more_vertAccording to the Guttmacher-Lancet Commission (May 9, p 2642),1 the sexual and reproductive health and rights of displaced people and refugees are being compromised in humanitarian settings because essential life-saving sexual and reproductive health and rights services are inadequate or not available. After the eruption of violence in the Rakhine state of Myanmar in August, 2017, nearly 1 million Rohingya refugees arrived in neighbouring Bangladesh, resulting in one of the biggest refugee settlements in the world in Cox’s Bazar.
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Latest healthcare variations atlas released
The Third Australian Atlas of Healthcare Variation has been released and identifies high-level variation in health care use by region.
But AMA President Dr Tony Bartone said the Atlas does not satisfactorily explain the causes or offer solutions, so it should only be considered as a statistical guide.
Dr Bartone said the Atlas provides a statistical, wider-population overview of the health system that, when considered along with the many other variables at a local level, has the potential to lead to improvements in clinical decision-making and the allocation of medical services.
“The reasons for any observed variation in health service utilisation reflect regional differences in people’s health care needs, variation in the patient’s treatment preferences, or other factors that require further examination,” he said.
“Some variation in patterns of health care utilisation should be expected. Once any variation is identified, the next step is identifying good variation from bad variation, and investigating the cause.
“It is very important for policymakers to be clear what the Atlas data is and isn’t. It is good at highlighting variation in health utilisation at the regional level, but it is not good at explaining why.
“The Atlas must be considered a statistical guide only, and is definitely no substitute for clinical experience and expertise.
“For example, it is important for health care providers to be aware of the latest evidence guiding the optimal gestation period for newborns. But it is also important to remain measured when interpreting the hospital data.
“In reporting variations in caesarean sections, the Atlas claims that up to 60 per cent are being performed before full term without a medical reason.
“There is an implication that these are ‘sinful’ caesareans done before 37 weeks for no good reason.
“In fact, the most recent available data from the Australian Institute of Health and Welfare (AIHW) estimates that only about 1.6 per cent of births in Australia are truly maternal-request caesareans.
“The same data shows that less than 9 per cent of caesarean sections are performed before 37 weeks, and these are almost always because of problems such as hypertension, breech labour, or bleeding.
“About one third of caesareans performed before 37 weeks are emergency cases.
“The real-life, real-time patient experience is a better clinical indicator than statistics in many areas of medical practice.”
Dr Bartone said the AMA fully supports efforts to continually improve the level of safety and quality, and the delivery of evidence-based, high-value care.
“Clinical stewardship is a core tenet of the AMA Code of Ethics,” Dr Bartone said.
“But clinicians must always retain the autonomy to exercise professional judgement in the care and treatment of their patients.
“The analysis in the Atlas typically analyses the utilisation levels of a single health care service in isolation.
“Patients are more complex than this, and rarely have a single condition or health care need. Patients frequently present with multiple conditions with multiple causes.
“A treatment that is high value for some patients might be low value for others. Clinician-led care takes the whole patient into account before advising treatment options.
“This does not mean there is no room for improvement. Governments must acknowledge, however, that the greatest successes in boosting evidence-based care and reducing low-value care are clinician-led, based on reliable patient data.”
NPS MedicineWise CEO Steve Morris said reinforces the value of the work done by key healthcare bodies across the country to improve healthcare outcomes for Australians.
The Atlas can be viewed at: https://www.safetyandquality.gov.au/Atlas
[Health Policy] Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UK
This report presents further evidence on the escalating alcohol consumption in the UK and the burden of liver disease associated with this major risk factor, as well as the effects on hospital and primary care. We reiterate the need for fiscal regulation by the UK Government if overall alcohol consumption is to be reduced sufficiently to improve health outcomes. We also draw attention to the effects of drastic cuts in public services for alcohol treatment, the repeated failures of voluntary agreements with the drinks industry, and the influence of the industry through its lobbying activities.
Occurrence of and referral to specialists for pain-related diagnoses in First Nations and non-First Nations children and youth [Research]
BACKGROUND:
Indigenous youth have higher rates of chronic health conditions interfering with healthy development, including high rates of ear, dental, chest and musculoskeletal pain, as well as headache, arthritis and mental health issues. This study explores differences in pain-related diagnoses in First Nations and non–First Nations children.
METHODS:
Data from a study population of age- and sex-matched First Nations and non–First Nations children and youth were accessed from a specific region of Atlantic Canada. The primary objective of the study was to compare diagnosis rates of painful conditions and specialist visits between cohorts. The secondary objective was to determine whether there were correlations between early physical pain exposure and pain in adolescence (physical and mental health).
RESULTS:
Although ear- and throat-related diagnoses were more likely in the First Nations group than in the non–First Nations group (ear 67.3% v. 56.8%, p < 0.001; throat 89.3% v. 78.8%, p < 0.001, respectively), children in the First Nations group were less likely to see a relevant specialist (ear 11.8% v. 15.5%, p < 0.001; throat 12.7% v. 16.1%, p < 0.001, respectively). First Nations newborns were more likely to experience an admission to the neonatal intensive care unit (NICU) than non–First Nations newborns (24.4% v. 18.4%, p < 0.001, respectively). Non–First Nations newborns experiencing an NICU admission were more likely to receive a mental health diagnosis in adolescence, but the same was not found with the First Nations group (3.4% v. 5.7%, p < 0.03, respectively). First Nations children with a diagnosis of an ear or urinary tract infection in early childhood were almost twice as likely to have a diagnosis of headache or abdominal pain as adolescents (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1–3.0, and OR 1.7, 95% CI 1.2–2.3, respectively).
INTERPRETATION:
First Nations children were diagnosed with more pain than non–First Nations children, but did not access specific specialists or mental health services, and were not diagnosed with mental health conditions, at the same rate as their non–First Nations counterparts. Discrepancies in pain-related diagnoses and treatment are evident in these specific comparative cohorts. Community-based health care access and treatment inquiries are required to determine ways to improve care delivery for common childhood conditions that affect health and development.
[Correspondence] Artificial intelligence can augment global pathology initiatives
The Lancet Series on pathology and laboratory medicine in low-income and middle-income countries is a promising addition to global health efforts towards building capacity for universal health coverage. Michael Wilson and colleagues (May 12, p 1927)1 reported the magnitude of unmet pathology and laboratory medicine services in low-income and middle-income countries, which function with a debilitatingly low share of resources despite hosting 87% of the global population.
[Correspondence] Artificial intelligence can augment global pathology initiatives – Authors’ reply
We read with interest the correspondence from Junaid Nabi, which suggests that use of artificial intelligence (AI) along with telepathology can provide temporary, scalable solutions to improve access to pathology services, until requisite financing schemes are implemented by developing countries. Although AI will play some role in diagnosis in the future, we believe that solutions of this type could actually detract attention from proven, basic investments that are necessary to provide access to pathology and laboratory medicine services in low-income and middle-income countries (LMICs).
Steadfast support
BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE
As 2018 rushes to a close I want to reflect on some of the AMA’s activities this year in supporting GPs in their role as the primary provider of medical care. The primacy of the role that the usual GP and their general practice plays in a patient’s health care is something that the AMA steadfastly defends. Throughout this year we have strongly advocated for an improvement to GP funding to sustain and nourish general practice in effectively delivering patient-centred quality care and in meeting the health care needs of the community.
GP services are in high demand as the population ages, complex and chronic disease become more prevalent, and poor lifestyle choices add to the risk for and burden of disease. Yet, general practice is the most efficient and cost-effective part of Australia’s health system. Given the increasing cost pressures general practices have experienced over the years, this is a true testament to the general practice profession.
While the Federal Budget this year made some down-payments towards improving GP funding, much more is required to support our vision for general practice into the future. A vision that involves general practice being supported as its patients’ medical home and that strengthens and supports team-based care. A vision that involves GPs being rewarded for the non-face-to-face work involved in caring for patients, that enables better access to quality GP care to patients in aged care facilities and at home, that supports greater use of technology to enhance access to care and its continuity and delivery. A vision that ensures quality improvement is supported and rewarded.
The Government must invest, and invest significantly, to make this vision a reality.
This is a message that AMA leadership and advocacy has continually impressed upon key politicians and around Commonwealth departmental meeting tables throughout the year.
Our proposal and advocacy for the integration of non-dispensing pharmacists into general practice to enhance medication management resulted in incentive reforms that will see practices further supported to build their practice-based health care teams. From July 1 2019, the Workforce Incentive Program will see the provisions of the Practice Nurse Incentive Program expanded to include non-dispensing pharmacists and allied health providers for all eligible general practices regardless of location.
While the MBS Review process has had its issues, when it comes to general practice and primary care the AMA is optimistic that our message around improved rebates, the centrality of the GP to the health system and to patient care has resonated. The AMA is keen to see the recommendations of the MBS Review Taskforce in this space support longitudinal care, patient centred and multi-disciplinary care, and provide for enhanced access via telehealth services.
Finally, the AMA, through a number of submissions, in our discussions and representations, has worked hard to convey the risks to patient care and health system expenditure of moves that would fragment primary care. Proposals for inappropriate expansions of scopes of practice, prescribing rights, and models of care that would see skilled GPs excluded from elements of the cradle to grave care they provide have been and will continue to be stridently argued against.
The coming year, I’m sure, will provide many more opportunities for the AMA to advocate for and support general practice.
In the meantime I wish you all safe and happy holidays.
AMA supports asylum seeker medical treatment bill
The AMA supports the asylum seeker Urgent Medical Treatment Bill being promoted by Independent MP and former AMA President, Professor Kerryn Phelps.
The AMA has gained assurances on key amendments to the legislation in recent days.
The Phelps bill will allow the temporary removal of children from offshore detention, create a workable system providing proper health care for refugees and asylum seekers under the protection of the Australian Government, and keeps in place deterrents that prevent asylum seekers risking their lives at sea and endangering themselves and others.
AMA President Dr Tony Bartone said that it was vital that all asylum seekers and refugees in the care of the Australian Government have access to quality care.
“There is compelling evidence that the asylum seekers on Nauru, especially the children, are suffering from serious physical and mental health conditions, and they should be brought to Australia for appropriate quality care,” Dr Bartone said.
“This week’s alarming Médecins Sans Frontières report on the health of detainees on Nauru was another signal that urgent action is needed.
“This is a health and human rights issue of the highest order. We must do the right thing.
“The amended Phelps bill is an important measure that will allow the temporary transfer to Australia from Nauru and Manus sooner for those in need of urgent care.
“The AMA has been advocating strongly for better health care for asylum seekers for many years.
“Our 2015 Position Statement, Health Care of Asylum Seekers and Refugees, called for the removal of all children from offshore detention, among other measures.
“We want a new national statutory body of clinical experts, independent of government, with the power to investigate and advise on the health and welfare of asylum seekers and refugees.”
The AMA is pushing for further legislation that incorporates the following reforms:
- asylum seekers and refugees should have access to the same level of health care as all Australian citizens;
- asylum seekers and refugees living in the community should have continued access to culturally appropriate health care, including specialist care, to meet their ongoing physical and mental health needs, including rehabilitation;
- all asylum seekers and refugees, independent of their citizenship or visa status, should have universal access to basic health care, counselling, and educational and training opportunities; and
- asylum seekers and refugees living in the community should have access to Medicare and the Pharmaceutical Benefits Scheme (PBS), state welfare and employment support, and appropriate settlement services.
Dr Bartone wrote to Prime Minister Morrison in September calling for the children on Nauru to be brought to Australia for appropriate medical care, with similar letters going to all MPs and Senators.
“We have worked closely with the Chief Medical Officer of the Home Affairs Department, and we acknowledge that the Government has since removed some of the children from Nauru,” Dr Bartone said.
“But we need a compassionate and enduring long-term solution that ensures quality appropriate health care for all asylum seekers and refugees in the care of the Australian Government.”
AMA before Queensland inquiry on mandatory reporting
AMA President Dr Tony Bartone has given evidence to a Queensland Parliamentary Committee over the mandatory reporting laws in that State.
With AMA Queensland President Dr Dilip Dhupelia beside him, Dr Bartone addressed the Health Practitioner Regulation National Law and Other Legislation Amendment Bill 2018 and told the Health, Communities, Disability Services and Domestic and Family Violence Prevention Committee that things had to change.
He said Queensland’s laws should reflect those in Western Australia, where doctors are not automatically reported for seeking health and mental health care.
“I’m here to tell you we are hurting,” Dr Bartone said.
“Outside of Western Australia, doctors do not have the same level of access to health services as the patients they treat. They do not feel they can reach out to talk to their local doctor.
“When they feel stress – and they do, being only human – they have no one to turn to.
“There isn’t a doctor in this country that would tell you the best treatment for a patient who is suffering – mentally or physically – is to ignore it.
“But that is the effect of our national law for doctors. The fear of being reported is just too high.
“Some suffer in silence. Some, I’ve heard, fly to Western Australia, just to see a GP like me.
“The fear treating doctors face is similarly high. The current interpretation of the law means they feel they have to try and ‘guess’ the risk their doctor ‘patient’ may be in the future.
“It’s an unreasonable request. It results in reporting where, in reality, it is not necessary.
“The stigma spreads, and doctors avoid treatment. The problem worsens. The worst happens. It happens to doctors we know.”
Dr Bartone referenced a literature review by mental health organisation Beyondblue, which highlighted that the medical profession is at considerably higher risk of suicide, as well as reporting higher rates of psychological distress and suicidal thinking.
The same Beyondblue report revealed that one of the most common barriers to seeking treatment for a mental health condition was concerns about the impact on their medical registration (34.3 per cent).
Dr Dhupelia said the Queensland model was not working.
“I see doctors who come to see me for their health and I can sense when they are not telling me what they have actually come for,” he said.
“… I want them to come into my room … not feeling like they are coming into a court room.”
Dr Bartone said that in considering a change to a new, nationally consistent model of mandatory reporting, he wanted highlight that the profession has a vastly increased regulatory, compliance and professional conduct apparatus in place, governing the medical sector.
“I know there are concerns about risk being introduced by changing this aspect of the law,” he said.
“All those health practitioners who work with the doctor will not be exempt from reporting any concerns. That will remain, as it does in the current WA model.
“Poor practice is most likely to be witnessed, in the work place – and this proposed change will not impact that being reported. There will still be mandatory reporting occurring. The WA experience shows this.
“Australian Health Practitioner Regulation Agency (AHPRA) annual report figures show that mandatory notifications have risen in Western Australia since the exemption came into effect – from 12 in 2011/12 to 38 in 2017/18.
“A change in the law will not mean that our professional and ethical responsibilities will disappear.
“They remain, we take them seriously, we always will. It just means an exemption for the treating practitioner, for treating health issues, of another practitioner.”
CHRIS JOHNSON
Vax exemption sees chickenpox outbreak in North Carolina school
A school in North Carolina with a high vaccination religious exemption rate has experienced that State’s worst outbreak of chickenpox in more than 20 years.
By the end of November, 36 students at Asheville Waldorf School had contracted the varicella virus, most commonly known as chickenpox.
It is the largest outbreak there since the disease’s vaccine became available more than two decades ago.
The school has one of the highest vaccination exemption rates in the North Carolina.
Dr Jennifer Mullendore of Buncombe County Department of Health and Human Services said the outbreak was concerning, even though chickenpox is not usually life-threatening.
Two to three out of every 1,000 children infected with chickenpox required care in a hospital, she said.
“People don’t think it’s a serious disease, and for the majority of people it’s not. But it’s not that way for everybody,” Dr Mullendore said.
“To me, that’s not a mild disease, and if you’re the parent of one of those children, you probably don’t think so either.”
Asheville Waldorf School has 152 students and 110 of them have not received the chickenpox vaccine, which was made available in the United States in 1995.
During the 2017-2018 school year, the school had a higher rate of religious exemptions for vaccination than all but two other schools in all of North Carolina.