AMA LIST OF MEDICAL SERVICES AND FEES – 1 NOVEMBER 2013

The 1 November 2013 edition of the AMA List of Medical Services and Fees will soon be available both in hard copy or electronic format.

Members listed as being in private practice or with rights of private practice should receive their hard copy no later than 31 October 2013. Salaried members who have ordered a hard copy should also receive their copy by 31 October 2013.

The AMA Fees List Online (http://feeslist.ama.com.au/) will be updated as at
1 November 2013. To access this part of the website, simply enter your username and password in the box provided on the screen. Members can view, print or download individual items or groups of items to suit their needs.

Electronic versions (PDF or CSV) of the AMA List will also be available for free download from the Members Only area of the AMA Website (www.ama.com.au/feeslist) from 22 October 2013.

A Fees Indexation Calculator is also available for members to calculate their own fee increase based on their individual cost profile.

To access this part of the website simply enter your username and password in the box on the right hand side of the screen and follow these steps:

1) Once you have entered your login details, from the home page hover over Resources at the top of the page.

2) A drop down box will appear. Under this, select AMA Fees List.

3) Select first option, AMA List of Medical Services and Fees – 1 November 2013.

4) Download either or both the CSV (for importing into practice software) and PDF (for viewing) versions of the AMA List.

5) For the Fees Indexation Calculator, select option 15. AMA Fees Indexation Calculator.

Members who do not currently have a username and password should email their name, address and AMA member services number to memberservices@ama.com.au requesting a username and password.

If you do not receive your hard copy of the 1 November 2013 AMA List of Medical Services and Fees or would like one, please contact the AMA on 02 6270 5400.

Better information to drive health investment decisions

Strengthening the use of data will prevent health decisionmakers from “flying blind”

Federal and state governments spend a large and increasing proportion of their budgets on health care. Although rising costs are partly driven by an ageing population, increases in the volume of services per patient are also a major cause, while advancing science, community expectations and defensive medicine contribute to “doing more”. The major challenge facing the Australian health care system in the next electoral term will therefore be to rein in rising costs while maintaining high standards of care and meeting new demands.

Better information about the delivery of health programs and services in Australia must drive policy responses to this challenge. Such information will inform community dialogue about our health care spending priorities and underpin decisions about when new programs, tests or treatments should be offered, continued or ended.

The past decade has seen progress towards high-quality, timely and locally relevant information required by health decisionmakers. However, if Australia is to meet the challenge of rising health care costs, the information and its effective use must be considerably strengthened — otherwise, health decisionmakers are “flying blind”. For example, a better understanding of the causes of unwarranted variations in practice can provide powerful insights into how to reduce costs while maintaining the quality of care and meeting growing demands. In the United States, a twofold difference has been found between geographic regions in per capita Medicare spending; but for some conditions, higher spending does not result in better patient outcomes.1 Considerable variations in practice also exist in Australia.

Improved data systems and more sophisticated approaches to understanding the causes and meaning of variation will be required to make good use of this information in health decisions. A recent article in the Journal illustrates the importance of testing the methods and data, if the right conclusions are to be drawn from performance monitoring and analysis.2

Another opportunity to inform health decisions is to embed rigorous evaluations into the rollout of new policies, programs and service delivery models. It is sometimes possible to structure the rollout of a program to provide for rigorous testing of policy alternatives. For example, in the United Kingdom, a randomised trial was established within the implementation of the national breast cancer screening program to test whether inviting women aged in their forties reduced deaths from the disease.3 More often, it would be possible to establish multifaceted evaluations that shed light on different components of the program, such as that established by the Scottish Government to assess the impact of a smoking ban in public places. Seven separate evaluations examined the impacts of the program, including its effect on hospital admissions for acute coronary syndrome, reduction in second-hand smoke exposure in 11-year-olds, reduction in second-hand smoke at public bars and public support for the policy.4 The evaluation of both of these initiatives influenced subsequent policy decisions.

Although evaluating the operation of programs and services in routine practice is critical to investment or disinvestment decisions, rigorous evaluation is not commonly practised in Australia. Where it does occur, evaluation is often insufficient to draw meaningful conclusions about costs and benefits. The failure to routinely incorporate rigorous evaluation means “we have wasted huge opportunities to learn”.5 The political will to encourage or mandate routine high-quality evaluation of new policies, programs or services would do much to inform health decisions. In the UK, for example, the Treasury places evaluation at the heart of programs and planning.6

Finally, a strong information base for health decisions will require closer partnerships between researchers and health decisionmakers. Health decisionmakers often report that research does not address the questions of most interest to them such as program cost and scalability, and the most likely beneficiaries. Engaging health decisionmakers as partners in the design and implementation of research will result in more robust information for health decisions. Several agencies overseas have pioneered new models of research funding, including the Canadian Health Services Research Foundation and the UK National Institute for Health Research. In Australia, the National Health and Medical Research Council has initiated Partnership Projects and the new Partnership Centres for better health.

The recent McKeon Review emphasised the benefits of continued support for research intended to inform health decisions.7 Supporting this type of research will, over time, help improve care while keeping costs under better control.

Extending the medical workforce debate: let’s talk about self-sufficiency

To the Editor: Until recently, Australian medical workforce planning has seemed a rather
ad-hoc affair. We have self-induced an undersupply of doctors (having actually reduced student numbers in the mid 1990s,1 taken a decade to increase production, and now have crashed into entirely foreseeable undersupply of intern placements). The establishment of Health Workforce Australia has promulgated some much needed detailed, future-focused planning, although the fragmented data landscape has clearly proved challenging.2–4

Australia’s medical workforce “shortage”, which is worse in rural areas because of maldistribution,
has resulted in a great reliance on international medical graduates. We question whether this reliance on overseas-trained doctors is a de facto or “silent” policy, or a reactive response to the perceived shortfall
in the national health workforce.

Globally, there is currently an alarming shortage of skilled health care workers, particularly in developing countries. A significant contributor to this shortfall is the reliance of developed countries on overseas-trained health care workers to meet their workforce needs.5 Australia contributes to the drain of doctors from countries already poor in terms of medical human resources — we import more than 3000 doctors a year, with a likely seven of the top 10 source countries having low or middle incomes.6 Many of these countries have doctor-to-population ratios
of less than one per 1000, while Australia’s ratio is more than three
per 1000 population.

Australia is a signatory to international voluntary codes of conduct regarding health care worker recruitment,7,8 and is arguably well placed to play a leading role in developing and implementing ethical approaches to the recruitment of overseas-trained doctors. To achieve the ethically appropriate goal of self-sufficiency, we will have to continue to improve our forecasting of future needs; and greatly improve co-ordination and resourcing of training places as the number of graduates increases. The opportunity to channel the increased workforce towards rural areas should also not be lost.

We call upon students, doctors, academics, colleges, and policymakers in the relevant agencies and governments to help Australia move beyond lip-service and begin an open conversation on self-sufficiency. Progress will need to accelerate to meet the needs of our own population and to make Australia a more responsible global citizen.

Are we there yet? A journey of health reform in Australia

Five years on from the establishment of the National Health and Hospitals Reform Commission in March 2008, it is timely to review progress. Here, I provide a reminder of the context for reform, a high-level summary of some of the actions taken to date, and some personal reflections and commentary highlighting areas of concern and priority as we continue our reform journey. In presenting this commentary, I hope to pull together the big picture and raise the profile of the many actions underway, some of which are not much in the public eye. A more comprehensive monograph was recently published for the University of Notre Dame Australia College of Medicine Health Leadership Series.1

The context for reform

In the lead-up to the 2007 federal election, the Australian health system was in crisis. Pressure on public hospitals, quality and safety issues, and poor morale in the health workforce were combined with a “blame game” of finger pointing between federal and state governments. There was public confusion about who was in charge. Community concern was on the rise,2 and the momentum for reform was palpable, with an unprecedented readiness for change across the system and the community.

Enter Kevin Rudd with a bold promise to fix the health system and, “if by the middle of 2009 the State and Territory [governments] have not begun implementing a national reform plan, [to] seek a mandate from the Australian people … for the Commonwealth to assume full funding responsibility for the nation’s public hospitals”.3 The compelling appeal of this commitment was soon put to the test.

In announcing the establishment of the National Health and Hospitals Reform Commission in February 2008, the new Prime Minister said that Australia’s health system needed reform to meet “the long term challenges in our system: duplication, overlap, cost shift, blame shift, ageing population, the explosion in chronic diseases, not to mention, long term workforce planning”.4 Ten independent Commissioners with diverse expertise, experience and perspectives were appointed, and the work of the Commission began. After 16 months and arguably the most extensive consultation process ever mounted in health policy development in Australia, my colleagues and I delivered our final report.5

The report, released by Prime Minister Rudd in July 2009,6 presented 123 recommendations organised under four themes, each a message of reform:

Taking responsibility: individual and collective action to build good health and wellbeing — by people, families, communities, health professionals, employers, health funders and governments
Connecting care: comprehensive care for people over their lifetime
Facing inequities: recognise and tackle the causes and impacts of health inequities
Driving quality performance: leadership and systems to achieve best use of people, resources and evolving knowledge.5

Reform action update

In March 2010, the Australian Government released its plan for a National Health and Hospitals Network.7 This was followed in April 2010 by the signing of the National Health and Hospitals Network Agreement between the federal government and, except for Western Australia, all state and territory governments.

In a changing political landscape, the Australian Government’s response to the Commission’s blueprint for reform has seen some shifts in direction, particularly in relation to the reshaping of federal and state roles and responsibilities. A centrepiece of the 2010 National Health and Hospitals Network plan was a shift of financing responsibility that would see the federal government take full public funding responsibility for primary health care and majority funding responsibility for public hospitals, paying a 60% share of the cost using an efficient activity-based funding approach. In the subsequent National Health Reform Agreement, ultimately signed by all First Ministers in 2011 and currently being implemented, the federal government does not take responsibility for primary health care. It will, however, provide increasing funding to public hospitals, with a 45% share of the growth using an efficiently priced, activity-based funding approach from the 2014–15 financial year, and a 50% share of growth from 2017–18.1

Overall, the Australian Government’s response to the Commission’s report has been very positive. Of the 123 recommendations, 48 were agreed to, 45 supported, 29 noted, and only one was not supported.8 My review of progress to date suggests that 44 recommendations are being actioned as proposed, 61 have been amended or partly implemented, and 17 have not yet been actioned. Some of the key reforms currently being implemented are described below under the Commission’s reform themes.

Taking responsibility

An important and much anticipated initiative was the establishment in 2011 of the Australian National Preventive Health Agency to target effective prevention of obesity, tobacco use and harmful use of alcohol. This focus on prevention recognises that there is more to good health than health care, and that prevention and health risk management are vital contributors. Further investment and collaborative action are required to promote a healthy Australia.

The development of the MyHospitals website (http://www.myhospitals.gov.au) in 2011 and publication of Healthy Communities reports9 in 2013 are part of new structures for public reporting on health system performance and health status to inform consumer choices and community action and policy. We are yet to see effective systems that provide feedback to individual clinicians and teams on their practice and outcomes compared with best-practice benchmarks and peers.

Introduction of the personally controlled electronic health record is underway, with registration available to individuals through http://www.ehealth.gov.au from 1 July 2012. Further system enablement and increased engagement and participation of medical practitioners are required ahead of a more comprehensive uptake and adoption strategy. Registrations reached 600 000 by 1 August 2013.

Connecting care

Strengthening primary health care has been a reform priority, with the establishment across Australia of 61 primary health care organisations — Medicare Locals — to support preventive action in local communities and more coordinated care for chronic disease, and to connect health care across settings, particularly with hospitals and mental health and aged care services.

Stronger devolution of governance to local hospital networks has been implemented by each state as part of the National Health Reform Agreement. More than 55 substantial local hospital networks have been formed, with some smaller networks in rural areas. Boundaries of Medicare Locals and local hospital networks are generally well aligned in most states, which should assist local planning, service collaboration and sharing of resources.

The Commission described subacute care services as the “missing link” in the continuum of health care. A key reform investment by the federal government has been to support development of subacute care, such as stroke recovery, rehabilitation services and palliative care, as part of a National Partnership Agreement with the states. However, funding is due to expire in June 2014.

End-of-life care and advance care planning initiatives are being explored, and aged care services reforms were the subject of a Productivity Commission inquiry.10 While not embracing some of the fundamental reforms, the government is implementing recommendations to expand community and home-based care options and simplify the assessment process.

Facing inequities

The health of Aboriginal and Torres Strait Islander peoples is a focus of the national Closing the Gap strategy. However, the one recommendation of the Commission that was not supported by the government was the establishment of a National Aboriginal and Torres Strait Islander Authority,5 which was proposed to perform an active health care purchasing role similar to what the Department of Veterans’ Affairs does for veterans and their families.

Mental health care has received more attention with the creation of a National Mental Health Commission and significant new investment, and it has been given greater priority by most state governments.11

Dental health care has received an injection of funding to reduce public waiting lists. A more substantial investment to provide dental benefits to children in lower-income households has also been foreshadowed.12

Addressing inequity in access to health care for people living in rural and remote areas has led to initiatives such as strengthening of rural clinical schools to recruit and train doctors in rural areas, development of multipurpose centres and telehealth services.

The National Disability Insurance Scheme is an important health and social justice initiative for people living with disabilities, and their carers. This welcome development requires further detail on its financing and scope.

Driving quality performance

A new transparent, nationally consistent approach to federal financing of public hospital services by efficient activity-based funding is a major element of the reforms. Greater clarity of the Australian Government contribution to the growing costs of public hospitals is also important to the financial sustainability of state health systems, although it remains unclear whether the ultimate federal government share will adequately address the vertical fiscal imbalance between state and federal governments.

To support the new arrangements, two independent national bodies have been formed: the Independent Hospital Pricing Authority, which is determining the national efficient pricing for public hospital service activity; and the National Health Performance Authority, which reports on around 50 measures across the health care continuum through Hospital Performance and Healthy Communities reports.

Health Workforce Australia has provided a platform for a national, coordinated approach to health workforce planning, training and innovation. Meeting the demands for training places across the system, including postgraduate and advanced training, is a national challenge currently being explored in the public and private sectors and various health settings. Strengthening involvement of universities, vocational training organisations and professional colleges, as well as the private sector, would be valuable.

Knowledge management systems, smart use of health information through data linkage, and analysis of patterns of health service use and unwarranted variation are receiving some limited attention. The Commission’s recommendation to link data from the Medicare Benefits Schedule, Pharmaceutical Benefits Scheme and public and private hospitals5 has still not been implemented. Further investment will be vital to reduce waste and inefficiency and increase quality and equity in health care, and will be greatly aided by health systems research to support local and systemic solutions.

The government’s response to the recent McKeon review on health and medical research13 is pending. More than ever in this era of active reform, it is crucial that research is recognised as an integral element of what our health system produces and not just a bolt-on activity. Active involvement in research across clinical settings requires investment, support systems and a cultural shift. More effectively translating evidence into clinical practice and health policy requires focus, and robust evaluation of the outcomes of reforms and health system performance is a priority.

Challenges ahead

Even with this extensive and complex package of reforms, major challenges remain. Nations around the world are grappling with four issues in particular:

financial sustainability — tackling waste and inefficiency in health care in a systemic way, as well as innovating to get value-based purchasing into how we pay for health activity;
coordinating and connecting care for patients across service settings and over time;
how to best leverage the benefits of public and private health financing and care provision; and
changing lifestyles, the rise of non-communicable diseases and the broader social determinants of health.

Financial sustainability and vertical fiscal imbalance

Sustainability of health financing, the vertical fiscal imbalance and the re-emergence of the blame game cannot be ignored. I would like to see the governments of Australia revisit the original proposition in the 2010 National Health and Hospitals Network plan — that the federal government takes full public funding responsibility for primary health care and community-based care and 60% of public hospital funding on an efficient activity basis.

Alternatively, the federal government’s share of growth under activity-based funding of public hospitals and health services could be increased to 60% from now and include a broad range of out-of-hospital services in its scope. This would avoid the need for negotiations on the goods and services tax or other financial adjustments, and would shift to an increased forward exposure to the federal government for public hospital care, similar to the level originally planned.

Tackling the vertical fiscal imbalance will not solve all the health system’s problems, but it would remove a major distraction and point of tension that fuels the blame game.

Getting the best value from the health dollar

There is inefficiency in our health system at many levels. Waste in health care is both an ethical and an economic issue. Introducing efficient activity-based funding of public hospitals does not in and of itself deliver efficiency, but it will be a useful tool. Hospitals also require access to analytical capability, change management skills and, in some instances, capital and technology investment. Additional ideas to improve efficiency are presented in Box 1.

Effective national leadership across the system

National leadership across the system as a whole remains a structural challenge. One idea is to form an expert reference body, independent of jurisdictions and health departments, with members offering clinical, economic and community perspectives to inform, advise, monitor and publicly communicate on progress toward agreed outcomes. This could be a constructive watchdog or advisory health assembly.

Moving to a single national public funder model with a national health authority responsible to the Council of Australian Governments could provide a system-wide approach that builds on the strengths of a national funder and purchaser. This is not to say that the federal government would be the sole funder (federal and state contributions could be pooled), nor that the federal government would manage the public hospital system (state governments would continue to operate public hospitals with transparent activity-based funding, and private hospitals could add competition for funding of public patient care). The independent national body could be an active purchaser across the continuum of services, building on the platform of activity-based funding and exploring more innovative purchasing over time. In the meantime, we could further explore “Medicare Select”, as recommended by the Commission, where greater consumer choice, competition and innovation in purchasing may also enable better use of our mixed system of public and private financing and provision.5

The right care in the right place at the right time

The challenge of delivering the right care in the right place at the right time in a coordinated way is a challenge all health care systems face. Whatever the financing system — whether a single funder (eg, the United Kingdom’s National Health Service), social insurance models (eg, in France and Germany) or a private insurance system (eg, in the United States) — all still struggle with achieving connected care across the continuum. As such, while moving to a single public funder model may reduce fragmentation, give a whole-of-system view and potentially enable greater financing innovation, it does not guarantee it.

In addition to more innovative approaches to health funding, there are five steps that we need to take to get the right care at the right place at the right time (Box 2).

Health is about more than health care

Good health is about more than good health care. Many other factors influence our health — our biology, lifestyles and behaviour, the environment we live in, and social, economic and cultural factors. We need to get more serious about prevention. As with tobacco products, a package of actions is required — from education, social marketing and behavioural change through to regulation and taxation measures. It requires time, investment and the involvement and collaboration of many parts of government, the health system and society. It must be evidence-led where possible, and new initiatives must be actively evaluated.

It is unacceptable to walk away from personal and shared responsibility. We should each have the starring role in our own health and health care decisions. However, inequities mean we do not all have the same life experiences and opportunities. Health literacy, educational attainment, employment, stable housing and many other factors may affect our capacity to make healthy choices. If we are serious about the good health of Australians, we must be serious about making healthy choices easier and fairly available.

In addition to health service reform, there is a serious need for a national action plan that crosses governments and portfolios to address factors in the social environment that affect health status.

Conclusion

Health needs to be a live issue on the national agenda. While there has been some valuable progress, we have not yet resolved the structural flaws in funding and governance that fragment health care delivery in Australia. We have focused largely on public health financing and public hospitals but have not yet considered innovative approaches, such as Medicare Select, to better use the private sector.

We have a long way yet to go on our reform journey, and we need political leadership and strong engagement with the health sector and community as we continue to move towards a sustainable, high-quality and responsive health system for all Australians.

1 Ideas for tackling inefficiency and waste

Map unwarranted variations in health service delivery to help inform local analysis and action
Support end-of-life care and advance care planning to help enable people’s preferences to die at home instead of in hospital
Address the inefficient allocation of care in hospital because of service gaps (eg, rehabilitation services, aged care and palliative care)
Provide evidence portals to support use of best evidence in clinical practice
Provide feedback to doctors on their own practice patterns and patient outcomes against best practice and their peers
Support secondary prevention, such as falls prevention and management of osteoporosis after first fracture
Reduce adverse drug events through a range of measures
Use shared informed decision-making tools to help people decide whether they want a procedure, particularly when treatment choices and evidence are unclear
Use evidence to disinvest in procedures and treatments that do not work
Make better use of multidisciplinary team skills to increase productivity
Minimise duplication and non-value-adding administrative processes
Reduce unnecessary repeated pathology tests and imaging through better access to results from other sources
Use smart purchasing for value (ie, funding approaches that pay for performance and outcomes)

2 Five steps to get the right care at the right place at the right time

Better define appropriate care, in terms of both clinical evidence and explicitly seeking a person’s preferences and informed decisions
Fill service gaps, such as rehabilitation, palliative care, specialist teams in the community, home-based care and aged care services
Support people to navigate the system through a “health care home” as their core relationship from which care is coordinated, and with online tools and resources and telephone health coaching and advisory services
Connect care through better communication between patients, carers (where relevant) and health care providers, including innovations such as personally controlled electronic health records, apps and telehealth
Use smart purchasing to support appropriate care in the best setting and over time (eg, bundled packages and episodes of care across providers, with an outcome focus

Research using autologous cord blood — time for a policy change

It is now well established that type 1 diabetes is a chronic, multifactorial disease that results from autoimmune-mediated destruction of pancreatic β cells. However, no intervention has successfully prevented the disease to date. Recently, reinfusion of autologous umbilical cord blood has been proposed as a novel preventive therapy and is the focus of an Australian Phase I trial, the Cord Reinfusion in Diabetes (CoRD) pilot study (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363694). However, the use of publicly stored cord blood for research in Australia is currently limited by policy that restricts its use to recognised indications, including allogeneic haematopoietic stem cell transplantation for oncological, haematological, genetic and immunological disorders. There are also specific ethical issues associated with the collection and storage of cord blood, including storage (public v private), informed consent (from whom, when and how?), ownership (does it belong to the child or the parent?), access (exclusive autologous v allogeneic use) and the principle of beneficence.1

A substantial body of research in recent years has been directed towards prevention of type 1 diabetes. Primary prevention has largely targeted putative environmental risk factors such as early introduction of docosahexaenoeic acid or dietary cow milk protein.2 The latter is being investigated in the international randomised controlled Trial to Reduce the Incidence of Type 1 Diabetes in the Genetically at Risk (TRIGR).3 In contrast, secondary prevention trials have targeted immunomodulation through interventions such as nicotinamide and oral or parenteral insulin. While previous trials have failed to demonstrate significant therapeutic benefit,2 and evidence-based guidelines state that no interventions are recommended for use in clinical practice to delay or prevent the onset of type 1 diabetes,4 the role of intranasal insulin is under investigation through the Type 1 Diabetes Prevention Trial.5 Nevertheless, there is a compelling argument to explore novel approaches to the prevention of type 1 diabetes.

An alternative preventive strategy is to modify the regulatory components of the immune system — in particular, Foxp3+ regulatory T cells (Tregs). There is emerging evidence in animal models and in humans to suggest that the loss of normal immunological self-tolerance in type 1 diabetes, a crucial step in its pathogenesis, may be attributable to the failure of Tregs.6 The specific Treg abnormalities involved in type 1 diabetes are yet to be fully elucidated, but may include defects in Treg number and function, and increased resistance to regulation by effector T cells.6

Umbilical cord blood is rich in Tregs, which become functionally suppressive on antigen stimulation,7 and is also a source of haematopoietic and pluripotent stem cells.8 Thus, there is a strong scientific rationale behind the potential for cord blood to prevent or delay the onset of type 1 diabetes. The CoRD trial will examine whether autologous cord blood infusion can prevent type 1 diabetes in high-risk children with serum antibodies to multiple β-cell antigens. In parallel, the trial will study the immunological effects of cord blood infusion. This is the first time such a trial will be undertaken for the prevention of type 1 diabetes in humans, although studies have used autologous cord blood after the onset of type 1 diabetes. In a Phase I trial involving 24 children (median age, 5.1 years) with type 1 diabetes,9 infusion of autologous cord blood after a median diabetes duration of 3 months was associated with a transient increase in total and naive Tregs at 6 and 9 months, respectively. No adverse events were observed. Nevertheless, the intervention did not preserve β-cell function, as C-peptide levels decreased after infusion. However, the time after diagnosis at which the infusion was given may have been important; a rapid loss of β-cell mass has been frequently observed, and this decline may have occurred before the infusion was given. In a pilot study of 15 individuals (median age, 29 years) with type 1 diabetes,10 circulating lymphocytes were cocultured with allogeneic cord blood-derived stem cells and subsequently reintroduced into the circulation. There was a significant improvement in mean fasting C-peptide levels and a reduction in glycated haemoglobin levels and daily insulin requirements, in parallel with an increase in Tregs. The procedure was well tolerated, with no adverse events. These two studies suggest that cord blood may increase the frequency of Tregs in people with type 1 diabetes and may therefore induce immune tolerance. Whether cord blood has the same effect among people with prediabetes is unknown.

There are several fundamental methodological issues that must be addressed in the development of trials such as CoRD, which involve autologous cord blood. Studies that have demonstrated either no or minimal adverse effects in the use of autologous cord blood have involved small study samples.9,10 While the safety of autologous cord blood may also be inferred from the known safety of allogeneic cord blood, further data are required, particularly in the paediatric population. Rates of microbial contamination are low (< 5% in privately banked samples), although such samples are generally not suitable for use. In addition, samples with low total nucleated cell counts may be ineffective;11 however, private banks specify a lower limit of 108 total nucleated cells for storage, thereby reducing the likelihood of inadequate samples being collected.

Despite the clear need for well designed trials to examine the specific therapeutic applications of cord blood, there are important differences in the ways in which public and private banks collect, store and provide access to cord blood, which could affect potential research. Public banks store donated cord blood units for allogeneic use, with around 3000 units stored per year in Australia (about 1% of live births). The rate of collection in public banks is dependent on available funding and only a few hospitals participate in collection nationally. In contrast, private banks provide storage for personal and familial use, for a fee. The storage rate in private banks is around 4000 units per year (Mark Kirkland, Cord Blood Bank Director, Cell Care Australia, personal communication), and growth is estimated at 12%–15% per annum.12 Globally, over a million cord blood units have been stored in private banks. Nevertheless, the chance of using a privately stored cord blood sample is less than 0.01%.13 Although a number of potential therapeutic indications for autologous cord blood have been proposed — such as cerebral palsy, hypoxic–ischaemic encephalopathy,14 congenital hydrocephalus and stroke15 — there are few published data. The number of published clinical trials using autologous cord blood is limited; however, there are 14 ongoing trials registered on ClinicalTrials.gov using both publicly and privately stored cord blood.16

The expansion of cord blood trials, along with high consumer demand for storage, places pressure on regulatory bodies to develop and adapt policies to meet these needs. Although the regulatory framework surrounding cord blood banking in Australia has undergone significant development, issues remain regarding access to publicly donated cord blood. In particular, there is no clear guideline that addresses degifting and use of publicly stored cord blood for autologous reinfusion beyond recognised indications. At present, the use of publicly banked cord blood is essentially limited to well researched and established applications, particularly for haematopoietic reconstitution, and does not extend to research purposes (Anthony Montague, National Cord Blood Network Operations Manager, Australian Bone Marrow Donor Registry, personal communication). These processes are, however, currently under review. Beyond being a policy issue, this raises deeper ethical questions regarding the rights of public donors to access their donated cord blood and equity between public donors and those who privately bank cord blood, particularly as the private industry continues to expand.17,18

While the future applicability of cord blood-based therapeutics, including prevention of type 1 diabetes, is at present unclear, this is an emerging area of research. An evidence base is clearly needed in response to the burgeoning interest in the community for storage of cord blood. However, important questions regarding the storage and use of publicly donated cord blood remain unanswered. Should cord blood banks be permitted to degift altruistically donated samples to enable participation in research? Will novel therapeutic uses for cord blood lead to changes to public cord blood banking policy? Given the likelihood of future cord blood-based clinical trials, the existing framework of cord blood banking policy must be reviewed to meet the needs that will be posed by such research, which may lead the way to expanding novel uses of cord blood.

Developing a global agenda for action on cardiovascular diseases

Australian health policy can and should address, as a core aim, cardiovascular health in less economically advanced nations

Cardiovascular diseases have snatched the mantle of top-priority global health problem from infectious diseases including tuberculosis, malaria and HIV/AIDS. This is because of the deaths attributable to cardiovascular diseases, the years of life lost, and the longer-term disability from heart failure and stroke.1 While deaths due to cardiovascular diseases among people younger than 65 years have fallen dramatically in the past 50 years in Australia, in less economically advanced communities one-third of these deaths occur among people younger than 65 years.2

Cardiovascular diseases are potent widow- and orphan-makers. Particularly in developing communities, they can precipitate poverty. The cost of care in communities lacking affordable health insurance and effective primary care can be catastrophic.

The effect on a nation’s lost productivity and growth is no less disastrous. Every 10% rise in chronic non-communicable diseases is estimated to bring a 0.5% decrease in economic growth.3 It has also been estimated that deaths in developing countries attributable to chronic disease will grow from 46% of all deaths in 2002 to 59% of all deaths in 2030, or to more than 37 million lives lost per year.3

Why the delayed recognition? These circumstances have been many decades in the making. Three principal reasons for global inaction over those years stand out.

First, in many countries maternal and infant mortality rates are high, visible, tragic and immediate, and a natural priority for scarce health care resources. Such countries that now also face the cardiovascular crisis are war-weary from fighting infant and maternal mortality, tuberculosis, malaria and HIV/AIDS. But great gains have been made in these conditions, and it is now imperative that we encourage and support those nations to address chronic diseases.

Second, perception of cardiovascular diseases, in relation to human behaviour, differs radically from that of infectious diseases. As with type 2 diabetes, obesity and chronic lung disease, cardiovascular diseases occur principally among older people, in social conditions of fast economic development and generally favourable, poverty-reducing urban development. They depend on human behaviour — smoking tobacco, overeating fats and sugars, abandoning traditional (usually healthier) nutrition, and underexercising. Potential donors who wish to improve international health consider cardiovascular diseases off limits for funding, since these diseases are “the sufferers’ fault” or diseases of old age. It is hard to convince major donors that such adverse individual health behaviour is largely determined by domestic, community, work and economic environments and that older people matter.

Preventive strategies for chronic disease that respond to the individual and the social environment behind these disorders appear soft and diffuse. They are complex compared with, say, an immunisation program with its clean start, jab and finish. Interest groups that profit from an environment that promotes chronic diseases, especially cardiovascular diseases, resist efforts that encourage change.4

But these detached, judgemental and indolent attitudes are changing, stimulated by a 2011 United Nations meeting on the global chronic diseases crisis.5 The UN meeting resulted from years of advocacy by a few governments, including Australia’s, and non-government agencies concerned about cardiovascular diseases, diabetes, cancer and chronic respiratory disease — the NCD Alliance. The Lancet has shown admirable academic leadership in non-communicable diseases research by creating an action group, publishing special issues and providing support for international meetings.

Often the recognition of a crisis jolts us to take the matter seriously, and so it is with cardiovascular diseases. A political declaration from the UN meeting articulated goals and strategies for preventing and controlling non-communicable diseases over the following 5 years. This has pushed international agencies such as the World Health Organization to act. The WHO is responding with global strategies: enhancing tobacco control, addressing dietary salt reduction, nominating essential medicines (including antihypertensives), and advocating for fuller and more stable primary care services everywhere.

In addition, chronic diseases are being reconceptualised, and are now frequently perceived as an impediment to social development, thus adding them to the agenda for discussion concerning the next steps to be taken after the Millennium Development Goals conclude in 2015.6

The third factor behind our relative inaction, despite indisputable progress, has been those massive holes, only now beginning to close, in knowledge about what to do, and how to implement the knowledge we have.

Although we have had the major risk factors for cardiovascular diseases nailed for the past 50 years, and can use them to explain most of the variance in cardiovascular disease frequency, more basic and clinical research is required alongside health services research to translate these insights into effective policy, population interventions and individual behaviour change.

Fruitful fields of inquiry include events in early life capable of setting the later epigenetic, physiological and behavioural trajectories for chronic disease.7

Australia has generally done well with cardiovascular disease control, although onset and mortality occur a decade earlier in our Indigenous communities than in the rest of the population.8 Overall, rates of deaths due to coronary heart disease in Australia fell by 83% between 1968 and 2000, as newer medical and surgical interventions have exerted a spectacular positive influence on individuals, and lifestyle changes have contributed positively at the individual and population levels.9

Tobacco smoking is now less common in Australia than in most other economically advanced nations. Our efforts, although incomplete, in cardiovascular disease prevention and management in urban and rural Indigenous communities might apply to other communities. In a spirit of mutual learning, we should share our experience with these efforts.

We know well the battles over entrenched behaviour, practices and social structures that nourish risk factors. The tobacco war is by no means over, and the food and alcohol wars are just beginning here and elsewhere. In the United Kingdom, the government has recently suspended the push for tobacco plain packaging legislation,10 and the same is likely to happen to a minimum alcohol pricing policy.11

In Africa, rapid modernisation will, by the middle of this century, potentially not only lead to food self-sufficiency but also surplus food to export.12 Although this will alleviate starvation, it will spell disaster for rapidly urbanising populations where, if the previous experience of developed societies is any model, cardiovascular disease rates will increase quickly.

Translating knowledge and science into resource-poor (or even just less-developed) settings is culturally, politically and logistically difficult. But as a good and progressive global citizen, Australia can still advocate for access to essential medications, meaningful aid and public health support. Such strategies have worked to combat infectious diseases globally, but now they must address non-communicable diseases.

Australia has much expertise and experience to share in international efforts to prevent and control cardiovascular and other chronic diseases. If this challenge is embraced by both major parties in the upcoming federal election, it would be pleasing indeed.

Challenges in health policy: the next 10 years

Hospital governance that prioritises waiting times or patient throughput does not adequately address health care quality

At the 2007 federal election, Kevin Rudd announced plans to reform the health system. The National Health and Hospitals Reform Commission (NHHRC) was established the following year to find solutions. In 2010, Rudd presented his response to the NHHRC’s report, proposing local hospital networks interfacing with primary health care, with governance in which health professionals would play a part.1 Regrettably, other forces with a focus primarily on external regulation of hospitals subsequently came to bear, and this became formulated as national policy by the Council of Australian Governments (COAG).2 But does the framework of the COAG agreement deliver what is needed?

The NHHRC saw that health care costs, internationally, were rising well ahead of the consumer price index. State governments, with fixed revenue bases, are unable to fund this. The first, welcome, outcome of the COAG agreement was a progressive increase in the federal share of funding from 40%, building to 50% by 2017.2

In the context of its new funding model, the COAG Reform Council now monitors hospitals against the politically sensitive yardsticks of waiting lists, waiting times in emergency departments, and hospital separation numbers. Performance is patchy across Australia.3 Sadly, none of the performance criteria assess quality of services or the key relationship between hospitals and primary care. Good health care must be a continuum between these two sectors.

Health care has vastly improved through innovations in diagnosis and treatment over many decades. This must continue with improving services, if patients are to get the care they need. The NHHRC and COAG envisaged that this would be handled by bodies in Canberra propounding models for treatment and the need for quality and safety. However, when management of hospitals is geared toward providing figures sought by government, it focuses on numbers rather than quality and safety for those treated. This has long been the case.

Even before the NHHRC report, egregious problems in patient care had hit the press. In the report of the Special Commission of Inquiry in New South Wales, Garling stated:

During the course of this inquiry, I have identified one impediment to good, safe care which infects the whole public hospital system. I liken it to the Great Schism of 1054. It is the breakdown of good working relations between clinicians and management which is very detrimental to patients. It is alienating the most skilled in the medical workforce from service in the public system.4

The problems identified by Garling and in the media were in hospitals that were performing well on the criteria of patient throughput and waiting times.

The perception of poor quality, safety and coordination of health services in Australia, compared with those in New Zealand, the Netherlands and the United Kingdom, is borne out by surveys conducted by the Commonwealth Fund.5

Good health care must be informed by ongoing research, and clinical research is the greatest safeguard of quality of care. To ensure appropriate resource allocation, monitoring of research outcomes should include economic evaluation. Where outdated strategies do not work, they must be replaced.

The report of the McKeon Review,6 released in April this year, is a breath of fresh air. It seeks better health through research. It argues that to have a $135 billion health sector with no systematic commitment to embedded research and development, which would ensure efficiency and sustainability, makes no sense. The authors propose a 10-year program progressing towards 3%–4% of government health budgets being devoted to research and development.

McKeon and colleagues also propose initial establishment of four to eight (building in time to 10–20) “integrated health research centres” across Australia. These centres would combine hospital and community-care networks with universities and medical research institutes. They could change the face of Australian health care by providing leadership in care that draws on cross-disciplinary professional and research skills. Health care would be tested and progressively developed, embracing not only hospitals but also primary care, mental health care, community nursing and aged care, with changed professional roles and overall monitoring of outcomes.

New Medicare Locals seek to better integrate primary medical care with other important health services. They also need to be linked with the hospital system and with training of health professionals. There are now big opportunities as we look to the future.

Supporting rural health care

Overcoming the barriers and seizing the opportunities to provide more equitable health care for Australia’s rural population

Australia’s rural population, which comprises a third of our total population, presents distinct challenges for health care delivery. The low population density of much of rural Australia, the great distances involved, and the limited number of larger centres offering high-level medical care make equitable health care delivery difficult to achieve. Added to these difficulties is the overrepresentation of socioeconomic disadvantage and Indigenous people in rural and remote communities. The overall picture is that of a population with a heavier disease burden, more barriers to accessing appropriate care, and poorer outcomes from cardiovascular disease, stroke, diabetes and cancer than the metropolitan population.

The rural health workforce is ageing and, particularly in remote areas, remains heavily reliant on international medical graduates. There is also a significant maldistribution of the medical workforce, with the rural sector having only a third to half of the workforce of metropolitan areas, on a population basis. Surgical and medical specialists are most markedly underrepresented.1

Certain medical interventions will always be difficult to deliver to some rural populations. For example, primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction and thrombolysis for acute stroke, while increasingly available in regional referral hospitals, rely on timely delivery to be effective, and this will not always be possible for people in more remote locations. The SNAPSHOT ACS study reported in this issue of the Journal indicates that not only are patients in rural areas less likely than those in urban areas to undergo echocardiography, coronary angiography and PCI, they are also less likely to receive guideline-recommended medications, cardiac rehabilitation and dietary advice.2 This finding is consistent with shortages of allied health workers and specialists in rural and remote settings.

Nevertheless, there have been recent initiatives that will benefit rural health in the long term. The Rural Clinical School program, operating for over a decade, is now reaping rewards, with graduates returning to rural areas as junior medical officers, general practitioners or specialists.3 Health Workforce Australia and the Royal Australasian College of Physicians (RACP) are supporting dual training in general medicine and a subspecialty, with two positions to be based in Orange and Dubbo in New South Wales next year.4 This initiative addresses the lack of rural advanced training positions — a key concern in the April 2013 report of the Mason review.5 Given that the inability to undertake a major portion of advanced training in a chosen specialty in a rural location is a significant barrier to rural recruitment, such training positions require funding. Queensland Health’s Rural Generalist Pathway and the RACP’s dual training model are two examples of programs that could be expanded both internally and into other specialties.

Opportunities to strengthen medical training — both before and after medical school graduation — should be seized. The Rural Clinical School program’s expansion beyond medical training into interdisciplinary education and simulation centres prepares trainees well for rural practice. However, this approach is challenged by insufficient rural intern positions. State governments should consider increasing the number of rural intern positions available.

Unless the complexity associated with the cost of providing health services to sparsely populated and geographically stretched communities is fully appreciated, activity-based funding will pose risks to rural service provision. Patient transport is often a limiting factor in appropriate and timely service provision, and this also needs to be reviewed.

The federal government is well aware of the issues in rural and Indigenous health, and several of its initiatives, such as improving rural training opportunities, need to be acknowledged. It is important that the medical profession continues to work with both the federal government and rural communities to support, promote and strengthen these initiatives. It is no longer realistic to expect one or two doctors in small rural communities to provide 24-hour care every day of the year. Instead, best practice requires groups of practitioners with complementary skills to work together to achieve appropriate, and safer, health care. An important function for politicians is to explain the necessity of these changes in medical practice to the community. Nurse practitioners could have a major role, and expansion of these positions in rural group practices and multipurpose services would facilitate better care, especially for patients with chronic illness.

Australia has made steady progress in recent years in providing effective health care to rural and regional communities. Future governments require strength of resolve, clear vision and sound policies to maintain that progress for the third of the Australian population who live beyond the major cities.

Psychosocial risk factors for coronary heart disease

A consensus statement from the National Heart Foundation of Australia

In 2003, the National Heart Foundation of Australia (NHFA) published a position statement relating to psychosocial risk factors and coronary heart disease (CHD).1 Here, we provide an updated review of the literature on psychosocial stressors, to complement a separate consensus statement from the Expert Working Group on depression and CHD.2 Psychosocial stressors include chronic stressors (in particular, work stress), acute individual stressors (such as bereavement or job loss) and acute population stressors (such as earthquakes and sporting events). The process for developing this consensus statement is described in Box 1. Treatment decisions should take into account the individual clinical circumstances of each patient.

Chronic stressors and coronary heart disease

Chronic work stress

The previous NHFA review found that there was neither strong nor consistent evidence of a causal association between work-related stressors and CHD.1 However, there is plausible evidence for work stress having a biological impact.4 Furthermore, work stress has a prominent place in the public perception of potential causes of CHD, particularly heart attacks.5

Most of the literature evaluating the effects of work stress on cardiovascular disease (CVD) has focused on job strain6 and effort–reward imbalance.7 Recently, the literature has broadened to include other concepts, such as job insecurity,8 organisational justice,9 job satisfaction10 and work hours.11 Throughout the literature, these concepts generally refer to individuals’ perceptions rather than external ratings of work stress. Studies of the impact of work stress on the development of CHD have been comprehensively reviewed since 2003.12–16 Differing study methodology (in particular, the method used to assess work stress) has a strong effect on whether or not an association between work stress and CHD is found.12,15

Job strain

People who report that the demands of their work are too great and that they have too little control over how and when their work is performed are considered to be experiencing “job strain”.6 One review found that for high versus low job strain, the age- and sex-adjusted relative risk (RR) of CHD was 1.43 (95% CI, 1.15–1.84), but this was not significant after adjustment for standard CHD risk factors and potential mediators.13 Another review found that a majority of studies of men found no independent association between job strain and CHD, while studies of women suggested trends toward an association.12 The relevance of this difference between the sexes is unclear. A European meta-analysis of individual participant data showed that for the 15% of employed participants who reported high levels of job strain, the hazard ratio (HR) for an incident CHD event was 1.23 (95% CI, 1.10–1.37), compared with the participants reporting low levels of job strain.16 However, job strain only accounted for 3.4% of the overall population attributable fraction (PAF; a reflection of the contribution of a risk factor to a disease) of CHD. This PAF is much less than that for standard CHD risks, such as smoking or hypertension. Confirming this, the Whitehall II study demonstrated that adding information on job strain does not improve 10-year risk prediction for CHD above the standard Framingham risk score.17

Effort–reward imbalance

This is the perception of an imbalance between the effort of work (which includes the demands and challenges of the work itself and the effort of balancing work with other aspects of one’s life) and the rewards of work (financial rewards, increased self-esteem and advancement opportunities).7 The RR for the combination of high effort and low reward in predicting CHD in one review was not statistically significant (1.58; 95% CI, 0.84–2.97);13 a finding of a trend only, that was confirmed by another review.12

Organisational injustice

The perception of organisational injustice (unfair treatment at work) has been associated with a significant RR of CHD (1.47; 95% CI, 1.12–1.95).13 However, as almost all of the evidence for this came from the Whitehall II study, no generalised conclusion about the association between organisational injustice and CHD can be reached.

Shift work

The impact of shift work on CHD was thoroughly reviewed and analysed in 2012.14 Shift work was found to be associated with a moderate increase in myocardial infarction (MI) (RR, 1.23; 95% CI, 1.15–1.31) and CHD events (RR, 1.24; 95% CI, 1.10–1.39), but not with increased rates of mortality. All shift work schedules studied, with the exception of evening shifts, were associated with a higher risk of CHD events, even after adjusting for unhealthy behaviour and other CHD risks.

Other types of work stress

The evidence of an association between the development of CHD and job (in)security,8 job satisfaction10 and working hours11 is mixed, and no firm conclusions can be made at this stage. It is recognised that the potential for bias in this area is large.

Work stress and prognosis of CHD

We identified no systematic reviews on this topic. Two Canadian studies have analysed work stress as a prognostic factor after a first CHD event.18,19 An association was found between chronic job strain and recurrent CHD in the period 2.2 years or more after a first coronary event (HR, 2.20; 95% CI, 1.32–3.66).18 Job strain remained an independent predictor of recurrent CHD after adjustment for potential confounders. In the other study, a high effort–reward imbalance showed a trend toward an association with recurrent CHD (HR, 1.75; 95% CI, 0.99–3.08), particularly in women.19 This association appeared to be explained by low reward rather than by high levels of effort.

Social isolation and social support

There has been consistent prospective evidence that poor social relationships are associated with higher mortality rates from all causes.20,21 The most comprehensive review suggested a 50% increased likelihood of survival for participants with stronger social relationships, with no differences between the sexes.20

However, a systematic review found that there is limited evidence for low social support or social isolation being a marker of, or risk factor for, the development of CHD in healthy people.22 A more recent study evaluating people either at risk of or with existing atherothrombosis showed that people who lived alone were at higher risk of cardiovascular death than those who lived with someone (8.6% v 6.8%; P < 0.01).23

In contrast, “prognostic” studies of the effect of low social support after MI are more numerous and compelling.22,24–26 These studies have consistently found low social support to be a marker of poor prognosis, being associated with increased mortality, readmission and re-infarction rates. In a review of prognostic studies,22 low “functional support” (the aid that is provided to an individual by his or her social network, including help doing tasks and emotional support) increased cardiac and all-cause mortality. Adjusting for other risk factors had little or no effect on these results (HR for all-cause mortality, 1.59; 95% CI, 1.21–2.08). The effect of “structural support” (number and frequency rather than “quality” of contacts) was less evident (adjusted HR for combined cardiac or all-cause mortality, 1.12; 95% CI, 0.98–1.29).

Reducing social isolation and increasing social support are difficult to achieve. In the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) trial, which involved people with low social support or depression after an MI, those who received counselling sessions showed greater improvement on the five-item ENRICHD Social Support Instrument than did the controls.27 However, this was not associated with any improvement in CHD outcomes. There have been no treatment studies on which recommendations about targeting social support as a way of improving CHD outcomes can be based.

Acute stressors and coronary heart disease

The 2003 NHFA position statement found that acute life-event stressors could trigger CHD events but that it was difficult to study and quantify the magnitude of their effects.1 Since then, further publications have supported the link between acute stressors and CHD. However, there is potential for recall bias in this evidence, arising from case-crossover28 and observational29 studies, and for other potential confounders or varying individual responses to stressors to influence the results. While many psychological stressors have a clear time of initiation, others are less precise.

Several reviews have examined the relationship between acute psychological stressors and CHD.30–33 One review assessed studies of triggers of non-fatal MI and calculated PAFs.34 Taking into account the odds ratio (OR) and the prevalence of exposures, the estimated PAFs included negative emotions (3.9%) and anger (3.1%).

Pathophysiology

There are several mechanisms by which acute psychological stress might trigger an acute MI.35 Psychological stress produces significant increases in heart rate and blood pressure that may lead to increased myocardial oxygen demand and plaque disruption. There is also evidence that mental stress may lead to a primary reduction in myocardial oxygen supply. Whereas coronary arteries of people without CHD dilate during mental stress, impaired dilation and even constriction have been demonstrated in atherosclerotic arteries.36 In some studies, mental stress has been found to enhance platelet aggregation.37

Individual stressors

Acute emotional responses

Individual studies have shown a varying transient RR of about 2–9 (compared with baseline) for anger triggering MI, typically using a 2-hour hazard period after an episode of anger. Anger shortly before MI has been reported in 2%–17% of different populations.38–40 Acute anger episodes have also been reported to trigger ventricular arrhythmias.41 A higher likelihood of anger triggering MI has been observed in people with socioeconomic deprivation and lower educational attainment.42

Acute anxiety episodes are also associated with a transient increase in cardiac risk. In the Determinants of Myocardial Infarction Onset Study (the Onset study), experiencing anxiety symptoms in the 2 hours before MI symptom onset was associated with a significant RR of 1.6 (95% CI, 1.1–2.2; P = 0.01).38 However, these studies are prone to recall bias.

Bereavement

Increased cardiac mortality in bereaved people is well described.33,43 In a cohort of middle-aged widowers, a 40% relative increase in mortality rate was observed in the first 6 months after bereavement.43 Using the new criteria in the fifth edition of the Diagnostic and statistical manual of mental disorders, many of these bereaved individuals could now be diagnosed as having “depression”.44 The risk appears to be maximal in the first few weeks. In the Onset study, there was a 21.1-fold (95% CI, 13.1–34.1) increase in incidence rate ratio of non-fatal MI in the 24 hours after bereavement, with a fourfold increase in the first month after bereavement.45

Acute work-related stressors and job loss

Acute work stressors (eg, high-pressure deadline), when linked to negative emotions, have been associated with a transient increase in risk of MI (OR, 6.0; 95% CI, 1.8–20.3).46 However, confirmatory studies are needed.

Job loss is a major stressor that may disrupt socioeconomic dimensions, such as income and social connections, and is commonly thought to be a cause of adverse health events.47–49 The United States Health and Retirement Survey found that involuntary job loss (eg, from workplace closures or redundancies) among older workers was associated with a more than doubling in MI (HR, 2.48; 95% CI, 1.49–4.14) relative to working people, after adjustment for potential confounders.47 A greater number of job losses experienced by an individual was associated with a greater risk of MI.49 This risk increased incrementally from one job loss (HR, 1.22; 95% CI, 1.04–1.42) to four or more cumulative job losses (HR, 1.63; 95% CI, 1.29–2.07). The risk of MI was elevated within the first year of unemployment (HR, 1.27; 95% CI, 1.01–1.60) but not thereafter.

In contrast, studies from Europe and New Zealand have shown no link between job loss and CVD.50–53 The reasons for these different findings may relate to differing study approaches. The US studies all used self-reporting for determination of CHD,47–49 whereas the European and New Zealand studies used national data linkages for more robust determination of CHD deaths and hospitalisation.50–53 Also, the context may have an influence; for example, in the US, employment is important in accessing health care. The impact of job loss during a recession, when such loss is more common, is different to the impact of job loss during a boom.54 Paradoxically, country-level data have shown temporal associations of decreasing unemployment with increased deaths from CVD.55,56 It has been suggested that this effect may reflect people using the extra time to undertake healthier behaviour. Overall, while job loss may have detrimental economic and psychological consequences, its association with CHD remains unclear.

Population stressors

Natural and other disasters

Earthquakes and wartime missile attacks are associated with acute increases in cardiovascular event rates,29,57–59 possibly moderated by the time of the event. It is postulated that the added stress of abrupt awakening may have contributed to the triggering of MI by the 1994 Los Angeles earthquake, which occurred at 4.31 am.59 In the 60 days after the September 11 terrorist attacks in 2001, there was a 49% increase in patients with MI admitted through New York emergency departments, compared with the 60 days before (118 v 79; P = 0.01).60

Sporting events

Sporting events provide another example of population stress.61,62 On the day of the 1996 European football championship quarterfinal in which the Netherlands narrowly lost to France, Dutch men had an increased RR of mortality from MI or stroke of 1.51 (95% CI, 1.08–2.09). However, there was no increased risk for Dutch women.61 A German study of the football World Cup provided further evidence for the triggering of cardiovascular events during emotional stress associated with watching sporting events.62

Takotsubo cardiomyopathy

There has been increased recognition of takotsubo cardiomyopathy and its relationship to acute emotional stress.63–65 The use of angiography has led to the recognition of takotsubo cardiomyopathy in 1%–3% of patients presenting with suspected acute coronary syndrome. A distinctive abnormality of left ventricular contraction, leading to a systolic appearance on angiography that resembles the short, narrow neck and round bottom of a Japanese octopus trap (a takotsubo), gave the entity its name. Takotsubo cardiomyopathy is characterised by signs and symptoms of myocardial ischaemia in the absence of obstructive CHD.63 Acute myocarditis may present with similar symptoms and with normal coronary arteries, but without the distinctive left ventricular appearance of takotsubo cardiomyopathy. Although incidence rates vary, an episode of acute psychological stress frequently seems to trigger the onset of takotsubo cardiomyopathy, which is also referred to as “stress cardiomyopathy”. However, the absolute incidence is low.63 Women, particularly postmenopausal women, are a susceptible population, accounting for up to 90% of affected individuals.63 Takotsubo cardiomyopathy appears to have a neurohormonal basis associated with high catecholamine levels.65 Full recovery of left ventricular function usually occurs within several days.65

Preventive strategies for triggered acute risk

While the evidence supports a link between acute psychological triggers and cardiovascular risk, there is no convincing evidence for specific prevention at an individual level. It is therefore important to note that the absolute risk from a single triggering event, and likewise the risk reduction from any single episode of therapy, is very low.38,66 Any low additional transient risk also needs to be considered in the context of an individual’s overall risk factor profile. Suggested approaches to protecting against MI triggered by acute emotional stress include reinforcing the value of general cardiovascular risk factor modification, with an emphasis on lowering lipid levels, reducing blood pressure, smoking cessation, regular physical activity and maintaining a healthy weight.66 A range of resources regarding these measures and general workplace wellness are available from health promotion organisations including the NHFA.67 Other approaches include education about reducing anxiety and anger responses to stress.68 The use of agents that have a cardioprotective effect, such as aspirin and β-blockers, has been shown to alter the physiological response to acute stressors and may result in reduced risk of trigger-related MI,38,66 although this requires further study.

From a population perspective, the recognition that acute stressors can trigger CHD supports the need for cardiac care to be available for large gatherings of people who may experience mental stress. This could include availability of public-access defibrillators at sporting venues and airports, or as part of the initial rescue response to natural and other disasters, such as earthquakes.29,69,70

Conclusion

A summary of the key evidence-based points is provided in Box 2 and Box 3.

There is now consistent observational evidence that some aspects of work stress, high perceived job strain and shift work are associated with a small increased risk for development of CHD. These studies have been conducted almost entirely in northern Europe and may not be generalisable to the Australian context, with its different health system, job market and sociodemographic structure. There is also considerable publication bias in the available literature, and the measures of work stress are often only assessed once and are highly variable.

The increased RR of CHD events (about 20%–30%) may account for between 3% (job strain) and 7% (shift work) of all CHD events, as job strain and shift work are so common. Although notable, this effect is far weaker than that from standard CHD risk factors such as smoking, hypertension, abnormal lipid levels and depression. Knowledge of an individual’s work stress levels does not appear to help clinicians in predicting future CHD events. Furthermore, no studies have been conducted to show whether any intervention for work stress can reduce the development of CHD. With the many factors involved and the uncommon occurrence of CHD events in working populations, the likelihood of workplace stress prevention programs demonstrating an effect on CHD events is remote. More promising is the potential of workplace programs aimed specifically at weight loss, exercise and other standard cardiovascular risk factors, although no evidence is yet available regarding the effect of such programs on the development of CHD.71 Insufficient evidence was found for an association between CHD and organisational injustice, job (in)security or satisfaction, or working hours, and no firm conclusions can be made about these at this stage.

Given the large body of consistent observational evidence that social isolation after an MI is associated with an adverse prognosis, attempts to enhance social support and reduce isolation should be encouraged. Such attempts will almost certainly produce positive psychosocial effects for most people, even though there is no definitive evidence that they will result in improved CHD outcomes.

Extensive literature supports a role for acute emotional stress in triggering MI and takotsubo cardiomyopathy, with potential mechanisms for the link described. However, the absolute increase in transient risk from an individual stressor is generally very low.

While there is evidence of a link between acute psychological triggers and CHD, there is no convincing evidence for specific prevention at an individual level. However, there is a rationale to consider minimising cardiac risk factors to offer some protection against MI. Efforts to interrupt the link between the stressor and the cardiovascular event by non-pharmacological and pharmacological means require further research. The recognition that acute stressors can trigger CHD events supports the NHFA recommendation that wider public access to defibrillators be made available where large groups of people gather, such as sporting venues and airports, and as part of the response to natural and other disasters. From a public health perspective, awareness of the potential for increased cardiovascular risk among populations exposed to natural disasters and other conditions of extreme stress may be useful for emergency services response planning.

1 Process used to develop this National Heart Foundation of Australia consensus statement

The Expert Working Group members performed relevant literature searches for systematic and literature reviews using key search phrases including, but not limited to, “cardiovascular diseases”, “myocardial infarction”, “angina pectoris” and “coronary disease” combined with “job strain”, “demand”, “control”, “effort reward imbalance”, “job (dis)satisfaction”, “job (in)security”, “organisational justice”, “work conditions”, “long working hours”, “social isolation”, ”triggers”, “emotion”, “stress”, “anger”, “anxiety”, “life events” or “bereavement”. Searches were limited to evidence published in English between 2003 and December 2012 and were complemented by reference lists compiled from reviews and personal collections of the Expert Working Group members.

The evidence statements (Box 2) and the recommendation (Box 3) made in this consensus statement have been graded according to National Health and Medical Research Council guidelines.3 The aetiology or prognosis hierarchies were used, except where there was an appropriate or ethical intervention available that dictated use of the intervention hierarchy (Appendix). Where there was an absence of interventional evidence, no clinical recommendations were made. This consensus statement is a summary of the current state of knowledge. The Royal Australian and New Zealand College of Psychiatrists and the Cardiac Society of Australia and New Zealand were consulted during the development of this document and have endorsed its content.

2 National Heart Foundation of Australia evidence statements regarding psychosocial stressors and coronary heart disease (CHD)

Evidence statement

Grade

Level

Chronic stressors

Risk factors for onset of CHD (aetiology)

1 High job strain increases the risk of CHD

I†

2 Shift work increases the risk of CHD

I†

3 Limited evidence that social isolation is a risk factor for CHD

I†

Outcome of CHD (prognosis)

1 Limited evidence that high job strain increases the risk of a poor CHD prognosis

II‡

2 Social isolation increases the risk of a poor CHD prognosis

I‡

Acute stressors

1 MI can be precipitated by negative emotional states

III-3†

2 CHD events can be precipitated by bereavement

II†

3 No consistent evidence that involuntary job loss causes CHD

II†

4 Takotsubo cardiomyopathy can be precipitated by acute emotional stress

III-3†

5 Acute population stressors (eg, earthquakes, missile attacks and sporting events) may transiently increase cardiovascular events

III-2†

MI = myocardial infarction. * Clinical impact is unclear. † Using National Health and Medical Research Council (NHMRC) aetiology hierarchy.3 ‡ Using NHMRC prognosis hierarchy.3

3 National Heart Foundation of Australia recommendation regarding psychosocial stressors and coronary heart disease

Recommendation

Grade

Level

1 Wider public access to defibrillators should be available where large populations gather, such as sporting venues and airports, and as part of the response to natural and other disasters

III-2*

* Using National Health and Medical Research Council intervention hierarchy.3

Appendix: Definition of National Health and Medical Research Council (NHMRC) grades of recommendations and evidence hierarchy*

Definition of NHMRC grades of recommendations

Grade

Description

Body of evidence can be trusted to guide practice

Body of evidence can be trusted to guide practice in most situations

Body of evidence provides some support for recommendation(s) but care should be taken in its application

Body of evidence is weak and recommendation must be applied with caution

NHMRC evidence hierarchy: designation of levels of evidence

Level

Intervention

Prognosis

Aetiology

A systematic review of level II studies

A randomised controlled trial

A prospective cohort study

III-1

A pseudorandomised controlled trial
(ie, alternate allocation or some other method)

All or none

III-2

A comparative study with concurrent controls:

Non-randomised, experimental trial
Cohort study
Case–control study
Interrupted time series with a control group

Analysis of prognostic factors among persons in a single arm of a randomised controlled trial

A retrospective cohort study

III-3

A comparative study without concurrent controls:

Historical control study
Two or more single arm study
Interrupted time series without a parallel control group

A retrospective cohort study

A case–control study

Case series with either post-test or
pre-test/post-test outcomes

Case series, or cohort study of persons at different stages of disease

A cross-sectional study or case series

* From NHMRC additional levels of evidence and grades for recommendations for developers of guidelines.3

Stroke care in Australia: why is it still the poor cousin of health care?

To the Editor: In their editorial on stroke care in Australia, Hoffman and Lindley state “only 7% of ischaemic stroke patients received thrombolysis treatment, yet for every 100 patients who receive it, there are up to 10 extra independent survivors”,1 citing the most recent meta-analysis.2 This research also found a significant increase in the risk of early death with thrombolysis, mostly from intracranial haemorrhage. For the individual patient, predicting final neurological outcome is difficult in the early hours after the onset of stroke. Patients considering thrombolysis treatment must weigh up an increased risk of early death against possible improvement in final function if they survive. In addition, any benefits from thrombolysis appear modest at best.

The third International Stroke Trial (IST-3), the most recently published and largest randomised trial of thrombolysis in stroke, in fact showed no improvement in the proportion
of patients alive and independent at
6 months.3 Hoffman and Lindley describe a number of evidence–practice gaps, including early assessment for transient ischaemic attack and access
to multidisciplinary stroke unit care. Patients and the community may be better served by directing resources to such areas where stronger evidence of overall benefit exists.