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Hotspots of health inequality -

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Norman Swan: Hello, I'm Norman Swan, and welcome to this week's Health Report. Today on the program, we offer succour to the sore knee, we offer reduced worries to women undergoing IVF, we take a hard look at Xanax, and persistently large variations in preventable hospital admissions in Australia, particularly looking at Queensland and Victoria. This is a report just released from the Grattan Institute in Melbourne. Stephen Duckett is the health program director and he joins us from the studio in Melbourne. Welcome Stephen.

Stephen Duckett: Good afternoon Norman.

Norman Swan: So this is about place? Just describe this study to us, because these are extraordinary variations where some parts of Australia, particularly Queensland and Victoria, 38 places in Queensland, 25 places in Victoria have 50% increased average hospitalisations that were preventable, and they've lasted for over a decade.

Stephen Duckett: Yes, so we got all of the hospital data for Queensland and Victoria, and we analysed…we decided there'd be a threshold of 50% worse than the state average. We used the list of so-called ambulatory care sensitive conditions or potentially preventable hospitalisations developed…

Norman Swan: So these are the ones that…ambulatory care is code for they could be treated by your GP in the community.

Stephen Duckett: That's right. And so we used the list that had been agreed by governments, and so we started by trying to identify those places which had high rates. What we found was that an area with a high rate in one year has a 50% chance of being not a high rate the next year.

Norman Swan: Really?

Stephen Duckett: So we were quite interested in the extent of persistence, that we've got to actually see if a place has got a high rate for three years or more, it's likely to stay, whereas if it's only one year it's not likely to stay high. So then we were even tougher and said we are interested in those areas which have had high rates every year for a decade, and it surprised us, we found these places that have…this is supposed to be potentially preventable hospitalisations where they are more than 50% above the state average every year for a decade.

Norman Swan: So what sort of places are we talking about? Are they surprises?

Stephen Duckett: Well, yes and no. We found places in metropolitan areas and in rural areas, remote areas. So some of the Aboriginal communities, Palm Island and so on, Aurukun, have got high rates. The lower socio-economic status areas in the suburbs, like Caboolture in Brisbane or Broadmeadows in Melbourne also have high rates. But what was quite interesting about this, we went in saying, look, all the low socio-economic status areas are going to have high rates of potentially preventable hospitalisations, but that turned out not to be the case. So in Melbourne…

Norman Swan: So it wasn't just about poverty?

Stephen Duckett: It wasn't just about poverty. So in Melbourne, Broadmeadows has got a high rate of potentially preventable hospitalisations every year for a decade. Sunshine never had a high rate of potentially preventable hospitalisations.

Norman Swan: And Frankston, which is a bit richer does too, so…

Stephen Duckett: Yes, so it's quite mixed. And we also looked at differences in patterns. So in some of these places a small number of people who have high rates of readmission drive the problem, but in other places there are not readmissions at all, even though many of these are chronic diseases. So it's a very localised issue and quite different in different parts of Australia.

Norman Swan: And what sort of conditions are we talking about here?

Stephen Duckett: So the standard sort of list of chronic diseases—angina, diabetes, asthma—but also some acute conditions like dental care, admissions for dental care, are also in our list.

Norman Swan: And extraordinary variations in dental care.

Stephen Duckett: It's quite extraordinary. So generally…in fact, if you look again at Melbourne, in metropolitan Melbourne, none of the postcodes had high rates of admissions for dental care. But in parts of rural Victoria there are places which are two or three times the state average. So Colac, for example, not a poor area, Mildura, have more than twice the state average rate of admission for dental care.

Norman Swan: So presumably for extractions.

Stephen Duckett: Extractions, gum disease possibly. And it is probably because neither of those places have had fluoride for very long. They basically fluoridated in 2010 in both of those cases, and so the community didn't have the public health intervention that they should have had in terms of fluoride in the water supply.

Norman Swan: So that's one cause. You call these hotspots and maintained heat in many ways over a 10-year period. What are the other factors that differentiate an area that looks very similar on paper yet doesn't have this unacceptably high unnecessary hospitalisation rate?

Stephen Duckett: Well, all we can analyse is the outcome, that is the hospitalisation, and occasionally we can look at the…well, we can look at the readmissions and so on but we actually don't know whether it's because there's just no primary care there or very poor primary care access, or because the primary care is there and is good but the disease burden is so high. We tried to look at the access to primary care…

Norman Swan: So this is general practice.

Stephen Duckett: Yes, so we asked for Medicare data to enable us to look at age, sex, standardised rates of admission by geographic area but we weren't allowed access to those data so we couldn't actually look at the…

Norman Swan: I thought the Commonwealth had this new policy that data were open to all with the aim of better health through data.

Stephen Duckett: That's our hope too, Norman, but we were given data with age and sex in it and we were given data with geography in it but never the twain could meet, so we couldn't do standardised traits.

Norman Swan: So the new era of open data has not quite arrived.

Stephen Duckett: Not quite in time for our study.

Norman Swan: So given you don't know what the causes are, how do you know what the solutions are?

Stephen Duckett: So what we are saying is the action has to be at the local level, and the new organisations that have been created with Commonwealth funding, the primary health care networks in our view, well, they are required by the Commonwealth to set priorities about what they should be doing. And we are suggesting that those organisations need to set priorities for these places which have had such disadvantage for 10 years in a row, they should be investigating what is it that's in the local community, what is it that's not there, what is it that is driving these admissions, and they should be developing local action.

And also we should be evaluating that, there should be a national evaluation of what's happening in these places because we've got to learn from each place to another place because the intervention strategies, what needs to be done isn't well known and we don't have a good evidence base for that.

Norman Swan: And given it is place-based, it's going to be different for different communities.

Stephen Duckett: Yes, there may be some commonalities, so these are chronic diseases, and so you might say, well, do they have in place self-management programs to teach people how to manage their own chronic disease better.

Norman Swan: And does that make a difference.

Stephen Duckett: And does that make a difference. Well, the evidence is it sort of does but we actually havn't tried that, we haven't evaluated it in the various…does it work in an Aboriginal community, does it work in suburban Melbourne or suburban Brisbane and so on.

Norman Swan: Well, we will watch with interest. Stephen Duckett, thanks for joining us on the Health Report.

Stephen Duckett: Thanks Norman.

Norman Swan: Professor Stephen Duckett, who is health program director at the Grattan Institute, and that report is available on their website. You're listening to the Health Report here on Radio National, ABC News Radio and CBC Radio in Canada, welcome to all our Canadian listeners.

Dr Stephen DuckettHealth Program Director, Grattan Institute

Further Information
Perils of place: identifying hotspots of health inequality

PresenterDr Norman Swan ProducerJoel Werner