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Patterns and trends of potentially inappropriate high-density lipoprotein cholesterol testing in Australian adults at high risk of cardiovascular disease from 2008 to 2014: analysis of linked individual patient data from the Australian Medicare Benefits Schedule and Pharmaceutical Benefits Scheme
  1. Farshid Hajati1,2,
  2. Evan Atlantis2,3,4,
  3. Katy J L Bell5,
  4. Federico Girosi1,2
  1. 1 Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
  2. 2 Capital Markets CRC, Sydney, New South Wales, Australia
  3. 3 School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
  4. 4 School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
  5. 5 School of Public Health, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Professor Federico Girosi; f.girosi{at}


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

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

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

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

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

  • epidemiology
  • cardiac epidemiology
  • chemical pathology
  • primary care

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  • Contributors All the authors conceived and designed the study. FH and FG were responsible for data analysis and interpretation. KJLB was responsible for the interpretation of clinical guidelines. FH, FG and EA were responsible for drafting the manuscript. All the authors contributed to drafting the work for important intellectual content, and approved the final completed article.

  • Funding FH received a PhD scholarship from Capital Markets CRC to complete this research. KJLB is supported by a Center for Research Excellence grant from Australian National Health and Medical Research Council (NHMRC CRE; 1104136).

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The MBS/PBS data used for this study were made publicly available from the Department of Health. Information about the dataset is available at At the time of writing, the website above contains the following statement: ‘This data is temporarily unavailable. The Department of Health is currently working on the dataset and hope to have it restored and available again as soon as possible’. The dataset is not available from the Dryad repository, and researchers interested using the dataset should contact the Department of Health directly.