Mapping healthcare variation across the country

By David Donaldson

November 27, 2015

Residents of disadvantaged outer suburbs in Australia’s big cities are the largest users of antimicrobial medicines — antibiotics, antivirals and antifungals — in the country.

A quick look at the Australian Atlas of Healthcare Variation — essentially an Australian health map — released on Thursday by the Australian Commission on Safety and Quality in Health Care, reveals a pattern. Low socioeconomic status suburbs, home to many with poor health, are prescribed the most antibiotics of anyone in the country. At the other end, residents of both very remote areas, who have poor access to services, and the wealthiest suburbs rely on them the least.

 Number of PBS prescriptions dispensed for antimicrobials per 100,000 people, age standardised, by local area, 2013–14.
Number of PBS prescriptions dispensed for antimicrobials per 100,000 people, age standardised, by local area, 2013–14.

The number of prescriptions of amoxycillin, the most commonly used antibiotic, is 20.5 times higher in the area with the highest rate — Tullamarine-Broadmeadows on the poor outer northern skirt of Melbourne — compared to the area with the lowest rate — Daly-Tiwi-West Arnhem in the Northern Territory.

Yet Western Australia seem to have been relatively successful at keeping rates of antimicrobial dispensing low — the highest rate for any area in Western Australia was lower than the Australian average rate.

 Number of PBS prescriptions dispensed for antimicrobials per 100,000 people, age standardised, by local area, 2013–14.
Number of PBS prescriptions dispensed for antimicrobials per 100,000 people, age
standardised, by local area, 2013–14.

It is the first time data from the Medicare Benefits Schedule, Pharmaceutical Benefits Scheme and Admitted Patient Care National Minimum Data Set have all been used to explore variation across different healthcare settings. The data reveal the sometimes huge variations in the use of services around the country, and will no doubt give pause for thought to many health bureaucrats.

Of course, some variation is to be expected due to differing needs across the population. “However, the weight of evidence in Australia and internationally suggests that much of the variation documented in the atlas is likely to be unwarranted,” notes the document, possible reflecting differences in clinicians’ practices, the organisation of health care, and in people’s access to services.

The numbers will open up many questions — are people in some areas using antibiotics inappropriately, such as to treat the common cold, potentially creating resistance problems down the track? Are other factors making residents of certain areas much sicker than others? Are some doctors not up to speed with the latest thinking on appropriate use of antibiotics?

Number of PBS prescriptions dispensed for antimicrobials per 100,000 people, age standardised, by local area, 2013–14.
Number of PBS prescriptions dispensed for antimicrobials per 100,000 people, age
standardised, by local area, 2013–14.

The findings have prompted the Australian Commission on Safety and Quality in Health Care to recommend the government develop benchmarks for best practice in using antimicrobials, and it hopes results from the atlas can be used to identify variations from these benchmarks and target interventions to reduce inappropriate use.

And it’s not just about antibiotics — the atlas presents a clear picture of substantial variation in other services, such as surgical, mental health and diagnostic services.

From the data, the ACSQ has identified as priority areas for investigation and action: the use of antimicrobials and psychotropic medicines; variation in rates of fibre optic colonoscopy, knee arthroscopy, hysterectomy and endometrial ablation; and inequitable access to cataract surgery.

There is a huge variation in the number of the prescriptions for psychotropic drugs handed out to children, for example.

When it comes to attention deficit hyperactivity disorder, the number of prescriptions in the area with the highest rate was 75 times greater than in the area with the lowest rate. Even when outliers were excluded, considerable variation persisted, with more than seven times higher in one local area compared to another.

The five highest areas in the country for antidepressant prescription are all in Tasmania.

Atlas Advisory Group chair Professor Anne Duggan said the publication of the atlas is just the beginning of a process to improve Australians’ health outcomes.

“The atlas identifies a number of geographic and clinical areas where marked variation in practice is occurring. This means that people with the same health conditions, concerns or problems may not be receiving the same care as others, elsewhere, with the same problems,” she explained.

“This raises concerns that we have unwarranted variation in our health care system — now the challenge is to work out what is right.

“This atlas is the first in a series, and while it represents a significant step forward, much more work is needed. The atlas should be seen as a catalyst for generating action, with the ultimate aim of improving people’s care and outcomes, through improving the efficiency and effectiveness of the healthcare system,” she said.

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