Healthy Communities: GP care for patients with chronic conditions in 2009–2013 - Report

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Healthy Communities: GP care for patients with chronic conditions in 2009–2013


Conditions such as heart disease, diabetes and mental illness are among the top 10 causes of premature death in Australia and people with chronic conditions account for a large share of the 635,000 potentially avoidable hospitalisations in 2011–12. Worldwide, the number of people living with chronic health conditions is increasing and placing greater demands on health care systems.

This is the first report to give a local-level breakdown of the care of patients with chronic conditions by determining how many of these patients there are, how often and in what ways their GP manages these conditions. Findings are described for 61 local areas and for seven clusters of similar areas called peer groups. Results are presented from data collected by the Bettering the Evaluation and Care of Health (BEACH) program, conducted by the University of Sydney, during the period from 2005 to 2013.

The report, which captures data from 2009 to 2013, finds:

  • Around half of the people (44% to 56%) who visited a GP once in a year had one or more chronic conditions such as back pain, high cholesterol, arthritis, type 2 diabetes, asthma and anxiety
  • GPs in some parts of Australia are up to twice as likely to prescribe drugs for some common health conditions such as depression and heart disease compared to doctors in other areas
  • Depending on the community, GPs spend from 51% to 66% of their consultations providing care to people with one or more common chronic conditions. However, GPs actively manage these conditions in just 34% to 50% of consultations through activities such as counselling, prescription of medicine or referral to a specialist
  • The report provides a unique profile of the management actions taken by GPs in respect of different medical conditions, by revealing what treatments were provided in different areas to patients with those conditions and who were actively managed for them.

What does actively managed mean?

About half of people that saw a GP had a chronic health condition, 44% to 56% across local areas. However, GPs spend more than half of their consultations providing care (for any health problem) to people with one or more common chronic conditions, 51% to 66% consulations. GPs actively manage chronic conditions (such as arthritis and depression) in one third to half of consultations, 34% to 50% GP management occasions. Depending on the community, GPs manage these chronic conditions differently through actions such as: counselling, referral, monitoring, imaging, medication.