Central and Eastern Sydney Primary and Community Health Cohort

Project Number

Project Status

Chief Investigators & Other Investigators
A/Prof Margo Barr (Principal), A/Prof Elizabeth Comino, A/Prof Elizabeth Harris, A/Prof Ben Harris-Roxas, Professor Mark Harris, Mr A.Y.M. Alamgir Kabir, Ms Heidi Welberry (CPHCE), Prof John Hall (SPHCM), , A/Prof Jane Lloyd (HERDU and CPHCE), Ms Lou-Anne Blunden, Dr Ann-Marie Crozier, Ms Deb Donnelly (SLHD), Prof Fiona Blyth (USYD and SLHD), Ms Katherine Clinch, Mr Tony Jackson (SESLHD), Mr Liam Shanahan, Ms Belinda Michie (CESPHN)

Other Team Members
Dr Greg Stewart (SESLHD), Dr Teresa Anderson (SLHD), Dr Michael Moore (CESPHN), Prof Jean-Frederic Levesque (UNSW and ACI)


It is anticipated that by 2030 there will be a significant increase in the ageing of the population and people living with long term conditions (including cancer) in Central and Eastern Sydney (CES) area. At the same time, it is expected that there will be a shift to providing more health care in the community. In response to these challenges the Central and Eastern Sydney Primary and Community Health Research Consortium commenced in 2016 bringing together two LHDS (Sydney and South Eastern Sydney) and the co-terminous local PHN (Central and Eastern Sydney) in one partnership to establish the CES Primary and Community Health Cohort/Resource (CES-P&CH) to inform joined-up primary and community services planning, program development and evaluation.


  1. To establish and maintain a de-identified linked dataset - the CES-P&CH which will support health services research and evaluation allowing decision makers to better understand their community’s health care needs.
  2. To undertake research and evaluation of questions of particular interest to participating organisations in relation to access to primary and community health care and its impact on health service use.
  3. To investigate the relationship between health service use and personal characteristics, health outcomes, and to examine how these relationships vary according to a range of sociodemographic, lifestyle and health related characteristics over time


The CES-P&CH currently includes 10 datasets linked together by the Sax Institute and the Centre for Health Record Linkage (CHeReL) based on the 45 and Up Study cohort, including 30,645 participants resident in CES area (20,337 in SES and 10,308 in Sydney).

The resource also has umbrella ethics approval until 2021 for mutually agreed health-service relevant research from the NSW Population & Health Services Research Ethics Committee (HREC/16/CIPHS/14). All analysis is conducted within the secure environment of the Sax Institute’s SURE workspace.

The project management group oversees the project with representatives from all funding partners. All programs of work are agreed in advance by the management group and dependent on the specific research interests of the partners at a given time.

An analytical framework for analysing health service utilisation within CES-P&CH is shown in below. The risk and outcome variables include:

  • Risk/Protective factors: Smoking, Physical activity, Fruit & Veg, Alcohol, Overweight/Obese, Treated for high BP, Treated for high cholesterol, Cared for/carer, Functional ability, Social capital, High Psychological Distress.
  • Primary care: a. GP attendance, b. Continuity of primary care provider, c. Use of primary care and diagnostic services, and d. Medication use)
  • Secondary care: a. First admission to hospital, b. Number of ED visits and hospital admissions, c. Total days in hospital, d. Cause-specific hospitalisation- including falls, stroke, heart failure, diabetes, e. Hospital readmission
  • Interface/integration of care: a. Access to integrated care, b. Time to follow up by GP following discharge from hospital, c. Continuity and coordination of care.


Progress and capacity

To date two major research projects have been/are being conducted using the CES-P&CH: care-planning and multi-disciplinary care (completed) and GP attendance following hospitalisation (currently underway). Results to date have shown: low use of care plan reviews, allied health use related to reduced hospitalisations, and that fewer than expected patients see a GP within two weeks of discharge from hospital.

The CES-P&CH, is uniquely positioned to make a substantial contribution to improving primary health care in older people in Australia. The resource brings together primary health longitudinal data, service level data, cutting edge researchers, practitioners, service providers and data analysts to answer policy relevant research questions and to facilitate translation of research to policy and practice.