Health Insurance Commission Research Articles

Preventable Hospitalisations for Diabetic Complications in Rural and Urban Victoria

The objective of the study was to describe and explain variations in rates of hospital admissions for long-term complications of diabetes mellitus in rural and urban Victoria as an indicator of the adequacy of ambulatory care services. The Victorian Inpatient Minimum Database (VIMD), Health Insurance Commission data for 1998, Medical Labour Force Annual Survey 1998, Socioeconomic Indexes for Areas 1996 (SEIFA) and Accessibility/Remoteness Index of Australia (ARIA) were merged to determine the extent to which hospitalisation for complications of diabetes can be predicted from accessibility and utilisation of general practitioner services. The rural and urban differentials for long-term diabetic complications and their strong relationship with GP services, the degree of remoteness, lack of insurance, and Aboriginality reflect issues related to equity and access, patient and GP education, and inclination to seek care, all of which have implications for planning of primary health services in rural areas. This study describes a model for the analysis of ambulatory care sensitive conditions, and illustrates the important use of routine databases combined with other sources of information in quantifying the impact of factors related to primary care services.

Sterilisation, drugs which suppress sexual drive, and young men who have intellectual disability

In 1992, the High Court of Australia ruled that all procedures involving the sterilisation of children (other than to treat some malfunction or disease) should be referred to the Family Court of Australia. There has been recent public debate about the sterilisation of young women who have intellectual disability. However, there appears to be very little known about the sterilisation of young men who have intellectual disability. Health Insurance Commission figures indicate that vasectomies and perhaps bilateral orchidectomies are occurring for some young Australian males under 19 years of age, some of whom are under nine years of age. In addition, the use of drugs to alter sexual behaviour in young men with intellectual disability remains controversial. Concerns include sexual behaviour, aggression and other aspects of human relationships of young men with intellectual disabilities. This paper reports on 51 responses to a request for information about sterilisation, drugs and young men who have intellectual disability in Australia. Several issues, including the influence of attitudes and the need for informed decision making are raised.

Over the Hill and Picking up Speed: Older Women of the Australian Longitudinal Study on Women's Health

Objective: The aim of the Australian Longitudinal Study on Women's Health is to explore the physical, psychological, social and environmental factors that affect the health of women in Australia. In this paper, we identify key health issues for the 12,900 women in the oldest cohort of the study and highlight issues to be explored longitudinally. Method: Women aged 70–75 years registered with the Health Insurance Commission were sent a postal questionnaire (response rate 40%). The questionnaire included 260 items on health, health related behaviours and health care use, and social circumstances. Results: Despite the high proportion of women reporting chronic medical conditions and recent symptoms, only 4% of the women rated their health as poor. Scores on the SF‐36 health‐related quality of life measure indicate that while physical health scores were lowest for the older cohort, mental health scores were higher than for the youngest (18–23 years) and mid‐age (45–50 years) cohort. In their comments, the older women emphasised the importance of their homes, social support and their active participation in their community as fundamental to their well‐being. Conclusion: This analysis highlights areas for follow‐up in the longitudinal study, importantly the older women in the study do not equate disease with poor health and a broader social view of health is justified

Factors relating to cervical screening in New South Wales, Australia

The aims of this paper were to describe the geographical variation in Pap smear screening rates, standardised for age and adjusted for rates of hysterectomies and to assess the sociodemographic and health care factors associated with the variation. The data used in the study were the percentage of women who had had Pap smears between the years 1990 and 1992 based on the records of the Australian Health Insurance Commission (HIC). The best predictors of screening extracted from the model were the Index of Economic Resources and the proportion of women within each region who were born in non-English speaking countries.

Primer postcard improves postal survey response rates

ObjectiveThis study measures the effect of an intervention to improve mailed survey response rates. MethodA randomised controlled trial of a ‘primer’ postcard was performed as part of a large survey in Victoria in 1997 Prior to the survey mailout, half the sample of 800 general practitioners supplied by the Health Insurance Commission was sent, at random, a primer card to request prompt return of the survey. ResultsThe intervention resulted in a more rapid return of the survey and improved overall response rates from 60% to 66%. The increased cost per returned survey (40°) was largely offset by fewer non-responders requiring follow-up. ConclusionsA primer postcard is a time and cost-efficient method to increase response rates in general practitioner surveys. ImplicationsPublic health researchers should consider implementing this intervention to improve response rates to postal surveys. Reports of other response maximising strategies should report the cost per returned survey to allow better comparison.

Acupuncture in Australian general practice: patient characteristics

To ascertain the incidence of acupuncture claims and the characteristics of patients claiming for acupuncture. Secondary analysis of Health Insurance Commission data on claims for acupuncture performed by a medical practitioner. A summary of all Medicare acupuncture claims for financial years 1984-85 to 1996-97 and a random sample of patients claiming a Medicare rebate in calendar year 1996. Claims for acupuncture by patients' State, sex, age, and the socioeconomic disadvantage index of patients' residences. Between 1984-85 and 1996-97 the number of acupuncture claims increased, but declined as a proportion of total Medicare claims. In 1996, 1.16% of patients claimed for acupuncture, which constituted 0.5% of all Medicare claims. Adjusting for age and socioeconomic disadvantage, women were more likely than men to claim for acupuncture (odds ratio, 1.40; 95% confidence interval, 1.36-1.45). This sex difference is proportionately greater than that for all medical services. Propensity to claim for acupuncture increased with age, peaking at 65-69 years, then declining. Acupuncture claims were more likely in areas just above those assessed as having the greatest social disadvantage. The number of acupuncture claims has increased since 1984. As a proportion of all Medicare claims, acupuncture has remained stable since declining in 1991-92. This suggests that acupuncture is now an established complementary medical practice.

Predictors of GP service use: a community survey of an elderly Australian sample.

As part of a study of an elderly community-dwelling Australian population, predictors of general practitioner (GP) service use were identified. The sample of 897 persons, aged 70 years or older and living in Canberra and Queanbeyan, were interviewed about their health and well-being. Data on the number of GP visits in the following 12-month period were obtained from the Health Insurance Commission. There were important gender differences in the prediction of both contact and volume of service use. Need variables (physical health in men, and disability and anxiety in women) were the most important predictors. Men who were older or who had lower occupational status used more medical services, as did women with less education or higher levels of extraversion. Men with lower social support were less likely to contact a GP, but social support was not related to volume of service use for either men or women. Since at most 21% of the variance in the volume of GP service use could be explained, despite the wide range of predictors considered and the different statistical approaches adopted, better measures of service use and predictors need to be developed.

Acupuncture in Australian general practice: practitioner characteristics

To ascertain the extent of the use of acupuncture and the characteristics of general practitioners using acupuncture. Secondary analysis of 1996 Health Insurance Commission data on claims by all non-specialist medical practitioners for Medicare Benefits Schedule items for an attendance where acupuncture was performed by a medical practitioner. Use of acupuncture by general practitioners and the practitioners' sex, age, place of primary medical qualification, and the socioeconomic disadvantage index of the practitioners' practice. 15.1% of general practitioners claimed for acupuncture. Acupuncture was more likely to be provided by male practitioners, by those aged 35-54 years, and by practitioners who have an overseas primary medical qualification. The socioeconomic index of the practice did not significantly affect the number of claims for acupuncture. Acupuncture is used by about one in seven general practitioners. Its use is associated with middle-aged practitioners, who presumably have more clinical experience. This level of use by experienced doctors suggests that a critical review of the appropriate role of acupuncture in general practice should be considered.

The stress of metropolitan general practice.

To identify the work-related stressors of Australian metropolitan general practitioners (GPs). A descriptive postal survey of metropolitan GPs from all States and Territories selected at random from the Health Insurance Commission database. 296 of 464 GPs (64%) surveyed in June 1996; 67% were male; 87% worked full-time (more than 6 sessions per week). Frequency and severity of work stressors in general practice; overall feelings of stress at work in the past 12 months; effects of the stressors on work satisfaction; contribution of work stress to overall life stress; responses to the 12-item General Health Questionnaire (GHQ) as potential correlates of occupational stress. "Time pressure to see patients" was the most frequently reported stressor. Threat of litigation was perceived as the most severe stressor. Of the top 10 severe stressors, seven were also in the top 10 for stressor frequency. Work was the major stressor in GPs' lives. The GHQ scores did not correlate significantly with major stress outcome measures, but 12.8% of GPs had scores indicative of severe psychiatric disturbance. Fifty per cent of respondents had considered leaving their current workplace and 53% had considered abandoning general practice because of occupational stress. GPs working 6 or more sessions per week were more likely to be moderately or severely stressed than those working part-time (P< 0.02, Fisher's exact test). Those who had considered leaving their current workplace or careers were also more likely to be moderately or severely stressed (P< 0.0001, Fisher's exact test). The most frequent and relatively severe stressful events in general practice involved time pressures. There are implications for government, which, through remuneration policies, might influence GPs to work at a rate beyond their capacity to cope. Strategies are required to manage or prevent stress in metropolitan GPs.

Prostate cancer in Western Australia: trends in incidence and mortality from 1985 to 1996.

To measure trends in recorded incidence and mortality rates of prostate cancer in Western Australia from 1985 to 1996 and to relate these to prostate-specific antigen (PSA) testing for prostate cancer. Descriptive study based on data from the Western Australian Cancer Registry, the Australian Bureau of Statistics and the Health Insurance Commission. All newly diagnosed cases of prostate cancer and all deaths from prostate cancer in Western Australia from 1985 to 1996. Recorded incidences and mortality rates for prostate cancer. After increasing steadily from 42 per 100,000 person-years in 1985 to 61 in 1992, the recorded incidence more than doubled to 134 per 100,000 person-years in 1994, then fell sharply to 87 in 1996. Among men aged 50 years or more, those aged 50-54 years had the largest annual increases: 14% (95% confidence interval [CI], 10%-19%) from 1985 to 1992 and 108% (95% CI, 84%-134%) from 1992 to 1994. They also had the smallest annual decline between 1994 and 1996 (8%; 95% CI, 1% increase to 16% decrease). The mortality rate showed no sudden increases or decreases. In men aged 60 years or older, the mortality rate increased annually by 2.9% (95% CI, 2%-4%) from 1985 to 1996. The number of Medicare reimbursements for PSA tests increased until May 1995, then fell. There was a significant correlation between the monthly number of PSA tests and new cases of prostate cancer (P < 0.01). Following a period of steady increase, the recorded incidence of prostate cancer increased dramatically in 1992 because of screening by PSA testing. From 1994, these incidence figures declined almost as sharply, partly because of reductions in testing. The mortality rate has not shown any systematic deviation from its long-term trend.

Cervical cancer screening in rural NSW: Health Insurance Commission data compared to self-report.

There are several sources of data for estimates of community Pap test rates, including self-report, pathology laboratory records and Health Insurance Commission (HIC) data. Estimates of screening rates can vary considerably according to the sampling frame and data source. This study aimed to compare the self-reported estimates of cervical cancer screening with HIC estimates for women in rural NSW towns. Self-report of a Pap test in the past two years from 2,498 women in 19 rural towns of NSW was compared to HIC-provided Pap test rates. Self-report levels were adjusted for non-HIC providers and HIC levels included data from the Victorian Cytology Register. Self-report estimates were significantly higher than HIC estimates in 18 of the 19 towns, with discrepancies ranging from 13% to 29%. HIC-recorded providers accounted for between 65% and 100% of Pap tests per town, according to self-report. The highest Pap test rate by self-report was 70.1%, the highest by HIC was 49.2%. The lowest Pap test rate by self-report was 45.2%, the lowest by HIC was 26.1%. There was significant variation in Pap test rates between towns for adjusted self-report estimates, but not for the crude self-report estimates. Researchers should always be aware of both the possible variations according to data source and the inherent biases for whichever data source is used. An extra caution is given to consider the public/private provider profile when exploring possible geographical differences in Pap test rates.

Examination of skin naevi in Australian general practice: dissonance between care and need?

Over 26 months, 223 general practitioners recorded consultations involving the management of skin naevi and some demographic details of the patients. We used data from the Health Insurance Commission and the Australian Bureau of Statistics to estimate population consultation rates. Of 749,171 consultations, 9,729 involved management of naevi. The annual rate per 1,000 of these consultation was 11.3 (95% CI 11.0-11.6) for males and 17.0 (95% CI 16.6-17.5) for females. The rate was significantly higher in the 15-44 year age group, at 21.8 consultations per 1000 individuals annually, compared to 6.3 for younger ages and 16.0, 16.1 and 8.6 for the 45-64, 65-74 and 75+ age groups respectively. There was a seasonal variation, with rates highest in the hot months (of about 16 annual consultations per 1,000 individuals) and lowest in the cooler months (14 for the two years' cooler seasons sampled). There was a significant variation between the rates of different states and territories, but this did not follow a latitude difference. There is a dissonance between the distribution of melanomas (relatively concentrated among older patients and males) and the general practice management of skin naevi (relatively concentrated among younger patients and females). Although melanomas (particularly those with the poorest prognosis) are relatively concentrated in older men, paradoxically, more skin naevi are managed in general practice among younger and female patients.

Near-patient testing for serum cholesterol: attitudes of general practitioners and patients, appropriateness, and costs.

To determine the attitudes of general practitioners (GPs) and patients to near-patient testing (NPT) for serum cholesterol level, the appropriateness of NPT, and cost compared with testing in a specialist pathology laboratory. A descriptive survey of registered Category 5 general practices in Victoria, 1994. Matched questionnaires were completed by GPs providing NPT and patients being tested. 13 GPs performing NPT and 206 patients having NPT. Thirteen of the 17 Victorian Category 5-accredited practices participated in this study (77%), and 203 of the 260 GP questionnaires and 206 of the 260 patient questionnaires were returned. NPT of serum cholesterol level was found to be appropriately used by GPs, and recommended management guidelines for lowering cholesterol level were followed. Both GPs and patients strongly supported the role of NPT in general practice on the basis of convenience, issues of patient care, quality, efficiency and cost, but GPs felt the registration and quality assurance fees were unreasonably high. We identified potential cost savings for patients and the Health Insurance Commission with NPT of cholesterol level by GPs compared with testing at specialist pathology laboratories. NPT appears to be of benefit to both GPs and patients and to provide cost savings. However, the registration charges and quality assurance fees for NPT laboratories may be limiting GPs' use of NPT.

Developing a funding model for an after-hours primary medical care service in a rural town.

The study described in this paper aimed to determine a funding model for an after-hours primary medical care service in the rural town of Moe, a socioeconomically disadvantaged area of Victoria suffering the rigours of industry restructuring and privatisation. It has 12.5 equivalent full-time general practitioners servicing 21,966 persons. A break-even analysis of the financial viability compared the expected costs of providing the service with the anticipated income. A mixed funding model is recommended. This would incorporate a general practitioner incentive scheme and State Government underwriting of infrastructure and basic non-medical staffing costs during the business development phase to supplement the income from the Health Insurance Commission.

Application of neural networks to detection of medical fraud

A multi-layer perceptron (MLP) network was trained to classify the practice profiles of a sample of medical general practitioners who had been classified by expert consultants into four classes ranging from having normal to having abnormal profiles. This method follows the two-class neural network classification of medical practice profiles developed at the Health Insurance Commission in 1990. A technique based on the probabilistic interpretation of the output of the neural network was used to see if it improved the performance of the MLP given the extent of noise (i.e. inconsistencies) in the experts' classifications. Kohonen's Self-Organising Map was also applied to analyse the consultants' classifications and it was found that an approach which combined the four classes into two was a more appropriate way to represent the classification data. The MLP network was then retrained using a two-class classification and a high agreement rate between the classifications of the MLP and the classifications of consultants was achieved.

Trends in the health burden due to urinary tract infection in children in Australia.

To estimate the health burden of urinary tract infection in children less than 15 years of age in Australia and to ascertain whether any significant change has occurred during the past decade. The number of children less than 15 years of age who were admitted in New South Wales for urinary tract infection between 1981 and 1994 was ascertained from the Department of Health, and age and sex specific incidence rates were calculated using Australian Bureau of Statistics population data. Costs for inpatient care were calculated using the cost weights from Australia National Disease Related Groups Version 3 for urinary tract infection (DRG 577). The frequency of the four most commonly requested renal tract imaging procedures in children following urinary tract infection and which qualified for Medicare reimbursement were obtained from the Health Insurance Commission for 1984-1994: micturating cystourethrography, intravenous urography, renal ultrasonography, and nuclear medicine renal studies. There were 1203 children who were admitted with urinary tract infection in New South Wales in 1994, at an estimated cost of $A1.6 million. Since 1981, the age standardized annual incidence of urinary tract infection requiring hospitalization has increased from 0.5 to 0.9 per 1000 children, largely because of an increase in the number of young children admitted (from 0.6 to 2.0 per 1000 children less than 5 years of age). In 1994, 46,230 non-inpatient renal imaging procedures were undertaken in children under 15 years of age at a cost of $A5.3 million. Urinary tract infection is an important and increasing health problem for Australian children, particularly for preschool children. Whether this represents a true increase in the incidence of urinary tract infection or improved diagnosis and more intensive management is not possible to establish with this study design. Prospective population based studies are required to assess more completely the frequency with which urinary tract infection occurs in children and any changes that may be occurring.

Trends in colorectal cancer incidence and mortality in New South Wales, 1973-1992.

To assess changes in incidence and mortality rates of colorectal cancer in different age groups in New South Wales (NSW) between 1973 and 1992. Descriptive analysis of data on incidence and mortality from the population-based NSW Central Cancer Registry and on colorectal cancer diagnostic tests from the Health Insurance Commission. Age-standardised incidence and mortality rates for colon and rectal cancer (defined by codes 153 and 154 in the International classification of diseases, 9th revision) by sex and age group (15-44, 45-59, 60-74 or > or = 75 years) and incidence by cancer spread at diagnosis; age-standardised rates for faecal occult blood tests, sigmoidoscopy and colonoscopy. From 1973 to 1992, colorectal cancer incidence increased significantly in NSW by an average of 2.0% per year in males (95% confidence interval [CI], 1.8 to 2.3) and 0.9% in females (95% CI, 0.7 to 1.1). Mortality rates remained nearly constant in males, but fell significantly in females by an average of -1.0% per year (95% CI, -1.3 to -0.7). In the youngest age group (15-44 years) both incidence and mortality rates fell significantly, while rates were stable or rose in older age groups, except for a significant fall in mortality in women aged > or = 75 years. Use of colonoscopy (an early detection method) increased, but a corresponding shift to detection of earlier-stage cancers was not seen. A reduction in risk factors and better treatment leading to longer survival may have contributed to the falls in incidence in younger people and in mortality in females.

The GP-hospital interface: attitudes of general practitioners to tertiary teaching hospitals.

To assess general practitioner (GP) perceptions of liaison with two local tertiary teaching hospitals. Questionnaire-based survey of GP attitudes. Melbourne and North West Melbourne Divisions of General Practice, in July and September 1994. All GPs (587) practising in the Divisions (identified from Health Insurance Commission lists of consultations charged at GP rates). Degree of agreement on a 5-point Likert scale to statements about GP-hospital liaison, and relevant open comments. 350 GPs (60%) responded, including 84% of vocationally registered GPs; 68% of the 350 were in full-time practice and 70% had been in practice for over 10 years. GPs had no clear strategy for obtaining admission of semi-urgent patients to public hospitals. For patients needing urgent admission, almost a third of GPs sometimes resorted to sending them to the emergency department without first telephoning. Most GPs agreed that hospitals did not notify them of patient admission (84%), major changes in patient condition, including death (87%), and patient discharge (75%). Most would interrupt a consultation to discuss a patient with hospital staff (92%). About half agreed they had poor access to outstanding results, and 65% were concerned that proposed early-discharge practices would be detrimental to patient care. The survey identified considerable GP dissatisfaction with hospital-GP communication and GP willingness to be more involved in liaison and communication with hospitals about patient care. Changes in hospital organisation and hospital staff attitudes are needed to allow this.

Cataract surgery in Australia 1985-94.

Cataract surgery is the most common form of major ophthalmic surgery in Australia and a common surgical procedure among the elderly. The purpose of this report is to compile the numbers and rates of cataract extractions and implant of IOLs over the period 1985-94 for Australia. Data were obtained for public and private cataract extractions and IOL implants from state and territory ministries of health and from the Health Insurance Commission. The data relating to cataract surgery were compared with the growth in the proportion of elderly people in the population. The number of cataract extractions has increased by 2.6 times over the ten-year period to 67,459 in 1994 and IOL implants have increased by 2.9 times over the same period to 70,084. The increase in the elderly population for the period was 1.3 times so that there is a relative doubling in the rate of surgery. The proportion of public patients has risen from 19% to 28% from 1985 to 1994. The numbers of cataract extractions and IOL implants was increased at double the rate expected from the growth in the elderly population. Advances in microsurgery and IOL technology have resulted improved outcomes and have created a greater patient demand. The improved outcomes have also lead to ophthalmologists recommending cataract surgery at better visual acuity levels than previously.

Vertical lens placement as a determinant of acceptance for access near vision lenses

Background: The Australian optometric profession was surveyed to provide updated information on the constitution and activities of the workforce. Methods: A survey form was sent to all registered optometrists in Australia, asking them to provide details about themselves and their professional activities. Statistical information on the Australian population and optometric consultations were obtained from the Australian Bureau of Statistics and the Health Insurance Commission. Results: In mid-1995 there were 2,695 optometrists registered in Australia. Of these, 2,235 were in active clinical practice. This was equivalent to 2,060 full-time optometrists. One-third of active optometrists were female. The average population per equivalent full-time optometrist was 8,950 and the average caseload was 1,271 initial consultations per year. The proportions of female practitioners, part-time practitioners and optometrists who do not provide optical dispensing services have all increased. Conclusions: Although the population per optometrist has fallen since the previous survey, changes in optometric practice and increasing utilisation of optometric services have resulted in slightly increased caseloads, suggesting that the workforce is adequate to meet current demand for optometric eye care. (Clin Exp Optom 1996; 79: 6: 246–254)