Practice Incentives Program Quality Improvement Measures: annual data update 2024–25

The PIP Eligible Data Set is based upon the RACGP definition of a regular/active client who has visited a practice 3 or more times in the 2 years prior to the date of data extraction.

A regular client does not necessarily mean that the client’s attendance at a practice has been recent. There may be a clustering of client visits to practices based around health service events. As some clients actively attend more than one practice, or the same practice more than once, including across more than one PHN region, these aggregated health service events may represent clients more than once.

Each QIM is only indicative of a cross section of regular clients that meet the inclusion criteria for each measure. It does not represent the total resident population, the total number of individuals who actively attended practices, the prevalence of cohorts or conditions, or the percentage of total population that attend practices.

As outlined in the Practice Incentives Program Quality Improvement Incentive Quality Improvement Measures User Guide for General Practices (Department of Health 2020c), visits are only considered if they are eligible for an MBS rebate including clients visiting one or more providers in that practice. If more than one visit occurs on the same day, these are counted towards the 3 visits.

Non-clinical events, such as administration and client notification activities are not counted as visits in this report. Clients who are deceased are excluded from the report.

A known limitation of some clinical information systems (CISs) is the inability to distinguish clinical and non-clinical visits (such as notes made in the client record) for the purposes of this report.

The capture of some data may be affected by the manual coding of diagnoses from free text data fields, and the sensitivity and specificity of the capture may vary with the accuracy of the manual input into a CIS.

Temporary telehealth MBS item numbers were made available from 13 March 2020 in response to the COVID-19 pandemic. These temporary MBS items were not included in the scope of MBS items used to calculate the SWPE for the purposes of payment calculations under the Practice Incentives Program (PIP) until January 2022. This includes payments for the PIP Quality Improvement Incentive (Department of Health and Aged Care 2022).

This means that telehealth consultations received during this period were not counted towards the RACGP definition of a regular client (patient) who visited a particular primary health care provider 3 or more times in the last 2 years.

Therefore, the actual aggregate QIM specific regular client cohort and proportions may be under-represented both nationally and in a PHN for that duration.

PHNs that used the POLAR extraction tool resupplied data from January 2022 that included recalibration of telehealth MBS item numbers into the count of RACGP regular clients.

As many GPs and their patients preferred telehealth consults over face-to-face visits during the COVID-19 pandemic, there would have been fewer opportunities to take physical measures such as blood pressure, weight and height thus impacting the overall regular client numbers for the related PIPQI measures.

Readers of this report should take these factors into consideration when interpreting the findings.

• Clients are classified as having diabetes for this measure, if they have Type 1 or Type 2 or undefined diabetes as a diagnosis in their GP record.
• Clinical definitions for diabetes vary across CISs, as different coding schemes are used. This may lead to some variation in the number of clients who will be picked up by different systems (AIHW 2025a).
• Any clients who had gestational diabetes but also have Type 1 or 2 diabetes are included in the measure.
• Multidisciplinary care delivered by multiple providers are often required to safely manage patients with diabetes and its complications. For example, younger patients and patients with Type 1 diabetes are more likely to receive shared care from specialist services. Missing information on HbA1c for these patients could relate to the information not being shared electronically between the specialist services and general practices.
• Results arising from measurements conducted outside of the service that are known and recorded in the GP record are included.
• Clients are excluded from the measure if they:
  • had secondary diabetes, gestational diabetes mellitus (GDM), previous GDM, impaired fasting glucose, impaired glucose tolerance,
  • had results from measurements conducted outside of the service which were not available to the service and had not visited the service in the previous 12 months.
• There are other administrative data collections where the data from these client-provider interactions are captured, for example, Medicare Benefits Schedule (MBS), the National Diabetes Service Scheme (NDSS) register, the Australasian Paediatric Endocrine Groups (APEG) state and territory registers.

• Clients aged between 15 and 29.999 years of age are included if their smoking status has been recorded within the past 12 months. Prior to October 2024, the Primary Sense extraction tool did not apply the 12-month reference period cut-off for recording smoking status in this age group for the numerator in QIM2. Therefore, results should be interpreted with caution when comparing between extraction tools.
• Clients aged 30 years and over are included if their smoking status has been recorded at least once since turning 30. Prior to October 2024, the Primary Sense extraction tool did not apply the criteria of recording smoking status since turning 30 for this age group. Therefore, results should be interpreted with caution when comparing between extraction tools.
• Results arising from measurements conducted outside of the service that are known and recorded in the GP record are included.
• This QIM does not include vaping / e-cigarettes.

• Includes only those clients with a smoking status recorded as defined in the numerator of QIM 02a.
• Results of “daily smoker”, “weekly smoker” and “irregular smoker” are aggregated into “current smoker”.
• The most recently recorded result is included in the measure, which are:
  • Clients aged between 15 and 29.999 years of age are included if their smoking status has been recorded within the past 12 months. Prior to October 2024, the Primary Sense extraction tool did not apply the 12-month reference period cut-off for recording smoking status in this age group for the numerator in QIM2. Therefore, results should be interpreted with caution when comparing between extraction tools.
  • Clients aged 30 years and over are included if their smoking status has been recorded at least once since turning 30. Prior to October 2024, the Primary Sense extraction tool did not apply the criteria of recording smoking status since turning 30 for this age group. Therefore, results should be interpreted with caution when comparing between extraction tools.
• This QIM does not include vaping / e-cigarettes.

• Clients aged between 15 and 24.999 years are included if both the height and weight measurement have been& recorded in the previous 12 months.
• Clients aged 25 years and over are included if height has been recorded since the client turned 25 years of age and a weight has been recorded within the previous 12 months.
• Results arising from measurements conducted outside of the service that are known and recorded by the service are included in the measure.

• Includes only those clients with a record of weight classification derived from a record of height and weight as defined in the numerator of QIM 03a.
• If clients had their BMI recorded more than once within the previous 12 months, only the most recently recorded result is included in this measure.
• Clients are excluded from the measure if they are 18 years or older and either shorter than 0.914 or taller than 2.108 metres; or refused measurement. The Primary Sense extraction tool did not apply this exclusion criterion to this measure. Therefore, results should be interpreted with caution when comparing between extraction tools.
• AIHW has been working with all software providers towards a consistent approach to the data specification interpretation, ensuring all interpretations are consistent. Due to the uneven exclusion criteria across QIM 03a and QIM 03b, not all software providers excluded people under 0.914 or over 2.108 metres in height from QIM 03b in line with the technical specifications.

• Data for clients aged 65 and over re included if the client has been immunised against influenza within the previous 15 months.
• Results arising from clinical intervention conducted outside of the service that are known and recorded by the service are included in the measure. Where immunisation was given elsewhere (for example, workplace or pharmacy) and the information is not recorded in the electronic record of the client’s usual general practice, then this may result in apparent missing information.
• Clients are excluded from the measure if they:
  • did not have the immunisation due to documented medical reasons (e.g. allergy), system reasons (vaccine not available), or client reasons (e.g. refusal); or
  • had results from measurements conducted outside of the service which were not available to the service.
• There are other administrative data collections where the data on influenza immunisation are captured for example, the Australian Immunisation Register (AIR).

• Data for clients with diabetes are included if they have received an influenza vaccine within the previous 15 months.
• Clinical definitions for diabetes vary across CISs, as different coding schemes are used. This may lead to some variation in the number of clients who will be picked up by different systems (AIHW 2025a).
• Results arising from clinical intervention conducted outside of the service that are known and recorded by the service are included in the measure. Where immunisation was given elsewhere (for example, workplace or pharmacy) and the information is not recorded in the electronic record of the& client’s usual general practice, then this may result in apparent missing information.
• Clients are classified as having diabetes, if they have Type 1 or Type 2 diabetes, or a diagnosis which indicates diabetes but does not specify between Type 1 or Type 2, listed as a diagnosis in their GP record. If clients had gestational diabetes but also Type 1 or Type 2 diabetes, they are included in the measure.
• Clients are excluded from the measure if they:
  • did not have the immunisation due to documented medical reasons (e.g. allergy), system reasons (vaccine not available) or client reasons (e.g. refusal),
  • had secondary diabetes, gestational diabetes mellitus (GDM), previous GDM, impaired fasting glucose, impaired glucose tolerance,
  • had results from measurements conducted outside of the service which were not available to the service.
• There are other administrative data collections where the data on influenza immunisation are captured for example, the Australian Immunisation Register (AIR).

• Chronic Obstructive Pulmonary Disease (COPD) includes any diagnosis of COPD.
• Clinical definitions for COPD vary across CISs, as different coding schemes are used. This may lead to some variation in the number of clients who will be picked up by different systems (AIHW 2025a).
• Data for clients are included if they have received an influenza vaccine within the previous 15 months.
• Results arising from clinical intervention conducted outside of the service that are known and recorded by the service are included in the measure. Where immunisation was given elsewhere (for example, workplace or pharmacy) and the information is not recorded in the electronic record of the client’s usual general practice, then this may result in apparent missing information.
• Clients are excluded from the measure if they:
  • did not have the immunisation due to documented medical reasons (e.g. allergy), system reasons (vaccine not available) or client reasons (e.g. refusal),
  • had results from measurements conducted outside of the service which were not available to the service.
• There are other administrative data collections where the data on influenza immunisation are captured for example, the Australian Immunisation Register (AIR).

• Includes in the numerator only those clients aged 15 years and over with an alcohol consumption status ever recorded in their GP record. There is currently no reference period for recording of the client status applied for this QIM within the technical specification documents. In July 2024, the POLAR extraction tool updated the coding of this QIM so that clients aged 15 and over with a known alcohol consumption status were included in the numerator. Previously, it only included regular clients aged 15 and over in the numerator QIM if they had a complete AUDIT-C. For this reason, these results should be interpreted with caution when comparing results over time and between extraction tools. 
• Data on alcohol consumption results (frequency and dose) are not captured in this measure.

• Data for clients are included if they have a record of necessary risk factors (age, sex, tobacco smoking status, diabetes type or HbA1c result or fasting glucose tests, blood pressure, lipid levels) to assess CVD risk assessment.
• Clinical definitions for CVD vary across CISs,& as different coding schemes are used. This may lead to some variation in the number of clients who will be picked up by different systems (AIHW 2025a).
• The reference periods for recording the risk factors of this QIM have been interpreted and coded differently by extraction tool providers. The POLAR extraction tool used by 6 PHNs and PAT tool used by 3 PHNs, applied reference period cut-off dates of 24 months for recording systolic blood pressure and 5 years for recording cholesterol/HDL levels and no reference period for recording smoking status and diabetes screening. In contrast, the PATCAT extraction tool did not apply any reference period cut-off dates for recording diabetes screening, systolic blood pressure, cholesterol/HDL levels. Prior to October 2024 the Primary Sense extraction tool did not apply the reference period cut-offs. For this reason, these results should be interpreted with caution when comparing results between extraction tools (DoH 2020a).
• Eligible clients who do not have a current diagnosis of a cardiovascular condition and have a record of age, sex, tobacco smoking status, systolic blood pressure, diabetes status/diabetes screening test, total cholesterol and HDL cholesterol levels in their GP record are included in the measure.
• Clients are excluded from the measure i they
  • refused measurement,
  • have a recorded diagnosis of CVD,
  • do not have information for ALL risk factors recorded.

• Data are reported quarterly for services delivered to female regular clients in the given period (5 years).
• Results arising from clinical intervention conducted outside of the service that are known and recorded by the service are included in the measure.
• Clients who had a sub-total hysterectomy are included n the measure.
• HPV tests where the sample is either collected by a health practitioner or self-collected are included.
• Clients are excluded from the measure if they:
  • had a complete hysterectomy,
  • did not have the test due to documented medical reasons, system reasons (test not available), or client reasons (e.g. refusal),
  • had results from measurements conducted outside of the service which were not available to the service, or
  • no longer require testing.
• There are other administrative data collections where the data on cervical screening test are captured for eligible persons with a cervix for example, the National Cancer Screening Register (NCSR).

• Clinical definitions for diabetes vary across CISs, as different coding schemes are used. This may lead to some variation in the number of clients who will be picked up by different systems (AIHW 2025a).
• Results arising from measurements conducted outside of the service that are known and recorded by the service are included in the measure.
• Clients are classified as having Type 1 or Type 2 diabetes, or a diagnosis which indicates diabetes but does not specify between Type 1 or Type 2, listed as a diagnosis in their GP record. If clients had gestational diabetes but also Type 1 or Type 2 diabetes, they are included in the measure.
• Clients are excluded from the measure if they had:
  • secondary diabetes, gestational diabetes mellitus (GDM), previous GDM, impaired fasting glucose, impaired glucose tolerance,
  • results from measurements conducted outside of the service that were not available to the service; and had not visited the service in the previous 6 months.
• There are other administrative data collections where the data from these client-provider interactions are captured, for example, Medicare Benefits Schedule (MBS), the National Diabetes Service Scheme (NDSS) register, the Australasian Paediatric Endocrine Groups (APEG) state and territory registers.