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4.0 Introduction

Ill health can be physical, mental or both. An illness can be acute (coming on sharply, often brief, intense and/or severe) or chronic (long-lasting with persistent effects), or both, to some extent, in some cases.

Some physical and mental conditions can occur across the lifespan among all people, while others occur more frequently among certain age or population groups. And some types of ill health have a bigger impact on our society than others in terms of healthy years of life lost due to illness or death—often referred to as burden of disease.

The impact of some types of illness can be surprising—for example, mental and behavioural disorders, which are mostly chronic rather than acute, rank only marginally behind cancer, musculoskeletal conditions and cardiovascular disease, in that order, in terms of disease burden in Australasia.

This chapter endeavours to highlight the leading causes of ill health in Australia, both physical and mental, and the impact of these illnesses. We also take a brief look at vaccine preventable diseases and vaccination coverage.

There is necessarily an emphasis, however, on chronic diseases. Chronic diseases, including cancer which is also featured in this chapter, are the leading cause of ill health and death in Australia, and have been for some decades, now that the impact of communicable diseases has diminished through vaccination and other prevention and treatment practices.

There has been considerable success in this country in preventing and treating many chronic diseases—for example, through national cancer screening programs that offer better and earlier detection. But overall, the adverse effects of behavioural and other health risk factors, combined with an ageing population, have led to an increase in their impact on our society.

Indeed, chronic diseases have been termed 'Australia's biggest health challenge' today and for the future, for 3 main reasons:

  • significant and increasing costs
  • most chronic diseases are preventable
  • a growing understanding that many of these diseases arise from common underlying causes and risk factors, and potentially share some prevention, management and treatment strategies.

4.1 Burden of disease

To ensure a health system is aligned to a country's health challenges, policy makers must be able to compare the effects of different conditions that cause ill-health and premature death. Burden of disease analysis simultaneously compares the non-fatal burden (impact of ill-health) and fatal burden (impact of premature death) of a comprehensive list of diseases and injuries, and quantifies the contribution of various risk factors to the total burden as well as to individual diseases and injuries.

The most recent global estimates come from the Global Burden of Disease Study 2010, which covered 241 diseases and injuries and 57 risk factors for 187 countries for 1990, 2005 and 2010 (The Lancet 2012). To enable global comparability on such a broad scale, the study needed to introduce innovative methods as well as manage limitations in data availability.

The last national burden of disease analysis that provided estimates for the Australian and Aboriginal and Torres Strait Islander populations was published in 2007, based on 2003 data. The AIHW is updating these estimates using the 2010 global burden of disease methodology where possible, with some enhancements to better suit the Australian and Indigenous contexts, and using more recent and detailed Australian data. The revised estimates are expected to be finalised in 2015.

What follows is a snapshot of the global study findings for the Australasia region (Australia and New Zealand) published in late 2012.

What contributes most to burden of disease in Australasia?

  • Non-communicable (largely chronic) diseases accounted for about 85% of the total burden of disease in Australasia in 2010, while injuries accounted for 10%. Communicable, maternal, neonatal and nutritional disorders accounted for 5%.
  • The largest contributors to the total burden were cancer (16%), musculoskeletal disorders (15%), cardiovascular diseases (14%) and mental and behavioural disorders (13%).
  • Cancer contributed 33% and cardiovascular diseases 26% of the fatal burden in 2010.
  • Musculoskeletal disorders contributed 26% and mental and behavioural disorders 23% of the non-fatal burden in 2010.

What were the biggest risk factors for Australasia?

  • Of the risk factors considered by the study, dietary risks (accounting for 11% of the total burden), high body mass index (9%) and smoking (8%) were the leading risk factors.
  • While these risk factors are known to be associated with many diseases, the main conditions affected by these risk factors were cancer, cardiovascular diseases, and diabetes, urogenital, blood and endocrine diseases combined.

How has this changed since 1990?

  • A larger fraction of the burden is now caused by ill-health rather than premature death (Figure 4.1).
  • Cancer (ranked 2 in 1990) and musculoskeletal conditions (ranked 3 in 1990) replaced cardiovascular diseases as the leading contributors to the Australasian total disease burden in 2010.
  • Unintentional injuries (other than transport injuries) replaced transport injuries as the largest contributor to injuries.
  • For risk factors, dietary risks and smoking were ranked 1 and 3 respectively in both 1990 and 2010. High body mass index was the second-highest risk factor in 2010, replacing high blood pressure, which was second highest in 1990.

Figure 4.1: Proportion of overall burden of disease due to premature death and health loss, Australasia, 1990 and 2010

Column chart showing the proportional increase in years lived with disability compared with years of life lost between 1990 and 2010.

Source: AIHW analysis of IHME 2013.

How does Australia compare internationally?

Many factors may contribute to differences between countries. Comparisons between Australia, New Zealand, Canada, the United States, the United Kingdom and Ireland for 2010 showed:

  • Ischemic heart disease, lung cancer and stroke were the top 3 contributors to the fatal burden in all countries, while low back pain was the top contributor to the non-fatal burden.
  • As a group, dietary risks was the largest risk factor contributor to overall burden in those countries.

What is missing from the picture?

The Global Burden of Disease Study 2010 is an important source of information for setting global health priorities. However, it does not provide estimates by population groups—in particular the Aboriginal and Torres Strait Islander population—or at a subnational level (for example, by state and territory, remoteness or socioeconomic classification). Indigenous and subnational breakdowns are key priorities for the current Australian Burden of Disease study.

The global study also included conditions and risk factors not experienced in Australia (for example, cholera), while other conditions and risk factors of policy interest to Australia were not included (for example, mesothelioma). Findings of the global study should be interpreted with this in mind.

Where do I go for more information?

More information on the AIHW Australian Burden of Disease study.

For more information on the 2010 global study, see Global Burden of Disease Study 2010.

References

IHME 2013. Data visualizations. Seattle: IHME. Viewed 6 November 2013.

The Lancet 2012. Global Burden of Disease Study 2010. The Lancet 380:2053–60.


4.2 Chronic disease—Australia's biggest health challenge

Chronic diseases are the leading cause of illness, disability and death in Australia, accounting for 90% of all deaths in 2011 (AIHW 2011b). The advent of chronic diseases follows successes in limiting infection and infant deaths during the late 19th and early 20th century. With changing lifestyles and ageing population, chronic diseases have become increasingly common and now cause most of the burden of ill health.

Many different illnesses and health conditions can be classified under the broad heading of chronic disease. They often coexist, share common risk factors and are increasingly being seen as acting together to determine the health status of individuals. There is great potential for integrating prevention and care, and treating selected chronic diseases together, to keep people healthy for as long as possible.

To simplify, chronic disease is often discussed in terms of 4 major disease groups—cardiovascular diseases, cancers, chronic obstructive pulmonary disease (COPD) and diabetes, with 4 common behavioural risk factors—smoking, physical inactivity, poor nutrition and harmful use of alcohol. Between them, these 4 disease groups account for three-quarters of all chronic disease deaths. Deaths alone, however, do not fully capture the impact of chronic disease. Notably, mental health-related issues are not a major cause of death, but they do cause significant ill health and disability in the Australian population (see Chapter 4 'Mental health in Australia').

Long common in Australia and other developed countries, illness and death from chronic disease is now becoming widespread in developing countries, as rising incomes, falling food prices and increasing urbanisation lead to global changes in diet, overweight and physical inactivity (AIHW 2012d; WHO 2011). The worldwide chronic disease 'pandemic' was the subject of a high-level United Nations meeting in 2011, which called for a 25% reduction by 2025 in mortality from chronic diseases among people aged between 30 and 70, adopting the slogan '25 by 25' (Beaglehole et al. 2011; Hunter & Reddy 2013).

Because of its personal, social and economic impact, tackling chronic disease and its causes is the biggest health challenge that Australia faces. A growing understanding that many of these diseases arise from similar underlying causes, have similar features, and share a number of prevention, management and treatment strategies, as well as significant and increasing costs, is challenging us to transform the way in which we respond to chronic disease.

Describing chronic disease

Typically, chronic diseases are long-lasting, and have persistent effects. They can result from complex causes, which can include a number of different health risk factors. They are a leading cause of disability, and have major impacts on health and welfare services (AIHW 2010). Many people have more than 1 chronic illness or condition at the same time.

Chronic diseases can range from mild conditions such as short- or long-sightedness, dental decay and minor hearing loss, to debilitating arthritis and low back pain, and to life-threatening heart disease and cancers. These conditions may never be cured completely, so there is generally a need for long-term management. Once present, chronic diseases often persist throughout life, although they are not always the cause of death. Examples of chronic diseases include:

  • cardiovascular conditions (such as coronary heart disease and stroke)
  • cancers (such as lung and colorectal cancer)
  • many mental disorders (such as depression)
  • diabetes
  • many respiratory diseases (including asthma and COPD)
  • musculoskeletal diseases (arthritis and osteoporosis)
  • chronic kidney disease
  • oral diseases.

These chronic diseases have each been the focus of recent surveillance efforts, because of their significant health effects and costs, and because actions can be taken to prevent them (AIHW 2011b).

Disease burden in Australia

From any perspective, the size of the chronic disease problem in Australia is large. Analysis of the 2007–08 National Health Survey indicates that one-third of the population (35%, or 7 million people) reported having at least 1 of the following chronic conditions: asthma, type 2 diabetes, coronary heart disease, cerebrovascular disease (largely stroke), arthritis, osteoporosis, COPD, depression or high blood pressure. The proportion increased with age (AIHW 2012a).

Table 4.1 gives a further indication as to how widespread these diseases are, with their consequent toll on health, their demands on primary health care and their cost.

Leaving aside more common chronic conditions such as short- or long-sightedness and hearing problems, Australian Health Survey data for 2011–12 indicate that almost 15% of the population had arthritis, 13% had back problems, 10% hypertensive disease, 10% asthma and 10% depression. In addition, the data show that about 360,000 people (1.6% of the population) were living with cancer, 999,000 (4.6%) were living with diabetes, and more than 1 million (5.0%) had heart or vascular disease, or had suffered a stroke (ABS 2013a, 2013b).

GPs report that the most common chronic diseases or conditions they see are hypertension, diabetes and depression, followed by arthritis and lipid disorders, including high blood cholesterol.

Table 4.1: Common chronic diseases in Australia

Common long-term conditions in 2011–12 Persons % of population
Arthritis 3,265,400 14.8
Back pain/problems/disc disorders 2,805,500 12.7
Hypertension 2,262,000 10.2
Asthma 2,254,600 10.2
Depression 2,143,100 9.7
Most common chronic conditions managed by GPs in 2012–13 % of chronic conditions % of all GP visits
Hypertension (non-gestational) 15.4 8.6
Diabetes (non-gestational) 7.6 4.2
Depression 7.3 4.1
Arthritis 6.8 3.8
Lipid disorders 6.0 3.3
Most common causes of death in 2011 Persons % of all deaths
Coronary heart disease (I20–I25) 21,513 14.6
Cerebrovascular disease (I60–I69) 11,251 7.7
Dementia and Alzheimer disease (F01, F03, G30) 9,864 6.7
Lung cancer (C33, C34) 8,114 5.5
Chronic lower respiratory diseases (J40–J47) 6,570 4.5
Greatest burden of disease in 2010(a)   Disability-adjusted
life years (DALYs)
% of all DALYs
Coronary heart disease 471,550 7.8
Low back pain 420,734 7.0
COPD 208,819 3.5
Depression 191,566 3.2
Cerebrovascular disease 183,477 3.1
Most costly disease groups in 2008–09 Amount ($ billion) % of total allocated
health expenditure
Cardiovascular diseases 7.74 10.4
Oral health 7.18 9.7
Mental disorders 6.38 8.6
Musculoskeletal 5.67 7.6
  1. Data are for Australasia, i.e. Australia and New Zealand.

Sources: ABS 2013a, 2013c; AIHW 2013; Britt et al. 2013; IHME 2013.

However, death rates for some chronic diseases appear to have peaked in Australia (Figure 4.2), particularly for cardiovascular disease and some cancers such as lung cancer. Since 1980, coronary heart disease (CHD) mortality has declined by 73%, cerebrovascular disease by 69% and all cancers by 17%. The relative contribution of these causes to total deaths has also changed—for CHD the relative contribution fell from 33% in 1980 to 15% in 2011, and for cerebrovascular disease from 15% to 8%. However, the relative contribution rose for all cancers, from 23% to 33%. Despite the falls in death rates and relative contributions to total deaths, the number of people dying from chronic diseases is still large because of Australia's growing and ageing population (see Chapter 6 'Ageing and the health system').

Figure 4.2: Changes in death rates for chronic diseases, 1979–2011

Chart showing the trending decline in death rates for chronic diseases between 1979 and 2011. The diseases shown are: coronary heart disease, cerebrovascular disease, diabetes, cancers, COPD and other chronic diseases.

Notes

  1. Rates have been age-standardised to the 2001 Australian population.
  2. Deaths registered in 2009 and earlier are based on the final version of cause of death data; deaths registered in 2010 and 2011 are based on revised and preliminary versions, respectively, and are subject to further revision by the ABS. Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of deaths in Queensland in 2010.

Source: AIHW National Mortality Database.

Currently, 9 in 10 deaths have chronic disease as an underlying cause. Cardiovascular diseases (coronary heart disease and stroke), dementia and Alzheimer disease, lung cancer and chronic lower respiratory disease including COPD are the most common underlying causes, together being responsible for 40% of all deaths.

Often more than 1 disease is associated with a death—3 diseases is the average. About 20% of deaths have 5 or more associated diseases (AIHW 2012c). When a chronic disease is the underlying cause of death, other chronic diseases, such as cancers of unknown primary site, hypertensive diseases, and coronary heart disease, are common associated causes of death. (see Glossary for 'cause of death' definitions and Chapter 3 'Multiple causes of death in Australia').

Since chronic diseases are responsible for the greatest amount of illness and death, it is not surprising that they also cause the greatest burden of disease (Table 4.1). The overall burden is measured by the disability-adjusted life year (DALY), which is expressed as the number of years lost due to ill health, disability or early death (see Chapter 4 'Burden of disease'). A recent international study found that in Australia and New Zealand, chronic diseases together caused 85% of the total burden of disease, a similar figure to chronic diseases accounting for 90% of the burden due to deaths alone (IHME 2013).

The largest disease groups contributing to the Australasian burden of disease in 2010 were cancer, musculoskeletal disorders, cardiovascular diseases, and mental and behavioural disorders. The 5 leading individual causes of disease burden—heart attack, low back pain, COPD, depression and cerebrovascular disease—accounted for one-quarter of the disease burden.

The cost is large

In addition to the personal and community costs, chronic diseases result in a significant economic burden because of the combined effects of health-care costs and lost productivity from illness and death. Estimates based on allocated health-care expenditure indicate that the 4 most expensive disease groups are chronic—cardiovascular diseases, oral health, mental disorders, and musculoskeletal—incurring direct health-care costs of $27 billion in 2008–09. This equates to 36% of all allocated health expenditure (Table 4.1).

This amount is conservative because not all health-care expenditure can be allocated by disease, particularly diseases predominantly managed in primary health care. Chronic disease costs would also be far greater if non-health sector costs, such as residential care, were included.

Although patterns of spending vary by disease group, most health dollars that can be allocated to diseases are spent on admitted patient hospital services, out-of-hospital services, medications, and dental services (see Chapter 2 'How much does Australian spend on health care?' and Figure 2.6). The large cost, in the order of several billions of dollars, is 1 of the key drivers for more efficient and effective ways to prevent, manage and treat chronic disease.

Chronic disease is not uniformly distributed

Chronic diseases affect some population groups more than others. They occur more often among Indigenous Australians, for example, and at a much younger age (AIHW 2010). Two-thirds of the gap in death rates between Aboriginal and Torres Strait Islander and non-Indigenous people is contributed by chronic disease (AHMAC 2012). Indigenous people report diabetes at more than 3 times the rate of other Australians, and rates of treatment for end-stage kidney disease are more than 7 times as great. Indigenous people were almost twice as likely as non-Indigenous people to report having asthma. Accordingly, rates of hospitalisation and death are higher among Indigenous people (see Chapter 7 'How healthy are Indigenous Australians?').

Chronic diseases, also occur more often and with greater effect among socioeconomically disadvantaged people, for example:

  • Coronary heart disease has a 40% higher death rate and has demonstrated a lesser rate of decline over time among people living in areas of lowest socioeconomic status compared with those in the highest (AIHW, forthcoming 2014b).
  • The rate of new cases of lung cancer for people living in areas of lowest socioeconomic status was 1.6 times that of people in the highest, which is linked to their higher rates of smoking. Survival of people diagnosed with cancer living in the lowest status areas is also lower (AIHW & AACR 2012).

People who live in areas of lowest socioeconomic status are also more likely to take part in risky health behaviour, or combinations of behaviours, which can lead to poorer chronic disease outcomes. In 2011–12, people living in areas of lowest socioeconomic status were 2.3 times as likely to smoke as those living in the highest (ABS 2013a). People living in these same areas of disadvantage were 1.7 times as likely to report having 4 or more risk factors (AIHW 2012b).

Many people live with more than 1 chronic disease. In 2007–08, 350,000 people (2% of the total population) reported having 4 or more concurrent chronic health conditions out of a list comprising asthma, type 2 diabetes, coronary heart disease, cerebrovascular disease, arthritis, osteoporosis, COPD, depression and high blood pressure. This proportion increases with age, so that among people aged 65 or older, 8% had 4 or more of these chronic diseases. Arthritis and high blood pressure are 2 conditions that commonly occur together among adults. Among younger age groups, asthma and depression is the most common comorbidity. Having multiple chronic conditions is associated with worse health outcomes, more complex disease management and increased health costs (AIHW 2012b).

Chronic disease through the life course

As already noted, the occurrence of chronic disease increases with age. Some diseases, such as asthma and type 1 diabetes, usually begin in childhood or adolescence. Others, such as coronary heart disease or cerebrovascular disease, are uncommon before adulthood, although the processes leading to their occurrence begin earlier in life. Still other diseases, such as arthritis and dementia, most commonly occur later in life.

It is useful to examine how chronic disease occurs across different stages of the life course, because of the strong links between earlier exposures and later health outcomes. Often, adult chronic diseases reflect the cumulative influence of prior physical growth, of reproduction, infection, social mobility and changes in behaviour. Some of these influences can begin before birth. Today's children, who are subject to increased behavioural risks at earlier ages through the consumption of energy-dense foods and poor diet, increased screen time and reduced physical activity, will live longer with risk factors such as obesity (Amschler 2002; Swinburn et al. 2004). Based on current knowledge, the future impact of these behavioural risks on individuals, populations and the health system will be significant.

Social determinants of health, experienced at different life stages, can also influence the development of chronic diseases, through their effect on biological processes (Lynch & Davey Smith 2005). Low birthweight babies, for example, are more likely to come from less affluent backgrounds, and low birthweight is associated with increased rates of cardiovascular disease and diabetes later in life. Adult risk factors for chronic disease also have their own histories; what people do or do not eat in adulthood, for example, is often established much earlier in life. Observing risk factors and chronic disease development in populations from an early age can provide valuable lessons for future disease management.

Coronary heart disease and COPD are leading examples of strong links between several life course risk factors and processes and the later development of chronic disease (see Table 4.2). Many of these risk factors can interact with each other as well as with chronic disease development. For example, in-utero biological effects, combined with poor nutrition early in life, may affect how particular forms of fat are tolerated later in life. Early social disadvantage may interact with affluence in later life to increase coronary heart disease risk. Cholesterol, blood pressure and overweight measures at young ages often persist into adulthood, and can predict the later occurrence of coronary heart disease. Smoking habits acquired in adolescence or early adulthood greatly increase the risk for cardiovascular diseases and COPD in adulthood and old age—along with cancers and many other chronic diseases. The age of quitting smoking is also important and a major influence in reducing later COPD, coronary heart disease, and other chronic disease risk.

Table 4.2: Some life course risk factors for coronary heart disease and COPD
Life course stage Coronary heart disease COPD
In-utero Maternal health, behaviour, stress and diet during pregnancy. Poor growth. Low birthweight. Low birthweight.
Infancy Infant feeding. Maternal attachment. Poor growth. Low socioeconomic status. Infections. Overcrowded dwellings. Second-hand smoke. Low socioeconomic status.
Childhood Low socioeconomic status. Poor growth. Nutrition. Obesity. Some infections. Low socioeconomic status. Poor growth. Crowding. Second-hand smoke. Obesity. Indoor/outdoor air quality.
Adolescence Low socioeconomic status. Nutrition. Physical activity. Obesity. Blood pressure. Cholesterol. Number of children (women). Low socioeconomic status. Poor growth. Smoking. Obesity.
Adulthood Low socioeconomic status. Short height. Smoking. Diet. Physical activity. Obesity. Cholesterol. Blood pressure. Binge drinking. Insulin resistance. Work. Psychosocial factors. Low socioeconomic status. Poor growth. Smoking. Diet. Obesity. Physical activity. Occupational exposure. Indoor/outdoor air quality.
Across generations Parental history. Maternal health, behaviour, stress and diet before pregnancy. Low socioeconomic status. Parental history.

Source: Lynch & Davey Smith 2005.

Older Australians are most affected by chronic disease. Around 15% of people in the 0–24 age group reported having either asthma, type 2 diabetes, coronary heart disease, cerebrovascular disease, arthritis, osteoporosis, COPD, depression or high blood pressure, in 2007–08. Among people aged 65 or over, the figure is 78%. Similarly, around half of people aged 65–74 had to cope with 5 or more chronic diseases, increasing to 70% of those aged 85 and over (AIHW 2012a).

The most common chronic diseases or conditions among older Australians are some degree of vision or hearing loss, arthritis or other musculoskeletal problems, and elevated blood pressure or cholesterol levels. Yet despite the frequency of chronic disease in later life, two-thirds of older Australians aged 75 and over rate their health as good, very good or excellent.

Common risks, common prevention and integrated care

Many chronic diseases share common risk factors that are preventable. Modifying these can reduce the risk of developing a chronic condition, leading to large health gains in the population through the reduction of illness and rates of death (see Chapter 8 'Prevention for a healthier future').

Chronic diseases are closely associated with modifiable risk factors such as smoking, physical inactivity, poor nutrition and the harmful use of alcohol. These behaviours contribute to the development of biomedical risk factors, including overweight and obesity, high blood pressure, and high cholesterol levels, which in turn lead to chronic disease (see Chapter 5 'Biomedical risk factors' and 'Behavioural risk factors' for further details). Seventy per cent of all cardiovascular disease mortality in Australia has been attributed to the combined effects of high blood pressure, high cholesterol and physical inactivity (Begg et al. 2007).

People often have combinations of risk factors, and as their number of risk factors increase, so does the likelihood of developing certain chronic diseases. For example, males with 5 or more risk factors are 3 times as likely to have COPD as males with 2 or fewer risk factors. Females with 5 or more risk factors are 3 times as likely to have had a stroke, and two and a half times as likely to have depression as females with 2 or fewer risk factors (AIHW 2012b).

Two risk factors that commonly occur together are risky alcohol drinking and smoking. In 2010, 38% of current smokers also consumed alcohol at risky levels, compared with only 12% of people who had never smoked (AIHW, forthcoming 2014a). Daily smoking is also more commonly reported by people with low levels of physical activity. People who are obese often also have high blood pressure (AIHW 2012b).

A group of risk factors, known collectively as the 'metabolic syndrome', greatly increases the risk of type 2 diabetes. This risk factor group comprises obesity, impaired fasting blood glucose, raised blood pressure, raised blood triglycerides and reduced HDL cholesterol.

The cumulative effect of risk factors magnifies the risk, with earlier and more rapid development of a condition, more complications and recurrence, a greater disease burden, and a greater need for management of the condition (AIHW 2012b).

A key focus of the Australian health system therefore is the prevention and better management of chronic disease to improve health outcomes. Many common chronic diseases are amenable to preventive measures such as changes in behaviour. These changes, together with timely and better medical treatments, are important in improving chronic disease health outcomes. Identifying populations most at risk and monitoring and evaluating preventive interventions are also important (AIHW 2011b).

There would seem to be great potential in an integrated and coordinated approach to chronic disease care using shared prevention, management and treatment strategies. Reducing obesity, for example, may prevent diabetes, hypertension, heart disease, and certain types of cancers. Assessing the risk of cardiovascular disease on the basis of the combined effect of multiple risk factors (absolute cardiovascular disease risk) can lead to better management of modifiable risk factors through lifestyle changes and pharmacological therapy (National Vascular Disease Prevention Alliance 2012). These strategies all involve better delivery and coordination across the health-care continuum, from health promotion and prevention, to early detection where appropriate, and to primary, secondary and tertiary care. GPs and their teams can perform a key role in screening and prevention, and coordinating services (RACGP 2012). Such an approach can strengthen and transform health-care systems, resulting in more effective, efficient, and timely care (Standing Council on Health 2013).

The future for chronic disease

If left unchecked, trends in chronic disease risk factors—especially physical inactivity and poor nutrition leading to overweight and obesity—combined with a growing and ageing population will lead to increasing numbers of people living with chronic diseases. Helping people to make good lifestyle choices at all stages of the life course can help to keep them in good health and prevent illness for as long as possible.

The growing chronic disease burden will require effective treatment of multiple chronic conditions and catering to complex health-care needs. Developing and implementing new and innovative treatment methods—including coordinated care and chronic disease management plans—holds great promise for future disease management (see Chapter 8 'Primary health care in Australia').

What is missing from the picture?

The availability of better statistical information on the incidence and prevalence of chronic diseases could benefit future health services planning. Some chronic diseases such as dementia are not readily identifiable in health surveys.

Additional data on comorbidity and treatment—including data on primary care, health service use, medications and whether these are being taken correctly, quality of life, and people's ability to carry out their daily lives—will also help in developing a picture of how chronic diseases affect people in Australia and the effectiveness of strategies.

Where do I go for more information?

More information on chronic diseases in Australia is available.

For specific chronic diseases, refer elsewhere in this chapter.

References

ABS (Australian Bureau of Statistics) 2013a. Australian Health Survey: first results, 2011–12. ABS cat. no. 4364.0.55.001. Canberra: ABS.

ABS 2013b. Australian Health Survey: updated results, 2011–12. ABS cat. no. 4364.0.55.003. Canberra: ABS.

ABS 2013c. Causes of death, Australia, 2011. ABS Cat. no. 3303.0. Canberra: ABS.

AIHW (Australian Institute of Health and Welfare) 2010. Contribution of chronic disease to the gap in adult mortality between Aboriginal and Torres Strait Islander and other Australians. Cat. no. IHW 48. Canberra: AIHW.

AIHW 2011a. Australia's welfare 2011. Cat. no. AUS 142. Canberra: AIHW.

AIHW 2011b. Key indicators of progress for chronic disease and associated determinants: data report. Cat. no. PHE 142. Canberra: AIHW.

AIHW 2012a. Australia's health 2012. Australia's health series no. 13. Cat. no. AUS 156. Canberra: AIHW.

AIHW 2012b. Risk factors contributing to chronic disease. Cat. no. PHE 157. Canberra: AIHW.

AIHW 2012c. Multiple causes of death in Australia: an analysis of all natural and selected chronic disease causes of death 1997-2007. Bulletin no. 105. Cat. no. AUS 159. Canberra: AIHW.

AIHW 2012d. Australia's food and nutrition 2012. Cat. no. PHE 163. Canberra: AIHW.

AIHW 2013. Health expenditure Australia 2011–12. Health and welfare expenditure series 50. Cat. no. HWE 59. Canberra: AIHW.

AIHW, forthcoming 2014a. Head and neck cancers in Australia. Canberra: AIHW.

AIHW, forthcoming 2014b. Trends in coronary heart disease mortality. Canberra: AIHW.

AIHW & AACR (Australasian Association of Cancer Registries) 2012. Cancer in Australia: an overview, 2012. Cancer series no. 74. Cat. no. CAN 70. Canberra: AIHW.

Amschler D H 2002. The alarming increase of type 2 diabetes in children. Journal of School Health 72:39–41.

AHMAC (Australian Health Ministers' Advisory Council) 2012. Aboriginal and Torres Strait Islander Health Performance Framework 2012 report. Canberra: AHMAC.

Beaglehole R et al. 2011. Priority actions for the non-communicable disease crisis. Lancet 377: 1438–47.

Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD 2007. The burden of disease and injury in Australia 2003. Cat. no. PHE 82. Canberra: AIHW.

Britt H et al. 2013. General practice activity in Australia 2012–13. General practice series no. 33. Sydney: Sydney University Press.

Hunter D J & Reddy K S 2013. Noncommunicable diseases. New England Journal of Medicine 369: 1336–43.

IHME (Institute for Health Metrics and Evaluation) 2013. DALY estimates for Australasia. Viewed 1 November 2013.

Lynch J & Davey Smith G 2005. A life course approach to chronic disease. Annual Review of Public Health 26: 1–35.

National Vascular Disease Prevention Alliance 2012. Guidelines for the management of absolute cardiovascular disease risk. Canberra: NVDPA.

RACGP (Royal Australian College of General Practitioners) 2012. Guidelines for preventive activities in general practice, 8th edn. East Melbourne: RACGP.

Standing Council on Health 2013. National Primary Care Strategic Framework. Canberra: Commonwealth of Australia.

Swinburn BA, Caterson I, Seidell JC & James WPT 2004. Diet, nutrition and the prevention of excess weight gain and obesity. Public Health Nutrition 7(1A):123–46.

WHO (World Health Organization) 2011. Global status report on noncommunicable diseases 2010. Geneva: WHO.


4.3 Cancer in Australia

Cancer is a diverse group of several hundred diseases in which some of the body's cells become abnormal and begin to multiply out of control. The abnormal cells can invade and damage the tissue around them, and spread to other parts of the body, causing further damage and eventually death. Despite a decline in cancer deaths and an increase in survival over time, cancer is still the second-most common cause of death in Australia—after cardiovascular diseases. Cancer has a significant impact on individuals, families and the health-care system and has had a prominent policy focus for decades.

Incidence

  • In 2010, 116,580 new cases of cancer were diagnosed in Australia (excluding basal and squamous cell carcinoma of the skin—the most common types of non-melanoma skin cancer). More than half (57%) of these cases were diagnosed in males.
  • The risk of being diagnosed with any cancer before the age of 85 was 1 in 2 for males and 1 in 3 for females.
  • The most commonly diagnosed cancers in 2010 were prostate in males (19,821), bowel (14,860), breast cancer in females (14,181), melanoma of the skin (11,405) and lung (10,296) (Figure 4.3).
  • The number and rate of new cases of cancer have increased over time. Between 1990 and 2010, the age-standardised incidence rate (see Glossary) for total cancers rose by 16%, from 422 new cases per 100,000 people to 488 per 100,000. This was driven by rises in the incidence of prostate, breast and bowel cancers, due largely to improved detection and diagnosis of these cancers.
  • The number of new cases of cancer diagnosed in Australia is projected to continue to rise over the next decade and is expected to reach 150,000 in 2020. This increase in the number of new cases, due primarily to population growth and ageing, is expected to be most evident among older populations.

Deaths

  • In 2011, there were 43,221 deaths from cancer in Australia, accounting for 3 in 10 deaths. The risk of dying from cancer was 1 in 4 for males and 1 in 6 for females.
  • The most common causes of cancer-related death in 2011 were lung (8,114 deaths), bowel (3,999), prostate in males (3,294), breast in females (2,937) and pancreatic (2,416) cancers.
  • The number of cancer-related deaths has risen over time, but mortality rates have fallen. Between 1991 and 2011, the age-standardised mortality rate for all cancers combined fell by 17%, from 210 deaths per 100,000 people to 172 per 100,000. The fall in mortality rates was driven by falls in lung, prostate and bowel cancer death rates among males, and falls in breast and bowel cancer death rates among females.

Figure 4.3: Incidence of the 10 most commonly diagnosed cancers, 2010

Bar chart showing incidence of the 10 most commonly diagnosed cancers in 2010. The top three were prostate, bowel and breast.

Source: AIHW Australian Cancer Database 2010.

Survival

  • In 2006–2010, people diagnosed with cancer had a 66% chance of surviving for at least 5 years compared with their counterparts in the general population (referred to as 5-year survival, see Glossary). Among people who had already survived 5 years past their cancer diagnosis, the chance of surviving for at least another 5 years was 91%.
  • Five-year survival from all cancers increased over time, from 47% in 1982–1987 to 66% in 2006–2010. Some of the likely reasons for this include better diagnostic methods, earlier detection and improvements in treatment.
  • The cancers with the largest survival gains were prostate cancer, kidney cancer and non-Hodgkin lymphoma. The cancers with a decline or no improvement in survival were bladder, larynx, lip and brain cancers, and chronic lymphocytic leukaemia.

Prevalence

  • In 2007, about 1 in 28 living Australians had been diagnosed with cancer at some time in the previous 26 years (referred to as 26-year prevalence, see Glossary). This equates to 775,000 people, or 3.6% of the total population. The 26-year prevalence was highest for breast cancer (151,152 women), melanoma of the skin (136,016), prostate cancer (129,978 men) and bowel cancer (105,144).

Hospitalisations

  • In 2011–12, there were more than 908,700 hospitalisations (see Glossary) for cancer or a cancer-related health service or treatment. Chemotherapy sessions accounted for 41% of these hospitalisations, followed by non-melanoma skin cancer (11%).

What is missing from the picture?

There are no national registry data on the stage (severity) of cancer at diagnosis, treatments applied to individual cases of cancer, the frequency of recurrence of cancer after treatment, or the incidence of non-melanoma skin cancers. The AIHW and Cancer Australia are working together to assess the feasibility of collecting, collating and reporting national data on: the stage of the disease when cancer is diagnosed; the treatments applied at each stage; and how frequently cancer recurs after treatment.

Where do I go for more information?

The reports, Cancer in Australia: an overview, 2012, Cancer incidence projections: Australia, 2011 to 2020, and Cancer survival and prevalence in Australia: period estimates from 1982 to 2010, are available for free download.

4.4 The changing cancer landscape

There have been many successes, and there are many remaining challenges, in cancer control. While the incidence of cancer is rising, the good news is that overall average mortality at the population level is falling and real improvements in survival are continuing.

These changes in the cancer landscape are not universal, and differ greatly by cancer type and population group. The overall average is not necessarily indicative or representative of individual experience, where a diagnosis of cancer is anything but 'good news'.

The observed rise in overall cancer incidence can be broadly attributed to advancements in early detection (through organised screening programs and better detection technology), the ageing population and changes in risk factor exposure. The observed fall in the overall cancer mortality rate can be mainly attributed to a combination of earlier detection (at a more treatable stage) and more effective treatments. The number of cancer-related deaths is attributable to changes in risk factor exposure and the ageing of the population.

The net result of increasing cancer incidence and decreasing overall mortality is more people living with cancer, that is, higher and gradually increasing prevalence due to increased survival in the population. Better survival rates for some cancers bring an increasing emphasis on living with, and after, a cancer diagnosis.

This article examines broadly some features of this changing landscape through:

  • describing cancer and the current disease burden
  • summarising the historical gains in cancer control
  • estimating the future cancer disease burden and discussing emerging issues
  • outlining areas where future gains could be made.

What do we know about cancer?

Box 4.1: Defining cancer

Cancer, also called malignancy, is a term for diseases in which abnormal cells divide without control and can invade nearby tissues.

Cancer cells can also spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is a cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is a cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukaemia is a cancer that starts in blood-forming tissue, such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord.

Source: National Cancer Institute 2014.

Cancer is a major cause of illness in Australia, with more than 116,500 people diagnosed with cancer in 2010 (excluding non-melanoma skin cancer), and around 43,200 dying from cancer in 2011 (see Box 4.1, Table 4.3). Cancer contributed 16% of the total disease burden in Australasia (Australia and New Zealand), based on findings from the Global Burden of Disease Study 2010. (For more information on the burden of disease, see Chapter 4 'Burden of disease'.)

In 2008–2009, the total health system expenditure in Australia on neoplasms (including cancer and non-cancerous tumours) was $4,526 million, an increase from $2,894 million in 2000–01, after adjusting for inflation (AIHW 2013). The majority of health system expenditure on cancer in 2008–09 was on hospital-admitted cancer services (79%), followed by prescription pharmaceuticals (12%) and out-of-hospital services (9%). Expenditure on national population screening programs was just over $332 million in 2008–09.

The cancer burden differs by sex, age and population group. These differences are summarised in Table 4.3.

Table 4.3: Cancer incidence, mortality and survival at a glance
Category Incidence Mortality Survival
Map of Australia clipart   There were 116,580 new cases of cancer in 2010 (excluding non-melanoma skin cancer), a rate of 487 per 100,000 people. There were 43,211 deaths from cancer in 2011, a rate of 172 per 100,000 people. In the period 2006–2010, 5-year relative survival for all cancers combined was 66%. That is, people diagnosed with cancer had a 66% chance of surviving at least 5 years compared with their counterparts in the general population.
Man and a woman clipart   The incidence of all cancers combined was 1.4 times as high among males (585 per 100,000) compared with females (406 per 100,000). Mortality from all cancers combined was 1.6 times as high among males (219 per 100,000) compared with females (137 per 100,000). Females (67%) tended to experience slightly higher survival than males (65%) overall.
Growth (three men of different sizes) clipart   Cancer can develop at any age but around 70% of all cancers are diagnosed in people aged 60 and over. Deaths from cancer are most common among older people, with more than 80% of all deaths from cancer occurring in people aged 60 and over. Survival decreased with age: from 86% among people aged 0–39 to 43% among those aged 80 and over.
Aboriginal flag clipart   Indigenous Australians were 1.1 times more likely to be diagnosed with cancer in 2004–2008 compared with their non- Indigenous counterparts. Indigenous Australians were 1.5 times more likely to die from cancer in 2007–2011 compared with their non-Indigenous counterparts. Indigenous Australians had lower 5-year relative survival (40%) in 1999–2007 compared with their non-Indigenous counterparts (52%).
Socioeconomic status clipart (a house, a car, a briefcase, a college cap, a dollar sign)   People living in areas of lower socioeconomic status had a higher incidence of all cancers combined (490 per 100,000) compared with people living in areas of higher relative socioeconomic status (482 per 100,000), in 2004–2008. People living in areas of lower socioeconomic status had higher mortality from all cancers combined (172 per 100,000) compared with people living in areas of higher relative socioeconomic status (151 per 100,000), in 2006–2010. People living in areas of lower socioeconomic status had lower 5-year relative survival (63%) compared with people living in areas of higher socioeconomic status (71%), in 2006–2010.
City and Rural areas clipart   Incidence rates of all cancers combined were higher for Australians living in Inner regional areas (504 per 100,000) than people living in Outer regional (495 per 100,000), Major cities (480 per 100,000) and Remote and Very remote areas (474 per 100,000), in 2004–2008. Mortality rates for all cancers combined were higher for Australians living in Remote and Very remote areas (196 per 100,000) and Outer regional areas (193 per 100,000) than for those living in Major cities (171 per 100,000) and Inner regional areas (185 per 100,000), in 2006–2010. Five-year survival from all cancers combined was highest among people living in Major cities (67%) compared with Inner regional (66%), Outer regional (65%) and Remote and Very remote areas (63%), in 2006–2010.

For more information, see Chapter 4 'Cancer in Australia'.

What has changed over time?

In Australia, there are some notable historical trends in cancer incidence, mortality and survival (Figure 4.4). The trend data presented here reflect the breadth (from first to most recent year) of available national data: 1982–2010 for incidence, 1968–2011 for mortality and 1982–1986 to 2006–2010 for survival.

The overall cancer incidence rate has on average increased by 0.9% per year between 1982 and 2010 (Figure 4.4). This increase reflects annual rises in the incidence of some of the most commonly diagnosed cancers such as prostate cancer, breast cancer and melanoma of the skin, as well as some rarer cancers such as liver and testicular cancers. In contrast, the incidence of some cancers, including lung, bladder and cervical, fell significantly in that same period. There has been a moderation in the overall trend in more recent years, with incidence rising by an average of 0.5% per year from 2001 to 2010.

Figure 4.4: Incidence (1982–2010), mortality (1982–2011) and 5-year relative survival (1982–1987 to 2006–2010) of all cancers combined, Australia

Line chart showing the trending increase in 5-year relative survival; the trending increase in incidence of all cancers combined; and the trending decline in mortality due to all cancers between 1982 and 2011.

Notes

  1. Deaths registered in 2009 and earlier are based on the final version of cause of death data; deaths registered in 2010 and 2011 are based on revised and preliminary versions, respectively, and are subject to further revision by the ABS. Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of deaths in Queensland in 2010.
  2. Data points for 5-year relative survival refer to the final year in each 5- or 6-year at-risk period: 1982–1987, 1988–1993, 1994–1999, 2000–2005, 2006–2010.

Sources: AIHW Australian Cancer Database 2010; AIHW National Mortality Database; AIHW 2012b.

The good news is that despite the overall substantial increase in incidence, overall mortality on average from all cancers, including the cancers that are the leading causes of death, fell by 0.3% per year between 1968 and 2011 (Figure 4.4). This fall reflects substantial improvements in survival, thought to include substantial real gains in survival—that is, delaying death, and not only earlier diagnosis extending the measured time between diagnosis and death. There has been a gain in the overall trend in more recent years, with mortality falling by an average of 1.0% per year from 1991 to 2011.

Between 1982–1987 and 2006–2010, 5-year relative survival for all cancers combined rose from 46.9% to 66.1%, a rise of 41% across that period. This trend was observed for most, but not all, cancer types: survival from bladder, larynx and lip cancers fell, although the change was only significant for bladder cancer.

Changes in cancer incidence, mortality and survival have been shaped by a wide range of factors, including changes in exposure to the risk factors for cancer, improved primary prevention, advancements in cancer treatment, and for some cancers, earlier detection through organised screening programs (bowel, breast and cervical) and opportunistic testing (prostate) (Armstrong 2013).

Changes in exposure to risk factors

Changes in exposure to cancer risk factors at the population level can increase or decrease cancer incidence, which in turn may produce a parallel change in cancer mortality, noting the lag in time between exposure and the onset of cancer (Armstrong 2013). For most cancers, the causes are not fully understood; however, some causal factors are well recognised, and include:

  • behavioural factors such as tobacco smoking, alcohol, diet, obesity and physical inactivity
  • family history, genetic susceptibility and reproductive and hormonal factors
  • occupational and environmental exposures (for example, radiation, asbestos, ultraviolet light and chronic infection)
  • medical and iatrogenic factors (AIHW & AACR 2012; IARC 2008; WCRF & AICR 2007).

Selected cancers strongly influenced by changes in exposure to known and quantifiable risk factors in previous decades include lung and stomach cancers, melanoma of the skin and cervical cancer.

Tobacco smoking is the largest single risk factor for lung cancer in Australia, and is responsible for about 90% of lung cancers in males and 65% in females (AIHW: Ridolfo & Stevenson 2001). Lung cancer incidence and mortality among males has declined steadily since the 1980s, which is attributed to the steadily declining rate in daily tobacco smoking: from 58% in 1964 to 16% in 2010. In contrast, for females, lung cancer incidence and mortality among females continue to rise. This is attributable to a later turnaround in smoking rates: from a high of 33% in 1976 to 14% in 2010 (AIHW 2012a; OECD 2013).

Ultraviolet radiation is the leading risk factor for melanoma of the skin. In Australia, the incidence of melanoma of the skin rose between 1982 and 2010—at around 5.0% per year during the 1980s, moderating to 2.8% per year after that. The initial rapid increase is partly attributable to individual behaviour and the use of solariums, resulting in increased exposure to solar ultraviolet radiation (Armstrong & Kricker 2001; Cust et al. 2011). The moderated trend after the 1980s is consistent with increased awareness of skin cancer and improved sun protective behaviours as a result of extensive skin cancer prevention programs dating back to the 1970s (AIHW 2012a).

The major causes of stomach cancer are the bacterium Helicobacter pylori, poor nutrition and smoking. There have been continuous falls in stomach cancer incidence between 1982 and 2010, and stomach cancer mortality between 1968 and 2011—2% and 3% per year, respectively. The falls are largely attributable to a decline in the prevalence of H. pylori, and to dietary improvements and the decline in smoking rates (Armstrong 2013). Further improvements in incidence and mortality are expected as a result of the continued decreasing trend in daily smoking.

Chronic infection with the human papillomavirus (HPV ) is the cause of around 70–80% of all cervical cancers (Brotherton 2008). The AIHW and the Victorian Cytology Service recently conducted a study to evaluate the effectiveness of the HPV vaccine against cervical abnormalities among school-aged women (Gertig et al. 2013). This study demonstrated that the population-based HPV vaccination program in Australia is preventing cervical pre-cancer lesions in young women, with a fall in cervical abnormalities after the program was implemented in 2007 (Gertig et al. 2013). The effect of the vaccine is expected to increase over time as women vaccinated at age 12–13 become eligible to be screened in the cervical screening program and enter the age ranges where cancer incidence is more common. This is an area where gains may also follow for other cancers with a similar viral aetiology (see Glossary) to cervical cancer.

Early detection through organised screening

Australia has national population screening programs for 3 cancers—breast, cervical and bowel cancer. BreastScreen Australia was introduced in 1991, the National Cervical Screening Program (NCSP) also started in 1991, and the National Bowel Cancer Screening Program (NBCSP) was introduced in 2006.

These screening programs aim to reduce illness and death from these cancers through early detection of cancer and pre-cancerous abnormalities and effective follow-up treatment. Since it was introduced, BreastScreen Australia has had a major impact in moderating an increasing incidence trend and in contributing to falling mortality in breast cancer. Similarly, the NCSP has had a major impact in enhancing decreasing trends for cervical cancer incidence and mortality (Figure 4.5).

The introduction of the BreastScreen Australia program resulted in an initial rapid increase in the number of breast cancers diagnosed in 1992–1994, followed by a more moderate increasing trend to 2010, accompanied by a steady decline in breast cancer mortality from 1994 (Figure 4.5A). The introduction of the NCSP resulted in a rapid decline (from an already decreasing trend) in cervical cancer incidence from 1991 to 2002, followed by a more stable trend to 2010 and a steady decline in cervical cancer mortality from 1991 to 2004, followed by a stable trend to 2010 (Figure 4.5B). A similar effect from the NBCSP is expected for bowel cancer in the longer term.

For more information on cancer screening programs, see Chapter 8 'Cancer screening in Australia'.

Figure 4.5: Incidence and mortality of breast cancer (A) and cervical cancer (B), Australia, 1982–2010

Two line charts (A. breast cancer-new cases/deaths per 100,000 females; B. Cervical cancer - new cases/deaths per 1000,000 females), one showing the trending increase in new breast cancer cases in females between 1982 and 2010, and the trending decline in mortality. The other chart shows the trending decline in both new cases and mortality of cervical cancer over the same period.

Notes

  1. Deaths registered in 2008 and earlier are based on the final version of cause of death data; deaths registered in 2009 and 2010 are based on revised and preliminary versions, respectively, and are subject to further revision by the ABS. Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of deaths in Queensland in 2010.
  2. The solid vertical line at 1991 indicates the introduction of the national screening programs.

Sources: AIHW Australian Cancer Database 2010; AIHW National Mortality Database.

Improvements in treatment

Broadly, a variety of improvements in cancer treatments are thought to have led to improvements in cancer outcomes, particularly decreasing mortality (improved survival). These include: advances in imaging and technology used to develop and administer treatments; more focused or targeted therapies; multi-disciplinary approaches to treatment; more options in, and access to, treatment settings; and clinical trials for patients.

Examples of improvements include:

  • the use of platinum-based chemotherapy, credited with the fall in mortality from testicular cancer (Einhorn 1981)
  • multi-disciplinary use of chemotherapy and radiotherapy, effecting a reduction in mortality from rectal cancer (Philip et al. 1995; Roh et al. 2009; Sauer et al. 2012; Woods et al. 2001)
  • the availability of and participation in clinical trials, a significant factor in reducing mortality from childhood cancers (Stiller et al. 2012)
  • the advent of targeted, precision or personalised treatments, such as Hereceptin for HER-2 type breast cancers, leading to improved survival from that breast cancer sub-type (Romond et al. 2005).

What might the future bring?

Projected incidence and mortality

Extrapolation of historical trend data for all cancer incidence (1982 to 2007) and mortality (1968 to 2010) shows that between 2011 and 2020:

  • numbers of new cases and deaths are expected to rise for both males and females
  • the incidence rate among females is expected to rise, although the change will not be significant
  • the incidence rate among males is not expected to change
  • the mortality rate is expected to fall for both males and females (Figure 4.6).

Figure 4.6: Projected cancer incidence and mortality among males (A) and females (B), all cancers combined, Australia, 2011 to 2020

Two line charts (A Males; B females) showing the projected increase in cancer incidence and mortality among males and females for all cancers combined in Australia between 2011 and 2020.

Note: Projected years 2011 to 2020 based on actual data from 1982 to 2007 (incidence) and 1968 to 2010 (mortality).

Sources: AIHW Australian Cancer Database 2010; AIHW National Mortality Database.

Based on these projections, in 2020:

  • 150,000 people are expected to be diagnosed with cancer, an increase of 29% from 2010
  • 50,800 people are expected to die from cancer, an increase of 18% from 2010.

Emerging issues

The combined effect of several factors—increasing incidence, decreasing mortality in some cancers, high and improving survival for some cancers, earlier diagnosis and detection, and developments in treatment and management of cancer—is a steady increase in the proportion of the population who have been diagnosed with cancer. This population is also termed the prevalent or survivorship population.

In 2007, there were around 775,000 Australians alive who had been diagnosed with cancer in the 26 years since incidence data were first collected at a national level (from 1982), accounting for 3.7% of the total Australian population in that year (AIHW 2012b). It is likely, based on the continuation of current projected trends in incidence and mortality, that this population will continue to slowly rise over time, with an accompanying rise in the economic and social burden of cancer.

This will all mean, now and into the future, major changes in the experience of cancer for some individuals, their families and carers (Hawkins et al. 2010; Quality Health 2013). It also means a challenge for the health system in responding to these changes, particularly with an ageing population.

These changes and challenges are being seen now in emerging issues such as the survivorship experience, caring for people with cancer, ageing with cancer, recurrent and multiple primary cancers, and cancer in the presence of other conditions (comorbidity).

Survivorship experience

Survivorship is increasingly recognised as beginning at diagnosis and continuing long after treatment ends. It is more than simply not dying from cancer, and focuses on living with, and after, a cancer diagnosis (Jackson et al. 2013). Cancer survivors often face emotional, physical and financial challenges as a result of the detection, diagnosis and treatment of cancer. In the longer term, people diagnosed with cancer:

  • may experience enduring physical symptoms following their treatment, such as late effects of radiation or post-surgical loss of function
  • can be at risk of recurrence, that is, the return of the same primary cancer after treatment and after a period during which cancer cannot be detected
  • may be at increased risk of developing other primary cancers due to the effects of treatment (for example, developing leukaemia after administration of alkylating agents), underlying genetics, and/ or other risk factors for cancer (Youlden & Baade 2011).

These longer-term risks, and the associated stressors and reduced quality of life for cancer survivors and their family, friends and caregivers, highlight the importance of follow-up health care and of survivorship as part of the cancer control continuum (Hawkins et al. 2010; Jackson et al. 2013).

Cancer, caring and ageing

The increasing size of the population who have had cancer also means a corresponding increase in the number of people caring for someone through cancer diagnosis, treatment and remission, often into old age. As some cancer treatment and care modalities move away from the acute (hospital) setting and into outpatient, primary, nurse-led or community care settings, greater support for and recognition of informal carers of people with cancer will be needed (Access Economics 2010; Cancer Council Australia & Clinical Oncological Society of Australia 2010). Many cancer support organisations and groups recognise the importance and growing size of this population, and provide support to carers, siblings and friends of people with cancer (Cancer Council Victoria 2011). This shift away from the acute care setting is also apparent in palliative care, with a South Australian study reporting that 70% of respondents would prefer to die at home than elsewhere, if faced with a terminal illness such as cancer (Foreman et al. 2006). (For more information on Palliative care, see Chapter 6 'Palliative care in Australia'.)

The increasing size of the aged population in Australia is a contributing factor to the projected increase in the number of new cancer cases and cancer-related deaths to 2020. Ageing, in the context of survivorship and the increasing prevalence population, also increases the likelihood of:

  • recurrent (returning) cancers, as people live longer and into old age after a cancer diagnosis
  • the occurrence of multiple primary cancers, with ageing compounding the effect of existing cancer risk factors (that lead to the first primary cancer)
  • cancer as a comorbid chronic disease.

The last of these, cancer and comborbidity, is discussed briefly below.

Cancer and comorbidity

As people survive longer with cancer it will become increasingly important for cancer to be considered in the context of patients' other ongoing health conditions. While it is not possible with current available data to examine the incidence and prevalence of cancer as a comorbid condition, it is possible to use mortality data to analyse the proportion of Australians who have both cancer and other conditions recorded as causes of death.

Current monitoring tends to focus on cancer as an underlying cause of death. However, this type of analysis excludes those deaths where cancer was an associated cause of death, that is, any cause other than the underlying cause. (For more information on multiple causes of death, see Chapter 3 'Multiple causes of death in Australia'.)

In 2011, cancer was recorded as the underlying cause in 43,221 deaths, accounting for 29% of all deaths in that year. Cancer was recorded as an associated cause in an additional 6,299 deaths, where the most common underlying causes were chronic ischaemic heart disease, acute myocardial infarction or other chronic obstructive pulmonary disease. In total, 49,520 deaths in that year (34%) included cancer as a cause of death (either underlying or associated).

When cancer was recorded as a cause of death (either underlying or associated), it was the underlying cause in 87% of those deaths. Of these, 35% had only 1 cause recorded (the underlying cause), followed by 23% with 2 causes, 19% with 3 causes and 12% each with 4 and 5 or more causes. The proportion of deaths reported as being caused by 3 or more causes rose from 32% in 1997 to 42% in 2011 (Figure 4.7).

Figure 4.7: Number of causes of death when cancer is the underlying cause of death, 1997 to 2011

Chart showing the number of causes of death when cancer is the underlying cause each year between 1997 and 2011. A single cause was the most common and occurred in approximately 40% of cases. There was a trending decline in this figure (from just over 40% to just under) over this period.

Note: Deaths registered in 2009 and earlier are based on the final version of cause of death data; deaths registered in 2010 and 2011 are based on revised and preliminary versions, respectively, and are subject to further revision by the ABS. Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of deaths in Queensland in 2010.

Source: AIHW National Mortality Database.

Where can future gains be made?

The data presented in the section 'What has changed over time?' indicate that, overall, there have been rises in cancer incidence, and falls in cancer mortality. This indicates that efforts in cancer control in recent decades have been successful in preventing and delaying deaths from cancer. Based on the latest projections presented in the section 'What might the future bring?', cancer incidence rates are expected to remain steady while cancer mortality rates are expected to continue to fall. For further gains to be made in cancer control, all aspects of the cancer control continuum will need attention, from primary prevention through to survivorship care. Areas where it appears that significant gains could be made are in risk reduction (primary prevention), early detection and multi-disciplinary care.

Risk reduction (primary prevention)

Reducing the risk of cancer can be achieved by reducing the prevalence of the genomic, modifiable, environmental and infectious risk factors for cancer in the population. Significant gains have already been achieved through control of modifiable risk factors such as tobacco smoking and sun exposure, and infectious risk factors such as HPV and H.pylori. Future approaches could build on these successes to focus on reducing modifiable risk factors such as abdominal overweight and obesity, alcohol and sedentary behaviour, and infectious risk factors such as hepatitis. Opportunities also exist in emerging technologies such as genome sequencing, which allows individuals to discover, and take appropriate preventive action to reduce or remove, their inherent cancer risk. (For more information on primary prevention, see Chapter 5 'Behavioural risk factors' and Chapter 8 'Prevention for a healthier future'.)

Early detection

Detecting cancer earlier, when it is most treatable and outcomes are likely to be better, has a significant impact on treatment outcomes and survival. Significant gains have already been achieved through the 3 existing population-based screening programs. These gains could be built on by implementing risk-based targeted screening programs and activities, expanding the existing screening programs (such as the planned expansion of the NBCSP) and investigating the potential for screening programs for other cancers where appropriate. (For more information on the existing national cancer screening programs in Australia, see Chapter 8 'Cancer screening in Australia'.)

Coordinated care models

Helping people with a cancer risk factor, pre-cancerous condition or cancer to get well and stay well will have a significant impact across the cancer continuum. Australia is fortunate in having evidence-based guidelines for all major cancers that are regularly reviewed and updated. Using standardised and coordinated approaches to survivorship care may help reduce the effect of risk factors, slow or prevent the progression of pre-cancerous conditions to cancer, improve treatment outcomes (including adverse and late effects) and reduce adverse psychosocial effects related to cancer diagnosis and treatment (Jackson et al. 2013).

What is missing from the picture?

In Australia, we are fortunate in having access to complete, timely and quality national cancer incidence and mortality data. However, there are broad areas for improvement, as outlined below.

Gaps in cancer data and information include areas where the data are:

  • not available, for example, the incidence of non-melanoma skin cancers and cancer staging data
  • incomplete, or not sufficient for national reporting purposes, for example, Indigenous status data.

Gaps in cancer analysis and reporting include areas where data are:

  • not yet available for analysis, for example, Indigenous trends over time
  • only now becoming available for analysis, for example, longitudinal cancer incidence data for recurrent and multiple primary cancer analyses
  • available but require linkage, for example, differences in cancer outcomes for people who participate in screening programs compared with those who do not.

Improvements in cancer data completeness, quality and availability will help provide a stronger evidence base on emerging cancer issues, the current and planned cancer control interventions, and future trends.

Where do I go for more information?

More information on cancer in Australia is available.

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Roh M, Colangelo L, O'Connell M, Yothers G, Deutsch M, Allegra C et al. 2009. Preoperative multimodality therapy improves disease-free survival in patients with carcinoma of the rectum: NSABP R-03. Journal of Clinical Oncology 27(31):5124–30.

Romond E, Perez E, Bryant J, Suman V, Geyer CJ, Davidson N et al. 2005. Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer. New England Journal of Medicine 353(16):1673–84.

Sauer R, Liersch T, Merkel S, Fietkau R, Hohenberger W, Hess C et al. 2012. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. Journal of Clinical Oncology 30(16):1926–33.

Stiller C, Kroll M & Pritchard-Jones K 2012. Population survival from childhood cancer in Britain during 1978–2005 by eras of entry into clinical trials. Annals of oncology 23:2464–69.

WCRF (World Cancer Research Fund) & AICR (American Institute for Cancer Research) 2007. Food, nutrition, physical activity and the prevention of cancer: a global perspective. Washington: AICR.

Woods W, Neudorf S, Gold S, Sanders J, Buckley J, Barnard D et al. 2001. A comparison of allogeneic bone marrow transplantation, autologous bone marrow transplantation, and aggressive chemotherapy in children with acute myeloid leukemia in remission. Blood 97(1):56–62.

Youlden D & Baade P 2011. The relative risk of second primary cancers in Queensland, Australia: a retrospective cohort study. BMC Cancer 11:83.


4.5 Arthritis and other musculoskeletal conditions

Arthritis and other musculoskeletal conditions, such as back problems and osteoporosis, affect the bones, muscles and joints.

Many Australians, young and old, are affected by these conditions, which vary in duration, severity, complications and associated disability, and can severely affect a person's health and quality of life. This places a substantial burden on the community, including through the use of hospital and other health services and lost productivity due to pain and disability.

How common are these conditions?

In Australia in 2011–12:

  • An estimated 6.1 million people (28% of the total population) had arthritis and/or another musculoskeletal condition.
  • Arthritis was the most common condition, affecting 3.3 million people (15% of the population), including 8% with osteoarthritis and 2% with rheumatoid arthritis. The prevalence is higher in females than males (18% compared with 12%) and increases with age (affecting 52% of people aged 75 or over).
  • Back problems and disc disorders affect about 2.8 million people (13% of the population). The rates are highest among people aged 65–74.
  • An estimated 725,500 people (3% of the population) reported that they had been diagnosed with osteoporosis or low bone density (osteopenia). Most cases were reported by women (82%) and people aged 55 and over (83%) (ABS 2012). As these conditions have no overt symptoms, the figures may be underestimated.
  • An estimated 64,200 children aged 0–14 had arthritis or another musculoskeletal condition (ABS 2012). Juvenile arthritis affected less than 1% of Australian children.

Impact

People with arthritis and other musculoskeletal conditions were more likely to report:

  • limitations in performing core activities (particularly self-care and mobility) than the overall population (44% compared with 15%)
  • high or very high psychological distress (17%) than people without these conditions (9%)
  • experiencing mental disorders than those without these conditions (1.5 times as high).

Health care

  • These conditions are predominantly managed in primary health care settings by a range of health professionals and involving a combination of medication, physical therapy, self-management education and (where necessary) referral to specialist care.
  • Survey data suggest these conditions were managed by general practitioners in about 18 per 100 patient encounters in 2012–13 (Britt et al. 2013).
  • In 2011–12, there were 494,228 hospitalisations of people with a principal diagnosis of a musculoskeletal condition.
  • There were 62,751 total joint replacements performed (38,679 knee and 24,072 hip) in people with osteoarthritis in 2011–12. Knee replacement was most common among females aged 75–79. Hip replacement was more common among males up to the age of 59 and females aged 60 and over.
  • The number and rate of total joint replacements increased over the 10 years to 2011–12 (see Figure 4.8). The overall rate of knee replacement increased by 54% and hip replacement by 20%.

Figure 4.8: Trends in total knee and hip replacements for osteoarthritis, 2002–03 to 2011–12

Line chart showing the trending increase in total knee and hip replacements as a result of osteoarthritis between 2002-03 and 2011-12. Knee replacements increased from approximately 100 per 100,000 in 2002-03 to approximately 150 per 100,000. Hip replacements increased more gradually from approximately 80 per 100,000 to 90 per 100,000.

Note: Rates have been age-standardised to the 2001 Australian population.

Source: AIHW National Hospital Morbidity Database.

What is missing from the picture?

The prevention, management and treatment of these conditions beyond hospital settings cannot be examined in detail because of a lack of information about primary health care.

There is no information about the use of vitamins, nutritional supplements and over-the-counter pharmaceuticals, such as paracetamol, which are often used to manage musculoskeletal conditions (RACGP 2009a, 2009b, 2010). Prescription pharmaceutical data can be used in some specific circumstances to better understand management, but is limited because it lacks information about the diagnosis for which the medication was prescribed.

There is also a substantial lack of data on the impact of these conditions, for example, in terms of quality of life and costs (although there are some estimates of direct health expenditure).

Where do I go for more information?

More information on arthritis and other musculoskeletal conditions in Australia is available. The report When musculoskeletal conditions and mental disorders occur together is available for free download. More information will also be available in the forthcoming AIHW reports Arthritis and other musculoskeletal conditions across the life stages and Data sources for monitoring arthritis and other musculoskeletal conditions.

References

ABS (Australian Bureau of Statistics) 2012. Australian Health Survey: first results. ABS cat. no. 4364.0.55.001. Canberra: ABS.

Britt H, Miller G, Henderson J, Bayram C, Valenti L, Harrison C et al. 2013. General practice activity in Australia 2012–13. General practice series no. 33. Sydney: Sydney University Press.

RACGP (The Royal Australian College of General Practitioners) 2009a. Clinical guideline for the diagnosis and management of early rheumatoid arthritis. Melbourne: RACGP.

RACGP 2009b. Clinical guideline for the diagnosis and management of juvenile idiopathic arthritis. Melbourne: RACGP.

RAGCP 2010. Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men. Melbourne: RACGP.


4.6 Coronary heart disease

Coronary heart disease (CHD) occurs when there is a blockage in the blood vessels that supply blood to the heart muscle. There are 2 major clinical forms of CHD: heart attack—an acute life-threatening event where the blood vessel is completely blocked, requiring prompt treatment; and angina—a chronic condition where there is a temporary deficiency in the blood supply. Although angina is less severe than a heart attack, people with the condition are at increased risk of heart attack or sudden cardiac death (see Glossary).

CHD kills more people in Australia than any other disease. However, it is largely preventable, as many of its risk factors are modifiable, including: tobacco smoking, high blood pressure, high blood cholesterol, physical inactivity, poor nutrition and obesity (see Chapter 5 'Biomedical risk factors' and 'Behavioural risk factors').

How common is coronary heart disease?

  • In 2011–12, an estimated 585,900 Australians had CHD, with the condition being more common in men (3.3%) than women (2.0%) and among those aged 70 and over (15% compared with 2.2% for those aged 25–69) (ABS 2013).
  • In 2011, an estimated 69,900 people aged 25 and over had a heart attack. There has been a 20% fall in heart attack rates over the last 5 years (age-standardised rate of 427 per 100,000 people in 2011 compared with 534 in 2007) (see Chapter 9 'Indicators of Australia's health' for more information).

Deaths

  • In 2011, there were 21,500 deaths with CHD recorded as the underlying cause of death. CHD contributed to 15% of all deaths in Australia and almost 1 in 2 cardiovascular disease deaths.
  • CHD death rates have fallen by 73% over the last 3 decades; however, the rate of decline has varied over time and across age groups. For some age groups, CHD death rates continue to fall at accelerated rates (such as for those aged 70 and over), while for others, such as the 55–69 age group, there has been a levelling-off or plateauing over the last 5 years (Figure 4.9).

Health care

  • In 2011–12 there were 153,700 hospitalisations for CHD (an age-standardised rate of 615 per 100,000 population), a 28% decline from 1993–94 when the age-standardised rate was 859 per 100,000.
  • The downward trend in CHD hospitalisations was similar for men and women (27% and 31%, respectively), although men are hospitalised at much higher rates than women.

Figure 4.9: Trends in coronary heart disease death rates among people aged 55 and over, 1979–2010

Line chart showing the trending decline in coronary heart disease death rates among people aged 55 and over between 1979 and 2010. There was a decline for all categories: men 70+ years, women 70+ years, men 55-69 years and women 55-69 years. Men 70+ years had the highest mortality rates with over 3,000 deaths per 100,000 population in 1979. This rate fell to close to 1,000 in 2010.

Notes

  1. Rates have been age-standardised to the 2001 Australian population.
  2. Deaths registered in 2008 and earlier are based on the final version of cause of death data; deaths registered in 2009 and 2010 are based on the revised and preliminary versions, respectively, and are subject to further revision by the ABS. Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of deaths in Queensland in 2010.

Source: AIHW forthcoming.

Prevention

Significant reductions in CHD deaths can be attributed to improvements in medical and surgical treatment. These include better emergency care and early identification of risk, the increasing use of antithrombotic and blood pressure- and blood cholesterol-lowering drugs, and cardiac procedures that restore blood flow to the heart by removing or bypassing blockages. Reductions in risk factors, such as tobacco smoking, high blood cholesterol and high blood pressure, have also contributed to these declines.

Variations among population groups

  • The burden of CHD is greater in Aboriginal and Torres Strait Islander people than in other Australians—rates of heart attack events in adults aged 25 and over were 2.6 times as high in 2011.
  • CHD death rates are also higher for Indigenous adults compared with other Australian adults (2.0 and 1.6 times as high for men and women, respectively, in 2009–2010).
  • CHD death rates were 1.4 times as high for adults living in the lowest socioeconomic status (SES) groups compared with the highest SES groups in 2007.

What is missing from the picture?

There are no reliable national and jurisdictional data on the number of new cases of CHD each year. Consequently, proxy measures have been developed that combine hospital and mortality data to estimate new cases of heart attack (including unstable angina, also known as 'acute coronary syndrome').

More data on the care pathways of patients with CHD as they move through the health system, and on the medicines prescribed in the various settings, could lead to better identification of any gaps in health care, and to potentially better care overall.

Where do I go for more information?

The following reports are available for free download: Cardiovascular disease: Australian facts 2011 and Health care expenditure on cardiovascular diseases 2008–09.

Two forthcoming AIHW reports of interest are Cardiovascular, diabetes and kidney disease: Australian facts 2014 and Coronary heart disease mortality trends in age groups and populations.

References

ABS (Australian Bureau of Statistics) 2013. Australian Health Survey: updated results, 2011–2012. ABS cat. no. 4364.0.55.003. Canberra: ABS.

AIHW, forthcoming. Coronary heart disease mortality trends in age groups and populations. Canberra: AIHW.


4.7 Stroke

Stroke occurs when an artery supplying blood to the brain either suddenly becomes blocked (ischaemic stroke) or begins to bleed (haemorrhagic stroke) (see Glossary).

This may result in part of the brain dying, leading to sudden impairment that can affect a range of functions. Stroke often causes paralysis of parts of the body normally controlled by the area of the brain affected by the stroke, or speech problems and other symptoms such as difficulties with swallowing, vision and thinking.

In many but not all cases stroke is preventable because many of its risk factors are modifiable, such as high blood pressure, physical inactivity, abdominal obesity and tobacco smoking (O'Donnell et al. 2010) (see Chapter 5 'Biomedical risk factors' and 'Behavioural risk factors').

How common is stroke?

  • In 2009, an estimated 375,800 Australians (205,800 males and 170,000 females) had had a stroke at some time in their lives. Most (70%) were aged 65 or over.
  • The rate of stroke events has fallen by 25% over the last decade (from an age-standardised rate of 186 to 140 per 100,000 population between 1997 and 2009). But the total number of Australians experiencing a stroke rose by 6% over the same period, reflecting the ageing of the population.
  • In 2009, over one-third (35%) of Australians who experienced a stroke had a resulting disability; this was an improvement from 1998 when the rate was 45%.

Deaths

  • In 2011, there were 8,800 deaths with stroke recorded as the underlying cause of death, accounting for 6% of all deaths in Australia (1 in 5 cardiovascular disease deaths; see Glossary and Chapter 3 'Multiple causes of death in Australia' for 'cause of death' definitions).
  • Over the last 3 decades, stroke death rates have fallen by almost 70% (from an age-standardised rate of 103 to 33 deaths per 100,000 population between 1979 and 2011) (Figure 4.10).
  • Death rates were similar for males and females (age-standardised rate of 33 compared with 32 deaths per 100,000 population respectively); but more females than males die from stroke (5,400 stroke deaths for females in 2011 compared with 3,500 deaths for males). This largely reflects that there are more older women than men.

Figure 4.10: Trends in stroke death rates, 1979 to 2011

Line chart showing the trending decline in stroke death rates (per 100,000 population) between 1979 and 2011 for both men and women. Rates fell from between 100-110 in 1979 to below 40 in 2011.

Notes

  1. Rates have been age standardised to the 2001 Australian population.
  2. The rates included in this report may differ from previous AIHW reports due to revised ABS Estimated Resident Populations (1991 to 2011).
  3. Deaths registered in 2009 and earlier are based on the final version of cause of death data; deaths registered in 2010 and 2011 are based on revised and preliminary versions, respectively, and are subject to further revision by the ABS. Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of deaths in Queensland in 2010.

Source: AIHW National Mortality Database.

Health care

  • In 2011–12, there were 36,800 hospitalisations for acute care of stroke and 27,400 hospitalisations for rehabilitation care for stroke. The average length of stay in acute hospital care for stroke was 9 days, and in rehabilitation care 14 days.
  • Over the last decade, hospitalisation rates for stroke fell by 17% (from an age-standardised rate of 174 to 145 per 100,000 population between 1998–99 and 2011–12).
  • Stroke units significantly improve health outcomes of stroke patients. Between 2007 and 2011, the number of stroke units in public hospitals increased from 54 to 74 and the proportion of patients receiving stroke unit care increased from 50% to 60%.
  • In 2009, informal carers played an important role in care of stroke survivors. Of the estimated 75,000 primary carers who provided assistance to people with stroke and resulting disability, more than half spent 40 hours or more per week in their caring role.

Variations among population groups

  • Aboriginal and Torres Strait Islander people were 1.7 times as likely to have had a stroke as non-Indigenous Australians. Further, hospitalisation rates for stroke among Indigenous Australians were twice as high as for other Australians and stroke death rates 1.5 times as high as for non-Indigenous Australians.
  • People living in remote areas of Australia and in the lowest socioeconomic status (SES) groups also have a higher burden of stroke compared with people living in Major cities and in the highest SES groups.

What is missing from the picture?

Currently, there are no comprehensive national data on the incidence of stroke (new cases) or treatment and care responses such as the time elapsed between the onset of stroke symptoms and emergency response, and the presentation to hospital. Nor are there national data on the uptake of best practice clinical guidelines or on medications given in acute care or at discharge.

Where do I go for more information

The following reports are available for free download: Cardiovascular disease: Australian facts 2011, Stroke and its management in Australia: an update and Health care expenditure on cardiovascular diseases 2008–09.

More information will also be available in the forthcoming AIHW report, Cardiovascular, diabetes and kidney disease: Australian facts 2014.

Reference

O'Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P et al. 2010. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 376:112–23.


4.8 Mental health in Australia

The term 'mental disorder' describes a spectrum of conditions that can vary in both severity and duration. The most common mental disorders are depression, anxiety and substance use disorders. Less common, and often more severe disorders include schizophrenia, schizoaffective disorder and bipolar disorder.

Mental illness can vary in severity. The National Mental Health Report 2013 reviewed the evidence on the epidemiology of mental illness and estimated that 2–3% of Australians—around 600,000 people—have severe disorders, as judged by diagnosis, intensity and duration of symptoms, and degree of disability. This group is not confined to those with psychotic disorders who represent only about one-third of those with severe mental illness; it also includes people with severe and disabling forms of depression and anxiety. Another 4–6% of the population (about 1 million people) have moderate disorders, and a further 9–12% (about 2 million people) have mild disorders (DoHA 2013).

Mental disorders may have a damaging effect on both individuals and families, and far-reaching effects on society as a whole. For those with severe conditions, it can interfere significantly with a person's cognitive, emotional and/or social abilities and is commonly associated with economic disadvantage, unemployment or under-employment, homelessness and reduced productivity. (McLachlan et al. 2013; Slade et al. 2009). People with a severe mental disorder are often isolated by the symptoms of their illness and may experience stigma or discrimination because of their disorder (Morgan et al. 2011).

The importance of good mental health has been recognised by the Australian Government and all state and territory governments. Over the last 3 decades they have worked together, via the National Mental Health Strategy, to develop mental health programs and services to better meet the mental health needs of Australians. Through these arrangements, state and territory governments have tended to fund and provide specialist care for Australians affected by severe disorders. The Australian Government funds a range of services for Australians with mental disorder (through the Medicare and Pharmaceutical Benefits Schedules) and also provides social support and income support programs, the latter group most notably through the Australian Government disability and carer support income payment programs.

More recently a number of governments have established Mental Health Commissions to help them monitor and guide their mental health reform activities. The Australian Government established the National Mental Health Commission in 2012 and the Western Australian, New South Wales and Queensland governments have also established state-based commissions. The commissions have emphasised a collaborative approach across all sectors of Australian society, rather than specialist mental health services alone, to help Australians living with a mental health difficulty or problem to live successfully in the community. The National Mental Health Commission uses the term 'a contributing life'.

In early 2014, the Australian Government requested the National Mental Health Commission to undertake a wide-ranging review of existing mental health programs and services across the government, not-for-profit and private sectors to find ways to deliver services more efficiently and effectively.

Box 4.2: Mental Disorders

'Mental disorders' is a general term that refers to a group of specific disorders that includes:

'Clinical depression'—a group of illnesses characterised by excessive depressed mood which affects the person's life. Clinical depression is more intense than the unhappiness experienced in daily life.

'Anxiety disorders'—a group of illnesses characterised by feelings of high anxiety. People are likely to be diagnosed with an anxiety disorder when their level of anxiety is so extreme that it significantly interferes with their daily life. Anxiety disorders include panic disorder, post-traumatic stress disorder, obsessive compulsive disorder, agoraphobia and other phobias, social anxiety, generalised anxiety disorder and other conditions.

'Substance use disorders'—characterised by dependence on, or harmful use of alcohol or other substances.

'Schizophrenia'—a psychotic disorder typically characterised by hallucinations, disorganised thinking and impairment in functioning.

'Schizoaffective disorder'—a mental illness where the person has symptoms of a mood disorder (either mood swings, or depression) along with other symptoms similar to those found in schizophrenia.

'Bipolar disorder'—a psychotic disorder that involves extreme mood swings, from depression and sadness to elation and excitement.

What do we know?

How many Australians have a mental disorder?

In recognition of the importance of mental health, the Australian Government conducted a program of population-based surveys (referred to collectively as the National Survey of Mental Health and Wellbeing) to determine the extent and impact of mental disorders. The survey program consisted of 3 components: a 1997 and 2007 survey of the adult population (ABS 1998, 2008), a 2010 survey of people living with psychotic illnesses (Morgan et al. 2011) and a 1998 survey of children and adolescents (Sawyer et al. 2000).

A new child and adolescent survey is currently being conducted by the University of Western Australia, with results expected in mid-2015.

From these surveys we know that there is a high prevalence of mental disorders in the Australian population. Data from the 2007 survey of the Australian adult population estimated that 45% of Australians aged 16–85 had experienced a mental disorder sometime in their lifetime (equating to 7.3 million people), and that an estimated 1 in 5 (20%) of the population aged 16–85 (equating to 3.2 million people) had experienced a common mental disorder in the previous 12 months. Of these, anxiety disorders (such as social phobia) were the most common, afflicting 14.4% of the population, followed by affective disorders (such as depression, 6.2%) and substance-use disorders (such as alcohol dependence, 5.1%). These 3 groups of common mental disorders were most prevalent in people aged 16–24 and decreased as age increased (Figure 4.11). Prevalence was higher for females than males in all age groups.

From the child and adolescent survey conducted in 1998, 14% of children and adolescents aged 4–17 (an estimated 321,181 people in 2013) had a clinically significant mental health problem.

In terms of less common but more severe mental disorders, estimates from the 2010 National Survey of People Living with Psychotic Illness indicated that 0.45% of the population aged 18–64 (almost 64,000 people) were treated annually by public sector mental health services for a psychotic disorder, with schizophrenia being the most common disorder.

Figure 4.11: Prevalence of common mental disorders in the Australian population, 1997/1998 and 2007

Column chart comparing the prevalence of common mental disorders in the Australian population in 1997/1998 compared with 2007. Data are shown by age group. There was an overall increase in prevalence over this period. The only decline was seen in the 16/18-24 age group. No 2007 data are shown for the 4-17 age group.

Note: Data for the 4–17 age group pertain to 1998 (rather than 1997). For the 16/18–24 age group, the 1997 data relate to those aged 18–24 and the 2007 data to those aged 16–24.

Source: DoHA 2013.

What is the impact?

Mental disorders were estimated to be responsible for 13% of the total burden of disease in Australia in 2003, placing it third as a broad disease group after cancers and cardiovascular disease (Begg et al. 2007). More recently, the 2010 Global Burden of Disease Study has reaffirmed the contribution made by mental and substance use disorders to the burden of disease (see Chapter 4 'Burden of disease') and estimates that these disorders account for 7% of disability-adjusted life years lost worldwide (Whiteford et al. 2013). Some key findings from national surveys regarding the impact of mental health problems on people's lives are as follows:

  • Australians with affective (mood) disorders can experience severe levels of interference with life, including home responsibilities, work or study, close relationships and social life (up to 72%) (Slade et al. 2009).
  • Australians living with anxiety disorders can report high levels of psychological distress. For example, high or very high psychological distress was reported by 53% of people with generalised anxiety disorder in the 2007 survey of the Australian adult population (Slade et al. 2009).
  • One-third (32%) of Australians living with a psychotic disorder were assessed as having a significant level of impairment in their ability to care for themselves (Morgan et al. 2011).
  • Nearly one-quarter (22%) of Australians with a psychotic disorder participating in the psychosis study reported feeling socially isolated and lonely (Morgan et al. 2011).
  • The 2007 survey of the Australian adult population shows that suicidality (9%) (suicidal ideation, suicide plans and suicide attempts) in the previous 12 months was three and a half times as high for Australians with a mental disorder as for the general population (Slade et al. 2009).
  • Almost half (49%) of participants in the 2010 National Survey of People Living with Psychotic Illness reported that they had attempted suicide at some time over their lifetime.
Psychiatric disability

In 2012, about 4.2 million people in Australia reported living with disability. Of these, mental and behavioural disorders were 1 of the main disabling conditions, affecting 11.5% of those with a disability, or almost 486,933 people (ABS 2013). Of the 317,616 people who accessed a disability support service funded under the National Disability Agreement in 2011–12, 17.9% (56,733 people) reported psychiatric disability as their primary disability, and 27.6% (87,649) reported psychiatric disability as either their primary or additional disability.

Recent data from the Department of Social Services indicate that 31% of people receiving a Disability Support Pension (DSP) (256,380) have a psychological or psychiatric condition. These conditions have recently overtaken musculoskeletal conditions as the largest group of qualifying conditions for DSP (DSS 2013).

Comorbidity

Comorbidity is common among people with a mental disorder, and people with multiple disorders are more disabled and consume more health resources than those with only 1 disorder (ABS 2008). Data from the 2007 survey of the Australian adult population indicate that 12% of Australians aged 16–85 had a mental disorder and a physical condition concurrently, and that these people were more likely to be female, and aged in their early forties (ABS 2008). The most common comorbidity (9%) was an anxiety disorder combined with a physical condition, affecting about 1.4 million Australian adults (ABS 2008).

In general, comorbidity increased with increasing disadvantage. For example, people living in the most disadvantaged areas of Australia were 65% more likely to have comorbidity than those living in the least disadvantaged areas (AIHW 2012).

Prevention and early intervention

In recognition of the importance of prevention and early intervention in assisting children and adolescents with mental health difficulties, a number of initiatives have been taken recently by governments to support them in their important developmental years. For example, the Australian Government has funded 60 'headspace' youth mental health services for people aged between 12 and 25. Between 1 January and 30 June 2013, 21,274 clients received centre-based services from 55 headspace centres. Of these clients, 64% were female, 36% male and 0.7% transgender, intersex or transsexual; 7.7% identified as Indigenous and 7.0% were born overseas. The most frequently reported reason for presenting to a headspace centre was emotional problems, including feeling sad, depressed or anxious (72%), followed by relationship problems (11%) (Rickwood et al. 2014).

State and territory governments have also been developing and augmenting existing youth services; for example, Western Australia recently established Statewide Specialist Aboriginal Mental Health Services to provide specialist interventions to help in the transition from adolescence to adulthood.

Use of mental health services

The considerable variation in severity of mental health disorders and the uniqueness of each individual's experience of mental illness means that support needs and use of services are also diverse.

The estimated population treatment rate for people with mental disorders from the 2007 National Survey of Mental Health and Wellbeing was 35% (1.1 million people) (Slade et al. 2009). More than two-thirds (71%) consulted general practitioners (GPs), 38% consulted psychologists and 23% consulted psychiatrists. Eighty-six per cent of those with a mental disorder who did not receive mental health care reported that they perceived having no need for any of a range of services, including counselling, medication and information (Slade et al. 2009).

More recent analysis of administrative data (DoHA 2013; Whiteford et al. 2014) suggests that there has been significant improvement on the relatively low treatment rates observed in the 2007 National Survey of Mental Health and Wellbeing. The analysis suggests that the percentage of the population with a current mental illness who received care in 2009–10 was 46%, substantially higher than the 35% estimate found by the ABS in 2007. Growth in the proportion of the population seen by Medicare-funded mental health services is the sole driver of the change over the 3 years, primarily arising from initiatives introduced in 2006 to provide Medicare-funded access to mental health care by allied health professionals (see also Chapter 8 'Mental health services in Australia' for more detail on service usage).

In more recent times, the Australian and state and territory governments have concentrated on providing a wider range of support services for those experiencing mental health difficulties, with an emphasis on helping people to stay well rather than providing support only when they are in crisis. Initiatives have been community-based rather than institutional, and there has been a growing involvement of the non-government, not-for-profit sector in service delivery. New programs include: online therapy services for the treatment of mild to moderately severe depression and anxiety disorders; youth mental health services for people aged between 12 and 25; and state-based step-up and step-down services aimed at preventing admission to hospital and preparing participants for a return to the community.

What is missing from the picture?

The increasing use of more integrated and coordinated models of care to cater for the individual needs of Australians living with a mental disorder reinforces the need for the collection of pertinent data to determine whether these measures are making a difference. The AIHW is currently working with stakeholders to better meet the data and information collection challenges implicit in these changing models of care. In particular, national initiatives are currently being progressed to collect and report more detailed information about consumer and carer perceptions of mental health care.

An expert reference group chaired by the National Mental Health Commission also recently reviewed Australia's current range of mental health indicators. The group emphasised the importance of a 'whole-of-life approach' in refining the current indicators. In particular, consideration of social determinants and factors outside the health domain were recommended for attention. Areas for further consideration included life expectancy, recovery, housing, employment, suicide attempts, stigma and discrimination and mental health wellbeing.

The publication of the 2013 child and adolescent survey by the University of Western Australia in mid-2015 will fill the current gap in contemporary information about the extent and impact of mental illness on children and adolescents; the last survey was undertaken in 1998. With other major national surveys also now becoming dated, consideration of cost-effective methods of ensuring regular and up-to-date information about prevalence and trends is warranted.

Where do I go for more information?

More information on mental health in Australia is available.

References

ABS (Australian Bureau of Statistics) 1998. Mental Health and Wellbeing: profile of adults, Australia, 1997. ABS cat. no. 4326.0. Canberra: ABS.

ABS 2008. National Survey of Mental Health and Wellbeing: summary of results, 2007. ABS cat. no. 4326.0. Canberra: ABS.

ABS 2013. Disability, ageing and carers, Australia: summary of findings, 2009. ABS cat. no. 4430.0. Canberra: ABS.

AIHW (Australian Institute of Health and Welfare) 2012. Comorbidity of mental disorders and physical conditions 2007. Cat. no. PHW 155. Canberra: AIHW.

Begg S, Vos T, Barker B, Stevenson C, Stanley L & Lopez AD 2007. The burden of disease and injury in Australia 2003. Cat. no. PHE 82. Canberra: AIHW.

DoHA (Department of Health and Ageing) 2013. National Mental Health Report 2013: tracking progress of mental health reform in Australia 1993–2011. Canberra: Commonwealth of Australia.

DSS (Department of Social Services) 2013. Characteristics of Disability Support Pension customers, June 2013. Canberra: DSS.

McLachlan R, Gilfillan G & Gordon J 2013. Deep and persistent disadvantage in Australia. Canberra: Productivity Commission.

Sawyer MG, Arney FM, Baghurst PA, Graetz BW, Kosky RJ, Nurcombe B et al. 2000. The mental health of young people in Australia. Canberra: Department of Health and Aged Care.

Morgan VA, Waterreus A, Jablensky A, Mackinnon A, McGrath JJ, Carr V, et al. 2011. People living with psychotic illness: report on the second Australian national survey. Canberra: Commonwealth of Australia.

Rickwood DJ, Telford NR, Parker AG, Tanti CJ, McGorry PD. 2014. headspace—Australia's innovation in youth mental health: who are the clients and why are they presenting? Medical Journal of Australia 200:108–111.

Slade T, Johnston A, Teesson M, Whiteford H, Burgess P, Pirkis J et al. 2009. The mental health of Australians 2. Report on the 2007 National Survey of Mental Health and Wellbeing. Canberra: DoHA.

Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE et al. 2013. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet 382:1575–86.

Whiteford HA, Buckingham WJ, Harris MG, Burgess PM, Pirkis JE, Barendregt JJ et al. 2014. Estimating treatment rates for mental disorders in Australia. Australian Health Review 38:80–5.


4.9 Chronic respiratory conditions

Chronic respiratory conditions affect the airways and are characterised by symptoms such as wheezing, shortness of breath, chest tightness and cough. Conditions include: asthma, a chronic inflammatory condition of the airways associated with episodes of wheezing, breathlessness and chest tightness; chronic obstructive pulmonary disease (COPD), which includes both emphysema and chronic bronchitis; and a range of other conditions, such as allergic rhinitis ('hay fever'), chronic sinusitis, cystic fibrosis, bronchiectasis, occupational lung diseases and sleep apnoea (see Glossary).

Smoking is a major risk factor for chronic respiratory conditions. A range of environmental factors (such as exposure to viral infections and air pollutants) and genetic factors (such as for cystic fibrosis) also play a role.

This snapshot does not examine acute respiratory conditions such as the common cold and influenza.

How common are these conditions?

  • In 2011–12, about 3 in 10 Australians (29%) suffered from 1 or more chronic respiratory conditions (6.3 million people).
  • Hay fever and asthma were the 2 most common conditions, affecting an estimated 3.7 million (17%) and 2.3 million Australians (10%) respectively.
  • Asthma was one of the most common chronic health conditions among children, affecting an estimated 393,000 children aged 0–14 (9%) in 2011–12.
  • COPD was comparatively rarer, affecting an estimated 529,000 Australians (2%).
  • Both COPD and asthma were more common in areas of lowest socioeconomic status than in areas with the highest status (4% compared with 2% for COPD, and 12% compared with 9% for asthma).
  • There was a small fall in the age-standardised prevalence of asthma and COPD between 2001 and 2011–12, from 12% to 10% for asthma and from 4% to 2% for COPD (ABS 2012).

Deaths

  • In 2011, COPD caused 5,900 deaths, asthma 378 deaths and bronchiectasis 314 deaths.
  • The age-standardised death rate from asthma fell from a peak of 6.6 per 100,000 population in 1989 to 1.5 per 100,000 in 2011.
  • The death rate from COPD for males has decreased markedly over the past 40 years, with the age-standardised rate in 2011 less than one-third of that in 1970 (falling from 95 to 30 per 100,000 population). In contrast, there was a small rise in the death rate for females over this period (from 13 to 18 per 100,000 population) (Figure 4.12). This may reflect differences in smoking prevalence and history among males and females.

Figure 4.12: Death rates for COPD, 1964–2011

Line chart showing the trending decline in male death rates for COPD between 1964 and 2011, and the trending increase in the rates for females.

Notes

  1. Rates have been age-standardised to the 2001 Australian population.
  2. Deaths registered in 2009 and earlier are based on the final version of cause of death data; deaths registered in 2010 and 2011 are based on revised and preliminary versions, respectively, and are subject to further revision by the ABS. Data for 2010 have not been adjusted for the additional deaths arising from outstanding registrations of deaths in Queensland in 2010.

Source: AIHW National Mortality Database.

Health care

  • Chronic respiratory conditions are predominantly managed in primary health care. Survey data suggest that asthma was the most common chronic respiratory condition managed by general practitioners, accounting for about 2 per 100 GP–patient encounters in 2012–13 (Britt et al. 2013).
  • In 2011–12, only 24% of people who reported asthma as a long-term condition had a written asthma action plan (ABS 2013).
  • The hospitalisation rate for asthma was 173 per 100,000 population in 2011–12. The age-standardised hospitalisation rate fell by 38% between 1998–99 and 2011–12 (37% for males and 39% for females).
  • The hospitalisation rate for COPD (among those aged 55 and over) was 1,200 per 100,000 population. The age-standardised hospitalisation rate for males aged 55 and over fell by 18% between 1998–99 and 2011–12. The rate for females aged 55 and over varied little over the same period.

What is missing from the picture?

The prevention, management and treatment of chronic respiratory conditions beyond hospital settings, including the appropriateness of care with respect to clinical guidelines, cannot be examined in detail because of a lack of information about primary health care.

There is also a lack of nationally comparable information in specific areas such as access to, and use of, long-term oxygen therapy and pulmonary rehabilitation for respiratory diseases such as COPD (AIHW et al. 2013a), management of asthma during pregnancy (AIHW et al. 2013b) and uptake of recommended vaccinations among people with chronic respiratory conditions (AIHW 2012).

Where do I go for more information?

More information on chronic respiratory conditions in Australia is available. The report Asthma in Australia 2011 and other recent publications are available for free download.

References

ABS (Australian Bureau of Statistics) 2012. Australian Health Survey: first results, 2011–12. ABS cat. no. 4364.0.55.001. Canberra: ABS.

ABS 2013. Australian Health Survey: health service usage and health related actions, 2011–12. ABS cat. no. 4364.0.55.002. Canberra: ABS.

AIHW (Australian Institute of Health and Welfare) 2012. Vaccination uptake among people with chronic respiratory disease. Cat. no. ACM 25. Canberra: AIHW.

AIHW: Marks G, Reddel H, Guevara-Rattray E, Poulos L & Ampon R 2013a. Monitoring pulmonary rehabilitation and long-term oxygen therapy for people with chronic obstructive pulmonary disease (COPD). Cat. no. ACM 29. Canberra: AIHW.

AIHW: Marks G, Reddel H, Guevara-Rattray E & Ampon R 2013b. Monitoring asthma in pregnancy: a discussion paper. Cat no. ACM 28. Canberra: AIHW.

Britt H, Miller GC, Henderson J, Bayram C, Valenti L, Harrison C et al. 2013. General practice activity in Australia 2012–13. General practice series no. 33. Sydney: Sydney University Press.


4.10 Diabetes

Diabetes is a chronic condition marked by high levels of glucose in the blood. It is caused either by the inability to produce insulin (a hormone produced by the pancreas to control blood glucose levels), or by the body not being able to use insulin effectively, or both.

The main types of diabetes are: type 1 diabetes—a lifelong autoimmune disease that usually has onset in childhood but can be diagnosed at any age; type 2 diabetes—usually associated with lifestyle factors and largely preventable; and gestational diabetes—when higher-than-normal blood glucose is diagnosed in pregnancy (see Glossary).

Diabetes may progress to a range of health complications, including heart disease, kidney disease, blindness and lower limb amputation. For example, diabetes was the leading cause and accounted for 1 in 3 new cases of end-stage kidney disease requiring dialysis or transplantation, in 2011 (see Chapter 4 'Chronic kidney disease').

While type 1 diabetes is believed to be caused by an interaction of genetic predisposition and environmental factors, type 2 diabetes is largely preventable by maintaining a healthy lifestyle. Modifiable risk factors for type 2 diabetes include physical inactivity, unhealthy diet, obesity, tobacco smoking, high blood pressure and high blood lipids (see Chapter 5 'Biomedical risk factors' and 'Behavioural risk factors').

How common is diabetes?

  • There are an estimated 1 million people aged 2 or over with diagnosed diabetes in Australia. However, this is likely to be an underestimate—for every 4 adults with diagnosed diabetes, there is estimated to be 1 with undiagnosed diabetes (ABS 2013a).
  • Of all people with diabetes, around 85% have type 2 diabetes and 12% have type 1 diabetes (ABS 2013a). In addition, gestational diabetes affects about 1 in 20 pregnancies each year.
  • Diabetes is becoming more common—the rate of self-reported diabetes more than doubled, from 1.5% to 4.2% of Australians, between 1989–90 and 2011–12.
  • In 2011–12, diabetes was more common in men (6%) than women (4%) and was more common in older age groups—affecting 15% of those aged 65–74 compared with 5% for those aged 45–54 (ABS 2013a).
  • In 2011, there were around 2,400 new cases of type 1 diabetes, with half of these being among people aged 18 or under. Rates of type 1 diabetes remained stable over 2000–2011, with age-standardised rates of around 10 to 12 new cases per 100,000 population per year.
  • In 2011–12, there were around 49,800 new cases of diagnosed type 2 diabetes among people 10 and over, based on preliminary findings. Despite nearly all cases (92%) occurring in those aged 40 and over, there were around 430 new cases among children and young people aged 10–24—even though type 2 diabetes is generally regarded as a disease of adulthood.

Deaths

  • Diabetes was the sixth leading cause of death in Australia in 2011, contributing to 10% of all deaths. In around 4,200 deaths diabetes was the underlying cause and in a further 10,900 it was an associated cause of death (see Glossary for 'cause of death' definitions and Chapter 3 'Multiple causes of death in Australia').

Health care

  • Diabetes was the principal diagnosis for around 40,000 hospitalisations in 2010–11, and was an additional diagnosis for a further 180,000 hospitalisations. Together, these represented 2.5% of all hospitalisations in 2010–11.
  • In 2012, almost 8.2 million prescriptions were dispensed for diabetes medicines: 11% for insulin and 89% for other blood glucose-lowering medications, with about half of these being for metformin.
  • Between 1992 and 2012, the annual number of prescriptions filled for metformin rose by an average of 8% a year; for other blood glucose-lowering medications the annual rise was 7%, and for insulin it was 5% (Figure 4.13).
  • In 2011, about 53,500 people began using insulin to treat their diabetes.
  • In 2011, there were 10,510 insulin pump users in Australia—representing 10% of people with type 1 diabetes. Almost half of all insulin pump users were aged under 25.

Variations among population groups

  • Aboriginal and Torres Strait Islander people were over three times as likely as non-Indigenous Australians to have diabetes, in particular type 2 diabetes (ABS 2013b).
  • People in the lowest socioeconomic status (SES) groups were more likely to have diabetes compared with people in the highest SES groups.
  • People living outside Major cities were more likely to have diabetes compared with people living in Major cities (ABS 2013c).

What is missing from the picture?

Currently, there is no national data collection on new cases of diagnosed type 2 diabetes each year. Symptoms are often absent in the early stages of diabetes, so people can go undiagnosed for a long time. In addition, there can be problems with misdiagnosis and misreporting of diabetes type.

There is a lack of good information on diabetes in Aboriginal and Torres Strait Islander people and people from different ethnic backgrounds. Further monitoring and surveillance of diabetes is crucial for guiding preventive measures, determining clinical care and informing health policy and service planning.

Figure 4.13: Prescriptions claimed for diabetes medicines, 1992–2012

Line chart showing the trending increase in the prescriptions for metformin, insulin and other blood glucose-lowering medications claimed between 1992 and 2012. Both metformin and other blood glucose-lowering medications increased from below 1 million to over 3 million during this period.

Source: Data extracted by AIHW (January 2013) from the Department of Human Services website.

Where do I go for more information?

The following reports are available for free download: Insulin pump use in Australia and Type 2 diabetes in Australia's children and young people: a working paper.

More information will also be available in 2 forthcoming AIHW reports, Incidence of insulin-treated diabetes in Australia, 2000–2011 and Cardiovascular, diabetes and kidney disease: Australian facts 2014.

References

ABS (Australian Bureau of Statistics) 2013a. Australian Health Survey 2011–12. Canberra: ABS. Viewed 10 December 2013.

ABS 2013b. Australian Aboriginal and Torres Strait Islander Health Survey: first results, 2012–13. ABS cat. no. 4727.0.55.001 Canberra: ABS.

ABS 2013c. Australian Health Survey: updated results, 2011–2012 . ABS cat. no. 4364.0.55.003 Canberra: ABS.


4.11 Chronic kidney disease

Chronic kidney disease (CKD) refers to all kidney conditions where a person has evidence of kidney damage and/or reduced kidney function, lasting at least 3 months. Many people do not know that they have kidney disease as up to 90% of kidney function can be lost before symptoms appear (Kidney Health Australia 2014). Fortunately, simple tests of kidney function and damage can detect the early signs of CKD.

End-stage kidney disease (ESKD), the most severe form of CKD, usually requires kidney replacement therapy (KRT ) to survive. KRT has 2 forms—a kidney transplant or dialysis. Dialysis is an artificial way of removing waste substances from the blood and is mostly provided in hospitals or satellite dialysis units, but can also be provided in a home setting. Not all patients with ESKD receive KRT. Prognosis, anticipated quality of life (with or without KRT ), treatment burden on the patient, and patient preference all play a part in the decision for or against KRT (Murtagh et al. 2007).

CKD is common, and largely preventable as many of its risk factors are modifiable, such as high blood pressure, tobacco smoking and obesity (see Chapter 5 'Biomedical risk factors' and 'Behavioural risk factors'). Many of the risk factors for CKD also apply to other chronic diseases such as cardiovascular disease and diabetes, which in turn, are risk factors for CKD.

How common is chronic kidney disease?

  • According to the 2011–12 Australian Health Survey, 1 in 10 people (or 1.7 million Australians) aged 18 and over have biomedical signs of CKD (ABS 2013).
  • There were about 2,500 new cases of KRT-treated-ESKD in 2011 (equating to an age-standardised rate of 10 people per 100,000 population or 7 new treated-ESKD cases per day).
  • Diabetes was the leading cause of KRT-treated-ESKD in 2011, accounting for 1 in 3 new cases (ANZDATA 2013).

Deaths

  • In 2011, CKD contributed to over 10% of all deaths in Australia (15,000 deaths)—with the vast majority of these deaths recorded as an associated cause of death (11,900 deaths; see Glossary for 'cause of death' definitions and Chapter 3 'Multiple causes of death in Australia').

Health care

  • Of the 1.4 million hospitalisations for CKD in 2011–12, 86% were for regular dialysis treatment. Dialysis treatment is the most common reason for hospitalisation in Australia.
  • Over the last decade, the number of hospitalisations for dialysis has almost doubled. In addition, the hospitalisation rate for CKD (excluding dialysis) has also increased substantially from an age-standardised rate of 125 to 156 per 100,000 people between 2000–01 and 2011–12.
  • The number of people with a functioning kidney transplant or on dialysis for ESKD has been increasing more rapidly for Indigenous Australians than non-Indigenous Australians. Over the period 2001 to 2011, the number of Indigenous Australians with KRT-treated-ESKD almost doubled (from 762 to 1,491); this compares with a 59% increase among non-Indigenous Australians over the same period (from 11,613 to 18,289).
  • In 2011, dialysis was the most common form of KRT for ESKD, with 56% of KRT-treated-ESKD patients receiving dialysis and the remaining 44% treated with a transplant. Indigenous Australians with ESKD were far less likely to be treated with a functioning kidney transplant than their non-Indigenous counterparts in 2011 (13% compared with 47%, respectively).
  • Over the period 2001 to 2011, the proportion of dialysis patients receiving treatment in the home setting decreased from 37% to 27% of dialysis patients.
  • Not all people with ESKD receive dialysis or a transplant. During 2002–2010, for every new case of ESKD that received KRT, there was 1 that did not.
  • There were 825 kidney transplants in 2011, an increase from 470 in 1991 (ANZDATA 2013).
  • Over the last 2 decades, there has been a 45% increase in transplants from deceased donors, increasing from 392 to 570 deceased donor transplants between 1991 and 2011. There has also been a rapid rise in transplants from living donors—a fourfold increase from 78 to 354 living donor transplants between 1991 and 2008. However, in recent years the number of transplants from living donors has fallen (354 to 255 between 2008 and 2011, respectively).

Variations among population groups and impact

  • In 2010–11, almost 11% of people with ESKD who were beginning KRT identified as Indigenous, despite making up only 3% of the total population.
  • CKD hospitalisation rates (excluding dialysis) are also higher among Indigenous Australians, with the difference between Indigenous and other Australians increasing with remoteness—from twice as high in Major cities to 8 times as high in Remote and very remote areas (Figure 4.14).
  • The higher CKD hospitalisation rates among Indigenous Australians are due in part to the considerably higher rates of obesity and diabetes in this population.

For dialysis patients, the need to adhere to strict treatment protocols and the need for frequent treatment—normally 4–5 hour sessions 3 times per week for in-centre dialysis—places a large health, time and cost burden on patients, especially Indigenous Australians living in rural and remote areas who often need to relocate to access KRT (Preston-Thomas et al. 2007). This can result in a loss of social and cultural connectedness, loss of autonomy and control, and loss of status and authority (George Institute for Global Health 2011).

Figure 4.14: Hospitalisations with a principal diagnosis of CKD (excluding regular dialysis) by Indigenous status and region, 2010–11

Column chart showing the number (per 100,000 population) of hospitalisations with a principal diagnosis of CKD (excluding regular dialysis) by Indigenous status and region during 2010-11. Rate of hospitalisations was more than double for Indigenous Australians and increased the more remote the location.

Note: Rates have been directly age-standardised to the 2001 Australian population.

Source: AIHW National Hospital Morbidity Database.

What is missing from the picture?

Nearly all people with ESKD in Australia who receive KRT are recorded in the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry. But information on the number of people with ESKD not receiving KRT is lacking. By using data linkage techniques across the ANZDATA registry, and mortality and hospitals data, it may be possible to estimate the total number of current cases of ESKD in Australia (including cases not receiving KRT ). This work would expand on the AIHW's work on estimating the total number of new cases of non-KRT-treated and KRT-treated-ESKD.

Where do I go for more information?

The following reports are available for free download: Dialysis and kidney transplantation in Australia: 1991–2010, Chronic kidney disease in Aboriginal and Torres Strait Islander people, Chronic kidney disease: regional variation in Australia and Cardiovascular, diabetes and kidney disease: Australian facts 2014 (forthcoming).

References

ABS (Australian Bureau of Statistics) 2013. Australian Health Survey: biomedical results for chronic diseases, 2011–12. ABS cat. no. 4364.0.55.005. Canberra: ABS.

ANZDATA (Australian and New Zealand Dialysis and Transplant) 2013. ANZDATA Registry report 2012. Adelaide: Australia and New Zealand Dialysis and Transplant Registry.

George Institute for Global Health 2011. Central Australia renal study—final report. Canberra: DoHA.

Kidney Health Australia 2014. Fast facts on CKD in Australia. Kidney Health Australia. Viewed 18 February 2014.

Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS & Harris FE 2007. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrology, Dialysis, Transplantation 22:1955–62.

Preston-Thomas A, Cass A & O'Rourke P 2007. Trends in the incidence of treated end-stage kidney disease among Indigenous Australians and access to treatment. Australian and New Zealand Journal of Public Health 31:419–21.


4.12 Injuries

Injury has a major, but often preventable, impact on the health of Australians of all ages. It is the largest cause of death for those aged under 35, and leaves many with serious disability or long-term conditions. While the majority of injuries are relatively minor and require little or no treatment, more serious injuries may require hospital care or result in death.

Deaths due to injury

  • Injury was recorded as a cause of 10,668 deaths in 2009–10 in Australia, or 7.6% of all deaths.
  • One-third of male injury deaths and almost two-thirds of female cases occurred at ages 65 and older. Less than 2% of cases were at ages younger than 15.
  • The most common causes of injury deaths in 2009–10 were falls (32.2%), intentional self-harm (20.8%) and transport accidents (13.9%).
  • From 1999–00 to 2009–10, injury deaths comprised a fairly constant proportion of all deaths in Australia, ranging from 7.4% to 8.1%.
  • Adjusting for age, injury deaths decreased from 55.1 per 100,000 population in 1999–00 to 46.8 in 2004–05, with little change in more recent years. The injury death rate was 45.4 per 100,000 population in 2009–10.
  • For most external causes, rates of injury deaths tended to decline from 1999–00 to 2007–08—by 3.8% per year for transport injury, 3.3% for thermal injury (that is, exposure to smoke, fire, heat and hot substances), 5.5% for drowning, 3.2% for suicide and 5.5% for homicide. Rates of poisoning deaths involving pharmaceuticals fell sharply to 2001–02, then rose by 2.2% per year to 2007–08.
  • Rates of fall injury deaths did not show a marked trend (AIHW, forthcoming).

Hospitalisations due to injury

  • In 2010–11, there were 472,000 hospitalisations due to injury, or 5% of all hospitalisations. Given that some injuries result in more than 1 stay in hospital, it is estimated that these stays involved just over 438,000 people.
  • The age group with the highest number of injury-related hospitalisations was people aged 85 and older, at 10,945 hospitalisations per 100,000 population.
  • Males were more likely than females to be hospitalised for most types of injury.
  • Falls (40%), other unintentional injury (33%) and transport accidents (12%) (mostly motor vehicles) were the 3 main causes of injury. Other unintentional injury covers a broad range of causes, including exposure to electric currents, contact with venomous animals and plants, and being caught or jammed between objects.
  • The age-standardised rates of injury-related hospitalisations rose between 1999–00 and 2010–11 by an average of 1% per year. During this time, there were rises in the rates of injury-related hospitalisations due to falls (2% per year), intentional self-harm (1% per year), and assaults (1% per year). There were falls in the rates of injury-related hospitalisations due to poisoning by pharmaceuticals (5% per year) and by other substances (4% per year), and drowning and near drowning (1% per year, and 3% for children aged under 5) (Figure 4.15).
  • The number of injury-related hospitalisations per 100,000 population continued to be higher for Aboriginal and Torres Strait Islander people (3,838) than other Australians (1,897).

Note that these data exclude complications of medical and surgical care and conditions that are the consequence of previous injury. The 'Hospitalisations for injury and poisoning' indicator in Chapter 9 includes those types of injury.

Figure 4.15: Number of injury-related hospitalisations, by broad type of injury, 1999–00 to 2010–11

Line chart showing the number of injury-related hospitalisations by broad type of injury between 1999-00 and 2010-11. Falls and 'other unintentional' injuries were the most common with over 100,000 hospitalisations each in 1999-00. They both saw a significant increase in frequency over this period, there being approximately 170,000 and 140,000 hospitalisations respectively by 2010-11.  

What is missing from the picture?

Detailed information on injuries that do not require hospitalisation is not routinely available in Australia. People with less serious injuries often do not seek health care, or interact with the health system by visiting a general practitioner or an emergency department.

There is a lack of detailed information on primary health care (including general practitioners) in Australia. And current national emergency department presentation data do not include information on cause or nature of injury. That type of information will be available as part of the Non-admitted Patient Emergency Department Care National Minimum Data Set from late 2014, so work can begin now on how to best use these data for reporting on injury.

Information on injury could be collected in national population health surveys, as occurs for other health conditions. Injury information was not collected in the latest Australian Bureau of Statistics Australian Health Survey (for 2011–12), nor in recent predecessor surveys.

Where do I go for more information?

More information on hospitalisations due to injury in Australia is available. The report Trends in hospitalised injury, Australia: 1999–00 to 2010–11 and other recent publications are available for free download.

Reference

AIHW. Forthcoming report Trends in injury deaths, Australia, 1999–00 to 2009–10. Injury research and statistics series. Canberra: AIHW.


4.13 Oral health

On the whole, oral health has improved in Australia over recent decades, particularly in response to fluoride being added to water supplies from the 1950s. Recent trends, however, suggest that changes in diet and behaviour—such as increased consumption of bottled water, sports drinks and soft drinks—may be having some negative impacts on oral health.

What is the condition of our teeth?

Poor childhood oral health is a strong predictor of poor adult oral health. After falling steadily since the 1970s, rates of tooth decay in children slowly rose from the late 1990s onwards (Figure 4.16).

Figure 4.16: Trends in dental decay in children, 1977–2010

Line chart showing the trending decline in the average number of children's teeth affected by tooth decay between 1977 and 2010. Data are shown for both permanent teeth (at age 12) and baby teeth (at age 6).

Note: Data are combined for 2003 and 2004.

Sources: From 1977 to 1988, data are from the Australian School Dental Scheme evaluation. From 1989, data are from the Child Dental Health Survey.

Data from examination of children's teeth at public dental clinics in 6 Australian states and territories showed that, in 2010:

  • more than half of children aged 6 had experienced decay in their baby teeth
  • almost half of children aged 12 had experienced decay in their permanent teeth
  • on average, every child aged 15 had at least 1 filled permanent tooth, and at least 1 other with untreated decay.

Adult oral health has improved over time, though at a slower rate than in children.

  • From 1994 to 2010, of those adults who visited the dentist, the number who received a filling fell from 5 in 10 to 4 in 10.
  • Between 1994 and 2010, both the proportion of adults who had visited a dentist with a problem in the last year, and those who had visited for a check-up (not a problem), increased, from 56% to 62% and from 48% to 61% respectively. (People who have regular check-ups generally have fewer extractions and fillings.)
  • From 1999 to 2010, adults reporting 'fair' or 'poor' oral health fell from 1 in 4 to less than 1 in 5.
  • Despite these improvements, in 2005 more than 90% of adults had some history of decay in their permanent teeth.
  • In 2010, about 12% of adults had fewer than 21 natural teeth remaining and more than 20% had severe gum disease.
  • In 2010–11, the rate of hospitalisations for dental conditions which could have been avoided if the patient had received timely and adequate non-hospital care was highest for children aged 5–9 and lowest for adults aged 25–34. The highest rates were in Very remote areas and the lowest in Major cities.

Australia's oral health system

  • In 2011–12, spending on dental services ($8.3 billion) was 6.3% of total health spending. This was the lowest share of the total in 10 years.
  • Around half of all people aged 5 and over had some level of private dental cover in 2010. The majority of adults with insurance reported that their insurance paid some (79%) or all (8%) of the dental costs of their last visit. Only 9% of insured adults paid all their own dental expenses.
  • In 2012, for every 100,000 people there were about 57 dentists, 4 dental therapists, 5 dental hygienists, 3 oral health therapists and 5 dental prosthetists (full-time equivalent rates).
  • The highest number of employed dentists was in Major cities and the lowest in Remote and Very remote areas.

What is missing from the picture?

There is a lack of routinely collected dental service use data in Australia. Some data are collected from public dental services; however, governments fund less than 30% of total dental services expenditure. Public dental service data are also not necessarily representative, due to variation between jurisdictions in the scope and coverage of public dental programs.

Where do I go for more information?

More information on oral health in Australia is available at Dental and oral health. The reports Adult oral health and dental visiting in Australia: results from the National Dental Telephone Interview Survey 2010, Health expenditure Australia 2011–12, and Dental workforce 2012 are available for free download.

More information is also available at the Australian Research Centre for Population Oral Health , the Australian Government Department of Health and at National Oral Health Plan.

4.14 Immunisation and vaccine preventable disease

Vaccination is one of the most successful and cost-effective health interventions. There are 16 diseases for which vaccines are provided free in Australia to people of particular age or risk groups. The characteristics of diseases and vaccines differ. Sometimes it is possible to achieve disease eradication, while for other vaccines the aim is to limit severe disease in the most vulnerable. This looks at vaccination coverage and then considers the impact of vaccination on disease notifications, hospitalisations and deaths.

Vaccination coverage

  • At December 2012, 92% of children were assessed as fully vaccinated at each of the 3 childhood milestones (12, 24 and 60 months). Coverage at 12 and 24 months has been steady at around 90% since 2003, while at 60 months it rose substantially from around 80% in 2008 after a change in eligibility rules for incentive payments.
  • The proportion of Australian children vaccinated late varies by vaccine type and dose. The greatest delay was with the second dose of measles, mumps and rubella (MMR) vaccine, with 57% of doses given late and 9% given more than 6 months late (Figure 4.17).
  • 20% of infants received their vaccination due at 6 months of age at least 1 month after the due date in 2012, putting them at risk of severe diseases such as whooping cough.
  • Indigenous children at 12 months of age have coverage 6 percentage points lower than non- Indigenous children. Coverage for both groups is comparable at 24 and 60 months.
  • In 2012, 82% of females aged 14–15 had received at least 1 dose of human papillomavirus (HPV ) vaccination, and 71% had received all 3 doses. HPV vaccination coverage in all age groups was higher for earlier doses—as high as 82% for the first dose in females aged 14–15. Coverage was higher for younger females who were vaccinated at school—just under half (44%) of females aged 20–26 were fully vaccinated.
  • Influenza (in previous 12 months) and pneumococcal polysaccharide (in previous 5 years) vaccine coverage for older Australians (65 and over) was 75% and 54% respectively in 2009.

Impact of vaccine preventable diseases

  • Several previously common vaccine preventable diseases (VPDs) have been eliminated or are now rare, including diphtheria and poliomyelitis (0 cases in 2012).
  • In 2012, there were 7 deaths reported in young children due to VPDs. All children were either too young to be vaccinated, or incompletely vaccinated.
  • Each year, influenza infects an estimated 5–10% of the population, causes 13,000 hospitalisations (mainly in young children and the elderly) and 3,000 deaths (nearly all in the elderly) (Neuzil et al. 2002; Newall et al. 2008).

Figure 4.17: Vaccination delay for Australian children, 2012

Column chart showing the vaccination delay for Australian children in 2012 1-6 months after a schedule point and greater than 6 months after a schedule point. When there is a delay the delay for the majority of children is 1-6 months after the schedule point. Data are shown for the DTP3, MMR1, MENC1 and MMR2 vaccines. The MMR2 vaccine experiences the most delay with over 50%.

DTP3 = 3rd dose of a diphtheria (D), tetanus (T) and pertussis-containing (P) vaccine, schedule point at 6 months of age.

MMR1 = 1st dose of a measles, mumps and rubella vaccine, schedule point at 12 months of age.

MENC1 = 1st dose of a meningococcal C vaccine, schedule point at 12 months of age.

MMR2 = 2nd dose of a measles, mumps and rubella vaccine, schedule point at 48 months of age.

Note: This analysis is for doses assessed in 2012, allowing sufficient time to capture delayed doses.

Source: Australian Childhood Immunisation Register.

  • Pertussis (whooping cough) is the second most commonly notified VPD after influenza (see Figure 4.18). The highest incidence of whooping cough by age group was in infants aged under 6 months (1 in 300) but 50% of all cases were in adults aged 20 and over (Pillsbury et al. forthcoming). The most recent whooping cough epidemic was in 2009–2010. Between 2000 and 2010, multiple epidemics of pertussis occurred in Australia, with the highest rate of notifications reported in 2010 (156 cases per 100,000 population) (Department of Health 2013).
  • There were 888 hospitalisations recorded due to invasive pneumococcal disease in 2011–12, with the highest rates in people aged under 1 and over 80. Infant vaccination for pneumococcal disease also prevents an estimated 1,500 pneumonia hospitalisations in children each year (Jardine et al. 2010). In 2012, there were 123 deaths due to invasive pneumococcal disease, of which 86 were people aged over 65.
  • There were 1,280 hospitalisations recorded due to rotavirus in 2011–12. Hospitalisations for all cases of acute gastroenteritis are an estimated 7,000 a year fewer than in pre-vaccine years (Dey et al. 2012).
  • An average of 3,794 women a year aged under 25 had high-grade cervical abnormalities detected in 2010–2011, about 700 a year fewer than in 2004–2006—the period immediately before the human papillomavirus vaccine was introduced.
  • There were 805 hospitalisations for chickenpox in 2011–12, an estimated 600 fewer per year than in pre-vaccine years (1998–1999).

Figure 4.18: Most commonly notified vaccine preventable diseases in Australia, 2012

Bar chart showing the most commonly notified vaccine preventable diseases in Australia in 2012. By far the most numerous are Influenza (44,567 notified cases) and Pertussis (24,070).

Source: National Notifiable Diseases Surveillance System.

What is missing from the picture?

VPDs are most commonly monitored using reports of disease notifications (predominantly laboratory diagnoses), hospitalisations and deaths. Any diseases or manifestations not easily captured by these sources are more difficult to monitor.

There are no national data on vaccination coverage for adolescents for vaccines other than HPV. HPV coverage by Indigenous status is not available due to limitations in Indigenous status reporting. Vaccination coverage for the elderly is only obtainable when periodical Adult Vaccination Surveys are undertaken.

Where do I go for more information?

Communicable disease information including publications related to VPDs can be found at the National Notifiable Diseases Surveillance System. Information on the National Immunisation Program is at the Immunise Australia. See also www.ncirs.edu.au.

References

Department of Health 2013. The Australian Immunisation Handbook 2013. 10th edn. Canberra: Department of Health.

Dey A, Wang H, Menzies R & Macartney K 2012. Changes in hospitalisations for acute gastroenteritis in Australia after the national rotavirus vaccination program. Medical Journal of Australia 197:453–57.

Jardine A, Menzies R & McIntyre P 2010. Reduction in hospitalizations for pneumonia associated with the introduction of a pneumococcal conjugate vaccination schedule without a booster dose in Australia. Pediatric Infectious Disease Journal 29:607–12.

Neuzil KM, Zhu Y, Griffin MR, Edwards KM, Thompson JM, Tollefson SJ et al. 2002. Burden of interpandemic influenza in children younger than 5 years: a 25-year prospective study. Journal of Infectious Diseases 185:147–52.

Newall AT, Wood JG & MacIntyre CR 2008. Influenza-related hospitalisation and death in Australians aged 50 years and older. Vaccine 26:2135–41.

Pillsbury A, Quinn H & McIntyre P, forthcoming. Australian Vaccine Preventable Disease Epidemiological Review Series: Pertussis 2006–2012. Communicable Diseases Intelligence.