Patterns and trends of potentially inappropriate high-density lipoprotein cholesterol testing in Australian adults at high risk of cardiovascular disease from 2008 to 2014: analysis of linked individual patient data from the Australian Medicare Benefits Schedule and Pharmaceutical Benefits Scheme

Abstract

Objectives: We examine the extent to which the adult Australian population on lipid-lowering medications receives the level of high-density lipoprotein cholesterol (HDL-C) testing recommended by national guidelines.

Data: We analysed records from 7 years (2008-2014) of the 10% publicly available sample of deidentified, individual level, linked Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) electronic databases of Australia.

Methods: The PBS data were used to identify individuals on stable prescriptions of lipid-lowering treatment. The MBS data were used to estimate the annual frequency of HDL-C testing. We developed a methodology to address the issue of 'episode coning' in the MBS data, which causes an undercounting of pathology tests. We used a published figure on the proportion of unreported HDL-C tests to correct for the undercounting and estimate the probability that an HDL-C test was performed. We judged appropriateness of testing frequency by comparing the HDL-C testing rate to guidelines' recommendations of annual testing for people at high risk for cardiovascular disease.

Results: We estimated that approximately 49% of the population on stable lipid-lowering treatment did not receive any HDL-C test in a given year. We also found that approximately 19% of the same population received two or more HDL-C tests within the year. These levels of underutilisation and overutilisation have been changing at an average rate of 2% and -4% a year, respectively, since 2009. The yearly expenditure associated with test overutilisation was approximately $A4.3 million during the study period, while the cost averted because of test underutilisation was approximately $A11.3 million a year.

Conclusions: We found that approximately half of Australians on stable lipid-lowering treatment may be having fewer HDL-C testing than recommended by national guidelines, while nearly one-fifth are having more tests than recommended.

Keywords: cardiac epidemiology; chemical pathology; epidemiology; primary care.

Figure 1

The estimated number of high-density lipoprotein cholesterol (HDL-C) tests (bottom graph, scale on the left side) and lipid-lowering scripts per 1000 people (top graph, scale on the right side) from 2008 to 2014. The bars in the bottom graph show the lower and upper bounds of the estimate.

Figure 2

Underutilisation, correct-utilisation and overutilisation rates of high-density lipoprotein cholesterol test in the stable target population from year 2008 to 2014.

Figure 3

Costs that were averted because of underutilisation and total potential savings that could have been theoretically realised if all overutilisation were prevented. All the cost figures were converted to 2014 $A using the Australian Bureau of Statistics all groups Consumer Price Index.