Identify changes in clinical outcomes and activity related to the management of kidney patients at participating health services between 2004 and 2014. 


Analyse aggregated de-identified longitudinal clinical data from 2004-2014 to determine changes in  
1. screening and early identification of people at risk of developing chronic kidney disease (CKD)
2. management of comorbidities of people with CKD through the attainment of clinical targets
3. utilisation of Medicare Benefit Schedule (MBS) billable items aimed at facilitating best practice.


Aboriginal Australians experience a disproportionate burden of chronic diseases such as diabetes, heart disease and hypertension and are more likely to develop CKD and progress to the requirement for dialysis. 

In the Northern Territory the rates of progression to end stage kidney disease amongst Aboriginals Australians are between four and ten times that of non-Aboriginal Australians and in some regions this is as high as 30 times.

The need for earlier identification and evidence-based CKD management is now increasingly recognised as necessary to address the growing economic and public health burden. 

Implications for policy and practice: 

This analysis was intended as a supplementary tool to assist health services identify and understand potential gaps in screening, identification and monitoring of people at risk of chronic kidney disease.

Our research has found:  

CKD is a progressive loss of kidney function that results in significant morbidity and mortality. Despite growing recognition in some parts of the health community, public awareness of CKD and awareness among primary health services of the risk factors for CKD remains low. Additionally, the growing burden of chronic disease in the community is overwhelming primary health services, which struggle to keep abreast of screening and monitoring activities.  

Analysis of de-identified Communicare Data (2004-2014)

Chief investigator:

Project manager:

Project dates:

September 2015 to March 2017.