The data used in the Component B evaluation has been obtained from multiple sources. The contribution of each source to addressing the seven evaluation questions is shown in table 2.1.b
The remainder of this chapter gives a brief description of the data sources used and the statistical methods employed in their analysis.
2.2.1 Medicare Benefits Schedule data
2.2.2 Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme data
2.2.3 ATAPS minimum dataset
2.2.4 2007 National Survey of Mental Health and Wellbeing
2.2.5 Population denominators
Table 2.1 Relationship between the evaluation questions and key data sources
|Medicare Benefits Schedule data||Pharmaceutical Benefits Scheme data||Australian Bureau of Statistics Census data||Access to Allied Psychological Services projects' minimum dataset||2007 National Survey of Mental Health and Wellbeing|
|Question 1: To what extent has the Better Access initiative provided access to mental health care for people with mental disorders? Across all of Australia? Across all age groups?|
|Question 2: To what extent has the Better Access initiative provided access to affordable care?|
|Question 3: To what extent has the Better Access initiative provided equitable access to populations in need? (in particular people living in rural and remote areas, children and young people, older persons, Indigenous Australians, people from culturally and linguistically diverse backgrounds.|
|Question 4: To what extent has the Better Access initiative provided evidence–based mental health care to people with mental disorders?|
|Question 5: To what extent has the Better Access initiative provided interdisciplinary primary mental health care for people with mental disorders?|
|Question 6: To what extent has the Better Access initiative impacted on the use of medications commonly prescribed for treatment of mental disorders, in particular antidepressant medications?|
|Question 7: To what extent has the Better Access initiative impacted on related MBS (and other) services?|
2.2.1 Medicare benefits schedule data
Scope of dataData on the activity of all providers making claims through the Medicare Benefits Schedule (MBS) is collected by Medicare Australia. The MBS items used in this report included the 29 Better Access MBS items plus 66 'other mental health' MBS items. The Data Analysis & Program Evaluation, Workforce Development Branch, Mental Health & Workforce Division of the Department of Health and Ageing provided a spreadsheet identifying all mental health MBS items as at 4 August 2008. One additional Better Access item was subsequently added – item 2702 (GP Mental Health Treatment Plan by a general practitioner who has not undertaken mental health skills training), which was introduced in January 2010. A summary of the mental health MBS items is provided in table 2.2.
The MBS data used in this report were provided by the Medicare Financing and Analysis Branch of the Department of Health and Ageing. The data were extracted from a national dataset of all services rendered on a 'fee–for–service' basis for which Medicare benefits were paid. This dataset does not capture services provided to public patients in hospitals (where these are funded by state and territory governments), services provided through other publicly funded programs, or private services that are not subsidised by Medicare.
Data were extracted on two occasions during the course of this project. The first extraction included data for the period 1 October 2004 to 31 March 2009 and has regard to all claims processed up until April 2009. The second extraction included data for the period 1 January 2009 to 31 March 2010 and has regard to all claims processed up until April 2010. Footnotes to relevant tables have been used to denote the extraction to which data belong. Note that data provided in the first extraction were not revised in the second extraction to capture adjustments for late claims. The exception was data regarding the first quarter of calendar year 2009 which was included in both extractions, therefore the second extraction was used.
The data included counts of persons, services or benefits paid for MBS–subsidised mental health services received between 1 October 2004 and 31 March 2010. Most Better Access items were introduced on November 1 2006 (except 291 and 293 which were introduced on May 1 2005, and 2702 which was introduced on 1 January 2010), whereas the other mental health items included items existing prior to that date.
The data were provided in de–identified, aggregated format according to a set of specifications developed by the consultants based on the data required to address each evaluation question. Datafiles provided the relevant counts for various combinations of MBS items across various reference periods (usually quarterly or annual) in either of two formats: (1) Stratified by reference period, region, relative socio–economic disadvantage, gender and age group (0–14, 15, 16–17, 18–24, 25–34, 44–54, 55–64, 65–74, 75–74, and 85+ years); or (2) Stratified by reference period, Division of General Practice, gender and age group. Items were assigned to reference periods according to the date on which the service was provided, rather than the date on which the service claim was processed.
As most Better Access items were introduced on November 1 2006, counts provided for the December 2006 quarter will not contain data for most Better Access data items during October. The first quarter that provides complete coverage of Better Access uptake is the March 2007 quarter. A caveat to this effect has been included in tables that report quarterly data.
Data on services received includes: total services; total bulk–billed services; sum of fees charged; sum of benefits paid; total services for which a co–payment was paid; and sum of co–payments. For bulk–billed services the fee charged was set equal to the benefit paid.
Table 2.2 Mental health MBS items used in this reportTable 2.2 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.
Better outcomes in mental health careMBS item numbers for the following item groups:
- GP 3-Step Mental Health Care Plan (General Practice attendance)a - 2574, 2575, 2577, 2578
- GP 3-Step Mental Health Care Plan (other non-referred attendance)a - 2704, 2705, 2707, 2708
- GP Focussed Psychological Strategies - 2721, 2723, 2725, 2727
Better accessMBS item numbers for the following item groups:
- Psychiatrist - Initial consultationb - 296, 297, 299
- Psychiatrist - Assessment and Management Planb - 291
- Psychiatrist - Review of Management Planb - 293
- GP Mental Health Treatment - Planb - 2710, 2702e
- GP Mental Health Treatment - Reviewb - 2712
- GP Mental Health Treatment - Consultationb - 2713
- Psychological Therapy Services - Clinical Psychologistb - 80000, 80005, 80010, 80015, 80020
- Focussed Psychological Services (Allied Mental Health) - Psychologistb - 80100, 80105, 80110, 80115, 80120
- Focussed Psychological Services (Allied Mental Health) - Occupational Therapistb - 80125, 80130, 80135, 80140, 80145
- Focussed Psychological Services (Allied Mental Health) - Social Workerb - 80150, 80155, 80160, 80165, 80170
Chronic disease managementMBS item numbers for the following item groups:
- Community Case Conference - Psychiatrist - 855, 857, 858, 861, 864, 866
Enhanced primary careMBS item numbers for the following item groups:
- Enhanced Primary Care Plan - Mental Health Worker - 10956
- Enhanced Primary Care Plan - Psychology Health Service - 10968
Psychiatrist itemsMBS item numbers for the following item groups:
- Management Plan - Assessmentc - 291
- Management Plan - Reviewc - 293
- Consultation - Consulting room - 300, 302, 304, 306, 308, 310, 312, 314, 316, 318, 319
- Consultation - Hospital - 320, 322, 324, 326, 328
- Consultation - Other locations - 30, 332, 334, 336, 338330, 332, 334, 336, 338
- Consultation - Mixed - 289d
- Group Therapy - 342, 344, 346
- Consultation with non-patient - 348, 350, 352
- Telepsychiatry - 353, 355, 356, 357, 358, 359f, 361f
- Consultation post-telepsychiatry - 364, 366, 367, 369, 370
- Electroconvulsive Therapy - 14224
Psychologist itemsMBS item numbers for the following item groups:
- Psychologist Consultationd - 82000, 82015
OtherMBS item numbers for the following item groups:
- Family Therapy - 170, 171, 172
Table 2.2 footnotes
Source: Department of Health and Ageing spreadsheet (personal communication); Adapted from AIHW (2009).18
a Item groups discontinued April 2007;
b Commenced November 2006;
c Commenced May 2005 and discontinued October 2006;
d Commenced August 2008;
e Commenced January 2010;
f Commenced November 2007.
Methods used to determine age, gender, region, relative socio-economic disadvantage and division of general practiceSince consumers' demographic characteristics (namely, age group and address) can change during a reference period and thus result in an over–count of consumers, an 'updating' rule was applied. Date of birth, gender and patient postcode were obtained for each consumer from the last date of service record for the consumer (having regard to all mental health items) in the reference period. Age was derived as the age of the patient on the last mental health service the patient received in the reference period.
Regional data was based on the consumers' enrolment postcode and classified according to the Rural, Remote and Metropolitan Areas (RRMA) classification system.19, 20 The RRMA allocates geographical areas into seven classes: Capital cities (RRMA category 1); Other metropolitan centres (2); Large rural centres (3); Small rural centres (4); Other rural centres (5); Remote centres (6); Other remote areas (7). To facilitate analysis and interpretation, RRMA categories were aggregated into five regions by combining classes 3 and 4 into 'Rural centres' and classes 6 and 7 into 'Remote areas'.
The Index of Relative Socioeconomic Disadvantage (IRSD)21 was used as an area–based measure of relative socio–economic disadvantage. The IRSD is one of four Socio–Economic Indexes for Areas (SEIFA) produced by the ABS using census data. The IRSD score is calculated from socioeconomic characteristics of the residents of a locality relating to low income, low educational attainment, high unemployment, jobs in unskilled occupations, and other indicators of disadvantage such as Indigenous origin, public rental housing, and separated/divorced or single parent households. A concordance file obtained from the ABS website22 was used to map consumer enrolment postcodes to IRSD quintiles, where quintile 1 = most disadvantaged localities and quintile 5 = least disadvantaged localities. Data for postcodes not represented in the ABS concordance file (e.g., PO Box postcodes) were classified as 'unknown'. In the Northern Territory, a significant number of Medicare claims are through PO Box postcodes (around 25 per cent).
Division of General Practice was based on the consumers' postcode, rather than the Division in which the provider practices. Since some enrolment postcodes overlap Division of General Practice boundaries, a concordance file23 was used to allocate records to Divisions.
2.2.2 Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme data
Scope of dataMedicare Australia collects data on prescriptions funded through the Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Schemec (RPBS). Drugs captured by these Schemes are classified according to the Anatomical Therapeutic Classification (ATC) system developed by the World Health Organization.24,d The PBS and RPBS items used in this report included those relating to drugs in the following ATC Level 3 categories: (1) N05B Anxiolytics; and (2) N06A Antidepressants. The anxiolytic medications were Alprazolam, Bromazepam, Buspirone hydrochloride, Diazepam, Flunitrazepam, and Oxazepam. The antidepressant medications were Amitriptyline hydrochloride, Citalopram hydrobromide, Clomipramine hydrochloride, Desvenlafaxine succinate, Dothiepin hydrochloride, Doxepin hydrochloride, Duloxetine hydrochloride, Escitalopram oxalate, Fluoxetine hydrochloride, Fluvoxamine maleate, Imipramine hydrochloride, Lithium carbonate, Mianserin hydrochloride, Mirtazapine, Moclobemide, Nortriptyline hydrochloride, Paroxetine hydrochloride, Phenelzine sulfate, Reboxetine mesilate, Sertraline hydrochloride, Tranylcypromine sulfate, and Venlafaxine hydrochloride.
The PBS and RPBS data used in this report were provided by the Pharmaceutical Benefits Division of the Department of Health and Ageing. Data were extracted on two occasions during the course of this project. The first extraction included data for the period 1 October 2004 to 31 March 2009 and was undertaken in August 2009. The second extraction included data for the period 1 January 2009 to 31 December 2009 and was undertaken in June 2010. Footnotes to relevant tables have been used to denote the extraction to which data belong. Note that data provided in the first extraction were not revised in the second extraction to capture adjustments for late claims.
The data included counts of consumers making claims for mental health drugs subsidised by the PBS and RPBS, and the total number of prescriptions claimed, between 1 October 2004 and 31 December 2010.
The data were provided in de–identified, aggregated format according to specifications developed by the consultants based on the data required to address the relevant evaluation question. Datafiles provided the relevant counts for various combinations of mental health drug items across various reference periods (usually quarterly or annual) in the following format: stratified by reference period, Division of General Practice, contribution type (general or concessional)e, gender and age group (0–14, 15, 16–17, 18–24, 25–34, 44–54, 55–64, 65–74, 75–74, and 85+ years).
Items were aggregated into time periods according to the date on which the prescription was supplied, rather than the date of prescribing or that date on which the claim was processed. Records without a unique patient code were excluded from consumer–based analyses, but were included in prescription–based analyses.
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Methods used to determine age, gender, region, relative socio-economic disadvantage and division of general practiceMethods were the same as those described for the MBS data.
2.2.3 ATAPS minimum dataset
Scope of dataThe ATAPS minimum dataset captures routinely collected de–identified consumer–level and session–level information from the ATAPS projects that are currently being run by Divisions of General Practice under the BOiMHC program (see section 1.1 of this report for a description of BOiMHC). The dataset is managed by Strategic Data Ltd, data management subcontractors of the Centre for Health Programs, Policy and Economics at the University of Melbourne as part of an ongoing evaluation exercise.
Counts of persons who had received psychological treatments under the ATAPS projectsf were extracted from a consolidated datafile that captured session–level information including patient demographics (year of birth and gender) and referral characteristics (patient postcode at time of referral, GP postcode, Division of the referring GP) and date of psychological treatment session. Aggregated person counts were derived for each Division, stratified by reference period (quarterly or annual), gender and age group.
Methods used to determine age, gender, region, relative socio-economic disadvantage and division of general practiceAge was calculated as the difference between session year and year of birth.
Geographical area classification for Divisions was sourced from the Division Benchmarking Tool developed by the Primary Health Care Research and Information Service.25 The classification uses five categories based on the Rural, Remote and Metropolitan Areas (RRMA) classification. As a number of Statistical Local Areas (SLAs) contribute to each Division, allocation to the five RRMA categories takes this into account. The five categories were: (1) Metro (>95% of population in RRMA 1,2); (2) Metro/Rural (<95% of population in RRMA 1,2 & <95% in RRMA 3,4,5); (3) Rural (>95% of population in RRMA 3,4,5); (4) Rural/Remote (<95% of population in RRMA 3,4,5 & < 95% in RRMA 6,7); and (5) Remote (>95% of population in RRMA 6,7).
In the ATAPS datasets, Division of General Practice is assigned to each record according to the Division in which the referring GP practices. For consistency with other datasets in the current project a patient–based Division variable was derived from the patients' postcode, using a concordance file for mapping postcode to Division.23 In instances where patient postcode was not available (approx. 9% of session records), Division was derived from the GPs postcode or Division.
2.2.4 2007 National Survey of Mental Health and WellbeingThe 2007 National Survey of Mental Health and Wellbeing (2007 NSMHWB) was conducted by the Australian Bureau of Statistics (ABS) between August and December 2007.26, 27 The 2007 NSMHWB is a nationally representative household survey of 8,841 Australians aged 16 to 85 years. Chapter 5 of this report uses a number of measures from the 2007 NSMHWB. These are described below.
The survey instrument was based on a modified version of the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (WMH–CIDI 3.0). Lifetime diagnoses of mental disorders were assessed by the WMH–CIDI 3.0 according to International Classification of Diseases (ICD–10)28 criteria. Symptoms experienced during the 12 months prior to interview were also assessed, and combined with lifetime diagnosis information to determine 12–month disorder. The mental disorders assessed were: affective disorders (depression, dysthymia, and bipolar affective disorder); anxiety disorders (panic disorder, agoraphobia, social phobia, generalised anxiety disorder, obsessive–compulsive disorder and post–traumatic stress disorder); and substance use disorders (harmful use or dependence of alcohol or drugs).
The functioning module included a measure of 'Days out of role', defined as the number of days in the past 30 the respondent was unable to perform, or had to cut down on, their normal activities because of health problems. Psychological distress in the past 30 days was assessed with the Kessler Psychological Distress Scale (K10).29, 30
Suicidality in the past 12 months was assessed by presenting respondents with descriptions of three experiences – 'seriously thought about suicide' (suicidal ideation), 'made a plan for committing suicide' (suicide plan), and 'attempted suicide' (suicide attempt) – and asked if any of these experiences had happened to them in the past 12 months. Respondents were only asked about suicide plans and attempts if they reported suicidal ideation.
The service use module of the 2007 NSMHWB gathered information about respondents' 12– month and lifetime use of services for mental health problems. As part of this module, respondents were also asked whether they had been hospitalised for a mental health problem in the past 12 months.
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2.2.5 Population denominatorsPopulation estimates as at 30 June of each year of interest were provided by the Medicare Financing and Analysis Branch of the Department of Health and Ageing. The estimates were compiled from Australian Bureau of Statistics (ABS) estimated resident population (ERP) by gender, age (single year) and postal area data. Postal area data were used to map postal area data to Division of General Practice, and to IRSD and RRMA classification, using concordance files held by the Medical Benefits Division.
Aggregated population counts were provided in two formats, corresponding to the formats in which MBS and PBS data were requested: (1) stratified by Division of General Practice, gender and age range (0–14, 15, 16–17, 18–24, 25–34, 44–54, 55–64, 65–74, 75–74, and 85+ years); and (2) stratified by RRMA, IRSD, gender and age rangeg.
b It was originally planned that Evaluation Question 7 would also be informed by data from the Community Mental Health Care National Minimum dataset, which would be used to describe rates of use of public sector community mental health services. Unfortunately, it was not possible to obtain these data.
c Claims under the Repatriation Pharmaceutical Benefits Scheme (RPBS) have been included as they amount to approximately 5% of claims for mental health drugs.
d The current report uses the Schedule of Pharmaceutical Benefits version of the ATC classification system, which is slightly different from the WHO version. Notably, Lithium carbonate is classified as an Antidepressant in the PBS Schedule (rather than an Antipsychotic, as in the WHO version).
e There are 2 levels of co–payments: general ($32.90) and concession ($5.30) (as at January 1, 2009; History of PBS Copayments and Safety Net Thresholds web page available on the Department of Health and Ageing website (www.health.gov.au)). People who receive social security benefits because they hold a Pensioner card, a Health Care card or a Commonwealth Seniors Health card are eligible for the concession co–payment. Most are aged 65 and over. Military veterans covered by the RPBS pay the concession price. The PBS data do not include prescriptions where the average dispensed price is below the patient copayment.
f For the purpose of analysis the sample was restricted to consumers who received psychological services under the General, Telephone–CBT, and Postnatal depression ATAPS projects, as the diagnostic eligibility criteria are the same for these three programs. Consumers who received services under the Bushfires and Suicide early intervention ATAPS projects were excluded, due to the broader inclusion criteria of these projects. These latter projects accounted for only 2.7% of ATAPS sessions during the time period of interest.
g At the time of writing, these stratified population estimates were available for 2004 through 2008. 2008 data have been used as the population denominator for 2009 and the March 2010 quarter.