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Preference: Administration and Health Services

2

Veterans told: Govt does not pay gym memberships

The Government is cracking down on war veterans attempting to claim benefits for gym membership and participation in general exercise programs.

The Department of Veterans Affairs and Exercise and Sports Science Australia have jointly launched an education campaign to warn veterans and exercise physiologists that gym and exercise program memberships are not covered by the Commonwealth, and attempts to claim benefits are in breach of guidelines.

In a letter announcing the crackdown, senior DVA official Letitia Hope said the Department had “identified that, in some instances, exercise physiology services were being provided inconsistent with policy requirements.

Ms Hope said the Department funded exercise physiology as a specific form of treatment, and its duration was to be determined by clinical necessity.

“The aim…is for the exercise physiologist to devise an exercise regimen for the patient’s condition, and to provide the patient with th skills to manage the exercise component of their treatment on their own,” she wrote.

“DVA does not fund ongoing, regular participation in exercise programs or ongoing group exercise supervision by exercise physiologists.

“If veterans wish to continue with an exercise program following their treatment, it becomes a private arrangement between the veteran and the gym or exercise physiologist.”

Ms Hope said it was long-standing Department policy not to pay for gym memberships or general exercise programs.

Adrian Rollins

The utility of genetics in inherited cancer

Clinical genetics is a small but important component of patient care

Actress Angelina Jolie’s recent public disclosure of
her BRCA1 gene mutation1 has highlighted the
role of genetic testing in cancer prevention and management. Her endorsement of the genetic counselling and BRCA1 predictive testing process as helping her to be “empowered” and enabling “informed choices” to pursue preventive surgery has energised many people to actively participate in clinical decision making.

Over the past two decades, genetic services have increasingly used cancer predisposition genetic data to deliver benefits to patients. But any benefit depends on two factors. First, any gene implicated in pathogenesis needs to be validated as a significant and reproducible component of heritability. Second, penetrance — the likelihood that the carrier of the gene mutation will develop cancer — is pivotal for disease risk analysis. This affects counselling, surveillance for disease and the surgical options available.

Cancer genetic services can deliver significant benefits
to both patients and families. For patients, it provides optimised management of both the sentinel cancer and future cancer risks. For instance, a colon cancer can be analysed for the expression of protein products of the mismatch repair genes that cause Lynch syndrome. Absent staining leads to expedited genetic testing, and the option of subtotal colectomy for mutation carriers to remove the high risk of a second cancer,2 and, for women, the option of risk-reducing surgery for gynaecological cancers. Similarly, detection of BRCA1 and BRCA2, TP53 or PTEN mutations in a breast cancer triggers risk management for a second cancer. Cancer predisposition gene testing in patients and their relatives has been the standard of care for many years in a number of other cancers: familial adenomatous polyposis (APC gene),3 hereditary retinoblastoma (RB1 gene), multiple endocrine neoplasia type 1 (MEN1 gene) and type 2 (RET gene), and von Hippel–Lindau syndrome (VHL gene). Testing is also standard for bowel cancer predisposition genes (APC, MLH1, MSH2, MSH6, PMS2), renal cancer predisposition genes (VHL, BHD, SDHB, FH, MET) and genes associated with paraganglioma-phaeochromocytoma syndrome (genes for SDH subunit A, B, C and D).

Detecting mutation carriers among the patient’s relatives enables disease risk management. For instance, risk-reducing salpingo-oophorectomy alone increases absolute survival in BRCA1 carriers by 15%, and by a further 6% with the addition of breast imaging.4 Finding an APC mutation in a patient with multiple colonic polyps allows preventive strategies for mutation-carrying relatives, saving lives and sparing non-carriers unnecessary burden and cost.3 Reproductive options including pre-implantation genetic diagnosis are discussed where appropriate; combined with in-vitro fertilisation, at-risk couples have the option of ensuring their offspring do not carry the family-specific mutation.

Understanding the biology of the genetic component of neoplastic processes can lead to appropriate disease surveillance in both sentinel cases and relatives carrying the mutation. For instance, the interval between colonoscopies in people with Lynch syndrome needs to be shorter than in the general population because of the associated accelerated malignant transformation of polyps.

In the absence of a significant known family history — an issue in Australia with its high proportion of immigrant families — certain histopathological characteristics of tumours can indicate mutation carriage.5 Immuno-histochemical analysis of colorectal cancers in patients under 50 years and of endometrial cancers in younger women frequently shows loss of expression of the proteins encoded by mismatch repair genes. It is now standard practice to perform BRCA1 and BRCA2 gene mutation analysis in women under 40 years with oestrogen receptor-, progestogen receptor- and human epidermal growth factor receptor 2-negative breast cancers, especially in the presence of high-grade tumours.

Clinical presentation alone is enough to necessitate genetic analysis in some cases, such as in patients under 40 years with central nervous system haemangiomas, those with bilateral or multiple schwannomas, and in patients under 50 years with phaeochromocytoma or paraganglioma.

In the future, whole genome testing of both the tumour and germline DNA in affected individuals may determine cellular pathways that are potentially targetable by therapeutic agents, improving outcomes. However, the advent of testing for panels of genes and whole genome sequencing raises new ethical and social dilemmas. These include unexpected mutations in genes unrelated to the cancer being investigated, and cases where cancer predisposition gene changes are identified “incidentally” while investigating other disorders. Awareness of and preparedness for addressing these issues is essential in this expanding area of investigating tumour and germline mutations for risk assessment, risk management and tailored treatment.

Reports indicate that changes are needed to close the gap for Indigenous health

Major changes in health services are needed to redress health disparities

Two recently released reports from the Australian Institute of Health and Welfare (AIHW) make it clear that there must be major changes in the way health services for Indigenous Australians are delivered and funded if we are to improve Indigenous health and health care and ensure real returns on the substantial investments that are being made.1,2

These reports show Australia’s level of financial commitment to Indigenous health. In the 2010–11 financial year total spending on Indigenous health was $4.552 billion,1 almost double that spent in 2004–05. This was $7995 for every Indigenous Australian, compared with $5437 for every non-Indigenous Australian;1 over 90% of this funding came from governments. The surest sign that this money was not well invested in prevention, early intervention and community services is that most of it (on average $3266 per person but $4779 per person in remote areas) was spent on services for patients admitted to hospitals, while spending on Medicare services and medicines subsidised by the Pharmaceutical Benefits Scheme (PBS) on a per-person basis was less than that for non-Indigenous Australians by $198 and $137, respectively.2

The series of AIHW reports since the 1995–96 financial year highlights both where progress has been made and where programs have failed. There have been considerable increases in funding for primary care, acute care and community and public health. The 2010–11 data do not reflect the full implementation of the Indigenous Chronic Disease Health Package, but do suggest that the measure to subsidise PBS copayments for patients with chronic disease is having an effect, specifically in more remote areas where PBS spending is higher than in regional areas.

On the other hand, it is obvious that access to primary care services in remote areas remains limited, and access to referred services such as specialists and diagnostics is poor for Indigenous people everywhere, even in major cities. Per-person spending on non-hospital secondary services is about 57% of that for non-Indigenous people.2 Indigenous Australians receive nearly all their secondary care in hospitals.

The hospital data hammer the story home. In 2010–11, the overall age-standardised separation rate of 911 per 1000 for Indigenous people was 2.5 times that for non-Indigenous people; for people living in the Northern Territory the rate was 7.9 times that for non-Indigenous people.3

About 80% of the difference between these rates was accounted for by separations for Indigenous people admitted for renal dialysis, but further examination highlights how a lack of primary care and prevention services drives increased hospital costs. In 2010–11, total expenditure on potentially preventable hospitalisations for Indigenous Australians was $219 million or $385 per person, compared with $174 per non-Indigenous Australian.3 For all Australians most of this spending is for chronic conditions like complications from diabetes, but, too often, Indigenous Australians are hospitalised for vaccine-preventable conditions like influenza and pneumonia, acute conditions like cellulitis, and injury.

Avoidable hospitalisations are an important indicator of effective and timely access to primary care, and provide a summary measure of health gains from primary care interventions. The inescapable reality is that current primary care interventions are not working.

We know what the problems are. Around two-thirds of the gap in health outcomes between Indigenous Australians and other Australians comes from chronic diseases such as cardiovascular disease, diabetes, respiratory diseases and kidney disease.4 Suicide and transport accidents and other injuries are also leading causes of death.5 Half of the gap in health between Indigenous and non-Indigenous Australians is linked to risk factors such as smoking, obesity and physical inactivity.6 A number of studies have found that between a third and half of the health gap is associated with differences in socioeconomic status such as education, employment and income.7

The 2006 Census (the latest available data) found that 39% of Indigenous people were living in “low resource” households (as defined by the Australian Bureau of Statistics8), almost five times the non-Indigenous rate.9 Such disparities in income limit Indigenous people’s capacity to pay for health care and provide some context for why they are more likely to use public hospitals than privately provided services that require copayments.

There are commitments from all the major stakeholders, political parties and policymakers to close the gap. There is a new National Aboriginal and Torres Strait Islander Health Plan 2013–2023. And, arguably, there are enough funds if these are spent wisely. What is needed is a new approach to how health care is developed for and delivered to Indigenous Australians.

The approach needs to be grounded in three broad principles:

  • Adhering to the principle of “nothing about me without me”.10 Shared decision making must become the norm, with patients and their needs at the centre of a system they drive.

  • Addressing the social determinants of health, in particular, the impact of poverty.

  • Addressing cultural barriers in the way that Indigenous people want.

These are not new ideas and all the right words are in the new national health plan, as they were in the previous strategy document — cross-portfolio efforts, partnership, sustainability, culturally competent services, community, a rights-based approach to providing equal opportunities for health. What we must do is move beyond these fine words to meaningful action.

We have the exemplar of how to do this with Aboriginal Community Controlled Health Organisations (ACCHOs), and we need to (i) provide increased opportunities for engagement, collaboration and service delivery with ACCHOs and (ii) expand this way of working into mainstream services. This will require a different approach to policy development and implementation.11

The key barriers to health care for urban and remote populations alike relate to availability, affordability and acceptability12 and the dominance of biomedical models of health.13 ACCHOs are a practical expression of self-determination in Indigenous health and health service delivery,14 and have been very successful at reducing many of the barriers that inhibit Indigenous access to mainstream primary care.15 Importantly, ACCHOs provide both cultural safety, which allows the patient to feel safe in health care interactions and be involved in changes to health services, and cultural competence, which reflects the capacity of the system to integrate culture into the delivery of health services.16

However, the success of the design and work practices of ACCHOs have had little influence on the mainstream health system17 which remains, necessarily, the source of health care for many Indigenous people. And it can be argued that the current funding and regulatory practices of Australian governments are a heavy burden and consume too much of the scarce resources of ACCHOs in acquiring, managing, reporting and acquitting funding contracts.18

Governments and all stakeholders, including Indigenous people themselves, need to be bold enough to redesign current mainstream health policies, programs and systems to better fit Indigenous health concepts, community needs and culture. This approach should not be seen as radical — it is where we are currently headed with Medicare Locals. We should not ignore the fact that ACCHOs have led the way in developing a model of primary health care services that is able to take account of the social issues and the underlying determinants of health alongside quality care.19 Tackling these reforms will therefore benefit all Australians, but especially those Indigenous people who currently feel disenfranchised. Without real and meaningful change, we are all condemned to more government reports bearing sad, bad news and a continual yawning gap of Indigenous disadvantage.

Difficult but necessary conversations — the case for advance care planning

Modern medicine saves many people from acute illness who then live longer with chronic illnesses associated with trajectories of declining physical and mental function over months and years, often punctuated by episodes of acute illness or decompensation. Regrettably, considerable suffering as well as dissatisfaction with and overuse of health care result from a mismatch between the needs of chronically ill patients and current practice norms. Advance care planning (ACP) provides a means of ameliorating this mismatch but is yet to be embedded in routine clinical practice or public consciousness.

ACP is a process of making decisions about future health care for patients in consultation with clinicians, family members and important others. It aims to ensure patients’ wishes are respected if they lose decisional capacity. Conceptually, it comprises five sequential phases, from pre-contemplation to action and maintenance (Appendix 1),1 which include completion of a written advance care plan (or advance health directive [AHD], also termed “living will”) and the appointment of a surrogate decisionmaker. Unfortunately, in the past, ACP has often been focused on raising completion rates of AHDs, despite there being no guarantee such documents in themselves improve end-of-life care2 or correspond with future care preferences.3 A better focus is to encourage widespread use of ACP as a process for iteratively identifying and facilitating what patients consider important for a “good death” (such as managing symptoms, avoiding prolonged dying, achieving a sense of control, relieving burdens placed on the family and strengthening relationships) and for informally communicating their future wishes.4

At least 50% of all deaths in Australia each year are clinically expected because of advanced disease.5 In their last year of life, Australians with advanced disease will average eight hospital admissions and incur a 60%–70% chance of dying in hospital.5,6

More than half may be denied adequate opportunity to discuss end-of-life care wishes7 or have them fully enacted.8 Many patients at the end of life undergo futile (of no benefit at all) or inappropriate (harms outweigh potential benefits) interventions.9 Almost a quarter of intensive care beds are occupied by patients receiving potentially inappropriate care,10 while up to a quarter of health budgets are spent on inpatient care during the last 18 months of life without any real prospects of extending overall survival or impacting on quality of life.11 Most complaints received from bereaved family members about hospital treatment relate to end-of-life care, mainly perceived failures of communication and preparedness for death.12 In one study, doctors spent a median time of only 1 minute on do-not-resuscitate discussions with patients after admission.13

Randomised trials of ACP are few and report mixed results. The sentinel trial, SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments), which used nurse facilitators over 2 years to undertake discussions with seriously ill hospitalised patients and families and document their preferences, showed no improvement in patient control over their treatment.14 However, a more recent trial of ACP showed improved patient and family satisfaction and alleviation of anxiety in relatives of hospitalised patients.15 Observational studies have shown similar findings.16 Other randomised trials17 and before-and-after studies18 involving nursing home residents have shown 40% to 80% reductions in rates of hospitalisation and up to threefold increases in palliative care referrals resulting from advance care directives. Experience with ACP in the aged care sector in Victoria has shown that less than 3% of residents in aged care facilities approached about ACP declined it, and 90% of those who completed ACP died in the facility while receiving palliation rather than in hospital, compared with only 50% of those who had not completed ACP.19 Use of ACP invokes earlier initiation of more appropriate palliative care, which improves patient symptoms and mood, reduces undesired use of invasive interventions and life-sustaining treatments, lowers the likelihood of inhospital death, prolongs life of higher quality and decreases costs.20–22

Challenges in advance care planning

Regardless of potential benefits, ACP uptake in Australia has been slow, despite widespread professional and public endorsement coupled with supporting legislation in every state and territory. However, many hospitals and nursing homes are now implementing ACP programs, most along the lines of the Respecting Patient Choices program initiated at Austin Hospital in 2002.23 Factors inhibiting universal adoption of ACP are several:

  • Reluctance to acknowledge impending mortality: Reflecting societal norms, most individuals, including clinicians, find it difficult to think and talk about dying.

  • Perceived irrelevance: Many patients may perceive themselves as being “too healthy”, hope (often unrealistically) for medical technology to prolong healthy life, regard future events as a matter of fate, or consider their wishes are already known to doctors and family.24

  • Issues of timing: Intuitive prognostications of clinicians can be inaccurate, with formal prediction tools offering limited assistance.25 Consequently, “curative intent” remains the focus, with initiation of ACP often occurring too late, leading to rushed care decisions and suboptimal outcomes.

  • Diffusion of responsibility: The role of initiating and coordinating ACP, which must encompass all patient needs — clinical, emotional and spiritual — must be accepted by someone. Patients often wait for doctors to broach the subject, while clinicians wait for patients or family members to do so. General practitioners wait for a signal from specialists that may never come if multiple specialists are involved, with no one taking charge overall.26

  • Limited clinician time, skill and remuneration: The pressure of clinical work, a focus on managing acute medical problems and the absence of suitable training and remuneration discourages clinicians from dedicating time to ACP.

  • Limitations of surrogate decisionmakers: The views of proxies and patients are often discordant,27 or there may be conflicts between family members. Surrogate decisionmakers may not want to assume sole responsibility, and subsequent guilt, for terminating life-sustaining measures.

  • Ambiguous, inconstant or poorly recorded wishes: Patient preferences can change over time, are often based on wrong or insufficient information, or are documented in vague, incomplete terms on forms not easily retrieved when needed. Because of this lack of clarity at the time of decision making, doctors and surrogates may disregard or feel incapable of enacting expressed wishes, especially if legal or ethical concerns persist around patients’ decisional capacity at the time ACP documents were written or altered.

  • Differing perceptions of ACP: Many people feel intimidated by what they perceive as legally binding and irrevocable AHDs which arise from ACP. Others equate ACP with palliative care, which they assume indicates imminent death due to a rapidly terminal illness. Finally, some link ACP with euthanasia or assisted suicide, which has seen doctors in the United States who discuss ACP with patients being caricatured as “death panels”.28

Elements of successful advance care planning

Given these challenges, no single strategy will achieve the transition of patients and their proxies from pre-contemplation to action in ACP.29 The most effective and systematic, yet personalised, approach comprises structured, iterative conversations about values and preferences for end-of-life care led by trained, trusted and paid facilitators (who may include nurses and social workers as well as doctors). Such conversations occur over several visits, actively involve properly informed surrogates, and are supported by oral, written and videorecorded information. In these interactions, an advance care plan or a medical enduring power of attorney may serve as more versatile media for ACP than a static AHD.30

Timing of the conversation

Contemplation of ACP by patients and their clinicians often starts with recent serious illness or major surgery, worsening symptoms and functional decline, or experience with ACP involving significant others.31 Lay texts32 and public engagement campaigns such as the Conversation Project in the US (www.theconversationproject.org) and Dying Matters Coalition in the United Kingdom (www.dyingmatters.org) encourage people to have “kitchen table” end-of-life care discussions with family members and then with their doctors. Furthering these conversations requires proactive intervention by clinicians who are highly knowledgeable of the clinical profile of individual patients and the burdens of disease-specific treatment options, able to identify triggers for opportunistic discussions about ACP, cognisant of both physical and non-physical domains of health, and trained in communication and shared decision-making skills.

While the timing of ACP must be sensitive to patients’ readiness to enter into such conversations, a pragmatic three-step guide for clinicians33 is to consider ACP if:

  • “No” is the answer to this question: “In light of all you know about this patient, would you be surprised if he/she was to die within the next 6 to 12 months?”;

  • the patient’s general health is poor (eg, limitations in self-care, multiple hospitalisations); and

  • disease-specific indicators portend a poor prognosis (eg, advanced organ failure, dementia, disabling neurological conditions, progressive malignancies).

Specific triggers for ACP discussion might include: new diagnoses of life-limiting conditions; severe, irreversible deterioration in the patient’s health status; loss of response to, or complications from, disease-specific treatments; unrealistic expectations or requests for care by the patient or their family; or an expressed desire of the patient or their family to discuss ACP.

Initiating and holding the conversation

Initial reactions of patients and family to ACP can be negative, but responses usually improve as issues are clarified and resolved. Patient comfort in discussing end-of-life care is facilitated by a stepped approach and use of facilitative language (Appendix 2). The first step is a values discussion aimed at defining values, goals and preferences for care in general (advance statement of preferences or wishes) and only later moving to more binding decisions about specific forms of care under specific circumstances (advance decisions). A key task is ascertaining which patient wants what information at this particular time, while respecting preferences for silence. Identifying a surrogate decisionmaker and involving them in discussions around foreseeable events should also occur at an early stage. Patients and surrogates should be reassured that responsibility for terminating life-sustaining measures will be shared between clinicians (as technical medical experts) and themselves (as experts on patients’ values and preferences).

Further tips for ensuring successful ACP conversations are listed in Box 1,34 and useful resources, including ACP document templates, are available in various texts35 and from several websites: Advance Care Planning Australia (http://advancecareplanning.org.au); National Health Service Improving Quality (http://www.endoflifecare.nhs.uk/care-pathway/step-2-assessment,-care-planning-and-review/preferred-priorities-for-care.aspx); and the Conversation Project (www.theconversationproject.org). Legitimate concerns about ACP can be mitigated by instituting appropriate safeguards (Box 2).

Strategies for embedding advance care planning into routine care

In embedding ACP into routine practice, all health care organisations (general practices, hospitals, residential care facilities) need to become “conversation ready”; that is, committed to systematically eliciting, documenting and enacting patients’ care preferences.36 System-wide processes (Box 3) are needed that will consistently:

  • invite all eligible patients to consider ACP for future care relevant to their stage of illness;

  • provide competent assistance by trained and accountable personnel; and

  • ensure written plans (however documented) are

    • accurate, relevant and understandable to all stakeholders

    • stored, transferred and retrieved wherever the patient is being treated

    • updated and rendered more specific as illnesses progress

    • sighted and honoured at the right time.

Given their longstanding, trusted relationships with patients, GPs are probably best placed for timely ACP, but they need to be supported in this task by medical specialists, senior nurses and allied health professionals. Legal clarification is required regarding the need for advance care plans or AHDs to comply with specific forms, their transferability between jurisdictions, their scope in covering all future treatment decisions, and the enforceability of oral plans or directives. In all Australian jurisdictions, competent patients or surrogate decisionmakers cannot demand treatment that clinicians believe to be futile, including enteral or intravenous nutrition and hydration. There are no reports of Australian or UK courts overturning a carefully considered decision to withhold treatment doctors deemed to be futile.37

The goals of ACP are indisputable and its benefits are becoming evident. If ACP is to become a mainstream clinical activity, health care services and professionals must effectively educate themselves and their patients about its purpose. They must take practical steps to implement auditable ACP systems in routine practice, document ACP in accessible formats that enables patient wishes to accurately guide clinical management, review ACP decisions when clinically required, and evaluate the effects of ACP on clinical outcomes and the fulfilment of patients’ wishes.

1 Tips for successful advance care planning conversations*

  • The individual needs to be ready for the conversation and mentally capable of participating — conversation cannot be forced, but at the same time clinicians, in most instances, need to take the lead in initiating such conversations.

  • Capacity to engage in conversation must be maximised by treating any transient condition affecting communication and optimising sensory function (eg, by ensuring the patient’s hearing aid is being worn).

  • Conversations need to take place on more than one occasion (over days, weeks, even months) and should not be completed on a single visit in most circumstances.

  • Conversations take time and effort and cannot be completed as a simple checklist exercise.

  • Conversations should take place in comfortable, unhurried surroundings; time is a key factor.

  • Conversations should be devoid of medical jargon, language should be positive, and trust must be built using empathic listening skills.

  • A step-by-step approach to identifying and resolving issues should be used (see Box 2), coupled with “time-out” periods where doctors withdraw from the encounter for some minutes to allow patient and family to discuss between them the care options that have been presented.

  • Individuals should be given realistic information on prognosis and treatment options with emphasis on how their illness is expected to impact on their daily function.

  • Conversations should avoid focusing initially on medical interventions (eg, cardiopulmonary resuscitation, intubation) but rather determine values, goals, and preferences (eg, prolonging life and preserving mentation versus minimising suffering and avoiding undignified states or an unacceptable functional status).

  • Look out for cues suggesting individuals are becoming uncomfortable talking about certain issues or may wish to end the conversation.

  • Encourage patients to identify a surrogate decisionmaker and to discuss their wishes with that individual; if desired, offer to facilitate a conversation between patients and their surrogate or other family members; identify whether patients have specific desires for how information is shared among family members.

  • Summarise and check patient’s and, if they are present, surrogates’ understanding of what has been discussed at end of sessions.

  • Encourage patient and surrogates to have conversations documented but reassure them these documents are not necessarily final or binding.

  • Plan for a review as clinical circumstances change.

* Adapted from Advance care planning. Concise Guidance to Good Practice series, No. 12. London: Royal College of Physicians, 2009.34 

2 Concerns and safeguards in advance care planning (ACP)

Concerns

Safeguards

Lack of understanding and recall

  • Poor patient understanding following ACP discussions

  • Low concordance between recollections of patient and physicians or proxies

  • Lack of recall of care decisions into the future

  • Patient uncertainty about care wishes, especially among patients from non-English speaking backgrounds or with low levels of literacy

  • Provide comprehensible information sufficient to allow patients to feel comfortable with their level of understanding

  • Before terminating conversations, reiterate decisions to ensure patients, clinicians and proxies are all “on the same page”

  • Provide copies of summaries of conversations (including videorecordings of the sessions) on request at their conclusion

  • Involve family and interpreters in ACP conversations and documentation. Conduct conversations at the appropriate level of literacy and involve health professionals of similar ethnic background

Coercion

  • Undue influence of clinicians in care decisions who may rate patient quality of life considerably lower than patients themselves

  • Coercion of patients and proxies to agree to limitations of life-sustaining therapy

  • Involve more than one health professional in ACP conversations and include individuals who have not been directly involved in the patient’s care up to that point in time

  • Emphasise and reiterate the goals of ACP that respect patient autonomy and wishes within the bounds of care that is not deemed to be futile

Inflexibility

  • Inflexibility of “locked-in” ACP documents that are not responsive to changes in clinical circumstances and/or patient and proxy preferences

  • Use a range of ACP procedures — one size does not fit all — with initial emphasis on eliciting values and preferences rather than concrete treatment decisions

  • Apply any ACP document or advance health directive only to a decisionally incompetent patient or a patient who is unable to communicate. Competent and conversant patients can always speak for themselves

  • Undertake ACP conversations in non-emergent situations when patients are clinically stable and not mentally impaired by reversible illness

  • Update ACP documents regularly and whenever circumstances change significantly

3 System-wide strategies for embedding advance care planning (ACP) into routine care

Primary care settings

Use computer reminders to initiate ACP discussions in eligible patients at upcoming doctor appointments.

Mail introductory ACP material to eligible patients.

Dedicate time for ACP within annual comprehensive medical assessments and extended primary care consultations.

Train practice nurses or social workers to act as case managers
in ACP for patients following initial discussions with doctors.

Hospitals

Initiate conversations about ACP when admitting frequently hospitalised patients, formulating acute resuscitation plans or care pathways for chronically ill patients and caring for patients transferred from or to residential care facilities.

Place clinicians skilled in ACP in all units with sizeable numbers of chronically ill patients (general and geriatric medicine, oncology, cardiac and respiratory), tasking them with identifying and counselling suitable patients and imparting ACP skills to other staff.

Document the status of ACP discussions in discharge summaries. Discharge co-ordinators ensure ACP information is communicated to all external clinicians.

Foster staff awareness of ACP using screensaver messages on workstation computers and posters and brochures on noticeboards.

Residential care facilities

Routinely initiate ACP conversations between senior nurses and patients and their proxies following admission, after any major change in clinical status and at yearly intervals, or more frequently depending on change in clinical status.

Make easy-to-read ACP information available to all new residents, and display promotional material for staff and facility visitors.

Require facility-affiliated general practitioners and geriatricians, working with senior nurses, to undertake ACP training and information sessions and implement and audit ACP processes according to best practice.

Accessibility, standardisation and auditing of
ACP documents

Require hospital and health services, Medicare locals and residential care facilities to generate and use area-wide ACP document templates that are standardised, simple, patient-friendly and readily downloadable at the point of care. File copies of completed advance care plans and/or AHDs in a consistent manner, flag them on all patient records (including patient-controlled electronic health records) and ensure they are able to be rapidly retrieved, preferably via a centralised electronic registry.

Store ACP documents with electronic medical records to enable quick communication regarding changes in plans to all parties involved through shared portals.

Provide patient-held wallet cards or alert bracelets to flag the existence of ACP documents for the benefit of ambulance services and emergency physicians at times of crisis.

Regularly audit ACP processes and document the level of congruence between expressed patient wishes and the care actually received.

Professional training

Ensure all clinicians, especially doctors, case managers and social workers, undergo training in ACP and appropriate communication skills using simulation techniques, role-play, scenario analyses and computer-based decision aids.

Include measures of competency in ACP in professional credentialling processes.

Public awareness

Display brochures and texts that introduce ACP (such as Planning your future care, available at www.endoflifecareforadults.nhs.uk) in clinics and interview rooms and on noticeboards.

Recruit health professionals to sponsor and participate in public engagement campaigns that serve to both educate and prompt patients in discussing ACP.

Create a national clearinghouse for ACP information, document templates and related laws that cover all Australian state and territory jurisdictions.

Highlight user-friendly websites and resources for consumers and professionals in lay and professional news media.

Educate the public in the skills and benefits of shared decision making.

Preoperative cardiac evaluation and management of patients undergoing elective non-cardiac surgery

In the 2010–11 financial year, 2.4 million surgical operations were performed in Australian hospitals, most (80%) being elective non-cardiac surgery.1 Cardiac complications — myocardial infarction (MI), cardiac arrest and other serious arrhythmias, and acute heart failure — occur in about 5% of patients aged 70 years or older undergoing non-cardiac surgery.2,3 Such complications carry 30-day mortality rates between 15% and 20% and account for a third of all postoperative deaths.2,3 They also prolong hospital length of stay, increase illness burden and reduce long-term survival.4,5 Some are potentially preventable: the Australian Incident Monitoring Study found that 3.1% of adverse events in hospital resulted from inadequate or incorrect preoperative assessment or preparation of patients.6 Inadequate preoperative assessment and medical optimisation of patients also causes delays or cancellations in surgery.

In this article, we supplement evidence presented in previous guidelines7,8 relating to preoperative evaluation and management of cardiac risk in patients undergoing elective non-cardiac surgery.

Preoperative cardiac risk stratification

Clinical assessment

Risk stratification starts with simple bedside evaluation that integrates clinical risk factors, functional capacity and type of surgery. Patients at low risk could be offered early surgery after assessment by their general practitioner, while complex patients may need more detailed assessment by a perioperative physician or cardiologist, in liaison with anaesthetists, surgeons and GPs. This approach facilitates more efficient professional decision making, better communication with primary care-based teams, more rapid optimisation of a patient’s medical fitness for surgery, and more targeted postoperative management. It also allows patients to be better informed of both the potential benefits and risks of surgery when giving consent.

Clinical risk factors

The Revised Cardiac Risk Index (RCRI) is a multivariable predictive index for major perioperative cardiac complications (Box 1).9 All clinical variables contribute equally to the index (1 point each), with scores of 0, 1, 2 and ≥ 3 points corresponding to estimated risks of major cardiac complications of 0.4%, 0.9%, 7% and 11%, respectively. Low-risk patients have an RCRI score of 0, intermediate-risk patients have a score of 1 or 2, and high-risk patients have a score of 3 or more. A systematic review has shown the RCRI to discriminate well (concordance index, 0.75) between high- and low-risk patients undergoing non-cardiac surgery, but less well (concordance index, 0.64) among patients undergoing vascular surgery.10 The RCRI also does not account for age or history of hypertension; these have been included in an adapted index that better predicts cardiovascular complications in older patients.11

Functional capacity

Functional capacity, as measured in metabolic equivalents (METs) on the basis of history or exercise testing, ranges from poor (< 4 METs) to excellent (> 10 METs). The inability to walk four blocks or climb two flights of stairs (4 METs) carries an increased perioperative cardiac risk.12

Type of surgery

Surgically induced stress can predispose to coronary thrombosis and myocardial ischaemia. Surgical interventions can be divided into low-, intermediate- and high-risk groups, with estimated 30-day death or MI rates of < 1%, 1%–5%, and > 5%, respectively (Box 2).13 While laparoscopic surgery and regional anaesthesia confer better pain relief and earlier functional recovery than open surgery and general anaesthesia, it remains unclear whether they significantly reduce cardiac risk.14,15

An algorithm integrating the considerations discussed above in assessing cardiac fitness for surgery is outlined in Box 3,8 and a clinical case study is presented in Box 4.

Role of cardiac investigations

Investigations should only be performed if: a) the results are expected to accurately and significantly change clinical estimates of risk; b) these altered risk estimates consistently lead to changed management decisions; and c) the resultant management changes have been shown in clinical trials to improve clinical outcomes. As situations that satisfy all three of these criteria are rare in perioperative medicine, the value of investigations, apart from a routine 12-lead electrocardiogram (ECG), is limited in preoperative cardiac management. The most useful applications may be in reclassifying intermediate-risk patients to either low-risk (surgery can safely proceed without further intervention) or high-risk (needing more detailed evaluation and use of prophylaxis), or in determining unacceptable surgical risk in high-risk patients undergoing high-risk surgery (Box 3).8

Rest echocardiography

Rest echocardiography has little value in preoperative evaluation of cardiac structure and function in patients lacking clinical features of heart failure or valvular heart disease because of its inability to accurately predict perioperative events.18 A recent population-based retrospective cohort study of 264 823 patients showed no benefit in survival or hospital length of stay from rest echocardiography performed within the 6 months before surgery.19

Non-invasive stress testing

Treadmill stress testing, dobutamine stress echocardiography (DSE) and myocardial perfusion imaging (MPI) have limited value in predicting perioperative cardiac events and are not indicated in low- or intermediate-risk patients or those undergoing low-risk surgery.20 High-risk patients (those with an RCRI score ≥ 3) or those undergoing intermediate- or high-risk surgery may be eligible for testing if the results are likely to change management. In patients unable to exercise, DSE and MPI can detect moderate to large ischaemic burden with similar accuracy.20

Cardiopulmonary exercise testing

This assesses functional capacity more accurately than patient self-report, and measures of total oxygen consumption and anaerobic threshold (if above certain threshold values) seem to identify individuals at very low surgical risk.21 While cardiopulmonary exercise testing may provide additional prognostic information in older patients with cardiopulmonary disease or patients undergoing major thoracic or abdominal operations, there are currently insufficient data to show its routine use alters perioperative care or outcomes compared with bedside risk stratification methods.22

Biomarkers

Biomarkers such as high-sensitivity troponin and B-type natriuretic peptide (BNP) appear to add incremental prognostic information to the RCRI.23,24 However, until adequately powered trials show such revised risk estimates change management and improve patient outcomes, biomarker tests should not be used routinely.

Computed tomography coronary angiography

This imaging procedure for coronary artery anatomy may provide additive value to the RCRI in assessing patients undergoing intermediate-risk surgery,25 but its impact on decision making and clinical outcomes remains unclear.

Perioperative cardiac prophylaxis

Several preventive strategies may be considered in intermediate- and high-risk patients undergoing intermediate- or high-risk surgery. Medications patients are already receiving for known coronary artery disease (CAD) should be continued throughout the perioperative period unless specific contraindications supervene.

β-Blockers

β-Blockers are potentially useful in lowering cardiac risk by antagonising the effects of adrenaline and other stress hormones and exerting negative chronotropic and inotropic actions. However, results of randomised trials and meta-analyses suggest mixed effects, with further uncertainty resulting from the recent disclosure of several potentially fraudulent or negligent Dutch trials.26 The large Perioperative Ischemic Evaluation Study (POISE) showed a 31% reduction in the risk of non-fatal MI with β-blockers, at the expense of a 34% increased risk of all-cause mortality and 89% increased risk of non-fatal stroke.27 A recent meta-analysis of nine well conducted “secure” trials (including POISE, and excluding the “non-secure” Dutch trials) found initiation of β-blockers before surgery caused a 27% increase in 30-day all-cause mortality and a 73% increase in non-fatal stroke, while decreasing risk of non-fatal MI by 27%.28 The updated 2009 American College of Cardiology and American Heart Association guidelines give a Class 1 recommendation only for continuing β-blockers in patients with a pre-existing cardiac condition for which there is a strong indication.29

However, two large retrospective observational studies using propensity-based risk adjustment suggest that β-blockers reduce all-cause inhospital deaths proportionally to increasing cardiac risk, as measured by an RCRI score ≥ 2, while increasing deaths in those with an RCRI score < 2 (Box 5).30,31 In the former patients, one of the studies showed that, while β-blockers reduced risk of non-fatal MI and cardiac arrest, stratified analyses indicated these benefits were limited to patients undergoing non-vascular surgery.31

It thus remains unclear which patients benefit from β-blockers. If β-blockers are to be initiated, observational data suggest they be restricted to high-cardiac-risk patients,30,31 and should be commenced some weeks before surgery and haemodynamically titrated to a tolerable dose that lowers resting heart rate to 70 beats/min.32 Longer-acting agents such as atenolol appear to be safer than short-acting agents such as metoprolol.33

Statins

Statins improve endothelial function, reduce vascular inflammation and stabilise atherosclerotic plaque. Evidence of benefit of perioperative treatment in statin-naive patients is of limited quality and is dominated by observational studies34 or trials in cardiac surgery.35 The few secure randomised trials involving patients undergoing non-cardiac vascular surgery are underpowered and inconclusive.36 Patients already prescribed statins as chronic therapy should continue treatment in the perioperative period.

Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have not been shown to improve outcomes in the absence of left ventricular systolic dysfunction. Indeed, observational studies suggest they predispose to severe intraoperative hypotension (generally responsive to fluid loading and vasopressors), especially if combined with β-blockers or diuretics, and may increase 30-day mortality in patients undergoing major vascular surgery.37 There is debate about whether these agents should be withheld one half-life before anaesthesia induction if their indication is purely for hypertension (unless blood pressure is uncontrolled) or, given the preponderance of day-of-surgery admissions, to recommend continuation with adequate hydration.38 A prospective randomised trial is required to clarify the safety of perioperative use of these agents.

Aspirin

Aspirin interacts with the cyclo-oxygenase enzyme system and irreversibly inhibits platelet aggregation, theoretically lessening risk of coronary thrombosis but increasing risk of perioperative bleeding. No adequately powered trial has assessed benefits of aspirin prophylaxis in aspirin-naive patients. In patients with known CAD, excluding those with recent coronary artery stent insertion (discussed below), risk of subsequent death or MI is increased two- to threefold if aspirin is ceased before surgery.39 While the risk of major postoperative bleeding may offset this cardiac risk for certain procedures, such as extensive skin grafting, a recent meta-analysis of 41 studies involving 49 590 surgical patients shows that, overall, the cardiac risk exceeds bleeding risk for most surgical patients with known CAD whose aspirin is withheld.40

Coronary artery revascularisation

Percutaneous coronary intervention (PCI) or coronary artery bypass grafting is only indicated before non-cardiac surgery in clinically unstable patients (those with unstable angina, recent MI or ventricular arrhythmias) with significant left main or three-vessel (or two-vessel if this includes the proximal left anterior descending artery) CAD. A large trial failed to show any perioperative or long-term benefit of prophylactic revascularisation, compared with optimal medical treatment alone, in stable patients undergoing high-risk surgery.41

Other challenging scenarios

Congestive heart failure

Large observational studies show that symptomatic congestive heart failure (CHF) increases the absolute risk of perioperative death to 8% — more than twice the risk seen in established CAD without CHF.42 Other studies suggest stable, well controlled CHF does not necessarily increase risk.43 Current guidelines are uncertain about when left ventricular function should be reassessed using echocardiography in clinically stable patients with known CHF.7,18 The ability of BNP and N-terminal proBNP to discriminate cardiac risk among patients with CHF, who may have chronically elevated levels, has yet to be examined.18 It is also unknown whether optimising CHF management before surgery — including using a BNP-guided strategy to titrate therapy, correcting coexisting anaemia and strictly controlling ventricular rate in patients with atrial fibrillation — improves postoperative outcomes.44 What is agreed is the need to defer surgery in patients with decompensated or severe chronic CHF (worsening or new-onset CHF; New York Heart Association Class IV symptoms) until they are medically optimised and euvolaemic. In patients with newly diagnosed CHF, elective surgery should be delayed 3 months or more to allow adequate time for antifailure therapies to improve left ventricular function and remodelling.44 β-Blockers with proven mortality benefit (bisoprolol, carvedilol or metoprolol succinate) and ACE inhibitors or ARBs should be continued during the perioperative period unless precluded by hypotension or symptomatic bradycardia.

Severe valvular heart disease

In all patients with clinical features consistent with severe valvular heart disease, preoperative echocardiography and a 12-lead ECG are mandatory in assessing valve and left ventricular dysfunction. These are also important to screen for conduction system defects caused by perivalvular fibrosis that may predispose to bradyarrhythmias requiring perioperative pacing. Ideally, patients eligible for valve reconstruction or replacement, or transcutaneous valvuloplasty or valve implantation, should undergo these procedures before elective surgery. This is particularly pertinent in patients with symptomatic or critical calcific aortic stenosis with a valve area < 0.8 cm2, which carries a 10%–28% risk of perioperative sudden cardiac death.45 Patients with severe mitral regurgitation should be medically optimised before surgery, including rate control of chronic atrial fibrillation. ACE inhibitors or ARBs prescribed for afterload reduction should be continued despite a risk of anaesthesia-induced hypotension. In the absence of prior history of infective endocarditis, mechanical prosthetic heart valves, congenital heart defects, cardiac transplantation with valvulopathy, or rheumatic heart disease in Indigenous Australians, prophylactic antibiotics are usually not required. Exceptions to this are operations associated with a high risk of bacteraemia (dental procedures and periodontal disease; genitourinary procedures; surgery involving the oropharynx, respiratory tract, sinuses, nose or ear; incision and drainage of local abscesses; or surgery through infected skin).8,46

Recent percutaneous coronary intervention with stent insertion and dual antiplatelet therapy

Australian guidelines from 2009 recommend that elective surgery requiring cessation of dual antiplatelet therapy should be postponed for at least 6 weeks after insertion of bare-metal stents and 12 months after insertion of drug-eluting stents (DES).47 However, more recent American guidelines reflecting additional new evidence and experience with later-generation DES suggest a minimum period of 6 months after insertion of DES.48 A recent retrospective cohort study of more than 28 000 patients who underwent non-cardiac surgery within 2 years after stent insertion showed that major adverse cardiac events at 30 days were associated with emergency surgery, history of MI in the 6 months before surgery and an RCRI score greater than 2, but not with stent type or timing of surgery beyond 6 months after stent insertion.49 Ceasing dual therapy earlier than stipulated above carries a very high risk of stent thrombosis, with mortality rates up to 20%.50 Continuation of dual therapy confers little risk of major bleeding in most minor surgery (Box 6). In patients requiring urgent surgery associated with high bleeding risk within the recommended minimum time frames, aspirin should be continued and clopidogrel (or prasugrel or ticagrelor) withdrawn at least 5 to 7 days before surgery, depending on the agent.8,47 This should be coupled with consideration of bridging anticoagulation (heparin–tirofiban or heparin–eptifibatide) in selected highest-risk patients (although there are limited data in support of such treatments).47 Any discussion about postponing surgery or continuing, modifying or discontinuing antiplatelet therapy must involve close liaison between a patient’s GP, interventional cardiologist, anaesthetist, surgeon and haematologist to balance the risk and benefit of such decisions. Patients scheduled for PCI and requiring non-cardiac surgery in the foreseeable future should preferably receive bare-metal stents.

Oral anticoagulant therapy for thromboembolic disease

Whether and when to withhold anticoagulants depends on the balance between risk of thromboembolic events if interrupted and risk of major bleeding if continued (Box 6). Patients at low thromboembolic risk can cease taking anticoagulants with no need for bridging heparin, while those undergoing minor procedures with low bleeding risk do not require their cessation.51 In high-risk patients, bridging heparin is required after oral anticoagulants are ceased 5 days (for warfarin)51 or between 24 hours and 4 days (for the newer oral agents dabigatran, rivaroxaban and apixaban, as per manufacturer’s product information for each) before surgery. Bridging anticoagulation with subcutaneous low-molecular-weight heparin, if there are no contraindications, obviates the need for hospitalisation to administer intravenous unfractionated heparin. Bleeding risk with the newer anticoagulant agents is of concern, given the lack of both an antidote and reliable assays of anticoagulation effects. Early, effective and ongoing communication between GPs and specialists, combined with reference to detailed, up-to-date protocols, is required to maximise patient safety during perioperative transitions of anticoagulation.52

Obstructive sleep apnoea

Obstructive sleep apnoea (OSA) affects up to 25% of adult general surgical patients and up to 77% of those undergoing bariatric surgery.53 As many as 70% of cases are undiagnosed before patients present for preoperative evaluation. In a recent meta-analysis of case–controlled and cohort studies of patients diagnosed with OSA and undergoing elective surgery, postoperative cardiorespiratory events were twice those seen in patients without OSA (3.8% v 1.7%).53 Various screening questionnaires with equivalent predictive value in identifying patients with moderate to severe OSA are easy to administer.54 In cases where known OSA is mild or screening risk is low, surgery is low risk and there are no associated comorbidities, surgery can proceed without further intervention. In all other cases, formal evaluation by a sleep physician, initiation or titration of continuous positive airway pressure (CPAP) therapy where indicated, and close liaison with anaesthetists should be undertaken. The optimal duration of CPAP therapy in newly diagnosed patients awaiting surgery and how patients with known OSA who are non-compliant with CPAP therapy should be treated remain uncertain.

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) frequently coexists in patients with CAD or CHF who are, or have been, smokers. COPD is an independent risk factor for major cardiopulmonary complications and can complicate assessment of functional capacity and administration of prophylactic β-blockers. Clinical history and simple bedside spirometry are sufficient to gauge disease severity in otherwise stable patients. Routine chest x-rays and formal lung function tests add little value. In the absence of moderate to severe bronchospasm, a meta-analysis supports the safety of cardioselective β-blockers in most patients with stable COPD.55 Patients with combined bronchospastic disease and CAD who are undergoing high-risk surgery might derive cardioprotective benefit from α-2 adrenergic agonists (such as clonidine).56 Before surgery, patients with unstable COPD or asthma should receive oral steroids, which do not compromise wound healing, and all patients with COPD should totally abstain from smoking for at least 6 weeks.

Cardiac implantable electronic devices

For patients with these devices, especially implantable cardioverter defibrillators (ICDs), GPs or anaesthetists should ideally contact the relevant cardiologist to ascertain the type of device, its indications, current settings and mode of magnetic inactivation (if applicable). Such information allows appropriate safeguards to be organised, if required, before surgery.57 Surgical diathermy, particularly in chest, head or neck surgery, can cause electrical interference that may inhibit pacemakers or trigger shocks from ICDs.

Conclusion

High-quality evidence underpinning preoperative cardiac assessment and management is limited, and more research is required. GPs, working in liaison with perioperative physicians, cardiologists and anaesthetists, have important roles in stratifying patient risk using clinical risk assessment and selective use of investigations, implementing appropriate prophylaxis and optimisation regimens, and consulting with surgeons regarding if and when surgery should proceed after weighing up potential benefits and harm of surgery.

1 Revised Cardiac Risk Index9

One point for each feature:

  • High-risk type of surgery (see Box 2)

  • Ischaemic heart disease (any of: history of myocardial infarction, history of a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischaemia, use of nitrate therapy, or electrocardiogram with pathological Q waves)

  • History of congestive heart failure

  • History of cerebrovascular disease

  • Preoperative treatment with insulin

  • Preoperative serum creatinine level > 177 μmol/L

2 Estimated cardiac risk* of types of surgery13

Low risk (< 1%)

Intermediate risk (1%–5%)

High risk (> 5%)

  • Breast

  • Dental

  • Endocrine

  • Eye

  • Gynaecological

  • Plastic and reconstructive (skin grafts and flaps)

  • Orthopaedic — minor (knee)

  • Urological — minor

  • Abdominal

  • Carotid

  • Peripheral arterial angioplasty

  • Endovascular aneurysm repair

  • Head and neck

  • Neurological or orthopaedic — major (hip and spine)

  • Lung, renal or liver transplant

  • Urological — major

  • Aortic and major vascular

  • Peripheral vascular

* Risk of death or myocardial infarction within 30 days of surgery.

3 Algorithm for evaluating cardiac risk before non-cardiac surgery*

NHF/CSANZ = National Heart Foundation and Cardiac Society of Australia and New Zealand.
RCRI = Revised Cardiac Risk Index. METs = metabolic equivalents. * Adapted with permission
from the American College of Cardiology/American Heart Association ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery.7 † The 2006 guidelines for acute coronary syndromes16 and the 2011 update to the guidelines for heart failure.17 ◆

4 Clinical case study

Mrs C is a 65-year-old woman referred to a hospital perioperative service for preoperative evaluation and optimisation. She is booked for an elective left hemicolectomy for localised, well differentiated carcinoma of the sigmoid colon. Her preoperative evaluation finds significant functional impairment (metabolic equivalents [METs] < 4) and elevated jugular venous pressure, on a background of past myocardial infarction, lifelong smoking (50 pack-year history), hypertension, dyslipidaemia and chronic renal failure with a serum creatinine level of 190 μmol/L. A 12-lead electrocardiogram shows sinus rhythm, with Q waves in the inferior leads and T-wave inversion in the lateral leads. An echocardiogram shows severe systolic dysfunction with a left ventricular ejection fraction of 20% and akinetic scar in the inferior wall. Spirometry demonstrates moderate obstructive airway disease (forced expiratory volume in 1 second [FEV1], 51% predicted). Her Revised Cardiac Risk Index (RCRI) score is 3, with a predicted perioperative cardiac event rate of 9%–12%.

Key management questions to consider for this patient are:

  • Would you request any other investigations to refine your estimates of her cardiac risk?

  • How would you advise her in regard to the risks and benefits of surgery?

  • Would you be in favour of, or against, surgery at this time?

  • What steps would you take to optimise her medical fitness for surgery?

You and Mrs C both consider her cardiac risk — as assessed by her RCRI score, functional capacity and signs of uncontrolled congestive heart failure (CHF) — to be too great for surgery to proceed immediately. Given the prognostically favourable stage and histology of her carcinoma, you opt for an 8-week period to optimise her current therapies before surgery. As the patient reports no angina, has no other clinical stigmata of vascular disease, does not have diabetes and is not undergoing high-risk surgery, you decide against stress echocardiography or cardiopulmonary exercise testing, as you feel their results will not materially alter your estimate of her cardiac risk or suggest additional methods for medical optimisation. You prescribe spironolactone and extended-release metoprolol succinate and uptitrate the dose of her angiotensin-converting enzyme inhibitor. You also initiate a long-acting β-agonist bronchodilator and steroid inhaler and refer her to a respiratory rehabilitation program for 6 weeks of total abstinence from smoking. With this treatment, her exercise capacity improves significantly, such that she can walk 200 m on the flat without difficulty (METs = 4). Her signs of CHF abate and her spirometry results improve to an FEV1 of 66% predicted. She undergoes surgery and recovers without complication.

5 Relation of absolute cardiac risk to β-blocker-associated reduction in all-cause inhospital death in two large observational studies*

London et al31

Lindenauer et al30

RCRI score

Relative risk for
inhospital death

NNT to reduce inhospital death

Odds ratio for
inhospital death

NNT to reduce inhospital death

0

1.26 (0.88–1.81)

na

1.43 (1.29–1.58)

na

1

0.89 (0.72–1.10)

na

1.13 (0.99–1.30)

na

2

0.63 (0.50–0.80)

105 (69–212)

0.90 (0.75–1.08)

227 (132–1091)

3

0.54 (0.39–0.73)

41 (28–80)

0.71 (0.56–0.91)

62 (48–92)

≥ 4

0.40 (0.25–0.64)

18 (12–34)

0.57 (0.42–0.76)

33 (28–42)

RCRI = Revised Cardiac Risk Index. NNT = number needed to treat. na = not applicable. * Data relate
to propensity-adjusted analyses in both studies, except for NNT in Lindenauer et al,30 for which only results of whole-study analyses were published. Numbers in parentheses are 95% confidence intervals.

6 Suggested risk stratification for perioperative thromboembolism and bleeding*

Risk of thromboembolism

Risk level

Mechanical heart valve

Atrial fibrillation

Venous thromboembolism

High

  • Any mitral valve prosthesis

  • Any caged-ball or tilting disc aortic valve prosthesis

  • Recent (< 6 months) stroke or TIA

  • Prior stroke or TIA during temporary interruption of anticoagulants

  • CHADS2 score of 5–6

  • Recent (< 3 months) stroke or TIA

  • Rheumatic valvular heart disease

  • Prior stroke or TIA during temporary interruption of anticoagulants

  • Recent (< 3 months) VTE

  • Severe thrombophilia (eg, deficiency of protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities)

  • Prior VTE during temporary interruption of anticoagulants

  • VTE > 12 months previously associated with pulmonary hypertension

Moderate

  • Bileaflet aortic valve prosthesis and one or more of the following risk factors: atrial fibrillation, prior stroke or TIA, hypertension, diabetes, congestive heart failure, age >75 years

  • CHADS2 score of 3–4

  • VTE within past 3–12 months

  • Non-severe thrombophilia (eg, heterozygous factor V Leiden or prothrombin gene mutation)

  • Recurrent VTE

  • Active cancer (treated within 6 months or palliative)

Low

  • Bileaflet aortic valve prosthesis without atrial fibrillation and no other risk factors for stroke

  • CHADS2 score of 0–2 (assuming no prior stroke or TIA)

  • VTE > 12 months previously and no other risk factors

Risk of major bleeding

High

  • Urological surgery and procedures comprising transurethral resection of prostate, bladder resection or tumour ablation; nephrectomy;
    kidney biopsy

  • Implantation of pacemaker or implantable cardioverter defibrillator device (risk of pocket haematoma)

  • Colonic polyp resection, typically of large (> 1–2 cm) sessile polyps

  • Surgery or procedures in highly vascular organs such as kidney, liver and spleen

  • Bowel resection (with risk of bleeding at anastomosis site)

  • Major surgery with extensive tissue injury (eg, cancer surgery, joint arthroplasty, reconstructive plastic surgery)

  • Intracranial or spinal surgery

Low

  • Cataract surgery, arthrocentesis, dental procedures, diagnostic endoscopic procedures

  • Excisional skin surgery and superficial surgery with easily compressible wounds

TIA = transient ischaemic attack. CHADS2 = congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or TIA. VTE = venous thromboembolism. * Adapted from Douketis et al48 with permission from the American College of Chest Physicians, with additional data from Dunn and Turpie.51

Antimicrobial stewardship in Victorian hospitals: a statewide survey to identify current gaps

The association between antimicrobial resistance and antimicrobial use is long established.1–3 Recognition of widespread inappropriate prescription of antimicrobials in hospitals has prompted action addressing this important patient safety issue. Antimicrobial stewardship (AMS) aims to improve the quality of care and clinical outcomes of patients requiring treatment or prevention of infection, while reducing adverse events and preventing the emergence of antibiotic resistance in local pathogens.4 In 2011, the Australian Commission on Safety and Quality in Health Care (ACSQHC) published recommendations for effective AMS programs in Australian hospitals, outlining five essential AMS strategies and four additional activities (Box 1).5 The new National Safety and Quality Health Service (NSQHS) Standards,6 which include specific criteria for AMS, have further heightened the sense of urgency around implementing these programs.

AMS typically uses combinations of strategies, including implementing guidelines, using formularies, restriction policies, audits, education, and encouraging de-escalation of therapy and parenteral-to-oral conversion where appropriate.7,8 Successful AMS requires multidisciplinary and interdepartmental collaboration.9,10 A 2008 snapshot survey of AMS activities in Australian hospitals11 found that there was a variety of AMS programs implemented with varying degrees of success. This was a modest survey with only 80 respondents, mainly from metropolitan public hospitals, but it provided generalised insight into some programs. The aim of the current study was to perform a more in-depth survey, to describe AMS activities currently being undertaken by Victorian hospitals, and to elucidate specific gaps when assessed against the ACSQHC criteria.

Methods

The survey was developed by the Quality, Safety and Patient Experience Branch of the Victorian Department of Health (Vic DoH), together with the Melbourne Health AMS Research Group, consisting of infectious diseases physicians, clinical microbiologists and pharmacists. The questions were developed with reference to the ACSQHC recommendations, following a review of the literature and in conjunction with discussion among the investigators, who have extensive experience in AMS implementation. Included was information on hospital demographics, AMS activities, governance structure, resources, workforce capacity and other cultural and organisational barriers. Usability testing for the survey was conducted at six pilot hospitals, selected to ensure generalisability. Positive feedback was received regarding the ease of use and time taken to complete the survey, therefore no changes were made.

A letter was sent to the chief executives of 84 public health services and 63 private hospitals by the Vic DoH in November 2011, requesting a qualified staff member to respond to the survey. A link to the secure online survey, hosted by the Vic DoH, was sent via e-mail to all nominees in January 2012, and data submission closed on 31 March 2012. All Victorian public and private hospitals offering overnight stays to patients were included in the study, with mental health facilities excluded due to low levels of antimicrobial prescribing. The survey consisted of 38 questions, which were mainly close-ended, some with the option of a free-text response, and two comment-style questions at the end relating to current AMS program improvements and barriers. All questions were compulsory and completed by all respondents. As this was a self-reported survey, in order to improve the accuracy of the data, answers were reviewed for inconsistencies; if inconsistencies were perceived to be present, a researcher would call to seek clarification. Data were then sorted into three groups: public metropolitan, public regional and private hospitals, according to the Australian Institute of Health and Welfare remoteness classification,12 allowing the determination of possible gaps across different sectors and locations. Results were reported descriptively and no statistical analysis was performed.

As the survey was a low-risk audit and quality assurance activity, ethics approval was not required. The Vic DoH Quality, Safety and Patient Experience Branch was involved throughout the survey development, data collection and analysis. Hospital data was de-identified before reporting and involvement in the survey was voluntary.

Results

The response rate for public hospitals was 96.4% (81 of 84 eligible health service networks covering 113 sites) and 67.7% for private hospitals (42 of 62 hospitals). The overall response rate was 84.2% (123 of 146 health services). The private hospital non-respondents did not differ systematically from respondents in geographical location, classification, co-location with a public hospital or the presence of an intensive care unit. Data on participating hospital characteristics are presented in Box 2.

Responses directly related to the ACSQHC five essential AMS strategies5 are shown in Box 3. The consensus guidelines for prescribing in Australia, Therapeutic guidelines: antibiotic,13 were readily accessible in almost all Victorian hospitals, although endorsement of their use was lacking in hospital antimicrobial prescribing policies, particularly in public regional and private hospitals, and few hospitals had a dedicated AMS committee. Most public metropolitan hospitals had an antimicrobial formulary in place that included restrictions on broad-spectrum antimicrobials, compared with few public regional and private hospitals. Postprescription review occurred in only half the hospitals surveyed. Only 5.2% of hospitals had a dedicated antimicrobial management team (a multidisciplinary team involving at least one doctor and one pharmacist or nurse) in place. Performance monitoring through regular antimicrobial audits and providing feedback to prescribers was carried out by less than half the hospitals surveyed. A very high proportion of hospitals reported receiving selective antimicrobial susceptibility results from the microbiology laboratory.

Responses to supplementary AMS strategies recommended by the ACSQHC5 and the governance structure for AMS programs are presented in Box 4. Data on point-of-care interventions were not included in the analysis, as these questions were answered poorly, due to ambiguity with interpreting the word “regularly”. Most public metropolitan health services provided staff education on antimicrobial prescribing, compared with very few regional public hospitals and only some private hospitals, with senior medical staff the least likely to receive education. Electronic decision support systems were available in some metropolitan public hospitals, and antibiograms were more commonly available in the private hospital setting.

Perceived barriers to the implementation of AMS programs are outlined in Box 5. Responses were selected from a list of prepared options compiled by the investigators, and respondents could choose multiple options if desired.

Discussion

With a public hospital response rate of 96.4%, these results may be regarded as census data for the sector, while the private hospital response rate (67.7%) can be regarded as representative data. However, with an overall response rate of 84.2% of eligible Victorian hospitals, this survey provides valuable insight into current AMS activities and highlights key areas for improvement when compared with the ACSQHC AMS strategies.

All health services are required to comply with the NSQHS accreditation standards effective from 1 January 2013, and the role of AMS is clearly outlined in Standard 3.14.6 At the time of this survey, hospitals across Victoria are at very different stages of implementing AMS; public metropolitan hospitals are generally well advanced, while there are considerable gaps in public regional and private hospitals.

It is evident that additional work is required in some key areas, such as the implementation and promotion of antimicrobial guidelines through inclusion in hospital policies and staff education programs. There is also a need to establish antimicrobial formularies with restrictions in public regional and private hospitals. These have been shown to improve consumption patterns of broad-spectrum antimicrobials, adverse drug reactions and expenditure,14 while reducing the local prevalence of some resistant pathogens.15,16 Further, there is an observed gap in the ability to perform postprescription review and audits, including dissemination of findings to prescribing clinicians, an element considered essential for successful AMS.17 This shortcoming is possibly due to limited staffing and resources. As lack of training and education in safe and effective antimicrobial use was perceived to be the number one barrier to implementing an AMS program in all hospital sectors, there is a need to extend antimicrobial education, particularly to senior clinicians, and to make education an essential strategy rather than supplementary activity.

Lack of resources, including pharmacy, infectious diseases and clinical microbiology services, was among the top three barriers reported. Lack of leadership and unwillingness of doctors to change their prescribing practices were the other major barriers, confirming previous findings.11 Building effective workforce capacity requires funding for dedicated AMS staff and activities, and is key to program success and sustainability. Without executive and senior staff support, implementing change into an organisation is challenging. Creating the correct governance structure and developing policies and procedures for the program with support from relevant hospital committees are important change management strategies.18–20

These data represent the situation in Victorian health services. However, we expect that other Australian states and territories face similar challenges; there has also been a recent AMS survey of Queensland hospitals with similar findings (Minyon Avent, AMS Pharmacist, Mater Pharmacy Services, Brisbane, personal communication). The introduction of AMS as an accreditation criterion within the new NSQHS standards will play an important role in driving the organisational changes required to meet the challenge of implementing AMS in Australian hospitals. To assist with the gaps and barriers outlined here, the Melbourne Health AMS Research Group is currently undertaking research into developing evidence-based recommendations to guide the national implementation of AMS programs in regional and private hospitals.

1 Effective antimicrobial stewardship5

Five essential strategies

  • Implementing clinical guidelines that are consistent with the latest version of Therapeutic guidelines: antibiotic,13 and which take into account local microbiology and antimicrobial susceptibility patterns.

  • Establishing formulary restriction and approval systems that include restricting broad-spectrum and later-generation antimicrobials to patients in whom their use is clinically justified.

  • Reviewing antimicrobial prescribing with intervention and direct feedback to the prescriber — this should, at a minimum, include intensive care unit patients.

  • Monitoring performance of antimicrobial prescribing by collecting and reporting unit- or ward-specific use data, auditing antimicrobial use and using quality use of medicines indicators.

  • Ensuring the clinical microbiology laboratory uses selective reporting of susceptibility testing results that is consistent with hospital antimicrobial treatment guidelines.

Activities that may be undertaken depending on local priorities and available resources

  • Educating prescribers, pharmacists and nurses about good antimicrobial prescribing practice and antimicrobial resistance.

  • Using point-of-care interventions, including streamlining or de-escalation of therapy, dose optimisation or parenteral-to-oral conversion.

  • Using information technology such as electronic prescribing with clinical decision support or online approval systems.

  • Annually publishing facility-specific antimicrobial susceptibility data.

2 Characteristics of participating hospitals

Hospitals, by location

No. (%)

Location

Public

Private

Total

Metropolitan

32 (28.3%)

28 (66.7%)

60 (38.7%)

Regional

81 (71.7%)

14 (33.3%)

95 (61.3%)

Total

113 (

42 (

155 (

Public hospitals (n = 113), by classification11

Classification

No. (%)

Principal referral

19 (16.8%)

Large major cities

6 (5.3%)

Specialist women’s and children’s

2 (1.8%)

Large regional and remote

7 (6.2%)

Medium (group 1)

6 (5.3%)

Medium (group 2)

13 (11.5%)

Small regional acute

22 (19.5%)

Small non-acute

9 (8.0%)

Multipurpose services

9 (8.0%)

Unpeered and other

20 (17.7%)

3 Number of respondents answering “yes” to the presence of elements of the five essential antimicrobial stewardship strategies,5 by hospital type

No. of respondents (%)

Essential strategy

Public metropolitan
(n = 32)

Public regional
(n = 81)

Private
(n = 42)

Total
(n = 155)

Implementing clinical guidelines that are consistent with the latest version of Therapeutic guidelines: antibiotic,13 and which take into account local microbiology and antimicrobial susceptibility patterns

Therapeutic guidelines: antibiotic is available (online or paper-based copies or both)*

32 (100%)

81 (100%)

37 (88.1%)

150 (96.8%)

Establishing formulary restriction and approval systems that include restricting broad-spectrum and later-generation antimicrobials to patients in whom their use is clinically justified

Antibiotic guidelines are promoted or included in hospital antimicrobial policy

29 (90.6%)

37 (45.7%)

9 (21.4%)

75 (48.4%)

A formulary covering antimicrobials is available

30 (93.8%)

31 (38.3%)

7 (16.7%)

68 (43.9%)

The formulary specifies restrictions on the use of broad-spectrum antimicrobials

30 (93.8%)

14 (17.3%)

2 (4.8%)

46 (29.7%)

Reviewing antimicrobial prescribing with intervention and direct feedback to the prescriber — this should, at a minimum, include intensive care unit patients

Feedback is provided to prescriber following the review of antimicrobial prescription

24 (75.0%)

41 (50.6%)

16 (38.1%)

81 (52.3%)

The hospital has a dedicated antimicrobial management team

7 (21.9%)

0

1 (2.4%)

8 (5.2%)

Monitoring performance of antimicrobial prescribing by collecting and reporting unit- or ward-specific use data, auditing antimicrobial use and using quality use of medicines indicators

Regular audits of antimicrobial prescribing are conducted

20 (62.5%)

29 (35.8%)

22 (52.4%)

71 (45.8%)

Feedback is provided to prescribers on outcomes of antimicrobial prescribing audits

13 (40.6%)

21 (25.9%)

15 (35.7%)

49 (31.6%)

Ensuring the clinical microbiology laboratory uses selective reporting of susceptibility testing results that is consistent with hospital antimicrobial treatment guidelines

The microbiology service selectively reports antimicrobial sensitivities†

31 (96.9%)

74 (91.4%)

39 (92.9%)

144 (92.9%)

* All public hospitals had access to the electronic version of Therapeutic guidelines: antibiotic,13 via the Clinicians Health Channel (the Victorian public health online information portal); some private hospitals had electronic access, but 24 (57.1%) had paper-based copies only. † As selective reporting is standard practice in Australian laboratories, it is likely that the remainder also do this, but that the respondent was unaware.

4 Number of respondents answering “yes” to the presence of elements of the recommended supplementary antimicrobial stewardship strategies5 and other governance issues, by hospital type

No. of respondents (%)

Supplementary strategy

Public metropolitan
(n = 32)

Public regional
(n = 81)

Private
(n = 42)

Total
(n = 155)

Educating prescribers, pharmacists and nurses about good antimicrobial prescribing practice and antimicrobial resistance

Senior medical staff

12 (37.5%)

7 (8.6%)

2 (4.8%)

21 (13.5%)

Junior medical staff

22 (68.8%)

9 (11.1%)

0

31 (20.0%)

Pharmacy

21 (65.6%)

6 (7.4%)

2 (4.8%)

29 (18.7%)

Nursing

8 (25.0%)

16 (19.8%)

9 (21.4%)

33 (21.3%)

No education provided

5 (15.6%)

59 (72.8%)

29 (69.0%)

93 (60.0%)

Using information technology such as electronic prescribing with clinical decision support or online approval systems

An electronic clinical decision support or approval system is available

21 (65.6%)

0

0

21 (13.5%)

Annually publishing facility-specific antimicrobial susceptibility data

Antibiograms are provided by the microbiology service

8 (25.0%)

8 (9.9%)

14 (33.3%)

30 (19.4%)

Other governance issues pertaining to good antimicrobial stewardship

There is an antimicrobial prescribing policy in place

29 (90.6%)

38 (46.9%)

9 (21.4%)

76 (49.0%)

A dedicated committee to oversee antimicrobial stewardship exists*

22 (68.8%)

11 (13.6%)

6 (14.3%)

39 (25.2%)

Funding is available for antimicrobial stewardship activities

Pharmacist

10 (31.3%)

1 (1.2%)

0

11 (7.1%)

Medical staff

9 (28.1%)

0

0

9 (5.8%)

* Some regional health services reported that although they did not have a dedicated antimicrobial stewardship committee, other associated committees such as infection control or drug and therapeutics oversee antimicrobial use at their hospital.

5 Perceived barriers to antimicrobial stewardship implementation, by hospital type

No. of respondents (%)

Perceived barrier

Public metropolitan (n = 32)

Public regional (n = 81)

Private
(n = 42)

Total
(n = 155)

Lack of training and education in antimicrobial use

23 (71.9%)

47 (58.0%)

26 (61.9%)

96 (61.9%)

Lack of leadership to promote antimicrobial stewardship

11 (34.4%)

33 (40.7%)

19 (45.2%)

63 (40.6%)

Lack of support from senior clinicians

7 (21.9%)

12 (14.8%)

7 (16.7%)

26 (16.8%)

Lack of infectious diseases/clinical microbiology services

15 (46.9%)

40 (49.4%)

18 (42.9%)

73 (47.1%)

Lack of pharmacy resources

18 (56.3%)

58 (71.6%)

14 (33.3%)

90 (58.1%)

Lack of willingness from doctors to change their prescribing practices

12 (37.5%)

23 (28.4%)

18 (42.9%)

53 (34.2%)

Lack of enforcement by hospital management

12 (37.5%)

10 (12.3%)

12 (28.6%)

34 (21.9%)

High level of transient/seconded staff

11 (34.4%)

10 (12.3%)

2 (4.8%)

23 (14.8%)

Chiropractic Observation and Analysis Study (COAST): providing an understanding of current chiropractic practice

There are about 4400 registered practising chiropractors in Australia,1 making chiropractic the eighth largest registered health profession (out of 10).2 During 2005, 16% of Australians, over 3 million people, consulted a chiropractor at least once3 at an out-of-pocket cost of $905 million.4

Despite the large number of people who receive chiropractic care, very little is known about why people seek this care and what care chiropractors provide. With the increased attention, and criticism, directed at the chiropractic profession, it is important to have reliable up-to-date information about what is actually happening in chiropractic clinical practice.5

Previous attempts to document this practice in Australia are now outdated.6–13 Worldwide, systematic approaches to gathering information about chiropractic practice have been limited by study design, including chart abstraction, patient recall surveys, practitioner recall surveys and reviews of administrative databases.14–22

The Chiropractic Observation and Analysis Study (COAST) aimed to describe the clinical practices of chiropractors in Victoria, Australia. COAST used methods developed by the Bettering the Evaluation and Care of Health (BEACH) program. BEACH is a continuous, rigorous, national study of Australian general medical practice clinical activity and has been running since 1998.23,24 COAST documented the following:

  • demographic characteristics of chiropractors;

  • characteristics (demographic and health profile) of the people who sought chiropractic care;

  • the reasons people sought chiropractic care (reasons for encounter);

  • the problems and diagnoses chiropractors identified; and

  • the care chiropractors provided.

Methods

COAST was a cross-sectional observational study of chiropractic practice in Victoria, Australia.

Recruitment

A random sample of 180 chiropractors from the list of 1298 chiropractors registered on the Chiropractors Registration Board of Victoria were invited to participate, using a modified tailored design method.25 BEACH investigators have determined that a minimum sample of 40 health care practitioners is required to ensure reasonable precision for more frequent events; on this basis, and given the resources available to complete this study, we approached 180 chiropractors, anticipating a 30% response rate.

Selected chiropractors were sent a primer postcard, followed 1 week later by an invitation letter and a reminder letter after a further 2 weeks. Non-responders were contacted by telephone for a further 4 weeks. Incentives for participation were continuing professional development points (12.5 formal learning activity hours) and an honorarium ($200 gift voucher). Chiropractors were included if they were currently in clinical practice in Victoria. Locum chiropractors were excluded.

Consecutive patients were invited to provide encounter data until 100 encounters were recorded per chiropractor, or when 4 weeks of recording had elapsed.

Data collection

Chiropractors recorded anonymous patient encounter data by hand on paper encounter recording forms, with items in free text or check box format (Appendix 1). A pad of 106 forms was supplied to each chiropractor, with extra forms provided in case of mistakes. The encounter recording form was based on the BEACH study encounter form and was modified to reflect chiropractic practice. The forms were first piloted with five chiropractors with varying practice styles who each collected data on 10 consecutive patients. The data collection form is available on request.

Chiropractors recorded terms on the encounter form that they believed most accurately described the encounter. These terms were then entered and classified by a coder according to the International classification of primary care, 2nd edition (ICPC-2) using the Australian ICPC-2 PLUS general practice terminology.26,27 For example, for the patient reason for encounter (RFE) or the problem and diagnosis, the research team anticipated that terms would be recorded by the chiropractors to describe patients who presented with little or no symptoms at the time of the encounter. Terms used to describe such visits would be related to wellbeing, wellness, health maintenance and check-up.28,29 Such wellness-related terms were coded to the ICPC chapter “general and unspecified”.

Where an RFE, a problem and diagnosis, or process of care was documented that had no corresponding ICPC-2 PLUS term, a new term (and code) was created. A detailed explanation of the coding, process for generating new terms relevant to the chiropractic profession, and subsequent coding and grouping system has been previously published.30

Data analysis

Descriptive statistics were used to summarise chiropractor, patient and encounter characteristics. RFEs were reported by ICPC chapter, and chiropractor-identified problems and diagnoses were reported by groups of related ICPC-2 PLUS terms. For each chiropractor, patients attending more than once during the 100 encounters recorded were identified by date of birth, sex and postcode. Analyses were undertaken using Stata version 12 (StataCorp) and 95% CIs were calculated for all relevant estimates. The survey estimator procedures in Stata were used to adjust for the clustering effect and to calculate the design effect (Deff). The intracluster correlation coefficient (ICC) was then calculated from the Deff using the formula ICC = (Deff − 1)/(k − 1), where k is the average number of consultations across all chiropractors.31

We compared participating chiropractors’ sex and years in practice, and the proportion practising in a rural setting, with data on all practising Victorian chiropractors provided by the Chiropractors Registration Board of Victoria. We also compared chiropractor characteristics with available data (age and sex only) from the Australian Health Practitioner Regulation Agency.1 We used one-sample t tests using population mean (years in practice) and population proportion (sex, rural practice setting), along with the χ2 goodness-of-fit test for age ranges (with recoding of COAST data to ensure ranges were uniform across the two datasets).

The project was approved by the University of Melbourne Human Research Ethics Committee (HREC 0931651: Chiropractic in Australia), and all participants (chiropractors and patients) provided informed consent.

Results

Of the original 180 chiropractors approached, 24 were ineligible. Of those who were eligible, 72 agreed to participate (46% response rate); 20 of these withdrew and did not provide any data, and 52 (33%) completed the study. Participating chiropractors provided information on 4464 chiropractor–patient encounters between 11 December 2010 and 28 September 2012. Appendix 2 shows the flow of chiropractor participants through the study. Not all chiropractors provided information on 100 encounters: 33 out of 52 provided information on at least 100, 13 provided information on 50–100, and six provided information on less than 50 encounters.

Box 1 shows the characteristics of participating chiropractors. Compared with all registered chiropractors in Victoria, those who participated in COAST had similar mean time since graduation (16 years), and a similar proportion worked in an urban location (35/52 [67%] compared with 626/894 [70%]). However, a smaller proportion of COAST participants were women (14/52 [27%] compared with 399/1050 [38%]), but this difference was not statistically significant. Similarly, compared with all Australian chiropractors, participating chiropractors were of similar age, but there was a non-statistically significant under-representation of women in this study (14/52 [27%]) compared with national data (1679/4664 [36%]).

Box 2 shows the demographic details of patients who sought chiropractic care and the source of payment for encounters. In most chiropractor–patient encounters (71%), patients were aged 25–64 years. In 9% of encounters, patients were younger than 15 years old, and in 13%, patients were aged 65 years and older. In 81% (95% CI, 76%–86%) of encounters, patients paid for some or all of the consultation fee. For 13% of encounters, it was a repeat visit where a patient presented at least twice during the 100 recorded encounters.

There were 5188 RFEs reported. Ninety-nine per cent of patients’ RFEs were coded to two ICPC chapters, “musculoskeletal” chapter and “general and unspecified”. RFEs were coded to the “musculoskeletal” chapter at a rate of 60 per 100 encounters (95% CI, 54–67 per 100 encounters), and to “general and unspecified” at a rate of 39 per 100 encounters (95% CI, 33–47 per 100 encounters). RFEs were coded to the “neurological” chapter at a rate of 9 per 100 encounters (95% CI, 8–11 per 100 encounters). RFEs were coded to all other ICPC chapters only occasionally, including “psychological” at a rate of 3 per 100 encounters (95% CI, 2–7 per 100 encounters) and “digestive” at a rate of 1 per 100 encounters (95% CI, 0.5–3 per 100 encounters). All other chapters were coded in fewer than 1 per 100 encounters (full results available on request).

The distribution of problems and diagnoses managed in the encounters, as identified by the chiropractors, is shown in Box 3. Spinal problems, including chiropractor-recorded terms such as “chiropractic subluxation” (a term used by some chiropractors to describe a perceived dysfunction detected in a joint segment32), and joint dysfunction were the most commonly identified problems and diagnoses. Box 4 shows the techniques and care provided by the chiropractors. The most frequent were manual adjustments (manipulation) and soft tissue therapy. Other care provided by chiropractors during the encounters included (reported as rates per 100 encounters): therapeutic exercise prescription (52; 95% CI, 44–61), advice about exercises in general (21; 95% CI, 15–29), advice about posture (21; 95% CI, 10–18), and recommendations to use ice packs (11; 95% CI, 7–18), heat therapy (8; 95% CI, 4–18) and supplements (5; 95% CI, 3–8). Other recommendations were coded at a rate of less than four per 100 encounters (full results available on request).

The median duration of all encounters was 15 minutes (interquartile range, 11–20 minutes). Chiropractors indicated that the patient required a follow-up appointment in 85 per 100 encounters (95% CI, 81–90). Patients had been referred to the chiropractor by another patient in 52 per 100 encounters (95% CI, 43–64). Patients had been referred to a chiropractor by a GP in four per 100 encounters (95% CI, 2–10), and chiropractors referred patients to a general practitioner in three per 100 encounters (95% CI, 2–7).

Discussion

People who present to chiropractors are mostly adults with a musculoskeletal condition. People also commonly consult a chiropractor for “maintenance and wellness” or check-ups. The most frequent care provided by the chiropractors during the study period was spinal manipulative and soft tissue therapy. This is the first comprehensive profiling of chiropractic practice undertaken in Australia using BEACH methodology to describe who seeks chiropractic care, why patients seek care, the diagnoses and problems chiropractors identify, and the care that they provide.

There is evidence of patient referral between GPs and chiropractors, albeit in only a small proportion of encounters. In the general population, most people who see a chiropractor, and other complementary and alternative practitioners, also consult a medical practitioner.3 Further research is required to maximise the patient benefit that can be gained through a team approach to primary care.

The common use of maintenance and wellness-related terms reflects current debate in the chiropractic profession. “Chiropractic wellness care” is considered by an indeterminate proportion of the profession as an integral part of chiropractic practice,28 with the belief that regular chiropractic care may have value in maintaining and promoting health, as well as preventing disease.29 The definition of wellness chiropractic care is controversial, with some chiropractors promoting only spine care as a form of wellness, and others promoting evidence-based health promotion, eg, smoking cessation and weight reduction, alongside spine care.28 A 2011 consensus process in the chiropractic profession in the United States emphasised that wellness practice must include health promotion and education, and active strategies to foster positive changes in health behaviours.28

Compared with all other practising chiropractors in Australia, COAST chiropractors were similar in age, years in practice and proportion in a rural location. However, COAST participants had an underrepresentation of female chiropractors. For variables other than age, years in practice and female sex, we were limited in determining non-response bias in this study because of the limited data available from all practising chiropractors in Australia. Also, because it was too difficult for locum chiropractors to undertake the study, only chiropractors who practised in their own practice were included. A larger sample size and more representative chiropractors would provide more robust findings. However, this is the largest study using BEACH methods in the chiropractic profession in Australia, the first of its kind in the world, and a first step to providing robust information about chiropractic practice.

The response rate for this study, 33% of the eligible chiropractors approached, is higher than that achieved in the BEACH study in 2011 (27%).23 The response rates for two recent Australian national surveys of the chiropractic profession, one about workforce and one about low back pain, were 23%33 and 37%,34 respectively. The response rate for this study was similar to that obtained in the first general practice morbidity and prescribing survey conducted from 1969 to 1974 (29%).35,36 For simple postal surveys of health professionals, response rates have been declining over the past 10 years.37 The burden on practitioners to participate in this study may have affected response rates, further compounded by 28% of chiropractors withdrawing after initially agreeing to participate, some of whom withdrew when they realised the amount of work involved. However, of those who did complete the study, 78% indicated they would recommend participating in COAST to other chiropractors. Ideally, data obtained in this study would be routinely collected in chiropractic practice, but infrastructure is not in place to facilitate this, with two-thirds of chiropractors who participated using paper-only clinical records; hence clinical data cannot be easily captured.

This study provides valuable information in an under-researched area of Australian health care. A range of conditions are managed by chiropractors in Victoria, but most of these conditions are musculoskeletal problems. In workforce development, education can be aligned with health conditions commonly managed by chiropractors. Health care policy can be guided to ensure that provision of services is directed to areas of greatest need. Future research relevant to the chiropractic profession can be guided to ensure it is directed towards the most common presentations, so it can potentially help the most people.

1 Characteristics of 52 chiropractors participating in COAST

Characteristics

Chiropractors*

Chiropractor characteristics

Mean age in years† (range; SD)

42.3 (24–64; 9.3)

Mean years in practice‡ (range; SD)

16.3 (1–39; 8.5)

Female†‡

14

Graduated in Australia

44

Holds postgraduate qualification

18

Involved in teaching

8

Membership

Chiropractors Association of Australia

37

Chiropractic and Osteopathic College of Australasia

12

Practice characteristics

Mean no. of clinic sessions worked per week (range; SD)

6.4 (2–11; 2.3)

Mean no. of patient care hours worked per week (range; SD)

27.0 (3–48; 10.3)

Mean no. of patients seen per week (range; SD)

86.4 (13–220; 48.2)

Solo practitioner

22

Imaging services available at same premises

8

Other non-chiropractic health care practitioner available
at same premises

35

Consults in a language other than English

6

Practice in urban region‡

35

Paper-only clinical records

31

COAST = Chiropractic Observation and Analysis Study. * No. of chiropractors, unless otherwise indicated. † The age distribution and proportion of female practitioners do not differ significantly from these parameters in all Australian chiropractors (χ2 goodness-of-fit test for age ranges, 7.66; P = 0.053; t test for sex P = 0.173). ‡ These proportions do not differ significantly from that of all Victorian chiropractors (t test for years in practice P = 0.675; t test for sex P = 0.105; t test for practice in urban region P = 0.687).

2 Characteristics of patients in encounters recorded by participating chiropractors

Patient characteristics

No. (%) of
recorded
encounters*
(n = 4464)

95% CI

Sex

Female

2429 (55.74%)

(53.06%–58.54%)

Missing data

106

—

Age in years

< 1

44 (1.00%)

(0.32%–3.19%)

1–4

152 (3.47%)

(1.72%–7.01%)

5–14

182 (4.16%)

(3.05%–5.66%)

15–24

335 (7.65%)

(6.59%–8.88%)

25–44

1543 (35.24%)

(31.58%–39.32%)

45–64

1560 (35.62%)

(32.56%–38.98%)

65–74

371 (8.47%)

(7.08%–10.14%)

≥ 75

192 (4.38%)

(3.23%–5.96%)

Missing data

85

—

New patient

Yes

212 (6.13%)

(4.72%–7.97%)

Missing data

1008

—

Language

Non-English speaking background

35 (1.07%)

(0.34%–3.40%)

Missing data

1191

—

Identifies as Aboriginal or Torres Strait Islander

Yes

5 (0.15%)

(0.07%–0.35%)

Missing data

1192

—

Occupation

Managers

481 (12.06%)

(9.99%–14.54%)

Professionals

876 (21.95%)

(18.67%–25.82%)

Technicians and trades workers

378 (9.47%)

(8.09%–11.10%)

Community and personal service workers

259 (6.49%)

(5.49%–7.68%)

Clerical and administrative workers

352 (8.82%)

(7.53%–10.34%)

Sales workers

182 (4.56%)

(3.74%–5.57%)

Machinery operators and drivers

102 (2.56%)

(1.84%–3.54%)

Labourers

107 (2.68%)

(1.94%–3.71%)

Home duties

312 (7.82%)

(6.56%–9.33%)

Retired

556 (13.93%)

(11.41%–17.02%)

Student

362 (9.07%)

(0.74%–11.11%)

Unemployed

23 (0.58%)

(0.33%–0.99%)

Missing data

474

—

Source of payment†

Workers compensation

83 (1.86%)

(0.85%–4.06%)

Transport Accident Commission

17 (0.38%)

(0.19%–0.78%)

Department of Veterans’ Affairs

41 (0.92%)

(0.52%–1.61%)

Medicare

82 (1.84%)

(0.90%–3.77%)

Private health insurance

2034 (45.56%)

(38.39%–54.08%)

Patient paid

3604 (80.73%)

(75.50%–86.33%)

No charge

195 (4.37%)

(3.15%–6.06%)

* Missing values not used in calculations. † Multiple payment options allowed, so total
not 100%.

3 Distribution of problems managed (20 most frequent problems), as reported
by chiropractors

Problem group

No. (%) of recorded diagnoses*
(n = 5985)

Rate per 100 encounters (n = 4417)

95% CI

ICC

Back problem

2757 (46.07%)

62.42

(55.24–70.53)

0.312

Neck problem

683 (11.41%)

15.46

(11.23–21.30)

0.233

Muscle problem

434 (7.25%)

9.83

(6.64–14.55)

0.207

Health maintenance or preventive care

254 (4.24%)

5.75

(3.24–10.22)

0.251

Back syndrome with radiating pain

215 (3.59%)

4.87

(2.91–8.14)

0.165

Musculoskeletal symptom or complaint, or other

219 (3.66%)

4.96

(2.39–10.28)

0.350

Headache

179 (2.99%)

4.05

(2.87–5.71)

0.053

Sprain or strain of joint

167 (2.79%)

3.78

(2.30–6.22)

0.115

Shoulder problem

87 (1.45%)

1.97

(1.37–2.83)

0.022

Nerve-related problem

62 (1.04%)

1.40

(0.72–2.75)

0.072

General symptom or complaint, other

51 (0.85%)

1.15

(0.22–6.06)

0.407

Bursitis, tendinitis or synovitis

47 (0.79%)

1.06

(0.71–1.60)

0.011

Kyphosis and scoliosis

47 (0.79%)

1.06

(0.65–1.75)

0.023

Foot or toe symptom or complaint

48 (0.80%)

1.09

(0.41–2.87)

0.123

Ankle problem

46 (0.77%)

1.04

(0.40–2.69)

0.112

Osteoarthrosis, other (not spine)

39 (0.65%)

0.88

(0.51–1.53)

0.023

Hip symptom or complaint

35 (0.58%)

0.79

(0.53–1.19)

0.006

Leg or thigh symptom or complaint

35 (0.58%)

0.79

(0.49–1.28)

0.012

Musculoskeletal injury

33 (0.55%)

0.75

(0.45–1.24)

0.013

Depression

29 (0.48%)

0.66

(0.10–4.23)

0.288

ICC = intracluster correlation coefficient. * Excludes repeat problem group managed at encounter.

4 Distribution of techniques and care provided by chiropractors, with 95% CI

Activator = hand-held spring-loaded device that delivers an impulse to the spine. Drop piece = chiropractic treatment table with a segmented drop system which quickly lowers the section of the patient’s body corresponding with the spinal region being treated. Blocks = wedge-shaped blocks placed under the pelvis. Chiro system = chiropractic system of care, eg, Applied Kinesiology, Sacro-Occipital Technique, Neuroemotional Technique. Flexion distraction = chiropractic treatment table that flexes in the middle to provide traction and mobilisation to the lumbar spine.

Estimated impacts of alternative Australian alcohol taxation structures on consumption, public health and government revenues

Evidence suggests that alcohol taxation, as a means of increasing the price of alcohol, is one of the most effective policy interventions to reduce the level of alcohol consumption and related problems, including mortality rates, crime and traffic accidents.1,2 Even small increases in the price of alcohol can have a significant impact on consumption and harm. Despite its reported effectiveness, taxation as a strategy to reduce alcohol-related harm has been underutilised in Australia.3

Aside from some positive features, such as lower tax on light and mid-strength beer and the higher tax on ready-to-drink products (RTDs), the alcohol taxation regimen in Australia is flawed from both an economic and public health perspective.4 The National Preventative Health Taskforce reported that while there are some positive aspects to the current regimen, such as the relatively lower rate of tax on low-alcohol beer, there are large inconsistencies in the way different alcohol products are taxed — they are not consistently taxed according to their alcohol content level or their propensity to cause harm.5 The Australian Government’s own review of the tax system (the Henry Review) concluded that current taxes on beer, wine and spirits are incoherent and if alcohol taxes are to be effective in reducing social harm, the taxation of beer, wine and spirits should be reformed. The review highlighted that “in particular, the wine equalisation tax, as a value-based revenue-raising tax, is not well suited to reducing social harm”. The ideal tax structure, it was suggested, would be a volumetric tax on all alcoholic beverages, applied at the same rate of tax per litre of alcohol across all beverages.6 However, the review did not provide any detailed estimates or modelling of the optimal tax rate on alcohol nor how this would affect government revenue, overall consumption or changes in the social costs from harmful consumption.

There is growing evidence of public health benefits from taxing alcohol according to alcohol content. One study identified taxation as the most cost-effective strategy to reduce alcohol-related harm in Australia and suggested that the government could achieve over 10 times the health gain if they reallocated the current level of investment to an optimal cost-effective package of strategies starting with taxation changes.7 This analysis was extended to measure the cost-effectiveness and change in taxation revenue as a consequence of a volumetric tax.8 Collectively, these two studies demonstrate that a volumetric tax can increase government revenue and save millions of public dollars by averting alcohol-related disease and injury.

Our research undertakes further economic and epidemiological modelling to estimate the impact of alternative alcohol taxation structures on consumption, public health and government revenues.

Methods

Taxation scenarios

Seven different alcoholic beverage types are included in the scenario modelling: low-strength beer; high-strength beer; wine; fortified wine; straight spirits; RTDs; and cider. Of these seven, each is further disaggregated into offsite (bottle shops, supermarkets and alcohol warehouses) or onsite (licensed premises such as pubs, clubs and restaurants) sales.

The range of modelled taxation scenarios were selected on the basis that they are under consideration by the Australian Government, or being proposed by parts of the alcohol beverage industry or public health groups in Australia. Four scenarios are modelled in this analysis:

  • Replace the wine equalisation tax (WET) on wine and cider with a volumetric excise rate equal to the current excise tax rate applicable to low-strength beer sold offsite.

  • Apply an excise tax rate to all beverages equal to a 10% increase in the current excise tax rate applicable to spirits and RTDs.

  • Apply an excise tax rate to all beverages, increasing it exponentially by 3.0% for every 1.0% increase in alcohol content above 3.2%.

  • Apply a two-tiered volumetric excise tax rate: the first tier applies to beer and wine and increases exponentially by 3.0% for every 1.0% increase in alcohol content above 3.2%; the second tier applies the current excise tax rate applicable to spirits and RTDs.

Economic modelling

Detailed methods are provided in the Appendix. Briefly, the economic modelling considers the extent to which each taxation scenario affects price, consump-tion and subsequent taxation revenue. Base-case estimates were derived using a combination of data sources. Taxation and duty levies imposed on alcoholic drinks were obtained from Euromonitor International.9 Taxation revenue related to sales of beer and wine was sourced from the federal Budget, while revenue received from the sales of spirits was calculated using Euromonitor International sales data.9 Information on annual volume, average value and price of all alcoholic beverages (sold onsite and offsite) were sourced from Euromonitor Inter-national. Although the current taxation regime categorises beer into three categories of low, mid and heavy strength, our modelling is based on heavy- and low-strength beer (ie, combined low- and mid-strength) with the excise and subsequent onsite or offsite discounts based on the weighted averages (in volume) of mid- and low-strength beers. We used estimates of price elasticity derived by Purshouse et al to explore variations in consumption patterns as a consequence of varying beverage prices.10

Epidemiological modelling

The method we used to model the taxation scenarios is based on the ACE (Assessing the Cost Effectiveness)-Alcohol project. The method and several applications are reported in detail elsewhere7,8 and in the Appendix. Briefly, using a health sector perspective, health outcomes were evaluated in disability-adjusted life-years (DALYs) using a multistate, multiple-cohort life-table model to determine changes in incidence, prevalence and mortality of alcohol-related diseases and injuries due to each scenario. Cost-effectiveness ratios were derived from cost and health outcomes measured over the lifetime of the Australian population in the baseline year of 2009. Future costs and health outcomes were discounted at 3% per annum.

Results

Base case

Box 1 provides data by alcoholic beverage on annual quantity of alcohol consumed; total value of sales; excise, goods and services tax (GST) and total tax collected; price per litre, price and taxation per standard drink.

The base-case results indicate that 2.83 million litres of alcohol were consumed. Based on average alcohol content levels, per capita consumption of pure alcohol was 8.09 litres per person. High-strength beer was the most common alcoholic beverage consumed; 1.46 million litres (or 52% of all alcohol) were sold offsite and 0.34 million litres (or 12% of all alcohol) were sold onsite.

The value of sales for alcoholic beverages in 2010 was $31.7 billion; high-strength beer accounted for $13.1 billion (or 41% of total sales) with offsite beer sales accounting for $7.7 billion (or 24% of total sales) and onsite beer sales accounting for $5.4 billion (or 17% of total sales).

Total taxation (excise + GST) revenue collected from the consumption of alcohol was $8.6 billion; high-strength beer sold offsite accounted for $2.8 billion (or 32% of total revenue) and spirits sold offsite at $1.3 billion (or 15% of total revenue).

The price per litre of alcohol ranged from a low of $4.49 for low-strength beer sold offsite to a high of $134.73 for spirits sold onsite. When converted to a price per standard drink (based on average alcohol content levels) RTDs sold onsite were the most expensive, at $7.49 per standard drink.

Significant discrepancies in the amount of excise tax per standard drink were identified, with amounts ranging from a low of $0.10 per standard drink for fortified wine to a high of $0.88 for RTDs sold onsite and spirits (Box 1). The largest discrepancies are found among the wine-based products that are subject to the WET.

Summary of modelled taxation scenarios

Box 2 provides a summary of results for each modelled taxation scenario. The key finding suggests that any of these variations to current taxation of alcohol beverages is a cost-effective health care intervention. All the modelled scenarios are classified as being dominant in comparison to current practice (ie, they save money and are more effective in reducing alcohol-related harm compared with what is currently being achieved).

Applying a universal tax rate on alcoholic beverages equivalent to a 10% increase in the current excise applicable to spirits and RTDs was the scenario that produced the greatest health and economic gains. Overall alcohol consumption would decrease by 10.6%, resulting in 220 000 DALYs being averted. The amount of alcohol-related disease and injury prevented in this scenario would save the health system $3.2 billion over the lifetime of the population. The cost of implementing this scenario ($22 million) is only a fraction of the savings achieved, which underscores how highly cost-effective this scenario would be.7 This scenario, however, does not address the inefficiencies of the current taxation system — it merely increases the tax for each beverage. Furthermore, under this scenario, overall taxation revenue was estimated to increase by 50% or an additional $4.3 billion per year.

Removing the WET and applying an excise rate on wine and spirits equal to low-strength beer sold offsite would reduce overall alcohol consumption by 1.3%, resulting in 59 000 DALYs being averted at a cost saving of $820 million. Overall taxation revenue would increase by 15% or an additional $1.3 billion per year.

Discussion

Our analysis has modelled a limited number of alcohol taxation scenarios that may be considered politically feasible. Both the National Preventative Health Taskforce and the Henry Review recommended taxing alcohol according to alcohol content. Our analysis takes these recommendations one step further by exploring subtle but important variations of volumetric taxation. Our modelling suggested that replacing the WET with a volumetric tax, alone, would increase taxation revenue by $1.3 billion, reduce overall alcohol consumption by 1.3%, significantly reduce alcohol related harm and save lives. A tiered volumetric approach will lead to even greater taxation receipts and higher falls in alcohol consumption.

Alcohol-related harm is now a major public health issue in Australia and globally. Given the substantial external costs associated with alcohol misuse, it has been argued that governments should be more proactive in developing an appropriate policy response to reduce this burden.4,11 The most cost-effective strategy that governments are able to adopt is changing the taxation system so that alcohol products are taxed according to alcohol content. Health, tax and economic experts all agree that Australia’s current alcohol taxation is incoherent and that reform is needed.5,6,11

Although the modelling approach is documented in the Appendix and a detailed consideration of the strengths and limitations is provided elsewhere, there are several limitations worth noting. Our estimates of price elasticity rely on United Kingdom data.10 Although these estimates are based on the latest evidence, there may be variations in Australian consumers’ responsiveness to price changes. Nevertheless, in the absence of comparable Australian data, the UK estimates remain the most appropriate. Our modelling also assumes an immediate reversal of risk for alcohol-related cancers as a consequence of lowering consumption. Adopting a lagged impact may be more appropriate, but the implication on overall results is likely to be minimal, given that cancers represent a small component of total health outcomes.

The political will of government to reform the current taxation of alcoholic beverages has been questioned, and it has been suggested that the government has a direct conflict of interest in alcohol policy, given its reliance on taxation revenue.12 Data from our analysis indicate that in 2010 the Australian Government collected close to $8.6 billion from the excise on alcohol products.

Worryingly, government has also been shown to put the alcohol industry’s interests ahead of public health. Despite the Henry Review recommending reform to the WET,6 the government announced that it would not do so “in the middle of a wine glut and where there is an industry restructure underway”.13

Overall, our findings suggest that by reassessing the rates of alcohol taxation, the Australian Government is able to improve health, reduce health care costs and substantially increase the amount of alcohol excise tax collected. This research clarifies what the evidence base can tell us about outcomes of specific policies and highlights the need for urgent action on alcohol taxation reform in Australia.

1 Base-case estimates of alcohol consumption, value and taxation receipts, using 2010 sales data and taxation rates

Alcoholic beverage

Annual quantity
consumed, ’000s litres

Annual litres per capita

Annual quantity
consumed,
’000s litres
pure alcohol

Annual litres pure alcohol per capita

Annual
value of
consumption, $millions

Annual excise tax collected, $millions

Annual
GST
collected, $millions

Total annual tax collected, $millions

Price
per litre

Price per standard drink

Excise
tax per standard drink

Low-strength beer offsite*

127

5.7

4.1

0.18

$569

$102

$52

$154

$4.49

$1.78

$0.32

Low-strength beer onsite†

30

1.3

0.9

0.04

$399

$10

$36

$46

$13.52

$5.36

$0.14

High-strength beer offsite*

1463

65.5

67.3

3.01

$7 683

$2060

$698

$2758

$5.25

$1.45

$0.39

High-strength beer onsite†

340

15.2

15.6

0.70

$5 387

$337

$490

$827

$15.84

$4.36

$0.27

Wine offsite*

338

15.1

42.0

1.88

$3 904

$559

$355

$913

$11.55

$1.18

$0.17

Wine onsite†

80

3.6

9.9

0.44

$3 343

$132

$304

$436

$41.79

$4.26

$0.17

Fortified wine offsite*

14

0.6

2.7

0.12

$145

$21

$13

$34

$10.68

$0.68

$0.10

Fortified wine onsite†

3

0.1

0.6

0.03

$124

$5

$11

$16

$38.65

$2.45

$0.10

Spirits offsite*

46

2.1

16.1

0.72

$2 313

$1116

$210

$1326

$49.97

$1.82

$0.88

Spirits onsite†

15

0.7

5.4

0.24

$2 087

$373

$190

$563

$134.73

$4.90

$0.88

RTDs offsite*

209

9.3

8.7

0.39

$2 510

$605

$228

$833

$12.02

$3.63

$0.87

RTDs onsite†

118

5.3

4.9

0.22

$2 918

$341

$265

$607

$24.78

$7.49

$0.88

Cider offsite*

33

1.5

1.6

0.07

$180

$24

$16

$40

$5.50

$1.39

$0.18

Cider onsite†

11

0.5

0.5

0.02

$152

$8

$14

$22

$14.00

$3.55

$0.18

Total

2826

126.5

180.6

8.09

$31 714

$5693

$2883

$8576

GST = goods and services tax. RTDs = ready to drink products. * Offsite = sold at bottle shops, supermarkets and alcohol warehouses. † Onsite = sold at licensed premises such as pubs, clubs and restaurants.

2 Health and economic impacts of revising current alcohol excise taxation, using 2010 sales data and taxation rates as the base case

Scenario

Annual quantity consumed, ’000s litres

Change in
quantity
consumed
(from base case)

Total annual tax collected, $millions

Change in total tax collected (from base case)

Mean DALYs averted* (95% UI)

Cost offsets, $millions* (95% UI)

Net cost, $millions* (95% UI)

Base case

2826

0

$8 576

0

–

–

–

Replace the WET on wine and cider with a volumetric excise rate equal to the current excise tax rate applicable to
low-strength beer sold offsite

2790

− 1.3%

$9 899

15.4%

59 000 (48 000 
to 71 000)

− $840 
(− $1200 
to − $530)

− $820 
(− $1200 
to − $510)

Apply an excise tax rate to all beverages equal to a 10% increase in the current excise tax rate applicable to spirits and RTDs

2528

− 10.6%

$12 848

49.8%

220 000 (180 000 
to 270 000)

− $3200 
(− $4600 
to − $2000)

− $3100 
(− $4600 
to − $2000)

Apply an excise tax rate to all beverages, increasing it exponentially by 3.0% for every 1.0% increase in alcohol content above 3.2%

2786

− 1.4%

$9 951

16.0%

110 000 (87 000 
to 130 000)

− $1500 
(− $2200 
to − $960)

− $1500 
(− $2100 
to − $940)

Apply a two-tiered volumetric excise tax rate: first tier applies to beer and wine and increases exponentially by 3.0% for every 1.0% increase in alcohol content above 3.2%; second tier applies current excise tax rate applicable to spirits and RTDs

2778

− 1.7%

$10 272

19.8%

83 000 (68 000 
to 99 000)

− $1200 
(− $1700 
to − $750)

− $1200 
(− $1700 
to − $730)

DALY = disability-adjusted life-year. RTDs = ready-to-drink products. 95% UI = uncertainty interval around the cost and DALY estimates, derived from multivariate sensitivity analysis propagating uncertainty around cost inputs, elasticity estimates, relative risks of disease outcomes and the prevalence of alcohol consumption. The intervals are bounded by the 2.5 and 97.5 centile values of 2000 iterations. WET = wine equalisation tax. * Over the lifetime of the population.

Evaluation of the Practice Nurse Incentive Program

Call for general practices and Aboriginal health services to participate in an interview to inform the Evaluation

The Practice Nurse Incentive Program (PNIP) was introduced in January 2012 to support practice nurses and Aboriginal health workers working in general practices, Aboriginal medical services and Aboriginal community controlled health services to undertake an expanded and enhanced role in preventive health, chronic disease management and care coordination. It replaced a range of funding arrangements including Practice Incentive Program, Practice Nurse Incentive, and six of the Medicare Benefits Schedule practice nurse items.

The Department of Health and Ageing has contracted KBC Australia, in collaboration with Thinc Health, to undertake an evaluation of the PNIP.

As part of the evaluation, KBC will interview general practices and Aboriginal health services to identify the impact of the changed funding mechanism on the:

·        role and function of practice nurses and GPs;

·        the business model of practices; and

·        the workforce mix within practices and Aboriginal health services.

Practice personnel to be interviewed

Key personnel to be interviewed could include the GP practice principal or medical director, and/or practice manager, CEO of Aboriginal health service, practice nurse manager or senior practice nurse.

Telephone interviews can be undertaken individually or in a group, dependent on the preference of the practice.

It is estimated that interviews will taken about one hour.

For inquiries, or to register your interest, please contact:

Monika Rickli at KBC Australia:

(02) 6361 4000

mrickli@kbconsult.com.au

AMA Careers Advisory Service

From graduates preparing their first resume to experienced doctors seeking to carve out a new career path in the Commonwealth public service, the AMA Careers Advisory Service is been on hand to provide practical advice and information.

Since the Service was launched in September 2012, AMA Careers Consultant, Kathryn Morgan, has handled dozens of inquiries from members looking for help and advice on advancing their careers, both within medicine and beyond.

The Careers website, which is at: http://careers.ama.com.au/, gives members access to both general and specific careers advice and information. In addition to direct links to external websites and specific sources of information, the Service also offers practical advice for medical professionals as their medical careers advance.

The Careers Service provides information and support relevant to all stages of an individual’s career, from medical students looking for assistance preparing internship applications – particularly writing resumes and covering letters – through to doctors in training who want to brush up their interview skills to give them a competitive edge at all-important medical college interviews.

But the Service is not only there for those in the early stages of their medical careers. It has also helped qualified medical professionals looking to apply their skills and expertise in jobs beyond medical practice. Among these have been those looking for non-clinical roles in Commonwealth and State public services that take advantage of their skills and experience.

The Service is constantly updating content on its website, including listings of career-related events being staged across the country, and uses feedback from members to help add and develop resources.

Members are encouraged to visit the website, if they haven’t done so already, and we welcome feedback, which can be submitted via the online feedback form on the website.

There will be further updates on developments in the Careers Service in coming months as we develop more ways to assist members along their medical career path.

If you or your colleagues would like to convene a skills workshop facilitated by Kathryn, please contact her at:

Phone: (02) 6270 5410; 1300 884 196 (toll free)

Email: careers@ama.com.au