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					BEACH
                              A BEACH SAND study


   Estimated prevalence of chronic illnesses
      (identified as Health Priority Areas)
        among general practice patients
                               Stephanie Knox (now at CHERE)
                                  Helena Britt
                              Christopher Harrison
                  Australian GP Statistics & Classification Centre
        A collaborating Unit of the Australian Institute of Health and Welfare
                             & the University of Sydney



    A collaborating unit of the Australian Institute of Health and Welfare and the University of Sydney
BEACH
         Today’s aims


   About us

   BEACH methods

   Representativeness

   Some changes in morbidity managed by GPs

   SAND sub-studies – methods

   Results of the prevalance study

           Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
          The Family Medicine Research Centre

  A University of Sydney Research Centre academically attached to the
   Department of General Practice & School of Public Health
      A Collaborating Centre of the World Organization of Family Doctors (Wonca)
      All moneys are self-generated through competitive grants,
       consultancies and contracts.
      Our work is health services research and development.
  The Australian GP Statistics & Classification Centre
      A collaborating unit of the Australian Institute of Health and Welfare and the
       University of Sydney, within the FMRC.
      Responsible for the BEACH program which is conducted under the AIHW
       Act, with Ethics approval from the University and AIHW Ethics Committees



                 Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        BEACH

   Began April 1, 1998
   Now in its 10th year (April 1, 2007)
   ~9,000 participants
     Representing 7,500+ GPs
     >40% of recognised GPs)
   Data available ~ 900,000 encounters
   Data being used by the profession,
    researchers, governments & industry

          Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH

             BEACH Aims

  to provide a reliable and valid continuous national data
   source of timely GP–patient encounter information
  to inform the community of the care provided to the vast
   majority of the population by GPs - the gate keepers of our
   medical system
  to assess patient health risk factors, prevalence of disease,
   or longer term management--on selected subjects in sub-
   samples of patients- up to 20 sub-studies per year
   (SAND- Supplementary Analysis of Nominated Data)

              Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        BEACH methods

   A cross sectional encounter based study
   Paper based data collection
   National GP random sample (drawn by DoHA)
   1,000 GPs per year
   20 per week x 50 weeks a year - ever changing
   100 consecutive encounters per GP
   All types of encounters included
   National data for 100,000 encounters p.a.

          Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH

         Post-stratification weights

 To ensure national representation of GP
  encounters, each year the data are weighted

 1. To correct for the under-representation of young
   GPs <35 years (small but important)

 2. To give more weighting to the encounters of
   busy GPs and less to (e.g.) part-time GPs data
   are weighted by HIC A1 Medicare claims
   previous quarter.

           Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Observed vs expected age distribution
        by state

                                            NSW

                  30
                  25
                  20                                                    Expected
         % encs




                                                                        encounters
                  15
                                                                        observed
                  10
                   5
                   0
                        0-4   5-   15- 25- 45- 65- 75+
                              14   24 44 64 74


  Expected = MBS (A1) claims, observed = BEACH sample

                  Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Observed vs expected age distribution
        by state




          Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Observed vs expected age distribution
        by state
                                                        WA

                        30
                                   Expected encounters
                        25         observed


                        20
               % encs




                        15

                        10

                        5

                        0
                             0-4       5-14     15-24     25-44   45-64   65-74   75+
                                                         Age gp




          Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH

           BEACH variables (see recording form)

       G.P characteristics (GP completed questionnaire)
       Practice characteristics (GP completed questionnaire)
       Patient characteristics
       Encounter details
       Patient reasons for encounter (up to 3)
       Problems managed (up to 4)


               Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH

        BEACH variables
 Management (of each problem)
  Medications prescribed, supplied, advised (up to 4/problem)
  Non-pharmacological treatments (up to 2/problem)
   • Clinical treatments
   • Therapeutic procedures
  New referrals & admissions (up to 2 – linked to problem(s))
  Pathology tests ordered (up to 5–each linked to problem(s))
  Imaging & other tests ordered (up to 2 - linked)
            (view form)

            Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH

        G.P Characteristics
    age
    sex
    country of graduation
    years in general practice
    FRACGP
    currently in training program
    practice location (State,RRMA, ARIA, SEIFA)
    practice size
    use of computers
         + other variables over the years




               Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH

        Patient characteristics

   Age (from DoB)
   Sex
   Status to the practice (new/seen before)
   NESB (Yes/no)
   Aboriginal (self ID – Yes/no)
   Torres Straight Islander (self ID – Yes/no)
   Health care card holder (Yes/no)
   VA card holder (yes/no)
   Reasons for encounter (up to 3)



            Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Some changes over time



        A quick look at:
             patients seen

             problems managed




        Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
           Age of patients at encounter
           changing over time (% of workload)
30
                                                                                1990-91
25                                                                              1998-99
                                                                                2005-06
20

15

10

 5

 0
     <15 yrs*   15-24 yrs        25-44*        45-64 yrs*         65-74             75 + *



                Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH

            Summary of problems over time
    160
                                                                             1990-91
    140                                                                      1998-99
                                                                             2005-06
    120

    100

     80

     60

     40

     20

        0
              RFEs            Problems           New problems            Chronic
                              managed                                   problems*



               Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Selected morbidity management rates over
        time - rate per 100 encounters
   6
                                               1990–91
   5                                           1998–99
                                               2000–01
   4
                                               2005–06
   3


   2

   1


   0

           sion             Lipid
                                  s                  r iti   s           et es
       pres                                    oart h               Diab
    De                                    Ost e




                  Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
            Other problems managed over time rate per
            100 encounters
        10
                                                                                                1990-91
         9
         8                                                                                      1998-99
         7                                                                                      2005-06
         6
         5
         4
         3
         2
         1
         0
                            i s*          *        I*             *             *                    *
                ion                    int     RT            t is          itis           OM      ma
              s           ld       pla       U             hi           ill            te      th
        ert en         ea        m                      nc           ns             cu       As
     yp             ag         co                   Br
                                                       o          To              A
   H             ph        c k                   e
              so        Ba                    ut
          Oe                                Ac


                       Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH

        Encounter data
 Tells us about:
    patient demand for care
    the problems managed
    How specific problems are managed by GPs
 It does NOT provide prevalence estimates of
  disease:
    among the attending population
     (attendance gives  chance of selection)
    among the population at large

            Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        SAND:
        Supplementary Analysis of Nominated Data
           “The bit on the bottom of the form”
  Questions usually asked of the patient
  Each GP pack divided into three: 40 + 30 + 30
    • 40 BMI, smoking status, alcohol intake
    • 30 nominated subject 1
    • 30 nominated subject 2
  Nominated subject 5 weeks -- 3000 random sample

            Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
                                                                Available through
                                                             http://www.fmrc.org.au
                                                                   (go to ‘BEACH’ and select
                                                                         ‘publications’)

                                                         Also see ‘Abstracts’ in the
                                                         publication section of our
                                                                  website
                                                        Hard copies of reports from
                                                          http://www.aihw.gov.au
                                                            (cost $15-27 each book in GEP
                                                                        series)

                                                                        AGPSCC
                                                                 Phone +61 2 9845 8151
                                                               email: gpstats@fmrc.org.au

    A collaborating unit of the Australian Institute of Health and Welfare and the University of Sydney
BEACH
        Population prevalence of disease

 Important for health policy and health service
  planning
 In Australia usually rely on results from the
  National Health Survey (NHS) (conducted by the
  ABS)
 NHS estimates population prevalence based on
  patient self-reported morbidity
 Using structured interview, with trained
  interviewer, in respondent’s home to elicit
  health-related information
            Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        National Health Survey

 Advantages:
  includes a representative sample of the total
    population (n = about 27,000 in 2004)
 Shortcomings:
  Only conducted every 3 years ( 4 in the past)
  Self-report likely to be unreliable (lack of
    clinical knowledge, recall issues etc)



           Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        The international scene

 Most countries rely on similar national surveys
 Many people question the reliability of such estimates
 Some studies suggest patient recall of morbidity better
  for well defined conditions (e.g. Diabetes, heart
  disease) than for ill-defined conditions (e.g. back pain)
 Accuracy of household health data tested by Moore
  (US) in 1972, on chronic disease prevalence
   One third reported 1+ chronic disease (n=333)
   106 medical records checked
   False positive chronic disease identification by
     patient self report = 25%; false negative 38%

            Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Prevalence data from EHRs?

 Some have tried to produce prevalence
  estimates from GP EHRs
 This works better in countries with patient
  registers than in fee for service system.
 Major issue is incompleteness of record
 Some question why we need to sample
  people who do not utilise the health care
  system (i.e. currently not a cost)
           Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Our study

  Aims:
   to use an ongoing national survey of GP
   activity to provide estimates of the
   prevalence of diagnosed morbidity among
   the population of general practice patients
   in Australia.


           Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Methods

 A SAND (Supplementary Analysis of Nominated
  data) substudy in the BEACH program
    ‘the bit on the bottom of the form‟

 BEACH GPs 12/07/05-19/08/05 & 25/10/05-28/11/05
 Each GP asked, for 30 consecutive patients
    „Does this patient have any of the following
    conditions which require ongoing
    management?‟
  Final sample 9156 from 305 GPs
            Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Conditions listed on the form
        Tick boxes provided, multiple response allowed
  Cardiovascular disease                        Psychological problems
   --Ischaemic heart disease                         --Depression
   --Cerebrovascular disease                         --Anxiety
   --Peripheral vascular disease                     --Insomnia
   --Congestive heart failure                        --Other psychological problem
   --Hypertension – complicated                  Other problems
   --Hypertension – uncomplicated                    --Hyperlipidaemia
   --Other                                           --Chronic back pain
  Arthritis                                         --Malignant neoplasms
   --Osteoarthritis                                  --Gastro-oesophageal reflux disease
   --Rheumatoid arthritis                        Respiratory problems
   --Other arthritis                                 --Asthma
                                                           -- mild
  Diabetes                                                --moderate
   --Type 1                                                --severe
   --Type 2                                          --Chronic obstructive airways disease
   --Other                                       None of these conditions.
                Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Prevalence among whom?

  Patient sample drawn at point of GP-patient
   encounters is biased towards frequent
   attenders, who are older and have more health
   problems than population as a whole.
  Sample will over-estimate prevalence of health
   conditions in the total patient population




          Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Adjust to patient population

 1. Enumerate the proportion of the sampled
    general practice patients who have a
    chronic condition requiring ongoing
    management
 2. Use these crude sample rates to estimate
    prevalence in the population of patients
    attending GPs at least once, by adjusting
    for annual visit rates.
          Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Methods (cont.)


 Crude rates calculated (% with the disease)
 Crude rate weighted by visit frequency
  related to age and sex, by weighting SAND
  sample against age-sex distribution of
  population who visited a GP (1+ times) in
  12 months (April 2004-March 2005)
 Used SAS V9.13 to adjust for the cluster
  design of the study.
           Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        The underlying theory


 Recording of morbidity present in the
  patient will be more reliable with the
  combined input of:
    the patient,
    the GP, and
    the medical record (where available)
   than patient self-report alone.


            Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
              Results – Age-sex distribution c/f
              population attending GP
             N = 9,156 patients from 305 participating GPs.
        50
                                                          National GP patient population
        45
                                                          SAND sample
        40

        35
        30

   %    25

        20
        15

        10
        5

        0
              Male       0-14 yrs 15-24 yrs 25-44 yrs 45-64 yrs 65-74 yrs 75+ yrs

                     Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
           Prevalence – crude rates
           (what’s in the waiting room)
      40
      35
      30
      25
      20
      15
      10
       5
       0
             ed      VD obl'm thritis rl ipid ORD thm a betes OAD ancy
        lis t ardi o     r     r             G   As           C       n
  ne of       C      ch p 1+ A    H ype              +D
                                                        ia
                                                                M alig
No        1+       sy                               1
              1 +P


                Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Prevalence – crude rates

             25
                                              Per cent of attending patients

             20


             15


             10


               5


               0
                      n            rt             rt                      VD
                 nsio        H ype          H y pe            IHD      reb
           e rte        plic          p lic                          Ce
        Hyp       nco
                      m
                                Co
                                   m
               U

                   Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Prevalence – crude rates

          25
                                            Per cent of attending patients

          20


          15


          10


           5


           0
                        on         e   ty               ia             er
                   si          nxi                   mn           Ot h
               res           A               In   so
         Dep

           Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
         Prevalence – crude rates

        25
                                                   Per cent of attending patients

        20


        15


        10


        5


        0
                            M                               id              n
             IDD
                M
                        IDD                 OA          ato          k p ai
                       N                            eum           bac
                                                 Rh        o ni
                                                                c
                                                          r
                                                       Ch
                Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Prevalence – crude rates

        25
                                    Per cent of attending patients

        20


        15


        10


         5


         0
               a               d               te                e
           t hm            Mi l           ra                 ver
         As                          Mode                 Se

              Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
           Prevalence – crude rates + adjusted
     30
                                                         Per cent of attending patients
                                                         Per cent of patient population
     25

     20

     15

     10

       5

       0
                                     t        rt
        io V
            D
                        nsio n ype r      y pe              IHD rebVD                       rl ip
                                                                                                 id
 C   ard           e rte mplic
                               H
                                    lic
                                        H                     Ce                       Hyp
                                                                                          e
                Hyp nco          mp
                   U          Co
                   Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Prevalence – crude rates + adjusted

             25
                                                       Per cent of attending patients
                                                       Per cent of patient population
             20


             15


             10


              5


              0
                        l'm               on          ty            ia            the
                                                                                     r
                    ro b              s si        xi e            mn
                  p              r   e          An           Ins
                                                                 o              O
        P sy c
              h               Dep

                   Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
              Prevalence – crude rates + adjusted
         25                                                       Per cent of attending patients
                                                                  Per cent of patient population
         20


         15


         10


          5


          0
                ll)           M            M              is      OA           id       a in
            s (a        IDD        NID
                                       D
                                                 art hrit                   ato       kp
         ete                                 y                        heu
                                                                          m        ac
  Dia
     b                                     An                       R          nicb
                                                                         C hro

                      Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Prevalence – crude rates + adjusted
         25
                                                     Per cent of attending patients
                                                     Per cent of patient population
         20


         15


         10


         5


         0
              D          a            d         te          re          AD           cy
           OR        thm          M il       era        ev e       CO            n an
         G         As                     Mo
                                            d         S                      alig
                                                                        M

              Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Est prevalence in GP patient pop’n c.f.
        population prevalence (NHS 2004)
          25
                                                Prevalence in patient population
                                                Population prevalence NHS
          20

          15

          10

            5

            0
                   n                                d
               sio          IHD        VD        ipi                 DM           DM
              n                     reb     e rl                  ID          NID
        e rte                     Ce     Hy
                                           p
    H yp
                Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Est prevalence in GP patient pop’n c.f.
        population prevalence (NHS 2004)
           25                                               Patient population
                                                            NHS
           20


           15


           10


            5


            0
                       l'm                       on                    ty
                h prob                 pres
                                            si                 A nxi e
          syc                     D   e
    A ny p

                  Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
          Est prevalence in GP patient pop’n c.f.
          population prevalence (NHS 2004)
            20
                                                                     Patient population
                                                                     NHS
            15


            10


             5


             0
                   tis        OA         toi
                                             d            P               a           cy
                hri                     a            in/B           st hm           an
            art                    um             pa            A                gn
          y                       e            ck                             ali
        An                      Rh         ba                            M
                                        ic
                                    r on
                                 Ch
                    Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        What about population prevalence?


 If we assume that all of the 15% who did
  not attend a GP in 2005 have none of the
  listed diseases under management,
  we have to add these into the
  denominator, to gain an estimate of
  prevalence among the total population


           Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH Prevalence in patient population –
      extrapolated to total population
      c.f. NHS
           20
                                                                      Extrapolated patient prevalence
                                                                      NHS 2004
           15



           10



            5



            0
                   n       IHD          lem ssio
                                                n         all   OA         ids         P        a           pl
               si o                  ob              itis
                                                                      rlip         in/B    t hm        n eo
             en                   pr        pr
                                              e   thr              pe           pa       As        g't
         ert                    h         De    Ar               Hy          ck                  li
   Hy
     p
                           s yc                                          ba                   Ma
                       P                                            ni c
                                                                  ro
                                                                Ch

                       Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Discussion

 Differences in question
    SAND ‘ongoing management’ vs NHS present/absent
    SAND Chronic back pain vs back pain
 Methods seem appropriate – supported by
  decrease population estimate for prevalence of
  Asthma to LESS than the NHS – this suggests that
  the assumption of no attendance = no disease
  does not apply to asthma.
 Certainly the costs of collection are marginal
  c.f. NHS
           Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
        Conclusion

  At marginal cost to the BEACH program we can gain
   reliable estimates of the prevalence of diseases classed
   as National Health Priority Areas, among the population
   who attend a general practitioner in Australia.
  These estimates would assist in health care planning by
   allowing estimates of future health service needs at a
   national and local level.
  Extrapolation to the total population may raise
   methodological questions, but the results may well be
   more reliable that the NHS.


             Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH




                                                        Many thanks
                                                        to the GPs


                                   BEACH 06-07
        Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH




                                        Beach 05-06
        Estimated prevalence of NHPA morbidities. SPH Seminar August 2007
BEACH
                                                                Available through
                                                             http://www.fmrc.org.au
                                                                   (go to ‘BEACH’ and select
                                                                         ‘publications’)

                                                         Also see ‘Abstracts’ in the
                                                         publication section of our
                                                                  website
                                                        Hard copies of reports from
                                                          http://www.aihw.gov.au
                                                            (cost $15-27 each book in GEP
                                                                        series)

                                                                        AGPSCC
                                                                 Phone +61 2 9845 8151
                                                               email: gpstats@fmrc.org.au

    A collaborating unit of the Australian Institute of Health and Welfare and the University of Sydney

				
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