NZ analysis: hidden chronic health burden is even bigger than thought, with GP records revealing 62,453 people

GP records reveal wider need

Researchers examined health records for 374,071 adults enrolled with general practices in ProCare, a primary health organisation serving greater Auckland. They linked GP information with national hospitalisation data and checked for evidence of 61 long-term conditions, including cardiovascular disease, diabetes, respiratory illnesses and cancer.

Hospital records alone showed that 14% had at least two long-term conditions. Adding GP records raised the figure to 31%, identifying another 62,453 people with multimorbidity. The records covered patients enrolled in January 2014, making the results a historical snapshot rather than an estimate of prevalence today.

Differences across age groups

Hospital records underestimated multimorbidity more among women than men across all age groups. The largest differences generally appeared among people aged 55 to 84. The overall burden rose substantially with age. More than 60% of people aged 65-74 had at least two long-term conditions, increasing to nearly 80% among those aged 75-84.

Much care happens in communities

Many long-term conditions are managed by GPs and other community health professionals, without hospital treatment. Even during a hospital admission, conditions unrelated to its main reason may not make it into the record.

Common conditions identified through GP records included high blood pressure, joint and spinal disorders, diabetes and chronic respiratory diseases such as asthma. Caring for people with several conditions can involve weighing treatments, drug interactions and side effects, and accounts for a sizeable share of GP consultations.

Implications for care and planning

New Zealand does not have a fully integrated national record of long-term conditions across general practice and hospitals. As a result, information held by GPs may not be available to hospital clinicians, complicating care decisions when conditions or medications interact.

Incomplete medical histories might raise the risk of adverse events and could contribute to longer hospital stays or avoidable readmissions. Depending heavily on hospital data may also lead planners to underestimate demand for community care, and the workforce and funding it requires.

General practices are already under pressure, while emergency departments face high demand. As the population ages, the number of people with multiple long-term conditions and the complexity of their care are likely to grow.