Subscribe
×

Preference: Administration and Health Services

2

Honey, I shrunk the kids (but it was probably worth it)

Anxious parents can take some comfort from two recent reviews that explore the impact of inhaled corticosteroids on the growth of children with mild to moderate persistent asthma. The first, which included 25 trials with more than 8400 children, concluded that steroids reduce growth during the first year of treatment (by about half a centimetre). The reduction is less pronounced in subsequent years, and seems minor compared with the known benefits of these drugs for controlling asthma. The second review, which included data on 3400 children from 22 trials, found that lower doses of corticosteroids have less impact on growth, supporting the “minimal effective dose” approach (doi: 10.1002/14651858.CD009471.pub2; 10.1002/14651858.CD009878.pub2).

Of course, when it comes to obesity, shrinking is desirable. The recently updated review of surgery for weight loss in adults, which now includes 22 trials with 1800 participants, found that compared with no surgery, body mass index was six units lower 1 to 2 years after surgery. This finding extended to improvements in health-related quality of life and aspects of diabetes. The review highlights potentially important differences in surgical procedures; for example, three studies found that gastric bypass achieved greater weight loss than adjustable gastric bands. Given that most trials followed participants for only 1 or 2 years, the long-term effects of surgery remain unclear (doi: 10.1002/14651858.CD003641.pub4).

There’s no doubting the effects of topical antifungal treatments for tinea cruris and tinea corporis. A new review, which includes 129 trials involving over 18 000 participants, contains that all-too-rare phrase, “All of the treatments examined appeared to be effective”. Terbinafine and naftifine were found to be effective, with only mild and infrequent side effects. Similarly, other topical antifungal treatments, particularly azoles, were also effective, but the high or unclear risk of bias of many studies made it difficult to pick a clear winner (doi: 10.1002/14651858.CD009992.pub2).

With shiftwork and non-standard working hours becoming an increasingly common feature of modern life (to say nothing of parenting), what can we do to counteract sleepiness and sleep disturbances? A new review of pharmacological interventions included 15 small trials involving 700 shiftworkers. It found that melatonin increases sleep length (by about 25 minutes) compared with placebo but not sleep quality, and that both modafinil and armodafinil increased alertness and reduced sleepiness but were associated with adverse events, meaning that neither drug is approved for shiftworkers in Europe. And what of the familiar staple, caffeine? In one trial, caffeine reduced sleepiness during night shifts, when workers also napped before shifts. Nothing about whether the analysis was barista-adjusted (doi: 10.1002/14651858.CD009776.pub2).

For more on these and other reviews, check out the ever-growing Cochrane Library at www.thecochranelibrary.com.

New TGA warning label for use of NSAIDs in fluid-depleted children

To the Editor: Non-steroidal anti-inflammatory drugs (NSAIDs) have been very widely used for many years in Australia and elsewhere, in both prescription and non-prescription settings.

Although their potential for gastrointestinal side effects is generally well understood within the community, the capacity for NSAIDs to cause renal damage, even after short-term use in susceptible individuals, is less well appreciated.

It has been well documented that the use of NSAIDs in those who are fluid-depleted, including their short-term use in otherwise healthy individuals, can lead to renal failure, albeit reversible.1,2

On 23 May this year, the Therapeutic Goods Administration updated its Medicines Advisory Statements on labels for non-prescription medicines. Included was a warning about paediatric products containing NSAIDs.3 The wording of the advisory statement is “Ask your doctor or pharmacist before use of the medicine in children suffering from dehydration through diarrhoea and/or vomiting”.

As the person who initiated the request to have this warning label added, my intention was to have this warning added to all non-prescription NSAID-containing products for both adults and children, because we know that people who are renally compromised for any reason are at risk of kidney damage from the use of NSAIDs. This, of course, includes those taking some antihypertensive medications containing a diuretic, the well known “triple whammy” effect.4,5

Nevertheless, I hope that the warning label on paediatric products containing NSAIDs will alert parents and carers to be vigilant if giving these medicines to children in their care, and to check with their doctor or pharmacist if the child is fluid-depleted from diarrhoea or vomiting.

Will current health reforms in south and east Asia improve equity?

To the Editor: Hipgrave and Hort review health reform initiatives in south and east Asia and draw attention to the increasing privatisation of services and the inequity created as the poor have less access.1 More importantly, countries in south and east Asia are enjoying a period of economic development that has resulted in urbanisation and lifestyle change, specifically dietary change, in both urban and rural populations. This has resulted in a nutrition transition, which is associated with the chronic non-communicable disease (NCD) “epidemic”.2 The trends are that the poor in these countries will have higher levels of risk factors for chronic NCD.3

Health systems in most low and middle income countries have been designed for episodic care for acute conditions, and not for primary health care involving the continuity of care required for managing chronic disease. Second, most of these countries have made negligible investments for prevention of risk factors through population-based programs. Third, intersectoral policies to deal with “upstream” issues, such as marketing of unhealthy food, are not yet in their reform agenda.

Australia’s success in tobacco control and reduction of HIV/AIDs are lessons that we can share. However, the same cannot be said of food policy, and many countries have failed to resist the pressures of the multinational food industry.4 Countries in south and east Asia require intersectoral policies on healthy food to achieve a long-term, sustainable solution to health inequity.5

Will current health reforms in south and east Asia improve equity?

In reply: Jayasuriya draws attention to the increasing problem of non-communicable diseases (NCDs) among countries in our region, and we agree that this contributes to health inequity. Prevention of NCDs requires action across many sectors, public and private, and at state, subnational, community and individual levels. Managing NCDs creates additional challenges for effective and equitable health service delivery. However, NCD-related services are only one example of currently ineffective primary health care in developing countries. We maintain that — across the disease spectrum — inadequate health reform and the lack of attention to health across sectors, the lack of public finance to provide equal access to services (including community-level preventive screening for and management of chronic NCDs), and inadequate attention to social determinants of health remain key to improving health equity.

Time to end the ban on HIV-positive proceduralists and dentists

To the Editor: This year, the ban on HIV-positive surgeons and dentists practising in the United Kingdom was removed on the provision that they are clinically well, are being treated, and have an undetectable viral load.1 This development aligns the UK with over 20 other countries. Australia is lagging behind other more progressive countries on this issue.2

During the height of the HIV epidemic in the early 1990s, there were no HIV transmissions among 22 171 patients exposed to pre-antiretroviral (ART)-era HIV-positive doctors and dentists during invasive operations.3

There have been only 10 published case reports indicating probable transmission from a proceduralist to patients since HIV was first reported.4 The current risk estimate is 1 in 1 672 000.2 No cases of inadvertent transmission have been reported in the literature from countries that allow HIV-positive proceduralists.2

ART is vital for reducing the risk of transmission. Extrapolating from the ongoing PARTNER study, there have been no transmissions between serodiscordant couples who have regular, unprotected, high-risk sex if the positive partner is receiving ART and virally suppressed 2 years into the study.5 The risk during procedures by HIV-positive virally suppressed proceduralists, with the use of standard universal precautions (such as gloves and sterile equipment), would likely be extremely low.

There are two major problems with a blanket ban on HIV-positive proceduralists. First, those facing a career-ending outcome of a test are likely to avoid being tested after an initial negative test result. Second, the wrong message is sent to the public that people with HIV are highly infectious and are somehow dangerous (despite treatment). Lifting the ban would lead to greater incentives for proceduralists to be regularly tested for HIV, leading to better outcomes for them and their patients. This is important as many infected individuals transmit the virus when they are seroconverting and are unaware of their diagnosis.6 Furthermore, postexposure prophylaxis could also be available to patients after possible exposure during a procedure by following occupational exposure guidelines.

It is time for Australia to align with other progressive nations and end theabsolute ban on HIV-positive proceduralists. The risk of transmission from them, when treated for HIV and using standard precautions, is likely to be negligible.

How do you keep them down on the farm?

Specialist training in the first two postgraduate years must be made available in both large and small rural hospitals

Some years ago, when I was seeking views on priorities in rural health, I went to a rural town, where the desert met the sea, the local river flowed under the sand and the streets were wide enough to turn a bullock train, to interview the mayor. What did she want for her municipality with a population of 7000? A radiotherapy service and a cardiac catheter laboratory — her husband had both cancer and cardiac disease.

While her wish was extreme, it illustrates the high expectations within our communities — large and small — for medical care. Indeed, these expectations are reinforced by the popular mantra that ours is the best health system in the world, and a pervasive myth that health care is free. Australia’s population, spread over an area the size of the United States minus Alaska, is concentrated along the eastern seaboard. It is in the area where this population is concentrated, particularly Melbourne and Sydney, where subspecialty medicine is sustained. Can anybody find a similar demographic collage elsewhere in the world from which our policymakers can draw inspiration?

The Australian Medical Workforce Advisory Committee (AMWAC) has set benchmarks for numbers of specialists per 100 000 population.1 Such ratios do little to inform the concerns expressed by the rural town mayor. Yet, ratios are always quoted to show the difficulty of assuring an “optimal” rural workforce, with assumptions based on an urban specialist paradigm. Fascination with workforce distribution solves nothing.

For instance, a Royal Australasian College of Physicians (RACP) position paper stated that five to seven full-time equivalent general physicians per 100 000 population are required to provide adequate service, and teaching and research capacity in general medicine.2 The AMWAC position paper1 did not consider general physician numbers.

What occurs in reality? In regional Victoria, the hospital at Wangaratta (population 28 000) has six consultant physicians. The hospital serving the towns of Echuca and Moama (population 20 000) has no consultant physicians. While both hospitals have registrars and interns, they provide after-hours care differently. The senior visiting medical staff at Wangaratta is predominantly specialist, while in the hospital at Echuca–Moama, medical care is provided predominantly by general practitioners with special procedural and non-procedural skills. Both hospitals supply the needs of their respective communities. The difference is that the general practitioners at Echuca–Moama also have the skills to undertake obstetrics, anaesthetics and emergency medicine — skills reserved for specialists at Wangaratta.

The aim must be to assure 24/7 medical cover while avoiding “doctor burnout”. So, when the hospital worlds of physicians, specialists and GPs collide in the rural setting, the first response should not be to fight for control of the hospital. The arrival of specialists should not see the gradual extinction of GPs in the hospital, because this invariably diminishes the pool of expertise and, importantly, a component of the sustainability of specialist services as GPs with specialist skills enhance such services

Echuca–Moama and Wangaratta have both interns and registrars. They form an engine room of intelligent, motivated young graduates who, under supervision, provide the continuity of purpose, as occurs in metropolitan hospitals. It is an engine room essential for succession planning

Australia has to balance a strong research metropolitan-centric hospital system with robust intellectual capital in rural and regional Australia. Rural areas require not only university commitment, but also a commitment to train doctors through a minimum of postgraduate years 1 and 2 (and possibly 3). This should ensure that there is a well trained cohort of doctors with “specialist skills” among both specialists and GPs. The aim should be not only to maintain a 24/7 roster, but also to provide young graduates with continuing intellectual stimulation. There are young graduates who prefer the rural lifestyle, but not as isolates. Those who want to become specialists need to go to a major metropolitan teaching hospital for part of their training. These young doctors need a stable job environment to which they can return, knowing that they will be welcome.

The rural clinical schools host initiatives such as the Murray to the Mountains (M2M) Intern Training Program.3 For prospective GPs, this provides the opportunity to gain further training in obstetrics, anaesthetics or any general specialty for which there is a demand, as rural medical generalists.

Postgraduate training is not the sole prerogative of metropolitan teaching hospitals, and it is crucial to acknowledge the importance of maintaining a strong education base in rural Australia.4 The development teaching hospitals where research is an integral part of their operation has previously been advocated,5and funding for such research should be set aside. However, the provision of such funding should acknowledge the increasing intellectual capital in rural medical schools, so any approach should be inclusive not elitist. One criticism that can be made of the US system is the disparity between the very best and the worst, resulting from the way resources are distributed.

With universities connected to regional health care services and mechanisms in place to meet the educational needs of the local medical workforce, the mayor of the small town can be confident that there will be sufficient expertise in her rural community to satisfy her expectations.

The key to recruitment and maintenance is the collegiality of the local workforce where universities have an important supporting role, together with connectivity of the whole workforce by way of either face-to-face meetings or by video or webinar links. The gap has been where there has been a rural clinical school, but no opportunity to undertake the first two postgraduate years in a rural hospital — the essence of collegiality.

Australia is a country where delivering medical services will always be a challenge if there is not a strong sub-stratum of doctors who have special interest skills, and who are available over the 24-hour cycle. Such doctors must also be sufficiently acquainted with subspecialty medicine to both explain the meaning of the limits of the health service and allay the concerns of the mayor about not having a radiotherapist or interventional cardiologist on her doorstep.

Orthogeriatric services associated with lower 30-day mortality for older patients who undergo surgery for hip fracture

Hip fracture is one of the most common, serious and costly injuries sustained by older people; it often results in disability and a need for enhanced levels of care, and it occasionally results in death.1–3

To improve outcomes after hip fracture, various models of care have been proposed and evaluated.1,4,5 One study has shown reductions in morbidity and mortality,1 another has produced inconclusive results,6 and a systematic review has found that hip fracture patients who receive multidisciplinary inpatient rehabilitation tend to achieve better outcomes, although it could not show this to a significant level.7

Orthogeriatric care is medical care for older patients with orthopaedic conditions that is provided collaboratively with the treating orthopaedic team. In Australia, it is predominantly provided by geriatricians. We examined the impact of orthogeriatric services on 30-day mortality and length of stay (LOS) for hip fracture patients undergoing surgery in public hospitals in New South Wales.

Methods

We conducted a retrospective analysis of patients aged 65 years and older who had a fractured hip and received surgical intervention between 1 July 2009 and 30 June 2011 at one of the 37 NSW public hospitals operating on hip fracture patients. Ethics approval was obtained from the NSW Population and Health Services Research Ethics Committee.

Data sources

Patient data were obtained from the NSW Admitted Patient Data Collection (APDC), which contains information on inpatient separations from all hospitals in NSW. It holds information on patient demographics, diagnoses, separation types and clinical procedures. For each patient, individual episodes of care were linked to form one record. The diagnoses and external cause codes are classified using the International Classification of Diseases, 10th revision, Australian modification (ICD-10-AM).8 Mortality data were obtained from the NSW Registry of Births, Deaths and Marriages (RBDM).

Identification of cases

Hip fracture patients undergoing surgical intervention were identified as those for whom the principal diagnosis was ICD-10-AM code S72.0, S72.1 or S72.2 (hip fracture) and the principal procedure code was ICD-10-AM code 47519-00, 47522-00, 47528-01, 47531-00, 49318-00 or 49319-00 (hip fracture interventions).

Data linkage

The APDC was linked to the RBDM mortality data by the Centre for Health Record Linkage. This enabled identification of the first admission for a hip fracture per person, any public or private hospital transfers related to the admission where a hip fracture procedure occurred on or after a hip fracture diagnosis, and any death within 30 days of surgery.

Identification of comorbidities

The Charlson comorbidity index (CCI) ICD-10 Deyo adaptation,9 with a 1-year look-back period, was used to identify comorbidities and for casemix adjustment. The number of comorbidities were summed for each patient, and patients were divided into three groups based on CCI scores (0; 1 or 2; and ≥ 3).

Identification of hospitals with orthogeriatric services

In 2012, a facility-level audit of all public hospitals in NSW providing surgery for hip fracture showed that 62% of hospitals provided some form of orthogeriatric care.10 Hospitals with an orthogeriatric service in 2012 were contacted to establish whether the service was available during the period 1 July 2009 to 30 June 2011.

Data analysis

Data analysis was performed using SAS Enterprise Guide 4.3 (SAS Institute). Time from admission to surgery (an estimate of time from fracture to surgery) was defined as the number of calendar days elapsing between the day of admission for the first recorded hip fracture diagnosis and the day of surgery. Adjusted mortality rates were calculated using indirect standardisation. Demographics were compared using descriptive statistics. A binomial logistic regression model was used to generate NSW-level predicted probabilities of 30-day mortality for each procedure conducted. Age, sex and comorbidity were included in the model. By summing the predicted probabilities for each hospital, the expected number of deaths within 30 days was calculated and compared with the actual number. For each hospital, this ratio was multiplied by the NSW unadjusted mortality rate to calculate the adjusted hospital-specific 30-day mortality rate.

Wilcoxon two-sample tests with one-sided P values were used to compare patient mortality for hospitals with and without an orthogeriatric service, and to compare patient mortality at hospitals that are major trauma centres and those that are not.

Results

From 1 July 2009 to 30 June 2011, there were 9601 hip fracture cases (in 9370 patients) for which surgery was done in the 37 hospitals that operated on hip fracture patients. There were 706 patient deaths within 30 days of surgery, giving an overall NSW unadjusted 30-day mortality rate of 7.4%. Median time from admission to death was 12.5 days.

Differences between hip fracture cases for which surgery was done in a hospital with an orthogeriatric service and those done in a hospital without an orthogeriatric service are shown in Box 1. The number of hip fracture surgeries and 30-day mortality in individual hospitals are shown in Box 2.

A funnel plot of adjusted 30-day mortality rates for hospitals, classified according to presence or absence of an orthogeriatric service and by major trauma centre status, is shown in Box 3. After adjustment for age, sex and CCI score group, the median 30-day mortality rate for hospitals with an orthogeriatric service was significantly lower than that for hospitals without an orthogeriatric service (6.2% v 8.4%; P < 0.002) (Box 1). The median 30-day adjusted mortality rate for hospitals that are major trauma centres was not significantly different to that for hospitals that are not major trauma centres (7.2% and 7.8%, respectively; P = 0.3).

Discussion

In our study, hospitals with an orthogeriatric service had lower 30-day mortality rates and longer LOS for patients who underwent surgery for hip fracture.

The difference in mortality rates may be due to medical optimisation before surgery, prevention and early detection of medical complications, better coordination of care, better communication between staff responsible for care, and better management of comorbidities. Results of other studies indicate that respiratory disease and cardiac disease are the biggest causes of mortality after hip fracture and that these diseases are likely to be managed better in hospitals with an orthogeriatric service.1,6,11 Equally, it could be argued that the presence of an orthogeriatric service reflects a better resourced hospital that provides treatment for larger numbers of hip fracture patients.

Various reasons can be put forward to explain the differences in LOS. Given that 50% of deaths occurred within 12.5 days of admission to hospital, it may simply be the survival effect that produced longer LOS in hospitals with an orthogeriatric service, although this is unlikely to solely explain the difference that we found. Without looking at readmission figures, it is difficult to know whether the longer LOS is appropriate and whether premature discharge may lead to higher rates of readmission.

Other studies that have examined mortality and LOS after hip fracture surgery at hospitals with and without specialised orthogeriatric or multidisciplinary services over the past decade have produced mixed results.1,6,12–14

Our study has four main limitations. First, the approach to delivery of orthogeriatric care varies across hospitals (eg, in some hospitals, physicians other than geriatricians provide medical input for hip fracture patients), and we did not account for such differences. Second, the APDC did not include information on cognitive state, prefracture ambulatory status or preadmission place of residence, which are predictors of health outcomes.6 While comorbidity is an important predictor of outcomes, it does not reflect disease severity. Third, we did not extract information on postoperative complications, which have been shown to differ based on the availability of an orthogeriatric service.1,6,11,15 Finally, we did not explore the potential for backwards causation due to better overall standards of care in hospitals that have an orthogeriatric service.

Time from hip fracture to surgery has been shown to affect health outcomes and LOS.16 The APDC does not record exact time from fracture to surgery, so we used a proxy measure (days between admission for first recorded hip fracture diagnosis and surgery).

In the United Kingdom, the establishment of the National Hip Fracture Database has been instrumental in driving changes in clinical care and patient outcomes, along with improvements in hospital services for treatment of hip fracture patients. As a result of many changes in the UK, 30-day mortality has decreased significantly.17 Similar work is now underway in Australia: national guidelines and standards of care are being developed, and a minimum patient-level dataset (available as a patient audit form) has been prepared to facilitate the recently launched Australian and New Zealand Hip Fracture Registry (http://www.anzhfr.org). Data collected by the Registry will be integral to future research on the key determinants of health outcomes and will help create more effective services for hip fracture patients.

1 Characteristics of hip fracture cases for which surgery was performed in public hospitals with and without an orthogeriatric service, New South Wales, July 2009 – June 2011

Characteristic

Hospitals with orthogeriatric service (n = 14)

Hospitals without orthogeriatric service (n = 23)

P

No. of surgeries

4575

5026

—

Mean (SD) patient age, years

84.4 (7.4)

84.2 (7.5)

0.20

No. (%) of surgeries on men

1239 (27.1%)

1326 (26.4%)

0.44

CCI score group

    

0.36

0

2715 (59.3%)

3018 (60.0%)

  

1 or 2

1256 (27.5%)

1393 (27.7%)

  

≥ 3

604 (13.2%)

615 (12.2%)

  

Overall 30-day patient mortality rate

6.5%

8.1%

0.002

Median (IQR) 30-day hospital mortality rate — unadjusted

6.6% (2.1%)

8.2% (2.3%)

< 0.02

Median (IQR) 30-day hospital mortality rate — adjusted*

6.2% (2.1%)

8.4% (2.4%)

< 0.002

Acute length of stay, days†

      

Mean (SD)

12.9 (10.9)

11.2 (9.1)

< 0.001

Median (IQR)

10 (8)

9 (8)

< 0.001

Total length of stay, days†

      

Mean (SD)

30.1 (22.8)

28.7 (29.5)

< 0.01

Median (IQR)

26 (31)

22 (29)

< 0.001

Time from admission to surgery, days

      

Mean (SD)

1.8 (2.7)

1.7(13.2)

0.63

Median (IQR)

1 (2)

1 (2)

< 0.001

CCI = Charlson comorbidity index. IQR = interquartile range. * Adjusted for age, sex and CCI score group. † Acute length of stay is the cumulative length of stay for all linked acute episodes of care (defined by the acute flag in the NSW Admitted Patient Data Collection); total length of stay also includes the linked non-acute episodes of care.

2 Mean number of hip fracture surgeries per year and 30-day mortality in public hospitals with and without an orthogeriatric service, New South Wales, July 2009 – June 2011*

* One hospital without an orthogeriatric service was omitted from the analysis due to low number of surgeries.

3 Adjusted 30-day mortality rates after hip fracture surgery in public hospitals according to presence or absence of an orthogeriatric service and by major trauma centre status, New South Wales, July 2009 – June 2011*

* One hospital without an orthogeriatric service was omitted from the analysis due to low number of surgeries.

Ethical challenges for doctors working in immigration detention

The health of asylum seekers in Australia’s immigration detention centres has been the subject of a doctors’ letter of concern and two recent reports.1–3 Here, we present an analysis of the ethical dilemmas faced by health practitioners working in these centres1 and seek to promote a strong and considered policy discussion.

Australia’s Department of Immigration and Border Protection (DIBP) contracts a private health service provider, International Health and Medical Services (IHMS), to provide health care to immigration centre detainees at an Australian standard.4 However, media and other reports from Christmas Island,1 Manus Island2 and Nauru3 have raised serious concerns about the quality of care provided and whether health care professionals have been able to fulfil their professional and ethical obligations to patients in these facilities.1–3

Ethical conflicts and challenges

Doctors working within the immigration detention system may experience conflicting loyalties to their patients, their employer and the DIBP. The Australian Health Practitioner Regulation Agency (AHPRA) code of conduct for doctors recognises the significance of conflicts of interest:

Multiple interests are common. They require identification, careful consideration, appropriate disclosure and accountability. When these interests compromise, or might reasonably be perceived by an independent observer to compromise, the doctor’s primary duty to the patient, doctors must recognise and resolve this conflict in the best interests of the patient.5

The Australian Medical Association (AMA) code of ethics6 also advises how doctors should respond to conflicts of interest and to conditions that are judged to be unacceptable for adequate health care:

Refrain from entering into any contract with a colleague or organisation which may conflict with professional integrity, clinical independence or your primary obligation to the patient.

… ensure that you do not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman, or degrading procedures …6

The AMA statement on medical professionalism7 further describes how a doctor’s ability to deliver patient-centred care may be compromised by an employer or government and advises that:

When responding to these challenges, the medical profession and its individual members have a duty to advocate that the health care environment remains patient-centred at all times and a responsibility to ensure that the health needs of patients remains the doctor’s primary duty.7

Despite its obligations to both its patients and the DIBP, IHMS has publicly maintained that no conflict of interest exists.8 However, the inadequate health screenings of asylum seekers on Christmas Island in 2013 demonstrate this type of conflict. In response to DIBP targets, health assessments were rushed, fewer investigations were performed and asylum seekers were transferred to regional processing centres within 48 hours, before results of investigations were available.1 This resulted in failure to identify acute and chronic illnesses before patients were transferred to sites with limited medical facilities.1 This practice continued in the face of objections from the Royal Australasian College of Physicians.1

Some tasks requested of doctors in immigration detention centres are inappropriate in the context of health care, such as requests to refer patients for age assessment by the DIBP. This process is not a part of the patients’ health care and is not in their best interests.1,9 Doctors have been required to prescribe medication en masse to expedite transfer to regional processing centres, with no patient consultation and despite potential contraindications.1 For example, the combination drug for malaria prophylaxis, atovaquone–proguanil hydrochloride, was prescribed without any individual patient consultation, and it was not clear if asylum seekers were informed about the indications for and possible adverse reactions to this drug.

Degrading, harmful and inappropriate incidents have occurred, including requiring asylum seekers to undergo health assessments while exhausted, dehydrated and filthy, with clothing soiled by urine and faeces; addressing individuals by number instead of name;1,2 artificial delays in transfer of patients for tertiary care;1 confiscation and destruction of medications, medical records and medical devices;1 and detention of children despite clear evidence of significant harm.1,9–11

These rushed and inappropriate practices can have harmful consequences for patient wellbeing. These have included the loss of an unaccompanied child’s hearing aid, which was not replaced, and the child went on to develop self-harming behaviour; and the abrupt cessation of anticonvulsants in a child, resulting in worsening of seizures.10,11 Tragically, delays in transfer are likely to have contributed to the recent death of an asylum seeker from sepsis, resulting from a cut to his foot.12

Responding to conditions of practice in immigration detention centres

Doctors who work in detention centres may feel an ethical responsibility to voice their concerns, but this may conflict with their obligations to their employer. The question should be asked: is working within immigration detention an ethically tenable prospect for Australian doctors and other health professionals? Several answers present themselves.

First, a doctor may advance the “no worse off” argument — that any individuals refusing to work within the system will be replaced by others willing to do so.

Second, it might be argued that it is better to have a compassionate person delivering the best care possible within the constraints of the detention system than to have that person leave, not knowing who the replacement will be. However, remaining silent goes against the imperative to advocate for patients’ interests.7

Third, a doctor might work as contracted in the system, yet still advocate for asylum seekers by speaking out about deficiencies in their care. But it is unclear how much “advocacy from within” is enough. If that advocacy becomes ineffective, is there a point at which the doctor becomes effectively complicit with the system?

Finally, some doctors terminate their contracts when they see the realities of the detention health care environment. However, while this strategy preserves the individual’s professional integrity, it may jeopardise patient care by resulting in an immediate workforce shortage.

The work culture in immigration detention centres discourages open expression of personal concerns by staff, with documented cases ending in dismissal.13 Formal complaints can be made but have rarely effected change.1 The diffusion of personal responsibility associated with reporting complaints to senior staff is a powerful factor in the immigration detention system. Health practitioners who lodge complaints to formalise their objections may judge this to have met their responsibilities. However, in reality, this may not represent effective advocacy for patients when failure to act on complaints is a systemic problem. Other doctors, increasingly frustrated with the lack of progress, may burn out and abandon their advocacy attempts. In our experience, many resolve to wait out their contracts and leave, never to return.

Appealing to bodies external to their employer becomes a last resort. However, individuals who do so face the possibility of legal action for breaching confidentiality agreements. Health care professionals can notify AHPRA, which provides protection from such agreements, but AHPRA’s scope is limited to the conduct of individual practitioners rather than dysfunctional health systems as a whole.14 There is little else individuals can do without significant personal risk.

Is it time for a boycott?

Given reports that the health care currently provided to asylum seekers in immigration detention may be both substandard and harmful, a coordinated response to the problem is now needed to ensure change occurs.

Should health care professionals consider boycotting the provision of services in immigration detention until conditions are made satisfactory? The potential role of a professional boycott to motivate change should be openly discussed. Any decision made requires leadership from the professional bodies responsible for ensuring standards of care and ethical conduct. Any resulting policy and advice in relation to health care within immigration detention needs to be clear.

We call on the colleges and the AMA to lobby for effective change, so that asylum seekers receive appropriate care and those delivering it are not professionally compromised. We also call for robust, independent and transparent monitoring of standards within immigration detention, and a system to register and independently deal with complaints.

Mandatory reports of concerns about the health, performance and conduct of health practitioners

Health practitioners are often well placed to identify colleagues who pose risks to patients, but they have traditionally been reluctant to do so.1–4 Since 2010, laws in all Australian states and territories require health practitioners to report all “notifiable conduct” that comes to their attention to the Australian Health Practitioner Regulation Agency (AHPRA).

Legal regimes in other countries, including New Zealand,5 the United States3,6 and Canada,7 mandate reports about impaired peers in certain circumstances. However, Australia’s mandatory reporting law is unusually far-reaching. It applies to peers and treating practitioners, as well as employers and education providers, across 14 health professions. Notifiable conduct is defined broadly to cover practising while intoxicated, sexual misconduct, or placing the public at risk through impairment or a departure from accepted standards. Key elements of the law are shown in Box 1.

Mandatory reporting has sparked controversy and debate among clinicians, professional bodies and patient safety advocates. Supporters believe that it facilitates the identification of dangerous practitioners, communicates a clear message that patient safety comes first,8 encourages employers and clinicians to address poor performance, and improves surveillance of threats to patient safety. Critics charge that mandatory reporting fosters a culture of fear,9 deters help-seeking,10 and fuels professional rivalries and vexatious reporting.11,12 Concerns have also been raised about the subjectivity of reporting criteria.13 The Australian Medical Association opposed the introduction of the mandatory reporting regime for medical practitioners, citing several of these objections.14

Little evidence is available to evaluate the veracity of these different views. We sought to provide baseline information on how the regime is working by analysing an early sample of mandatory notifications. Specifically, we aimed to determine how frequently notifications are made, by and against which types of practitioners, and about what types of behaviour.

Methods

We conducted a retrospective review and multivariate analysis of all allegations of notifiable conduct involving health practitioners received by AHPRA between 1 November 2011 and 31 December 2012. The Human Research Ethics Committee at the University of Melbourne approved the study.

Data sources

We obtained data from two AHPRA sources: mandatory notification forms and the national register of health practitioners.

AHPRA receives notifications on a prescribed form. Notifiers may access the form on AHPRA’s website or by calling a notifications officer on a toll-free number. Two of us (M M B, D M S) helped AHPRA develop the form in 2011. It includes over 40 data fields; most fields have closed-ended categorical responses, but there is also space for free-text descriptions of concerns. Notifiers may append supporting documentation such as medical records and witness statements.

We obtained PDF copies of all notification forms received in five states and two territories between 1 November 2011 and 31 December 2012. Reports from New South Wales were not included. Although health practitioners in NSW are subject to the same reporting requirements as those in other states, AHPRA has a more limited role in relation to notifications made in NSW: when AHPRA receives such notifications, they are referred to the NSW Health Care Complaints Commission to be handled as complaints. AHPRA cannot log and track these notifications in the same way as it can notifications arising in other jurisdictions.

Data collection

We collected data onsite at AHPRA’s headquarters in Melbourne from April 2013 to June 2013. Three reviewers were trained in the layout and content of the notification forms, the variables of interest, methods for searching the health practitioner register, and confidentiality procedures. For each form lodged during the study period, the reviewers extracted variables describing the statutory grounds for notification, type of concern at issue, and characteristics of the practitioner who made the notification (“notifier”) and the reported practitioner (“respondent”). We also coded a variable classifying the relationship of the notifier to the respondent (treating practitioner, fellow practitioner, employer, education provider). Practitioner-level variables extracted from the notification forms were cross-checked with information recorded on the register.

One of AHPRA’s core functions is to maintain a national register of licensed health practitioners. To enable calculations of notification rates, AHPRA provided a de-identified practitioner-level extract of the register as at 1 June 2013. The extract consisted of variables indicating practitioners’ sex, age and profession, and the postcode and state or territory of their registered practice address. Practitioners from NSW and those with student registration were excluded to ensure that the register data matched the sample of notifications. Postcodes were converted to a practice location variable with three categories (major cities, inner and outer regional areas, and remote and very remote areas), based on the Australian Statistical Geography Standard.15

Analyses

We calculated counts and proportions for characteristics of notifications, notifiers and respondents. We also calculated frequency of notification according to the professions of the notifiers and respondents, respectively.

We used multivariable negative binomial regression to calculate incidence of notifications by five respondent characteristics: profession, sex, age, state or territory, and practice location. Incidence measures reported for each characteristic were adjusted for the size of the underlying population and all other observed characteristics. Details of the calculation method and regression results are provided in the Appendix.

All analyses were done using Stata 13.1 (StataCorp).

Results

AHPRA received 850 mandatory notifications during the study period. After excluding notifications relating to nine practitioners from NSW and 22 students, our sample consisted of 819 notifications. The median time between the alleged behaviour and its notification to AHPRA was 18 days (interquartile range, 5 to 58 days).

Grounds and conduct

The distribution of notifications by statutory ground and type of concern, with examples, is shown in Box 2. This information was available for 811 of the 819 notifications. Sixty-two per cent were made on the grounds that the practitioner had placed the public at risk of harm through a significant departure from accepted professional standards; 17% alleged that the practitioner had an impairment that placed the public at risk of substantial harm (more than half of these related to mental health); 13% alleged that the respondent had practised while intoxicated; and 8% related to sexual misconduct (most commonly a sexual relationship between the practitioner and a patient).

Characteristics of notifiers and respondents

The characteristics of notifiers and respondents are shown in Box 3. Nurses and doctors dominated notifications, with 89% of all notifications (727/819) involving a doctor or nurse in the role of notifier and/or respondent. Nurses and midwives accounted for 51% of notifiers and 59% of respondents. Doctors accounted for 29% of notifiers and 26% of respondents.

Men constituted 37% of notifiers and 44% of respondents. Eighty per cent of notifications were about practitioners in three jurisdictions: Queensland (39% [321/819]), South Australia (22% [184/819]), and Victoria (18% [150/819]).

Nexus between notifiers, respondents and conduct

Among the 731 notifications for which it was possible to identify the professional relationship between the notifier and the respondent, 46% were made by fellow health practitioners (ie, health professionals other than the respondents’ treating practitioners) (Box 3). Forty-six per cent of notifications were made by the respondents’ employers; this included cases in which the notifier was also a registered health practitioner (eg, medical director of a hospital) but the notification was made in an employer rather than individual capacity.

Among 736 notifications for which it was possible to tell how the respondent’s behaviour came to the attention of the notifier, the conduct was directly observed by the notifier in about a quarter of cases (201/736). In more than half of notifications (376/736), the conduct at issue came to the notifier’s attention through a third party — the patient, a colleague or some other person. For the remainder, the conduct was either identified through an investigatory process such as a record review, clinical audit, or police or coronial investigation (81/736) or self-disclosed by the respondent (78/736).

Intraprofessional and interprofessional notifications

Among 697 notifications for which it was possible to determine the profession of the notifier and the respondent, the profession of the notifier and respondent was the same in 80% of cases (557/697). This concentration of intraprofessional notifications is depicted in Box 4 by the diagonal line of relatively large bubbles running from the bottom left to the top right of the figure. Nurse-on-nurse notifications (those involving nurses and/or midwives) and doctor-on-doctor notifications accounted for 73% (507/697) of notifications.

Interprofessional notifications mostly involved doctors notifying about nurses (7% [51/697]) and nurses notifying about doctors (3% [20/697]). The remainder were widely distributed across other interprofessional dyads.

Incidence of notifications

The unadjusted incidence of mandatory reporting was 18.3 reports per 10 000 practitioners per year (95% CI, 17.0 to 19.6 reports per 10 000 practitioners per year). Adjusted rates of notification for the five respondent characteristics analysed are shown in Box 5. Psychologists had the highest rate of notifications, followed by medical practitioners, and then nurses and midwives (47.4, 41.1 and 39.7 reports per 10 000 practitioners per year, respectively).

The incidence of notifications against men was more than two-and-a-half times that for notifications against women (45.5 v 16.8 reports per 10 000 practitioners per year; P < 0.001). Health practitioners working in remote and very remote areas had a much higher incidence of notification than those in major cities and regional areas (60.1 v 17.4 and 25.5 reports per 10 000 practitioners per year). There were also large differences in incidence of notifications across jurisdictions, ranging from 61.6 per 10 000 practitioners per year in South Australia to 13.1 per 10 000 practitioners per year in the Northern Territory.

Discussion

We found that perceived departures from accepted professional standards, especially in relation to clinical care, accounted for nearly two-thirds of reports of notifiable conduct received by AHPRA during the study period. Nurses and doctors were involved in 89% of notifications, as notifiers, respondents or both. Interprofessional reports were uncommon. We observed wide variation in reporting rates by jurisdiction, sex and profession — for example, a nearly fivefold difference across states and territories, and a two-and-a-half times higher rate for men than for women.

Our results suggest that some of the harms predicted by critics of mandatory reporting and some of the benefits touted by supporters are, so far, wide of the mark. Concerns that mandatory reporting would be used as a weapon in interprofessional conflict should be eased by the finding that the notifier and respondent were in the same profession in four out of five cases. Indeed, the low rate of notifications by nurses about doctors (3%) gives rise to the opposite concern. Although nurses are often well placed to observe poorly performing doctors, our data suggest that the new law has not overcome previously identified factors that may make it difficult for nurses to report concerns about doctors.2

On the other hand, supporters of mandatory reporting who heralded it as a valuable new surveillance system may be concerned by the low rates of reporting in some jurisdictions. Part of the variation in incidence of notifications across jurisdictions that we observed might reflect true differences in incidence of notifiable events, but it is also likely that differences in awareness of reporting requirements and differences in notification behaviour contribute to the variation. US research suggests that underreporting of concerns about colleagues is widespread, even when mandatory reporting laws are in place.3 The identified barriers to reporting fall primarily into four categories: uncertainty or unfamiliarity regarding the legal requirement to report; fear of retaliation; lack of confidence that appropriate action would be taken; and loyalty to colleagues that supports a culture of “gaze aversion”.2,3,16–18 Action to better understand and overcome these barriers could be aimed at jurisdictions with the lowest reporting rates.

The higher rate of notification for men that we observed is consistent with previous research showing that male doctors are at higher risk of patient complaints,19,20 disciplinary proceedings21 and malpractice litigation.22 While systematic differences in specialty and the number of patient encounters may explain some of the heightened risk observed for men, other factors, such as sex differences in communication style and risk-taking behaviour,23,24 are probably also in play.

The main strength of our study is that we included data from every registered health profession and all but one jurisdiction. The ability to access multistate data for research and evaluation purposes is an important benefit of Australia’s new national regulation scheme, and would not have been possible 5 years ago. Other federalised countries with siloed regulatory regimes continue to struggle with fragmented workforce data.

Our study has three main limitations. First, because mandatory reporting was implemented in concert with other far-reaching changes to the regulation of health practitioners, it was not possible to compare the incidence of notifications before and after the introduction of the new law. Second, it was not feasible to include information on the outcomes of notifications: too small a proportion of notifications had reached a final determination at the time of our study to provide unbiased data. As the scheme matures, it would be useful to explore what proportion of reports were substantiated and resulted in action to prevent patient harm, at an individual or system level. Third, our analysis did not include notifications against practitioners based in NSW.

This study is best understood as a first step in establishing an evidence base for understanding the operations and merits of Australia’s mandatory reporting regime. The scheme is in its infancy and reporting behaviour may change as health practitioners gain greater awareness and understanding of their obligations. Several potential pitfalls and promises of the scheme remain to be investigated — for example, the extent to which mandatory reporting stimulated a willingness to deal with legitimate concerns, as opposed to inducing an unproductive culture of fear, blame and vexatious reporting. Qualitative research, including detailed file reviews and interviews with health practitioners and doctors’ health advisory services, would help address these questions. Further research should also seek to understand the relationship between mandatory reports and other mechanisms for identifying practitioners, such as patient complaints, incident reports, clinical audit, and other quality assurance mechanisms.

1 Elements of mandatory reporting law for health practitioners in Australia

Who can be subject to a report?

All registered health practitioners in Australia (doctors, nurses, dentists and practitioners from 11 allied health professions)*

Who has an obligation to report?

Employers, education providers and health practitioners†

What types of conduct trigger the duty to report?

The practitioner: (a) practised the profession while intoxicated by alcohol or drugs, (b) engaged in sexual misconduct in connection with the practice of the profession, (c) placed the public at risk of substantial harm in the practice of the profession because of an impairment, or (d) placed the public at risk of harm by practising in a way that constitutes a significant departure from accepted professional standards

What is the threshold for reporting?

Reasonable belief that notifiable conduct has occurred

What protections are available to the notifier?

A reporter who makes a notification in good faith is not liable civilly, criminally, in defamation or under an administrative process for giving the information

What are the penalties for failing to report?

Individuals may be subject to health, conduct or performance action; employers may be subject to a report to the Minister for Health, a health complaints entity, licensing authority and/or other appropriate entity; education providers may be publicly named by the Australian Health Practitioner Regulation Agency (AHPRA)

* Registered students are subject to mandatory reporting if they place the public at risk of substantial harm because of an impairment, or are subject to certain criminal charges or convictions. † Health practitioners are exempt from the obligation to report if they reasonably believe that AHPRA has already been notified of the conduct, or if they become aware of the conduct in the course of legal proceedings, professional indemnity insurance advice or approved quality assurance activities. Treating practitioners are exempt from the obligation to report in Western Australia only.

2 Statutory grounds for notification and types of concerns at issue (n = 811)*

Statutory ground and type of concern

No. (%)

Example of alleged behaviour

Departure from standards

501 (62%)

  

Clinical care

336 (41%)

An optometrist failed to refer a child with constant esotropia to an ophthalmologist for 2 years, resulting in permanent visual impairment

Professional conduct

107 (13%)

A director of nursing engaged in bullying and intimidation, including rude and abusive outbursts towards nurses

Breach of scope or conditions

50 (6%)

An occupational therapist with conditional registration did not comply with a requirement that she work under supervision

Impairment

140 (17%)

  

Mental health

75 (9%)

A nurse with a history of bipolar disorder began to behave erratically and engaged in loud confrontations with patients

Cognitive or physical health

31 (4%)

A midwife suffered a head injury in a car accident and subsequently experienced cognitive deficits, including difficulty with maths calculations

Substance misuse

25 (3%)

An anaesthetist self-prescribed medication for anxiety and insomnia and developed a benzodiazepine dependency

Intoxication

103 (13%)

  

Drugs

61 (8%)

A nurse working in a hospital had an altered level of consciousness; empty morphine ampoules and syringes were found in her pocket

Alcohol

42 (5%)

A surgeon was noted to smell of alcohol and to have slow reactions during surgery; a breath alcohol test was used to confirm that he was intoxicated

Sexual misconduct

67 (8%)

  

Sexual relationship between practitioner and patient

31 (4%)

A psychologist began a personal relationship with her patient after the breakdown of his marriage and asked him to move in with her

Sexual contact or offence

28 (3%)

A male nurse in an aged care facility sexually assaulted an elderly female patient who was immobile after a stroke

Sexual comments or gestures

8 (1%)

A pharmacist asked a patient to lunch and when she refused he posted sexual comments and pornographic images on her Facebook page

* Statutory grounds were unknown for eight cases. Type of concern was missing for a further eight reports relating to departure from standards and nine relating to impairment.

3 Characteristics of notifiers and respondents*

 

Number (%)

Characteristic

Notifiers

Respondents

Profession

n = 754

n = 816

Nurse and/or midwife

387 (51%)

482 (59%)

Medical practitioner

220 (29%)

216 (26%)

Psychologist

38 (5%)

48 (6%)

Pharmacist

29 (4%)

33 (4%)

Dentist

7 (1%)

15 (2%)

Other health practitioner

16 (2%)

22 (3%)

Non-health practitioner

57 (8%)

—

Age

n = 750

n = 750

< 25 years

4 (1%)

16 (2%)

25 to 34 years

69 (9%)

111 (15%)

35 to 44 years

159 (21%)

204 (27%)

45 to 54 years

281 (37%)

227 (30%)

55 to 64 years

219 (29%)

145 (19%)

≥ 65 years

18 (2%)

47 (6%)

Sex

n = 791

n = 816

Female

498 (63%)

460 (56%)

Male

293 (37%)

356 (44%)

Relationship to respondent

n = 731

— 

Fellow health practitioner

335 (46%)

—

Employer

333 (46%)

—

Treating practitioner

58 (8%)

—

Education provider

5 (1%)

—

Practice location

—

n = 809

Major cities

—

535 (66%)

Inner or outer regional

—

229 (28%)

Remote or very remote

—

45 (6%)

Jurisdiction of practice

  

n = 819

Queensland

—

321 (39%)

South Australia

—

184 (22%)

Victoria

—

150 (18%)

Tasmania

—

25 (3%)

Western Australia

—

97 (12%)

Northern Territory

—

11 (1%)

Australian Capital Territory

—

31 (4%)

* Differences in n values are because of missing data.

4 Frequency of notifications, by profession of notifiers and respondents (n = 697)*

* Bubble sizes correspond to numbers of notifications in each of the 25 dyads shown.

5 Incidence of notifications per 10 000 registered practitioners per year, by characteristics of respondents*

* Rates are adjusted for all variables reported in the figure; dashed line indicates overall unadjusted incidence.

The cost of teaching an intern in New South Wales

To the Editor: While Oates and colleagues1 provide an insightful introduction to intern teaching in New South Wales, I offer an alternative to their views; what is considered teaching is not agreed on, and does not necessarily translate to learning.

Informal teaching (and learning) occurs during work-based activities like ward rounds, departmental meetings, grand rounds and quality improvement activities. These are set out as learning opportunities for interns by the Australian Medical Council.2

What supervisors consider to be informal learning probably does not coincide with interns’ expectations of teaching.

Junior medical officers should realise that, for them, learning from informal teaching is not about acquiring knowledge of diseases or skills, as it is for medical students. Rather, it is about acquiring knowledge of work processes and resource management — expertise not well described in medical literature. Fiona Lake, a developer of Teaching on the Run,

bases her own teaching on the idea that if something can be learnt from a textbook, it is of no help for her to teach it as well. ‘It’s a complete waste of time for me to teach it!’3

Adult learning forms a significant portion of any postgraduate vocational training and can occur by both a cognitive approach, based on andragogy theory, and an apprenticeship model, in which “learning by doing” and “master as role model” are the basis.4

Perhaps the main issue is not the perception of how teaching should be done, but how learning should occur.