Medicare safety net back down

Health Minister Sussan Ley has been forced to back down on proposed changes to the Medicare Safety Net after failing to convince crossbench Senators to back the savings measure.

In a decision that blows a $267 million hole in the Turnbull Government’s Budget, Ms Ley has pulled legislation that would have made it harder for patients to get financial assistance with medical expenses.

The changes, announced in the ill-fated 2014 Federal Budget and introduced to Parliament in October this year, were to have come into effect from 1 January 2016. But the Minister’s decision means that the reforms will be held over until at least next year – raising the risk that they become an issue in the lead-up to the next Federal election, due by late 2016.

Ms Ley tried to put a positive spin on the reversal by arguing she was unwilling to compromise on key aspects of the proposal in order to secure the support she needed to get it passed.

“This is a good measure that aims to address significant inequities in a system failing to help the very people it’s designed to protect – our most vulnerable patients with complex and costly medical needs,” she said.

Despite what she described as “constructive” discussions with the Greens and crossbench Senators, Ms Ley said she was “unwilling to compromise over the fundamental integrity of the policy’s intention and design in favour of a quick political solution”.

“Cutting and dicing good policies might result in short-term political fixes, but is not the way governments should manage a $65 billion health care system,” the Minister said.

The Federal Government wanted to replace the Original Medicare Safety Net, the extended Medicare Safety Net and Greatest Permissible Gap with a single Medicare Safety Net, increase the out-of-pocket costs patients pay before being eligible for assistance, and impose a universal cap on safety net benefits.

AMA President Professor Brian Owler said the proposed changes would have hurt the sickest and most disadvantaged the hardest, and called on the Government to scrap them altogether.

“The Government’s changes would have created a financial and emotional burden for Australian families with considerable and unavoidable health needs,” Professor Owler said. “We recommend that the Government scrap the proposed changes altogether.”

While the Minister’s decision will add to the pressure on the Budget, the AMA President urged her not to seek to fill the savings gap by turning the multiple reviews she has commissioned into the MBS, primary care and private health insurance into cost-cutting exercises.

“The Government must not be tempted to use the reviews to recoup the almost $267 million in Budget savings it was pursuing with the Safety Net changes,” Professor Owler said.

The safety net changes were expected to hit patients in need of complex and ongoing treatment, including cancer sufferers and those with mental illness, particularly hard, increasing Australia’s already high level of out of pocket costs.

Shadow Health Minister Catherine King said the Government’s back down was a vindication of Labor’s opposition to the changes.

Ms King said that although the Opposition was prepared to discuss what it considered to be sensible reforms, “we could not support this unfair and flawed legislation in its original form”.

Related: Worrying trend in MBS review

But Ms Ley hit back, saying that changes made by Labor while in government had not worked.

“Labor’s own failed safety net reforms taught us that tinkering around the edges by placing inconsistent caps on the claiming of some Medicare items, such as IVF, but not others, will not solve the problem,” the Minister said, and indicated that the Government had not given up on the reform proposal altogether.

The Minister said the Government would look to revisit the changes as part of its broader overhaul of Medicare and primary health care.

“The current measure will remain on the table while we continue to work…on an agreeable solution as part of our broader discussions on Medicare and primary care reform,” she said.

Adrian Rollins

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Who are you? 7 facts about the average doctor in Australia

An annual workforce report by the Australian Institute of Health and Welfare has provided a statistical snapshot of medical practitioners in Australia.

The AIHW uses survey data from APHRA about the 98,807 medical practitioners registered in 2014, which has increased by 7.4% in two years.

Other key facts are:

1. A third of medical practitioners are GPs

In the last 10 years, there has been a steady rate of supply of general practitioners, with 111 per 100,000 population in 2014. There were 32,606 registered GPs in 2014, making up 33% of medical practitioners in Australia.

2. There are more specialists now than 10 years ago

In the last 10 years there has been growth in the rate of specialist supply, from 110 to 132 per 100,000 population. Specialists working as clinicians increased from 19,043 in 2004 to 28,403 in 2014.

3. Anaesthesia is the most common speciality

The five most common specialities account for 38.7% of clinician specialists. Anaesthesia is the most common with 3,775 or 13.3% of clinician specialists followed by psychiatry, Diagnostic radiology, General surgery and Specialist obstetrician and gynaecologist.

4. The number of female doctors is increasing

The proportion of women employed as medical practitioners has increased steadily in the past 10 years. In 2014, women made up 39.4% of the medical workforce. There are substantially more men in the older age groups and more women than men in the 20-34 age group.

Graph: AIHW

5. Average age gap between men and women is decreasing

The average age of men is 48 in 2014 and has been relatively steady since 2004. The average age for women is 42 in 2014 however the average age gap over this period has narrowed slightly from 6.8 years in 2004 to 6.1 years in 2014.

6. Working hours have remained steady but on average, men work longer

The report found that medical practitioners work an average of 42.5 hours per week, which has remained steady since 2010. Men work on average 45.1 hour and women work on average 38.6 hours per week.

7. About a third of medical practitioners gained their qualifications overseas

66.4% of employed medical practitioners said they obtained their initial medical qualification in Australia. Among those who obtained their qualification overseas, those who qualified in India was the largest group followed by England and New Zealand.

Read more of the report on the AIHW website.

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Big questions hang over mental health reforms

Primary health care networks will be paid by the Commonwealth to provide tailored “integrated care packages” for patients with mental health problems in a major overhaul of the mental health system unveiled by the Federal Government.

In its long-awaited response to the National Mental Health Commission’s review of the system, the Government announced a fundamental shift away from direct funding and program delivery. Instead, it will set up a pool of funds which can be used to pay the nation’s 31 Primary Health Networks (PHN) to plan and commission local services for mental health patients.

“Just like any other chronic disease, mental illness is often complex and requires access to multiple health professionals and support services to address it properly,” Health Minister Sussan Ley said. “Experts recognise many patients with severe or complex mental health needs would benefit from an integrated health care package tailored to their individual needs, and that’s what we’re delivering.”

While patients can still choose to have Medicare-subsidised psychology sessions through GP-designed mental health plans, the Government expects a large proportion will opt instead for care packages provided by PHNs in partnership with Local Hospital Networks.

But AMA President Professor Brian Owler said that although the changes were well-intentioned, much hinged on funding and the capacity of the PHNs.

Professor Owler said the focus on tailoring care to individual need and local service planning and delivery was welcome, but a lack of detail on funding and service delivery left big questions hanging.

“The success of this new direction in mental health service delivery will depend very much on the capacity and capability of PHNs,” the AMA President said.

Professor Owler said the new framework needed to deliver genuine patient-centred care, rather than simply giving PHNs the power to determine what package of care patients can have, based on the services it has chosen to organise.

“It is particularly important that the system neither reduces nor compromises the patient’s choice of health care provider, and their ability to plan and manage their care with their GP,” he said. “It is equally important that the system does not lock people into a package of care provided or commissioned by the PHN with predetermined providers, with limited or no ability to change providers once the package has commenced.”

In addition to questions about the capacity of PHNs to develop and organise tailored care packages, concerns have been raised that the arrangements will add to administrative costs by essentially funnelling funding through an additional layer of bureaucracy.

In addition to commissioning PHNs to deliver tailored care packages, the Government will establish a phone and internet service to act as a single gateway for patients to access the full range of mental health services, and will redesign primary mental health care program to a “stepped care” model to better target services.

National Mental Health Commission Chair Professor Alan Fels said the Government’s plans were a “ringing endorsement” of the Commission’s Contributing Lives, Thriving Communities review, which condemned current arrangements as fragmented and inefficient.

“These reforms have far-reaching potential to improve the lives of millions of Australians,” Professor Fels said. “The focus must now be on effective and efficient implementation.”

But a key recommendation from the Commission that $1 billion be redirected from hospital mental health care services to bolster primary care has been rejected by the Government, underlining concerns about the adequacy of resources to be provided to GPs under the new arrangements.

The overhaul has also raised questions about the general approach the Federal Government is taking to reforms in health care.

Professor Owler said the fact that the new framework entailed Commonwealth withdrawal from funding and program delivery to instead assume a “strategic leadership” role was of concern.

He said the AMA would be watching closely to see whether the Turnbull Government adopted a similar approach in primary care and private health insurance policy, and tried to unload greater responsibilities onto the states and territories and the private sector.

Ms Ley said there would be a trial of the new arrangements this financial year, and they would be phased in over three years from early 2016-17.

Adrian Rollins

Don’t just sign on the dotted line: assessing fitness to drive

GP Dr Genevieve Yates shares “Don’t just sign on the dotted line: assessing fitness to drive”, a Pecha Kucha talk (6min 40sec talk comprising of 20 slides, each lasting 20 seconds) reminding us that driving is a privilege, not a right.

In July 2015, while visiting friends in LA, my partner was hit and killed while out jogging.

Since he died, I have been trying to find things that are positive and helpful to make a very horrible situation feel a little less senseless. One of these is by raising awareness of the dangers of unfit drivers on the road.

I hope that by sharing my personal story in this way, it might just result, indirectly at least, in someone’s husband, wife or child being spared.

Nothing can bring the love of my life back. But if sharing our story indirectly results in one fewer person being injured by an unfit driver, at least some good has come out of this senseless tragedy.

Dr Genevieve Yates is a doctor and medical educator from regional Australia. Read her blog here and follow her on twitter. If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

GPs in ‘unique position’ to help domestic violence victims

On International Day for the Elimination of Violence against Women, GPs are being reminded of their unique position at being one of the first people a victim may turn to.

RACGP President Dr Frank R Jones said GPs need to understand the nature of violence and abuse to help break the cycle.

“This includes identifying predisposing risk factors, understanding early signs and symptoms and managing the devastating consequences of family violence.”

The RACGP is one of a group of Australia’s peak medical bodies that have joined forces to help end domestic violence.

22 Colleges and peak health bodies issued a joint statement saying they will be wearing white ribbons in their workplaces and they will ‘indicate their willingness and availability to discuss this sensitive and difficult issue, should they be experiencing violence in their lives.’

Domestic violence tools

The RACGP’s white book Abuse and violence: working with our patients in general practice gives doctors evidence-based guideline on identifying domestic violence and how to respond. This edition also offers new insights into Aboriginal and Torres Strait Islander people as well as migrant, refugee and rural communities.
The National Sexual Assault, Domestic Family Violence Counselling Service 1800RESPECT last week launched a new toolkit to help GPs better recognise the signs of assault and empower them to respond. Visit 1800RESPECT to order your kit.
The AMA/Law Council of Australia document Supporting Patients Experiencing Family Violence kit contains information about specialist support services, including health, mental health, drug and alcohol, legal, family support and child protection services.
Victim support services and further reading on the AMA website.

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Don’t order vitamin B12 and Folate tests for tiredness: pathologists

Vitamin B12 and Folate don’t have overlapping risk factors and shouldn’t be tested together, particularly for non-specific symptoms such as tiredness, the Royal College of Pathologists has announced.

These new position statements provide context to recent changes to the Australian Medical Benefits Schedule.

“Testing for Vitamin B12 or Folate deficiencies in patients with non-specific symptoms, such as weakness and tiredness is not recommended,” Vice President Dr Michael Harrison said.

They say Vitamin B12 and Folate deficiencies should only be suspected in patients with:

neuropsychiatric symptoms
haematological disorders
malabsorption
Type 1 diabetes
malnourished and undernourished
patients taking proton pump inhibitors long term.”

Dr Harrison also reminds doctors that although rare, severe untreated Vitamin B12 deficiency can lead to permanent neurological damage and maternal folate deficiency is linked to fetal neural tube defects.

The RCPA testing recommendations are:

Vitamin B12 Testing Protocol – Measure serum Total B12, and if this result is less than a laboratory determined sufficiency threshold, perform a holotranscobalamin level. Depending on the outcome of this test, a metabolite of a Vitamin B12-dependant metabolic pathway, for example, homocysteine or methyl malonic acid (MMA) may then be measured.

New Folate testing Protocol – Serum Folate level is the first line test with red blood cell (RBC) Folate estimation only to be performed when the serum value is low.

Read the full Vitamin B12 and Folate position statement.

New faecal pathogen screening recommendations

The College also announced new recommendations for faecal pathogen screening to try to lower over treatment and diagnosis of patients.

It recommended using a multiplex PCR without Dientamoeba fragilis and Blastocystis species when testing for faecal pathogens.

Dr Harsha Sheorey, spokesperson on faecal pathogens for the RCPA, said recent DNA-based diagnostic methods have determined that these organisms are much more common than first thought.

“The PCR techniques have led to unnecessary diagnoses and the over treatment of these two organisms. This results in needless anxiety amongst patients and parents and can even cause possible harm due to the disruption of the normal flora from the use of antibiotics as treatment.”

If a PCR is requested and a positive result is found, the report should highlight the questionable pathogenicity of these two organisms.

Read the full faecal pathogen position statement.

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Gatekeeper role of GPs under scrutiny in MBS review

The crucial gatekeeper role played by GPs is coming under scrutiny as the Federal Government explores a possible overhaul of the operation of Medicare as part of its review of the MBS.

While around 35 Clinical Committees will be set up to conduct an item-by-item review of the MBS, a memorandum by Review Taskforce Chair Professor Bruce Robinson shows “high-level” issues affecting the overall functioning of the Medicare system are also under active consideration.

The Review Chair was at pains to insist that there was no set savings target for the MBS Review, but added there was “a need to look at the full breadth of the $19.1 billion MBS spend, not just general practitioner services”.

His comments came as it was revealed the final results of the MBS Review would not be submitted to the Government until December 2016, almost certainly putting them beyond the next Federal election, which is due by late next year.

Much of the attention so far has been on the Review’s appraisal of more than 5700 items on the MBS, and the fact that it also encompasses an examination of the over-arching rules governing the operation of Medicare is less well known.

But the far-reaching possibilities this entails started to become clearer at a series of stakeholder forums organised by the Taskforce, including fundamental changes in professional roles and responsibilities, models of remuneration, and the use of the MBS to “actively guide” clinical decision-making.

In his report on consultations, Professor Robinson said some had complained that the gatekeeper role played by GPs was limiting the effectiveness of team-based care, such as by requiring all referrals to be made through the GP.

The Taskforce Chair said that though some participants reaffirmed the importance of GPs as gatekeepers, there were suggestions that specialists be able to make direct referrals in selected cases, such as a physiotherapist requesting a knee x-ray.

Suggestions of any dilution in the central role played by GPs in coordinating care fly in the face of the latest advice from health experts here and abroad, who have argued that, far from diminishing the position of the family doctor, governments should enhance it.

In its latest review of the Australian health system, the Organisation for Economic Cooperation and Development argued strongly against any further fragmentation of the health system, and urged that primary health care be strengthened.

And University of Sydney researchers last month reported that GPs were holding health costs down by coordinating the care provided by hospitals, specialists, allied health professionals and community and aged care services.

“If general practice wasn’t at the core of our health care system, it is likely the overall cost of health care would be far higher,” the researchers said.

The MBS Review process has also included discussion about a shift away from the fee-for-service remuneration model to pay for performance – an issue being explored in detail by the Primary Health Care Advisory Group being led by former AMA President Dr Steve Hambleton.

“While many participants felt the MBS could improve quality of care by paying for performance, concerns were voiced that clinicians may be averse to taking on high-risk patients who are unlikely to achieve target outcomes,” Professor Robinson reported. “Furthermore, some rebates may need to reflect the additional risk that providers would be taking on – potentially a complex analysis.”

In addition to exploring so-called ‘macro’ issues, Professor Robinson provided more detail on how the review of individual Medicare items would proceed.

He said each of the Clinical Committees would conduct an initial “triage” of usage patterns, evidence and descriptors to identify items in need of more detailed investigation.

It would then conduct a rapid evidence review and make recommendations to the Taskforce based on its appraisal.

Given the scale of the task, Professor Robinson said the Committees, which would be peer-nominated and clinically-led, would be likely to appoint subsidiary working groups.

Already, six pilot Clinical Committees have been established, including in obstetrics.

The Taskforce Chair said items suggested for review fell into one of six categories: they were obsolete, misused, under-utilised, placed undue restrictions on providers or did not reflect modern practice.

He said participants stressed the importance of Taskforce plans to share the evidence used to support recommendations about items, to improve clinical practice and inform the future direction of research.

The Review Taskforce is due to provide an interim report to the Government by the end of the year.

Professor Robinson’s Memorandum of the MBS Review Taskforce November 2015 Stakeholder Forums can be viewed at: sites/default/files/Summary%20Memorandum%20MBS%20Review%20Stakeholder%20Forums%20November%202015%20%282%29.pdf

Adrian Rollins

The challenge for GPs: potential early cancer diagnosis vs over testing

General Practitioners face a balancing act when trying to trying to rule out an early cancer diagnosis in their patients.

Professor Jon Emery, the Herman Professor of Primary Care Cancer Research at the University of Melbourne wrote in the Medical Journal of Australia that GPs might only see 5-10 cases of non-cutaneous cancer each year among their several thousand consultations.

As a result, “even red-flag cancer symptoms have low positive predictive values”, he wrote.

“Only a few symptoms, such as [coughing up blood], breast lump and [blood in the urine], have a greater than 5% chance of being due to cancer in primary care. Most symptoms of cancer have more common benign causes in general practice. Further, cancers in general practice often present initially with more subtle non-specific symptoms.”

He said GPs are faced with the pressure of over-investigating patients who are unlikely to have cancer and the resultant costs to the patient and the health care system.

GPs also have limited access to key tests which leads them to order less appropriate ones.

There are a new range of risk assessment tools (RATs) such as the charts developed by Hamilton and colleagues and the QCancer model for men and women of Hippisley-Cox and Coupland.

However Professor Emery said “there is limited evidence on how GPs will use such tools or what impact they will have on diagnostic decision making”.

Read the full article in Medical Journal of Australia

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Hand hospitals, GP over to the states: OECD

The states and territories would assume exclusive responsibility for hospitals and primary care while the Commonwealth would steer policy and funding and oversee quality and performance under a far-reaching shake-up of the health system proposed by an international review.

As the states warn of the devastating effects of Federal Government cutbacks to hospital spending, the Organisation for Economic Cooperation and Development has recommended an end to the complex and confusing split of responsibility for health care between the two levels of government.

In its annual Health Care Quality Review of Australia, the OECD said that although the nation’s health system achieves good health outcomes for the amount of funding it receives – the sixth longest life expectancy among rich countries with only average health expenditure – the country could do better if it simplified lines of responsibility and boosted the role of GPs.

“Australia achieves good health outcomes relatively efficiently, with health expenditure at 8.8 per cent of GDP, about the same as the OECD average,” the Review said. “[But] the health system features a complex split of federal and state and territory funding and responsibilities which can make it difficult for patients to navigate their way through.”

Under current fragmented and nonsensical arrangements, both levels of government carry responsibility for overseeing health care quality, the OECD found.

But, within this, states are given the lead role as hospital “system managers” while the Commonwealth retains prime responsibility for primary health care.

It said arrangements for supervising private care were just as labyrinthine, with the states carrying responsibility for licensing private hospitals while health funds were regulated by the Federal Government.

“Better rationalised responsibilities, by making states and territories responsible for primary care, for example, would help ease some of the system’s complexity, as well as the tension that sometimes exists between the two levels of government,” the review said.

For decades the nation’s public hospitals have been caught up in outbreaks of the “blame game” between the Commonwealth and the –states over funding, and medical students battling for limited intern places are the latest victims of the blurred lines of responsibility.

The OECD said the states should assume responsibility for hospitals and primary health, leaving the Commonwealth to oversee quality and performance.

The OECD said it made sense for the Federal Government to play the lead role in steering health policy and overseeing quality and performance, noting the work of agencies like the Australian Commission on Safety and Quality in Health Care and the Independent Hospital Pricing Authority.

It said Australia also stood out among its peers for having a consolidated national registration scheme for practitioners.

“Greater harmonisation of quality monitoring and improvement approaches would make the states more comparable, providing opportunities for health services to be benchmarked against a larger pool of peers, and to draw lessons that could help improve health care quality,” the OECD said.

The Organisation said quality could be further enhanced by strengthening primary health care, particularly given the growing number of patients with chronic health problems.

It said an “unusual division” had developed between primary care and community health, adding to the fragmentation of the system, while the slow adoption of e-health made it difficult to coordinate care among different providers.

The OECD also took aim at fee-for-service payment model, which it said did little to promote the integration of care, and decried that the Practice Incentive Program, as a pay-for-performance scheme, remained largely under-developed.

“[It] consists of few incentives that are tied to quality and patient outcomes,” the Organisation said, and expressed surprise at the lack of data collected on primary health care quality and outcomes: “[this] provides general practitioners with very limited opportunity to compare their performance with that of their peers”.

Adrian Rollins

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General practitioners’ prescribing of lipid-lowering medications for Indigenous and non-Indigenous Australians, 2001–2013

Aboriginal and Torres Strait Islander Australians (Indigenous Australians) bear a disproportionate burden of disease in Australia and have a life expectancy 13 years shorter than that of other Australians.1,2 Heart disease is the leading cause of death among both Indigenous and non-Indigenous Australians, and it is also the single largest contributor to the gap in life expectancy between the two populations.3,4 The mortality rate associated with cardiovascular disease is 60% higher in Indigenous than in non-Indigenous populations; the prevalence of cardiovascular disease is 30% higher and that of its risk equivalent, diabetes, is three times greater among Indigenous Australians.3–6

Promoting access to prescription drugs and improving the management of chronic disease are key components of the national strategy for reducing health disparities in Australia. In 1999, the Australian Government eliminated out-of-pocket drug costs for Indigenous patients attending remote Aboriginal community-controlled health clinics.7 Two subsequent initiatives, in 2008 and 2010, reduced medication co-payments for Indigenous patients who attended non-remote Aboriginal community-controlled clinics or mainstream general practices.8,9 Further, the Pharmaceutical Benefits Scheme modified its criteria for subsidised lipid-lowering medications to include all Indigenous Australians with diabetes or a blood total cholesterol level above 6.5 mmol/L.10 The Indigenous Practice Incentives Program of the federal Department of Health provides bonus payments to general practitioners who enrol chronically ill Indigenous patients and prepare chronic disease management plans for them.11

Whether these efforts have translated into increased prescribing of cardiovascular medications to Indigenous Australians or better control of cardiovascular risk factors is unknown. We therefore evaluated trends in the prescribing of lipid-lowering medications for Indigenous and non-Indigenous Australians seen in general practice. We focused on therapies that reduce blood lipid levels because treating this modifiable risk factor can reduce coronary events and mortality in selected patients.12,13

Methods

Study design, source of data and population

We conducted an observational time trend study, from April 2001 to March 2013, that determined the proportion of patient encounters in which GPs prescribed lipid-lowering medications. We analysed data from the Bettering the Evaluation and Care of Health (BEACH) survey, which randomly samples 1000 GPs each year.14 The source population included all registered GPs and GP registrars who had claimed at least 375 Medicare service items in the past 3 months.

Each participating GP provided information about 100 consecutive patient encounters. The BEACH survey collects reasons for the encounter, problems addressed during the encounter, and clinical actions undertaken to manage each problem. GPs record up to four medications for each problem managed, and link each medication with a single managed problem. The final study sample encompassed 759 673 GP encounters with patients aged 30 years or over: 9594 with Indigenous and 750 079 with non-Indigenous patients.

Outcome measures

The primary outcome was the report that at least one lipid-lowering medication had been prescribed during an encounter. Lipid-lowering medications included five classes: statins, bile acid sequestrants, fibrates, niacin, and cholesterol absorption inhibitors. The primary independent variable was Indigenous status (dichotomous: yes v no), based on the GP’s record of the patient’s self-report during the encounter.

Statistical analyses

We calculated the unadjusted rate of prescribing lipid-lowering medications (ie, the proportion of encounters at which at least one such medication was prescribed) for Indigenous and for non-Indigenous patients. These data were further stratified by time period (1 April 2001 – 31 March 2005, 1 April 2005 – 31 March 2009, 1 April 2009 – 31 March 2013) and by the clinical condition that was addressed during an encounter (non-gestational diabetes mellitus, hypertension, ischaemic heart disease, lipid disorder). We also calculated the age–sex standardised rate of prescription of lipid-lowering medications for Indigenous patients, using 14 discrete age–sex subgroups (men and women in seven age groups spanning 10 years each). Age–sex standardisation yields an estimate of the lipid-lowering prescribing rate for encounters with Indigenous patients, assuming an age–sex structure identical to that of the non-Indigenous population.

A further subgroup analysis calculated the proportions of all lipid-lowering medications prescribed for each specified clinical condition. To assess whether there were statistically significant increases over time in the age–sex standardised rate of prescribing of lipid-lowering medications, we constructed logistic regression models, with the time period (the three 4-year time periods) as the independent variable.

All analyses were adjusted for clustering by GP using SAS 9.3 survey procedures (SAS Institute). Differences were considered statistically significant at P < 0.05. For routine analyses of BEACH data, we report a significant difference only if there was no overlap of the 95% confidence intervals of the two comparison groups. This is a stricter threshold than the usual P < 0.05 criterion, equivalent to P < 0.006, and reduces the risk of Type 1 errors when making multiple comparisons.

The University of Sydney Human Research Ethics Committee approved the study (reference 2012/130).

Results

Rate of prescription of lipid-lowering medications for Indigenous and non-Indigenous patient encounters

During the study period, lipid-lowering medications were prescribed during 4.9% (95% CI, 4.2%–5.6%) of encounters with Indigenous patients, and at 4.6% (95% CI, 4.5%–4.7%) of encounters with non-Indigenous patients. After age–sex standardisation (which adjusts the Indigenous but not the non-Indigenous rate), the rate of prescription during Indigenous patient encounters was 5.5% (95% CI, 4.7%–6.3%), significantly greater than that for non-Indigenous patient encounters.

For Indigenous patient encounters, the age–sex standardised rate of prescription of lipid-lowering medications increased from 4.1% during 2001–2005 to 6.4% during 2009–2013 (P = 0.013 for trend). For non-Indigenous encounters, the rate of prescription increased from 3.8% to 5.2% over the same period (P < 0.01) (Box 1). The point estimates for these proportions were higher for Indigenous patient encounters for each of the three time periods, but these individual differences were not statistically significant.

Specified clinical conditions addressed during Indigenous and non-Indigenous patient encounters

Diabetes and ischaemic heart disease were significantly more commonly managed at encounters with Indigenous patients than at those with non-Indigenous patients: in age-standardised analyses, diabetes was managed at 13.8% (95% CI, 12.6%–15.1%) of encounters with Indigenous patients and at 4.7% (95% CI, 4.6%–4.7%) of encounters with non-Indigenous patients. Ischaemic heart disease was managed at 3.2% (95% CI, 2.6%–3.8%) of encounters with Indigenous patients and at 1.7% (95% CI, 1.7%–1.8%) of those with non-Indigenous patients. Lipid disorders were managed significantly less frequently during Indigenous encounters (3.8%; 95% CI, 3.1%–4.5%) than during non-Indigenous encounters (4.6%; 95% CI, 4.5%–4.7%). There was no significant difference between the proportions of encounters at which hypertension was managed (12.6% for each group).

Rate of prescription of lipid-lowering medications, according to clinical condition

The proportion of Indigenous patient encounters involving diabetes, hypertension or ischaemic heart disease at which lipid-lowering medication was prescribed was similar to that for non-Indigenous patient encounters. However, for encounters at which GPs managed a lipid disorder, the age–sex standardised proportion at which lipid-lowering medication was prescribed was 78.4% (95% CI, 72.6%–84.2%) for Indigenous patient encounters, significantly greater than that for non-Indigenous patient encounters (65.2%; 95% CI, 64.5%–65.8%) (Box 2).

Proportion of lipid-lowering prescriptions linked with specific clinical conditions

Box 3 depicts the proportions of all 35 798 prescriptions for lipid-lowering medication according to the specified clinical conditions managed, and stratified by Indigenous status. Only the proportions linked with diabetes (Indigenous: 13.1% [95% CI, 9.1%–17.3%] v non-Indigenous: 4.2% [CI, 4.0–4.5]) and lipid disorders (Indigenous: 53.3% [95% CI, 46.1%–60.4%], v non-Indigenous 64.3% [95% CI, 63.5%–65.1%]) were significantly different between the two groups.

Discussion

There were three major findings from this nationally representative study of the prescribing of lipid-lowering medications for Indigenous and non-Indigenous adults managed in Australian general practice. First, the rates of prescription of lipid-lowering medication by GPs for both Indigenous and non-Indigenous Australians increased substantially from 2001–2005 to 2009–2013, with relative increases of 37% for non-Indigenous and 56% for Indigenous patients. Second, lipid-lowering medication was more likely to be prescribed at encounters with Indigenous patients than at those with non-Indigenous patients, including encounters at which lipid disorders were managed. Third, diabetes was about three times as likely to be managed at encounters with Indigenous patients.

We found that the rates of prescription of lipid-lowering medication were higher for all Indigenous patient encounters, and for encounters at which a lipid disorder was managed; the prescription rates at encounters during which diabetes, heart disease or hypertension were managed were similar for Indigenous and non-Indigenous patients. These findings may reflect extensive efforts by the Australian Government, clinicians and other stakeholders to identify and reduce cardiovascular risk among Indigenous people, to increase their access to medications, and to revise clinical and benefit guidelines for lipid-lowering prescriptions so that they include all Indigenous patients with diabetes or blood total lipid levels greater than 6.5 mmol/L.7–11 Our study cannot establish a causal link between these policies and increased prescribing of lipid-lowering agents. However, it is reassuring that, as lipid-lowering therapies have continued to diffuse into clinical practice over the past 15 years, we found no evidence that GPs were less likely to prescribe these agents to Indigenous patients.

As noted by other authors, screening for and managing cardiovascular risk in Australian general practice is suboptimal.15,16 It is therefore also possible that the equivalent prescribing rates may reflect underuse of these medications in both Indigenous and non-Indigenous patients who might benefit from these therapies. Future studies should characterise disparities in the proportion of clinically appropriate treatment candidates who are prescribed effective cardiovascular medications.

Our study has some limitations. First, the BEACH data do not include information on whether patients filled or adhered to lipid-lowering prescriptions. Second, data concerning managed conditions, medications prescribed, and the patient’s self-identified ethnicity may include errors, although we have no reason to believe that rates of misclassification changed over time. Third, the sample in our study included only patients seen in primary care. Fourth, the sample sizes for some subgroup analyses were small. Fifth, the data were collected at the encounter level, precluding calculation of the overall prevalence of lipid-lowering therapy in Indigenous and non-Indigenous populations. Finally, we lacked laboratory values and comprehensive data on comorbid conditions to determine the clinical appropriateness of prescribing decisions or to adjust for casemix.

In conclusion, we detected substantial increases in the rate of prescribing of lipid-lowering medication at encounters with both Indigenous and non-Indigenous patients in Australian general practice between 2001 and 2013, and found no evidence that Indigenous patients were less likely to be prescribed these agents. Indigenous patients were more likely than non-Indigenous patients to be prescribed lipid-lowering therapy during encounters at which a lipid disorder was managed. Our findings suggest some measure of success in expanding access to medications and reducing cardiovascular risk in Indigenous populations. Further efforts are needed to promote long-term adherence to effective medications and to improve cardiovascular health for Indigenous people in Australia.

Box 1 –
Age–sex standardised proportions of patient encounters (with 95% CI) at which lipid-lowering medication was prescribed, by time period and Indigenous status

Box 2 –
Age–sex standardised proportions of patient encounters (with 95% CI) at which lipid-lowering medication was prescribed, by specified clinical condition and Indigenous status

* Significant difference: no overlap of 95% confidence intervals.

Box 3 –
Age–sex standardised proportion of lipid-lowering medication (with 95% CI) prescribed for each specified clinical condition, by Indigenous status

* Significant difference: no overlap of 95% confidence intervals.