Study background

What is the National Integrated Health Services Information Analysis Asset?

The National Integrated Health Services Information Analysis Asset (NIHSI AA) is an enduring linked data asset managed under the custodianship of the Australian Institute of Health and Welfare (AIHW). It is available for analysis by the AIHW and participating jurisdictions for approved projects.

This data asset has enabled a wide range of complex issues to be analysed for the first time. For example, the AIHW has reported on the use of general practitioners (GP) and specialist services by people with dementia (AIHW 2021a) as well as the feasibility of predicting early dementia using Medicare claims (AIHW 2021c). Using the NIHSI AA has also enabled a richer understanding of the patterns of health service use and costs in the year before death than was previously possible from a single data source. As the NIHSI AA is longitudinal, trends, patient pathways, disease prevalence and severity can be better understood and analysed over time.

The first iteration of the NIHSI AA (version 0.5) used in this study contains linked data from 2010–11 to 2016–17. It presents data on:

  • admitted patient care services (in all public and, where available, private hospitals), ED services, and outpatient services in public hospitals for all participating states and territories (New South Wales, Victoria, South Australia and Tasmania)
  • Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme national data
  • Medicare Benefits Schedule national data
  • residential aged care national data (includes permanent residential aged care and/or respite care)
  • National Death Index data (deaths between 1 July 2010 and 31 December 2017).

The NIHSI AA is updated annually, with the latest version including data to June 2019. Data for 2019–20 is expected to be added by September 2022. NIHSI AA version 0.5 was the most recent version available at the time of analysis for this report.

How were health services and costs examined?

In this study, linked data in the NIHSI AA (version 0.5) was used to examine records for 4 main health service types – hospital admissions, ED presentations, MBS services, and prescriptions supplied under the PBS/RPBS – in 2 groups:

  • People in the last year of life – includes people who had a death record between 1 July 2010 and 31 December 2017. Health service use in the 12 months before death was examined for each person and associated costs calculated.
  • People not in the last year of life – includes people who did not have a death record between 1 July 2010 and 31 December 2017. Health service use between 1 July 2010 and 31 December 2016 was examined for each person and associated costs calculated.

The number of services used and associated costs were calculated over the study period for each group. They were then averaged by the number of years examined (7.5 years for people in the last year of life and 6.5 years for people not in their last year) and the number of people in each group. This gave the average annual number of health services used and costs per person, which allows us to make a fair comparison between the 2 groups.

The study period for people in their last year of life included all years of data available. However, for people not in the last year of life, the study period ended on 31 December 2016 (rather than 31 December 2017) because those who died in the following 12 months could not be identified in the last year of data.

Residential aged care data was used to indicate whether people in each group had used residential aged care or not. In this study, residential aged care includes people who lived in permanent residential aged care for all or some of the study period and/or those who stayed one or more days in respite care during the study period.

Costs for MBS services and for prescriptions supplied under the PBS/RPBS include Australian Government benefits paid and patient out-of-pocket costs. Hospital admitted patient and ED presentation costs include government (Australian Government and state and territory governments) costs only and were estimated using the Independent Hospital Pricing Authority’s activity-based funding formula.

See Technical notes for more information on the methods used to derive the 2 study populations and how people who used residential aged care were identified.

Key considerations when interpreting results

Considerations when interpreting results from this study include:

  • Health service use and costs for people who died at the beginning of the study period will not cover the full 12 months before death. This may result in a slight underestimate of health services used and associated costs for people in their last year of life.
  • Health service use outside the 12 months before death for people in their last year of life was excluded from the study. This may result in a slight underestimate of health services used and associated costs for people not in their last year, particularly those with chronic health conditions who use multiple services.
  • Health service use and associated costs may show slightly different patterns if the length of time spent in residential aged care, as well as proximity to health service use for people not in the last year of life, was factored into the analysis.

While it was possible to calculate total expenditure for the 4 health service types, it was not possible to calculate total health services used, because of differences in their units of measure. Comparing health service types was not considered comparable (for example, one prescription is not equivalent to one hospital admission). Therefore, estimates of the total and average annual number of services used per person are reported separately for each health service type.

Health services and costs excluded from the analysis

Non-government hospital and ED costs, such as out-of-pocket and private health insurance, are not included. These are estimated to represent around 21% of health expenditure (AIHW 2021b: Table 29). Other health system costs not included in the NIHSI AA (version 0.5) and therefore not in the analysis are:

  • admitted patient care services, ED services and outpatient services in all public hospitals in Queensland, Western Australia, the Australian Capital Territory and the Northern Territory
  • admitted patient care services in private hospitals in any state or territory except Victoria
  • ambulance services
  • community health, allied health and dental services
  • over-the-counter pharmaceuticals
  • Department of Veterans’ Affairs (DVA) primary care services (MBS equivalent and allied health) and residential care services
  • community-based aged care, such as in-home palliative care and community nursing
  • health-related care provided by residential aged care services that are not one of the 4 health service types examined
  • community and residential mental health services
  • mental health programs, such as headspace.

Aged care costs are not included in estimates for health system costs. However, aged care services can provide health-related services for people in their last year of life, with residential aged care services often providing end-of-life care.

Findings in this report indicate patterns of health service use and costs in the last year of life before the outbreak of the coronavirus disease (COVID-19) in Australia. Therefore, some patterns are likely to differ in 2020, 2021 and 2022, when lockdowns and restrictions affecting access to health services due to the pandemic were in place for some of the year.

What has previous research found?

Research is limited on this topic in Australia. Studies based on one-off linkage projects have been undertaken in New South Wales (Chróinín et al. 2018; Reeve et al. 2018) and Western Australia (Spilsbury and Rosenwax 2017), as well as survey data from the Australian Longitudinal Study on Women’s Health linked to health administrative data (Dobson et al. 2020; Harris et al. 2016). Internationally, larger studies were undertaken in countries such as New Zealand (Blakely et al. 2015; Hamblin et al. 2018), England (Luta et al. 2020) and Scotland (Diernberger et al. 2021).

These studies showed that, in general, health service use was higher for people in their last year of life than for those of similar age not in their last year of life. However, health service use and costs among people in their last year of life varied according to type of service, age at death, proximity to death (for example, 6 or 12 months before death), cause of death, and place of death (such as a residential aged care facility or a hospital).

Key findings include:

  • Health-care use and costs in the last year of life increase with proximity to death (Diernberger et al. 2021; Langton et al. 2016; Luta et al. 2020).
  • Health service use is higher for people in their last year of life than for those of the same age not in their last year. However, as people age (particularly after age 90), this difference diminishes for most health service types (Hamblin et al. 2018).
  • Overall health service costs are higher for young people in the last year of life compared with equivalent costs for people of the same age not in their last year of life. However, by age 95, there is little difference (Blakely et al. 2015).
  • Older age at death, particularly of people aged 95 and over, is associated with lower hospital admission rates and costs (Chróinín et al. 2018; Diernberger et al. 2021; Hamblin et al. 2018; Langton et al. 2016; Reeve et al. 2018).
  • Dying of cancer, compared with other causes, is associated with higher rates of hospitalisations, use of primary care services and prescription medicine, but lower rates of ED presentations (Diernberger et al. 2021; Langton et al. 2016; Reeve et al. 2018).
  • Dying from dementia is associated with lower average hospital admissions than dying from other leading causes such as cardiovascular diseases and respiratory diseases (Diernberger et al. 2021; Dobson et al. 2020).
  • Hospital use in the last year of life may be associated with factors independent of cause of death, such as the number and type of comorbidities and common principal diagnoses in hospital (Bardsley et al. 2019; Dobson et al. 2020; Luta et al. 2020). For example, a person may die from cancer but may be hospitalised for a pre-existing condition, such as cardiovascular disease.
  • People who die in residential aged care incur lower health service costs than people who die in hospital (Langton et al. 2016).
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