital cuts are going to be restored. Nor is there any indication about the required changes for the indexation freeze that we are seeing for GP and specialist patient rebates.

People need to remember that the indexation freeze is a freeze for the patient’s rebate. It is not about the doctor’s income. It is actually about the patient’s rebate and their access to services. There is no indication that those freezes are going to be lifted any earlier than 2018.

There have also been cuts of nearly $150 million taken out of general practice from changes to the child health checks, apparently because of ‘duplication’. It is very unclear where the so-called duplication occurs. Such a change would have been better dealt with as part of the MBS Review, rather than as a hastily conceived Budget saving measure.

There is also a lack of clarity around some of the announced cuts. There was a mystery package of $1.7 billion in cuts that was claimed to cover child health assessments, a number of dental programs, and ‘flexible funds’ for NGOs in the health sector. A big number, but little detail. The end result is a number of small organisations that do very good work looking after vulnerable people left wondering about their funding and their future.

The focus should have been on positives.

The AMA welcomed a range of other measures, including:

e-health changes, including the myHealth Record, particularly the opt-out component;
mental health plan;
support for the National Critical Care and Trauma Response Centre;
funding for Aboriginal Community Controlled health organisations;
organ donation programs; and
the Ice Action strategy.

The AMA has been invited by the Minister for briefing and clarification of issues such as Indigenous health program funding, after hours care, and preventive health.

Public and preventive health programs under cloud

The future of important public and preventive health and support programs for Alzheimer’s, palliative care, alcohol and addiction, rural and Indigenous health are under a cloud after the Federal Government announced almost $1 billion of cuts from health programs.

In a decision that has thrown doubts over the funding of organisations including Alzheimer’s Australia, Palliative Care Australia and the Foundation for Alcohol Research and Education, the Government said it would achieve savings of $962.8 million over the next five years by “rationalising and streamlining funding across a range of Health programs”, including so-called Health Department Flexible Funds, dental workforce programs, preventive health research, GP Super Clinics and several other sources.

AMA President Associate Professor Brian Owler the lack of detail around the savings was concerning.

“There is a lot of uncertainty in Canberra and around the country at the moment as to whether those important programs, those important organisations, such as Palliative Care Australia, Alzheimer’s Australia, the Foundation for Alcohol Research and Education, and many other non-government organisations, are going to be continued to be funded,” A/Professor Owler said. “Rather than announcing that these cuts of almost $1 billion are going to be made to those flexible funds, and leaving it up in the air for these organisations, we need to see certainty around where those cuts are going to be made, how they are going to be applied, so that these organisations can not only plan for their future but also continue their very important work.”

In addition, the Government has tagged the Health Department for an extra $113.1 million of savings in the next five years as part of its Smaller Government initiative.

It said this would be achieved by measures including consolidating the Therapeutic Goods Administration’s corporate and legal services into the Health Department, axing the National Lead Clinicians Group, replacing IT contractors by recruiting full-time staff and “ceasing activities that mirror the work of specialist agencies”, such as the Independent Hospital Pricing Authority, the National Blood Authority, and the Australian Institute of Health and Welfare.

Adrian Rollins

Asthma control in Australia: a cross-sectional web-based survey in a nationally representative population

Asthma is one of the most common chronic diseases in Australia, affecting 10% of the population1 and is a National Health Priority Area. Despite this, there is a widespread perception that it is no longer a problem in Australia, especially as asthma mortality has fallen by 70% from its peak in the 1980s. Asthma mortality in this country nevertheless remains high by international comparisons, particularly in young people (those aged 5–34 years).1 Further, asthma was the seventh-highest cause of years lived with disability in Australasia in 2010.2

Since 1989, Australia has taken a lead in developing and updating clinical practice guidelines for asthma. In March 2014, the new national guidelines3 were launched, and effective asthma control was affirmed as the key goal of treatment. Consistent with international recommendations,4,5 two domains of asthma control are now assessed: symptom control and the future risk of adverse outcomes, such as flare-ups (exacerbations). Asthma control is also one of the recommended National Asthma Indicators for monitoring asthma in Australia.6

To improve clinical practice and asthma policy, reliable population-based data on asthma control in Australia are needed. While statistics for several asthma indicators are available, including prevalence, general practice encounters, hospitalisations and mortality,1 there is little information on measures of asthma control. A recent review could find no population-level Australian data for validated composite measures of asthma control, such as the Asthma Control Test (ACT). Even the most recent population-based surveys of individual asthma control measures were conducted more than 10 years ago.7

Population-based data would also enable the impact of asthma treatment to be assessed. Asthma-related expenditure in Australia during the 2008–09 financial year was $655 million, of which 50% was spent on prescription pharmaceuticals.8 Preventer medications for asthma, such as inhaled corticosteroids (ICS) alone or in combination with long-acting β2-agonists (LABA), are subsidised by the Pharmaceutical Benefits Scheme (PBS), but analysis of PBS data1 indicates that they are prescribed at much higher doses and in more expensive combination formulations than necessary,3 and are also prescribed together with antibiotics for short-term respiratory conditions.9Further, of adults who are dispensed any preventer medication, only 9%–30% have it dispensed as often as would be consistent with minimal regular use.1 These data indicate that there are substantial quality problems in Australia with respect to both the prescribing and use of preventer medications.

Past gold standard approaches to population studies involved random-digit dialling and postal surveys of randomly selected participants. The declining ownership of telephone landlines in Australian homes, however, and survey participation rates below 30% (eg, in the study by Toelle and colleagues10) have increased the risk of both selection and response biases. Internet access is rapidly increasing across the socioeconomic spectrum, and there is growing interest in well designed, rigorously reported web-based surveys to minimise these problems.11

The aim of our study was to establish the relationship between control of asthma symptoms, medication use and health care utilisation by Australians aged 16 years and over with current asthma.

Methods

Study design and ethics

We undertook a cross-sectional web-based survey of adult Australians with current asthma (details [Checklist for Reporting Results of Internet E-Surveys, CHERRIES] in Appendix 1). Ethics approval was obtained from the Human Research Ethics Committee, Concord Hospital, NSW. All participants provided informed consent.

Inclusion criteria and recruitment

The target population was Australians aged 16 years and over with current asthma. Participants were recruited from an online panel of 224 898 people provided by Survey Sampling International (Melbourne, Australia). To minimise response bias, a three-stage randomised selection process was used: (i) panel members were randomly invited to take a survey, without specifying the topic of the survey; (ii) respondents were shown initial randomly selected profiling questions that included one which asked whether they had ever experienced any of several health conditions, including asthma; and (iii) those responding that they had experienced asthma were asked two questions, similar to those in the Australian Health Survey, to identify those with “current asthma”: “Have you ever been told by a health professional that you have asthma?” and “Have you had symptoms of asthma or taken medication for asthma in the last 12 months?” Those who responded “Yes” to both questions were included in the study sample. Recruitment was stratified by sex, age and state of residence, according to Australian data for people with asthma (2011–12 Australian Health Survey).12 Participants received “points” to a value of about $1.50 from the panel provider.

Questionnaire

The design of the survey instrument was based on information drawn from relevant scientific publications, qualitative research, and professional health care reviews; it was then cognitively tested in five people with current asthma and piloted in 600 panel members with current asthma. Survey topics included basic demographics, asthma history, asthma treatment and frequency of routine and emergency health care utilisation for asthma. Asthma symptom control was assessed with a validated five-item tool (Asthma Control Test; ACT13), used under licence from QualityMetric Incorporated. Symptom control was classified, according to standard cut-off points, as “well controlled” (ACT score of 20–25 points), “not well controlled” (16–19 points) or “very poorly controlled” (5–15 points). Overall health status was assessed with a question from the Australian Health Survey, “In general, would you say your health is….?”, with five response options ranging from “excellent” to “poor”. A standard screening question for assessing health literacy was included: “How confident are you filling out medical forms by yourself?”, with response options ranging from 1 (“not at all”) to 7 (“extremely”); responses of 4 (“somewhat”) or less indicate limited health literacy.14 Self-reported adherence to asthma treatment was assessed by asking “How often do you use your [inhaler name]?”, with eight responses ranging from “every day” to “a few times a year”.

Data analysis

Data were analysed using SPSS 19.0 (SPSS Inc). Analyses were weighted according to Australian asthma population benchmarks by age group, sex and state, based on data for people with current asthma in the 2011–12 Australian Health Survey.12 Results were reported using descriptive statistics, with means and 95% CIs Logistic regression analysis tested the effects of age, sex, Socio-Economic Indexes for Areas (SEIFA) scores,15 smoking status, health literacy, education level, and age at asthma diagnosis on the level of asthma control.

Results

Demographics and medications

The flow chart of participant selection is included in Appendix 2. Of the 80 518 panel members randomly invited to participate, 27 606 accepted and were shown the profiling questions (panel participation rate, 34.3%). Of these, 3033 people with current asthma were selected at recruitment stage (iii), and invited to participate in the survey; 3018 did so (asthma participation rate, 99.5%), and 2686 completed the survey (response rate, 89.0%). The demographic distribution of the sample closely matched national data for people with asthma (Appendix 3).

Box 1 includes the detailed demographic characteristics of the study sample. Of the respondents, 57.1% were women, and 40.4% were aged 50 years and over. A health care concession card was held by 54.7% of participants, and 40.7% lived in areas in the two lowest SEIFA quintiles (greatest socioeconomic disadvantage); 11.5% of participants responded “somewhat” or less to the question about confidence in completing medical forms, consistent with limited health literacy.14 One fifth of participants were current smokers, consistent with national data for people with asthma.1

In the past 12 months, 92.6% of participants reported using a short-acting β2-agonist reliever inhaler, and 60.8% reported using one or more ICS-containing medications, with 49.6% using combination ICS/LABA and 17.1% using ICS-only medications. Of the 1601 participants using ICS or ICS/LABA inhalers, 43.2% reported using them less frequently than 5 days a week, and 30.5% less than weekly (Box 2).

Asthma symptom control and health care utilisation

The mean ACT score of the 2686 participants was 19.2 (range 5–25; 95% CI, 18.9–19.3). Asthma was “well controlled” in 54.4%, “not well controlled” in 22.7%, and “very poorly controlled” in 23.0%. Multivariable analysis identified being male and a history of smoking (daily, less than daily, or in the past), as demographic characteristics that were significantly associated with “very poorly controlled” asthma, but not age group, education level, SEIFA category or age at asthma diagnosis (Appendix 4).

Only half (50.5%) of the 2686 participants reported having seen their general practitioner for a non-urgent asthma review during the previous year, and only 20.4% had discussed their asthma with a pharmacist; 10.6% had consulted a specialist regarding their asthma. Guidelines recommend that every patient with asthma should have a routine review at least yearly. Almost a quarter of participants (23.3%) had visited a general practitioner urgently about asthma at least once during the previous year, and 10.0% had attended a hospital or emergency department one or more times, with, in total, 28.6% reporting an urgent visit. Of the participants with “very poorly controlled” asthma, 44.2% reported one or more urgent GP visits during the previous year, compared with 12.5% of those with “well controlled” asthma (adjusted odds ratio [AOR], 5.98; 95% CI, 4.75–7.54). Similarly, 17.8% of those with “very poorly controlled” asthma had visited an emergency department or hospital, compared with 6.5% of those with “well controlled” asthma (AOR, 2.59; 95% CI, 1.91–3.53).

Preventer use and asthma control

Box 2 and Box 3 classify participants according to asthma symptom control and self-reported frequency of ICS-containing preventer medication use. Participants who reported using both an ICS-only medication and a non-ICS preventer in the past 12 months were excluded from this part of the analysis, as the structure of the questionnaire did not permit the frequency of use of these medications to be individually distinguished (these 32 participants (1.2% of sample) were asked how often they had used these medications, but not to break this down by specific medications).

Four main groups could be identified. Group A (40.0% of participants) had “well controlled asthma” while using a preventer less than 5 days a week or not at all; these patients are considered to have mild asthma.5 Group B (14.6%) had “well controlled” asthma while using a preventer at least 5 days a week. Conversely, group C (19.7%) had uncontrolled symptoms (ie, “not well controlled” or “very poorly controlled”) despite reportedly using their preventer medication at least 5 days a week. Group D (25.7%) had uncontrolled symptoms, and used no preventer medicine at all, or used it infrequently.

Discussion

This study provides the first nationally representative data on asthma control in Australian adults. Participants were recruited from a web-based panel of almost a quarter of a million Australians, using a three-stage randomised selection process to minimise selection and response biases. We identified significant personal and economic burdens associated with asthma. Symptom control was poor in 45% of participants, while 29% had needed urgent health care for their asthma during the previous year. The data indicated significant problems regarding the prescribing of asthma medications: in contrast with guidelines, many more participants had been prescribed expensive combination ICS/LABA inhalers than had been prescribed ICS alone. Adherence to inhaled maintenance therapy was also poor: 43% of preventer medication users reported taking it less than 5 days a week, and 31% used it less than weekly. Of the participants with uncontrolled asthma symptoms, 23% used preventer medication less than 5 days a week, while 34% did not use any preventer. Taken together, these findings indicate that a significant proportion of asthma morbidity and its associated costs in Australia are preventable.

Study strengths and limitations

Rigorous web-based surveys can be valuable for assessing the impact of asthma policy and practice in Australia. Obtaining a representative sample is crucial, and we chose a web-based design being aware of the low response rates associated with surveys that employ random digit dialling and postal questionnaires,16 and high levels of home internet access. For example, 83% of Australian households had home internet access in 2012–2013, including 59% and 77% of those in the lowest and second lowest quintiles of equivalised household income, respectively; 60% of those aged 55 years or over had accessed the internet in the previous 12 months.17

A further strength of our study was that it complied with the requirements of the CHERRIES criteria for reporting e-health surveys (Appendix 1).11 Many earlier internet surveys were advertised on open websites, and investigators could not accurately identify the denominator population (ie, those who had seen the invitation to participate), and were also subject to response bias resulting from topic-specific survey invitations. The potential for selection and responder biases was minimised in our study by the three-stage random selection of participants from a large web-based panel, by the stratification of recruitment and weighting of analyses by age, sex and state according to national data on people with asthma, and by the completion rate of 89%. We do not know whether our findings can be generalised to people without internet access, but comparisons of recruitment methods have found that probability-based internet sampling achieves the best balance of sample composition and accuracy.18,19 The use of a validated asthma control tool also increased the reliability of the findings.

The major limitations of our study were those associated with any asthma survey: the individual diagnoses of asthma cannot be confirmed, medication doses cannot be accurately established, self-reported adherence to treatment schedules may be overestimated, and inhaler technique (an important contributor to poorly controlled asthma20) cannot be assessed. However, our study fills important gaps in our knowledge about asthma in Australia and, if repeated in the future, would enable assessment of trends in asthma treatment outcomes.

Clinical implications of the study

Both poor asthma symptom control and flare-ups are effectively prevented by regular ICS-containing preventer medications, even at low doses. Despite the ready availability of these medications and the fact that they are subsidised by the PBS, we found significant treatment problems relevant to asthma control. It is difficult to assess the appropriateness of preventer prescribing for individual patients without information about past treatment adjustments and currently prescribed doses, but some patterns were nevertheless clear. Australian guidelines emphasise that good asthma control can be achieved in most patients with ICS alone, and only some need combination ICS/LABA medications, which are substantially more expensive for both government and patient.3 However, nearly three times as many participants reported using a combination ICS/LABA medication in the past 12 months as those who used ICS alone.

To elicit the key clinical implications of these data, we intentionally took a broad approach based on clinical information that is emphasised by asthma guidelines and is readily available to general practitioners: asthma symptom control and adherence to prescribed preventer medication. Four groups were identified that have differing implications for clinical practice (Box 3). The 40% of participants with “well controlled” asthma while using preventer medication infrequently or not at all (Group A) would generally be considered to have mild asthma, but may still be at risk of flare-ups,5 so their asthma and its management should be reviewed at least annually.3 For the 14.7% with “well controlled” asthma while using preventer medication at least 5 days a week (Group B), down-titration should be considered once symptoms have been well controlled for 2–3 months, in order to find the minimum effective preventer dose.3 Patients in Group C (almost 20%) had apparently uncontrolled asthma despite regular asthma preventer use; while some respiratory symptoms may be due to concomitant conditions, such as chronic obstructive pulmonary disease, and while patients often overstate their adherence to medication,21 much of the symptom burden in this group is probably due to incorrect inhaler technique.20 Finally, the 25.7% of participants with uncontrolled asthma symptoms while using no preventer treatment or taking it infrequently (Group D) are at significant risk of severe flare-ups, and interventions are needed to initiate preventer medication or to improve adherence to prescribed therapy.

Few previous Australian statistics on asthma control are available for comparison with our findings. No previous population-based studies have used validated asthma control tools, but it was found that 40% of adults in a 2007 non-random sample had poorly controlled asthma as indicated by an Asthma Control Questionnaire score of 1.5 or more.22 The most recent population-based data (from 2002–20077) suggested that asthma symptom control was poor in 12%–37% of adult patients. The level of control, however, may have been overestimated, as only individual control parameters were assessed.23 An urgent visit to a general practitioner because of asthma in the previous year was reported by 23% of the present sample, compared with 14.3% in a 2003 population-based survey.24 The proportion of participants in the present study with suboptimal asthma control according to ACT score (45%) lies between the rates reported by recent population-based studies in the United States (41%)25 and Europe (50%).26

In conclusion, this study provides the first nationally representative data on asthma control and treatment for Australians with current asthma. Substantial problems with respect to prescribing and use of medications were identified. For almost half the participants there was a gap between the potential control of their asthma symptoms and the level currently experienced. These findings challenge the perception that asthma is a “solved” problem in Australia, a view that may contribute to lack of attention to asthma in clinical practice. Our findings reinforce the key recommendations for primary care in the recently published Australian Asthma Handbook,3 including regular and structured assessment to identify patients with poor asthma control; checking for common problems, such as poor adherence to therapy and inhaler technique; and appropriate prescribing of preventer medications to optimise outcomes and minimise costs and risks to the patient and to the community.

1 Demographic characteristics, asthma treatment and health care utilisation for the 2686 respondents with current asthma

Characteristic	Participants

Age group*
16–19 years	207 (7.7%)
20–29 years	493 (18.4%)
30–39 years	523 (19.5%)
40–49 years	377 (14.0%)
50–59 years	441 (16.4%)
60–69 years	344 (12.8%)
70 years or over	302 (11.2%)
Sex
Female	1534 (57.1%)
Male	1152 (42.9%)
Smoking history
Never smoked	1293 (48.1%)
Past smoker	844 (31.4%)
Current smoker	549 (20.4%)
Highest level of education
Year 10 or below	458 (17.1%)
Year 11 or 12	518 (19.3%)
Certificate or diploma	908 (33.8%)
University degree	802 (29.9%)
In possession of a government concession card (Health Care Card, Pensioner Card, Commonwealth Seniors Health Care Card or Veterans (DVA) Card)	1468 (54.7%)
General health status*
Excellent	218 (8.1%)
Very good	872 (32.5%)
Good	1050 (39.1%)
Fair	402 (15.0%)
Poor	145 (5.4%)
Medication use in the past 12 months†
Short-acting β2-agonist (reliever)	2488 (92.6%)
ICS-only inhaler	459 (17.1%)
ICS/LABA inhaler	1332 (49.6%)
Any ICS-containing inhaler	1634 (60.8%)
LABA-only inhaler and one or more ICS-containing inhalers (not necessarily concurrently)‡	58 (2.2%)
LABA-only inhaler without any ICS in past 12 months‡	17 (0.6%)
Urgent health care for asthma in past 12 months
Urgent general practitioner visit for asthma	628 (23.3%)
Hospital or emergency department visit for asthma	269 (10.0%)
Urgent general practitioner visit and/or hospital or emergency department visit for asthma	769 (28.6%)
Spent at least one night in hospital for asthma	98 (3.7%)
Non-urgent visit to general practitioner for review of asthma in past 12 months	1355 (50.5%)

ICS = inhaled corticosteroids; LABA = long-acting β2-agonist. Data were weighted for age, sex and state of residence.

* The disparity between the sum of the numbers in these groups and the total number of participants is the result of rounding weighted data to whole numbers.

† Participants were asked which treatments they had used in the past 12 months, with the images and brand names of relevant medications shown on screen.

‡ Use of LABA without concurrent ICS (either in combination or as separate inhalers) is strongly discouraged by asthma treatment guidelines.

2 Asthma symptom control and frequency of ICS-containing preventer use over the past 12 months by 2654 participants who had not used non-ICS-containing preventer medications*

ICS = inhaled corticosteroids; LABA = long-acting β2-agonist. A = well controlled symptoms, infrequent or no preventer use; B = well controlled symptoms, regular preventer use; C = poorly controlled symptoms, frequent preventer use; D = poorly controlled symptoms, infrequent or no preventer use (see also Box 3 and discussion in text).

* 32 participants who had used an ICS-only and a non-ICS preventer in the past 12 months were excluded from this analysis because the questionnaire did not permit the frequency of use of the ICS to be distinguished. The medications used by the 32 excluded patients were: a leukotriene receptor antagonist (montelukast, 15 patients), cromones (sodium cromoglycate, 12 patients; or nedocromil sodium, 17 patients) and an anti-immunoglobulin E monoclonal antibody (omalizumab, four patients).

† ICS/LABA combinations (budesonide/eformoterol or fluticasone propionate/salmeterol) and/or ICS alone (beclomethasone, budesonide, ciclesonide, fluticasone propionate). For the 157 participants who reported using both an ICS and an ICS/LABA combination in the previous 12 months, the higher of the two reported frequencies was used.

‡ Percentage of total sample of 2654. All other percentages are based on the symptom control group.

§ The disparity between the sum of the numbers in these groups and the total number of participants is the result of rounding weighted data to whole numbers.

3 Implications for clinical practice — four major patient groups by level of asthma symptom control and self-reported frequency of preventer use