Health complexity, metabolic health and service use in a high need primary care population in Aotearoa New Zealand: a cross-sectional study.

AIM: The aim of this study was to understand the characteristics, health complexity and intensity of service provision for patients aged 16 years or older enrolled in a high-need practice.

METHODS

This cross-sectional study used routinely collected data from an urban Very Low Cost Access practice serving a high-need population in Cannons Creek, Porirua, Aotearoa New Zealand. All patients aged ≥16 years enrolled for a 12-month period were included. Demographic, clinical, biological, medication and service use variables were extracted, and individuals were categorised into normoglycaemia, prediabetes and diabetes groups. Analyses used descriptive statistics, age-standardised rates and comparative assessments of health complexity and service utilisation.

RESULTS

The population (n=4,715) was predominantly Pacific, with most living in areas of high socio-economic deprivation and 25% classified with prediabetes or diabetes. Younger adults with diabetes had disproportionately high HbA1c and elevated albuminuria. Long-term conditions (LTCs), particularly obesity-related conditions, increased progressively across the glycaemic spectrum, with twofold to fourfold higher rates in dysglycaemia. Prediabetes and diabetes groups had similar LTC profiles. Service use increased with worsening dysglycaemia, with individuals with diabetes having nearly double the consultation rates, triple the prescription counts and markedly higher emergency department and ambulatory sensitive hospitalisation rates.

CONCLUSION

Dysglycaemia and multiple LTCs are common and resource-intensive in this population. Together, these data highlight the urgent need for proactive, well-resourced, equity-focussed primary care models to address metabolic risk, LTCs and high service demand.