Patient-centred management of inflammatory arthritis: more than just disease control

It is important that patients’ broader health needs are addressed

Rheumatoid arthritis and seronegative spondyloarthropathies are the most common types of inflammatory arthritis. They cause pain, joint damage and progressive functional loss, which limit participation in life and constitute a significant disease burden.1,2 Over the past decades, great advances in management, with the availability of corticosteroids, synthetic disease-modifying antirheumatic drugs (DMARDs) and biological DMARDs, have significantly improved the disease control and outcomes. The guidelines, whose algorithms focus on drug prescription to achieve remission of disease,3,4 support everyday treatment. However, while they provide direction for the use of DMARDs, they do not consider the patients’ broader health needs.

When optimising outcomes for people with inflammatory arthritis, there are significant discrepancies between the patients’ perspectives of their own health and those of their health care professionals.5 To promote successful clinician–patient partnerships and shared decision making, we need to understand patients’ priorities and perceived needs and deal with the areas where these do not align with current health care guidelines and policies. In this article, based on the results of a systematic scoping study,6 we consider the needs of people with inflammatory arthritis and propose options to improve their situation. While the concept of patient-centred care is not a new one for effective chronic disease management, it is important for patients with inflammatory arthritis given that this disease commonly affects people from a younger age compared with other chronic health conditions. Health policy and practice strive to deliver patient-centred care; however, actual care delivery falls short of peoples’ needs.6

What do people with inflammatory arthritis need?

Therapies to relieve symptoms

People with inflammatory arthritis want treatments that reduce their pain and fatigue, prevent joint damage and help them maintain their mobility, function and independence.6 Although pharmacological treatment has improved significantly over the past decades, it is far from perfect, with individual medications failing to attain remission in most patients7 and leaving them feeling that their needs are not fully met. These needs align with the principles of contemporary practice: “treat to target”; however, patients do not always appreciate the rationale and need a better understanding of treatment options, particularly relating to drug safety and toxicity.6 Given this lack of understanding and a need for symptom relief, many patients seek other forms of supplementary care, including complementary and alternative therapies (CAM), despite limited evidence of efficacy.

Information to enable decision making and self-management

Patients’ perceived needs go beyond the use of medications; their involvement in decision making is increasingly viewed as important by both patients and health care providers and improves compliance, health outcomes and satisfaction.8 However, patients often perceive that the information they receive is suboptimal.6 Moreover, they want education regarding their disease and potential therapies so they may gain control of their health, learn strategies to manage their condition and plan for the future.6 This is key in inflammatory arthritis, where disease impact is often maximal in peak income-earning and family-planning years. Patients want strategies to reduce pain and methods to adapt to functional limitation.6 In addition, they want to know the effects of these strategies on their daily lives, such as implications for driving and dietary restrictions.6 They also want precise instructions about exercise and physical therapies, and self-help strategies to manage the emotional effects of the disease.6 In sum, patients need individually tailored, practical information delivered in a constructive manner; nevertheless, they feel these areas are often overlooked by clinicians.6

Access to health care professionals

It is important that patients have access to understanding, knowledgeable, thorough and empathic practitioners who take a holistic approach to care, do not rush consultations, provide continuity of care and are easy to access, particularly during a disease flare.6 Moreover, they need access to skilled allied health practitioners — such as physiotherapists and occupational therapists — to improve function, mobility and psychological wellbeing.6 Long waiting times are seen as a significant obstacle to optimal management.6

Broader health needs

Being socially connected, employed and having financial security are essential needs for people with inflammatory artrhritis,6 and some patients are frustrated by the lack of understanding of their condition by their family, friends, employers and society in general.6 Mobility impairments raise practical concerns regarding parking and transport options. Moreover, employment and job security are paramount to a person, affecting financial security, self-esteem and social connectedness.6

How can we manage these needs?

Improved communication and education on the disease and its impact on social functioning are important for the promotion of patient-centred care. Therefore, patients need to gain the knowledge and skills to manage their condition and better participate in shared decision making with their health care providers. This can be helped by providing decision aids; encouraging shared care models between medical specialists, primary care physicians and allied health professionals; and implementing interventions to facilitate question asking during consultations.9 In addition, practitioners should be trained to deliver patient-centred care and empower shared decision making during consultations.10 Better relationships will enable a non-judgemental discussion regarding medication use, compliance concerns, CAM use, practical strategies for self-care and pain coping, and consideration of psychosocial problems that have an impact on health behaviours and mental wellbeing.

Patients with inflammatory arthritis should have ready and timely access to knowledgeable health care practitioners, particularly rheumatologists, and skilled allied health providers. However, access to rheumatologists is limited in Australia, particularly in rural sectors.11 In addition, allied health providers receive little formal education in rheumatology, resulting in workforce capacity limitations.12 To manage this burden–service gap, alternative methods of health care delivery have been proposed in Australia and internationally.13 These methods focus on building workforce capacity and expanding workforce roles (eg, advanced scope roles, nurse practitioner roles), providing community-based shared care services and supporting contemporary service and information delivery to consumers through leveraging digital technologies, such as mobile and electronic health applications.10,14 Peer contact for patients may also assist in providing complementary information and education — often more effectively — about coping with the emotional aspects of this condition and providing social connections.6

Developing more effective and efficient models of care may be facilitated by involving patients in their planning.15 Health information materials need to be produced in collaboration between health professionals and consumers, to ensure they are relevant, targeted to patients’ needs, and disseminated appropriately.15 Involvement of patient representatives in developing clinical practice guidelines that manage the patient holistically by incorporating their perspective may be more closely aligned to their perceived needs.15 Investigation of patient-focused strategies, providing interventions tailored to different care settings, patient populations, economies and health care systems may provide novel, effective solutions.15

It will be more challenging to devise novel approaches to meet the broader health needs of people with inflammatory arthritis. Health promotion interventions (such as mass media campaigns and community events) may help bridge gaps in public understanding6,10 and encourage people with inflammatory arthritis to maintain social connectedness, for which peer support networks — traditional face-to-face and digitally-enabled — may be helpful.16 Job security may be optimised by liaison between health care practitioners and the workplace to facilitate job adaptation, including physical environmental aspects, such as parking and access, and flexibility in working hours.6 Moreover, patients identify cost, locality of services, compliance and lack of time as barriers to care.6 To manage these barriers, health care services may consider more flexibility in the provision of care (eg, after-hours services, community-based centres, telehealth services) and better coordination with different health care professionals, employers and allied health services.

Conclusions

There is an urgent need to direct future research initiatives on the efficient and effective management of inflammatory arthritides. Improved collaboration between Australian researchers, policymakers, funding bodies and patients may deal with these gaps in knowledge and improve care outcomes. While disease control using the “treat to target” paradigm is essential, to the individual, pain control, maintenance of employment and financial security are of paramount importance. Cooperation between patients, clinicians and policy makers to implement novel strategies to help patients remain productively in the labour force is required to improve this situation.

Older doctors and retirement

Planning for life after work should commence as early as possible

Many older doctors work beyond the traditional retirement age of 65 and have no clear retirement plans, as discussed by Wijeratne and colleagues in this issue of the MJA.1 Yet it is also known that older doctors are at higher risk of poor performance.2 The move towards revalidation, as being considered by the Medical Board of Australia (MBA), should be regarded as complementary to retirement planning, in that both involve components that need to start early in the doctor’s career. Successful retirement usually requires the doctor to have interests outside medicine, financial security, and good health, each of which should be developed during a long career. The trend to later retirement was noted 15 years ago.3 Since then, there has been a further ageing of the medical workforce, and around 1700 employed doctors in Australia are 75 or older, particularly in general practice, psychiatry, ophthalmology and general medicine.4 This delay in retirement is consistent with baby boomer trends in the general population.5

A recent systematic review of retirement planning by doctors found that continuing financial obligations delayed retirement, while strategies to mitigate career dissatisfaction, workplace frustration, and workload pressure supported their continuing to practice.6 Many of these factors are mirrored in the published literature about retirement in general.5,7 For some doctors, the centrality of work and a sense of responsibility for their patients, particularly if a replacement cannot be found to continue the practice, may add another dimension to retirement planning.1,8

Older doctors are acknowledged to have important mentorship, educational, leadership, medico-legal, and other roles in medicine. These benefits are counterbalanced by evidence that they have less factual knowledge, are less likely to adhere to standards of care, and may also achieve poorer patient outcomes.2 Such factors are among the drivers for the move towards revalidation of the medical workforce in Australia. According to the interim report of the MBA Expert Advisory Group on revalidation, the risk of poor performance increases with age.9 Both revalidation, defined as “the process by which doctors have to regularly show that they are up to date, and fit to practice medicine”,10 and retirement planning could be conceptualised as linked whole-of-career features, as noted by findings that retirement in the general population is influenced by life course, health, finances and work–life balance.6

A key problem, highlighted by Wijeratne and his co-authors,1 is the extent to which the medical career is central to the doctor’s life compared with their other life roles, including their marital and other intimate relationships. Relationships need to be nurtured throughout the career, and are particularly affected by overwork and using work to avoid dealing with communication and intimacy difficulties.11 Relationship and family problems are commonly cited reasons for retiring.1,8 Important lifestyle decisions can also be made early in the career that may accrue increasing value over time, eventually facilitating the retirement process and promoting satisfaction after retirement. Balancing work commitments with relationships and interests, such as the arts, sport, hobbies, and travel, is important throughout one’s career.1

Financial security is a second factor that influences retirement decisions, and many doctors extend their careers for this reason.1,3,6 While doctors working in the public sector are likely to have superannuation schemes with employer contributions, those who are self-employed, particularly general practitioners, can find it challenging to maintain a financial situation that provides an adequate, sustainable retirement income.2 Doctors need to obtain financial advice and develop a financial plan from early in their career, particularly if they are self-employed.

A third pillar of whole-of-career planning is the doctor’s own health. There is good evidence that health in later life is enhanced by attention to midlife lifestyle, including diet, exercise, health monitoring, and moderation of the use of alcohol and other drugs.12 A doctor having a GP is an important component of health monitoring, and may help avert self-neglect.11 Deteriorating health influences the decision to retire,8 but when finances are uncertain or the doctor has a dearth of other interests, such decisions may be compromised. It is noteworthy that the Royal Australasian College of Surgeons (RACS) changed its continuing professional development (CPD) regulations to include requiring ageing surgeons to have their own GP and to undergo regular health checks.13

The RACS includes modified performance requirements for ageing surgeons in their CPD program. This is consistent with the proposed model for revalidation of medical practitioners in Australia, which includes enhanced CPD and proactively identifying doctors who are either performing poorly or are at risk of poor performance.9,13 This style of CPD program also has the potential to assist older doctors to gradually step down from practice by progressively reducing work hours, modifying their responsibilities, developing new interests, and eventually retiring altogether. GPs and psychiatrists, given their ageing workforce and being less likely to intend to retire, might particularly benefit from such an approach.1,4 How to better identify the cognitively impaired doctor and assist their retirement has yet to be adequately addressed by the medical profession, but the increasing number of practising doctors over the age of 75 means that it needs to be discussed.4

The medical workforce will continue to age with the passing of the baby boomer generation, and older doctors will retain an integral productive role in health care, as do older workers in the general population.14 Although it might be easier for older doctors to retire if they have considered financial, health, lifestyle and professional issues earlier in their career, late career attention to these factors can still be beneficial. Healthy ageing programs have long established that even late adoption of lifestyle changes can have improve the wellbeing of older people.15 The ageing medical workforce may present the profession with challenges, but, as in the broader community, these challenges are not insurmountable.

Doctor as patient

DR RICHRAD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

In the week that the AMA released its 2017 Public Hospital Report Card, a dose of salmonella saw me experience first-hand the pressures that public hospitals are under, and appreciate the value of a GP home visit for urgent care in circumstances when you can’t access your usual GP.

I had flown into Canberra for a weekend meeting of the AMA Council of General Practice, already feeling unwell with established symptoms of food poisoning. I was becoming sicker and more dehydrated. With abdominal pain and rebound tenderness, I found myself at the local emergency department at 10pm on the night of my arrival.

During the next eight hours I got to see my hospital colleagues dealing with the pressures of managing multiple patients in varying states of illness and distress, with limited resources and a bed capacity unable to keep up with demand.

Here it seems the world revolves around assessing and prioritising the steady stream through the door, although things can quickly change when a major incident happens. While I was there, the deluge of more than 80 patients affected by a local bushfire appeared to almost overwhelm available resources. The doctors, nurses and other staff worked diligently to ensure that patients were seen as soon as possible but, on a night like this, benchmark targets seemed to have very little relevance.

Sometime around 5am, with blood cultures taken and intravenous rehydration commenced, a long awaited physical examination revealed that my earlier rebound tenderness had resolved although there was still significant point tenderness. With no acute abdomen I was discharged around 6am Saturday.

During the morning I deteriorated, with worsening diarrhoea, vomiting and abdominal pain. I desperately needed a doctor and did not want a return visit to the ED. It was time to call one of the after-hours GP services, which sent a GP to see me in my hotel room. Following a comprehensive examination, which revealed marked lower abdominal tenderness and a positive Murphy’s sign, I had a script for ciprofloxacin. Armed with this, some ondansetron and gastro-stop I tried to make my flight home only to be bumped because I was too sick. Following a visit to the after-hours chemist and after commencing my ciprofloxacin I finally turned the corner, improving enough to fly home Monday morning.

I understand the health system better than most and know how daunting it can be to navigate – particularly at times when your usual GP is not there to guide. This experience was a timely reminder of the challenges our patients experience when seeking care, and why the AMA’s advocacy for our profession and our patients is so important.

Besides getting a taste of what my patients experience when seeking care outside of surgery hours, this episode has also highlighted the importance of looking after our own health. I did try and soldier on for too long, not wanting to let my colleagues down.

We are not super human and we do get sick. When we are, perhaps we should consider what advice we would give a patient in the same situation. We need to be kind to ourselves and recognise when we need another’s medical expertise.

Will the bush ever have equitable broadband access?

DR SANDRA HIROWATARI, CHAIR, AMA COUNCIL OF RURAL DOCTORS

As some readers may know, the AMA released a Position Statement in January calling for better access to high speed broadband for regional, rural and remote health care. This Position Statement was developed in response to concerns by rural doctors that were highlighted in the findings of the AMA Rural Health Issues Survey conducted in April 2016.

The survey, which sought the views of rural doctors across Australia to identify key solutions to improving regional, rural and remote health care, found that access to high speed internet services was the number one priority for rural GPs and the second highest priority among all rural doctors.

The AMA Council of Rural Doctors, at its recent videoconference meeting in February, discussed this issue with representatives of the National Broadband Network Company (nbn) directly. We were told that at the time of the survey, the widely criticised Interim Satellite Service was providing internet services to regional and remote Australia. Since then, nbn has launched the first Sky Muster satellite, and will soon bring on board a second satellite that will offer business grade services around the second quarter of this year.

Currently 68,000 Australians are connected to the Sky Muster service, which has undergone a range of fixes and improvements since it first began offering services on 28 April last year, and according to the nbn this has led to far fewer drop-outs than used to occur. This is good news for those relying on satellite internet. The speed of these services will be either 12/1mbps (upload/download) or 25/5mbps, depending upon what plan you choose.

While these speeds are nowhere near the speeds available in the big cities that use fibre technology (up to 100/40mbps), they are sufficient for a range of uses, and should allow doctors, health services and hospitals to upload health summaries to the My Health record, undertake telemedicine via videoconference and exchange high resolution images. These speeds should also enable doctors to do business with Government, comply with Government requirements, participate in online continuing professional development and education activities, and reference online help such as clinical decision-making tools and other support.

Following our strong comments about data allowances, we understand that nbn is working on making eligible health centres, practices and large medical facilities Public Interest Premises. This will potentially afford them a higher data allowance (150GB per month).

Now comes the big HOWEVER. Will the data allowance be sufficient to do all this? There is much concern in the bush about the ‘data drought’. I understand the satellite technology has inherent limitations that restrict the amount of data available. There is a real need for ‘business style’ plans to be made available, recognising the unique nature of the speeds and data allowances that businesses require.

So, while the nbn will clearly deliver improved broadband access for satellite users, it is hard to see how it can keep up with the needs of an increasingly digitally enabled health system. It’s an area that the Government will need to give much greater thought to.

What I would also like to see happen over time is an extension wherever possible of the fibre and fixed wireless services into the satellite footprint and/or the introduction of alternative technologies to lessen the reliance on satellite for those living in rural and remote Australia. Maybe then, in time, we can say there is equitable access to broadband for all Australians.

Time to address the perennial problem of unequal distribution of the medical workforce

AMA VICE PRESIDENT DR TONY BARTONE

One of the questions I’m often asked as I travel across Australia is why can’t we get enough doctors to the bush, especially with all the medical students we are graduating.

The unequal distribution of the medical workforce is one of the perennial problems that has weighed down Australia’s health system. The reasons are many, as are the potential fixes offered.

Last year, we saw some positive signs that the Government has turned its gaze from funding more medical schools to addressing workforce shortages.

In this space, the issue du jour is the distribution of medical school places. As I write, a Government stocktake of the number and location of medical places, as well as the schools, campuses and clinical training sites is well underway.

The main focus is whether the distribution of medical Commonwealth-supported places should be changed. I understand that the recommendations that emerge from the review are likely to be considered by Federal Cabinet in April.

So would redistributing medical school places to universities with rural clinical schools, or to schools in rural areas ultimately get more doctors to the bush?

This question was given a great deal of thought by the AMA Medical Workforce Committee (MWC) at its recent meeting. As with many complex policy matters, there is no simple answer. But given the importance of the structure of medical training to Australia’s future medical workforce, it is critical that we get this issue right.

The MWC believes that unless there are more places for postgraduate training and in the undersupplied specialties, the problem of workforce shortages in rural areas will not go away over the longer term, no matter where the students are.

Should the Government decide to redistribute medical school places, then we believe it should be guided by three important principles.

Firstly, overall student numbers must remain unchanged (until medical workforce modelling recommends otherwise). Unless you are a university trying to improve your bottom line or a nervous politician in a marginal seat, it is accepted that workforce projections are on the money and we do not need to train more doctors or open new medical schools.

Secondly, any decision to redistribute places has to be based on rock-solid information. What are the infrastructure requirements at the destination university or region; what criteria will be used; will quality supervision and appropriate resources for teaching be assured?

Thirdly, any change to the distribution of places must be linked to improved availability of downstream postgraduate training posts.

On this last point, the AMA has a number of innovative policy proposals worthy of consideration. These include our community residency program and regional training networks model for enabling medical graduates to complete most of their training in rural areas.

We now recruit almost a quarter of medical students with rural backgrounds and almost a quarter of Australian students go through rural clinical schools.

Though the AMA believes these allocations could be expanded, we nonetheless have a promising number of rural graduates. What we need now is a strategic approach to providing the training pathways that will give them the opportunity for rewarding careers in the bush.

In the end, it is about better medical services for local communities.

These ideas are outlined in our recent submission to the review. It is available online at (URL to be advised). I encourage you to take a look.

Council of Private Specialist Practice created to respond to challenges

ASSOCIATE PROFESSOR JULIAN RAIT

The Council of Private Specialist Practice (CPSP) is the most recent of the Federal AMA’s Councils – created in 2016 to recognise and respond to the key challenges that face private practitioners within the Australian health system. Our Terms of Reference provide for us to identify issues relating to private specialist medical practice and make recommendations to Federal Council, as well as develop and draft policy or position papers on key topics.

Private practices are an essential component of a sustainable Australian health system. The private system alleviates much of the demand on the public system – providing nearly 70 per cent of all elective surgical admissions.

And as with all other advanced economies, Australia requires both a strong private and public health system to meet the challenges that lie ahead – including an ageing population, rising health care costs and increasingly complex care.

The structure and format of private specialist practice is also changing – with solo and group practices competing with corporate entities.

Two big “funders” of private health, the Commonwealth Government via the MBS, and the Private Health Insurers, continue to grapple with how best to fund the system in an era of escalating cost pressures. In response, they are seeking to drive down their costs, especially by curbing the growth in their outlays. This creates significant pressure on the private medical practitioner who is trying to deliver a high quality and economically viable service. Consequently, patients are incurring escalating out-of-pocket costs, prompting many to question the value of their private health insurance.

Private health is an area currently under extensive review, and subject to increasing scrutiny. We’ve seen the previous Health Minister announce the Private Health Ministerial Advisory Committee (PHMAC), and under this committee, a further number of working groups.

CPSP has been engaged, and supportive of the AMA’s work in relation to PHMAC’s deliberations– which clearly indicate that our Federal Government is considering various options in an attempt to make private health insurance a more attractive proposition for Australians. This includes considering clear categories of health insurance, reviewing of hospital contracting arrangements (and especially second tier funding provisions), while making polices easier to understand and removing impediments to policy portability for customers.

The reality is that a great deal of discussion will arise from the usual hot button media issues – with constraints on out-of-pocket costs and online rating sites being hailed as the ‘answer’ to make private health insurance “more attractive”. Meanwhile, health insurers continue to record extraordinary profits and breathtaking returns on equity. For example, news outlets are reporting NIB recently received approval to lift its premiums by 4.48 per cent after announcing a 65 per cent increase in net profit (compared to the prior year) and scoring a return on equity of 32 per cent – with the latter result being double that of the Commonwealth Bank.

The CPSP has, and will continue to, be firm advocates for the profession on these issues. A little known fact among the broader population is that medical fees only account for 16 per cent of private health insurance benefits with 85.6 per cent of medical services having no gap, and 92.3 per cent of services having nil or a known gap charge[1]. So you might agree that the gap fees of medical practitioners are not the leading cause of the PHI affordability challenge.

However, despite these modest figures, there is a perception that out-of-pocket costs are not being actively managed by the profession – a view apparently held by governments, consumers and mass media. The profession can no longer ignore the issue around significant or unexpected out-of-pocket costs without it being seen as a failure of the profession to self-regulate appropriately, and become the scapegoat for all the affordability problems of the system. Insurers and consumer groups have commenced research on the quantum and frequency patients experience these costs.

Moving beyond private health insurance reforms, we’ve also seen the Federal Government embark on changes to the medical indemnity insurance subsidy schemes. Many doctors would be aware that last year the Government included a funding cut of $36 million to one of these long-standing subsidies that underpin medical indemnity insurance in the Mid-Year Economic and Fiscal Outlook (MYEFO). Furthermore, they have announced a review into all the Government’s indemnity support schemes – signalling that strong consideration is being given to future cuts to these important Government subsidies for the profession.

To that end, CPSP will be closely monitoring any proposed changes and the AMA will be participating in the forthcoming review.

The AMA has already written to the Government, reminding them of the truly disruptive crisis that brought about the current support schemes, and warning that any changes made without effective consultation with the profession, and their indemnity insurers, could lead to significant unintended consequences. CPSP has also discussed the importance of universal coverage arrangements (whereby no registered doctor can be denied insurance) – agreeing that any changes here need to be carefully considered.

Finally, there continues to be a number of reviews underway which may have impacts upon private practice. The Senate Community Affairs Committee has an inquiry into Prosthesis List Framework, the Australian Competition and Consumer Commission is calling for submissions on their annual report to the Senate on Private Health Insurance, and of course the MBS Review Taskforce continues. CPSP will be navigating all these reviews, ensuring that the private practitioner’s voice continues to be well placed to advise the AMA on the implications of any changes.

The coming weeks will also see the release of the AMA’s Private Health Insurance Report Card – a good chance to shine a light on the key issues facing private health, so please continue to be attentive to our initiatives.

[1] Australian Prudential Regulation Authority (APRA). Private Health Insurance Quarterly Statistics. December 2016 (Released 14 February 2017).

Public hospitals – funding needed, not competition

ASSOCIATE PROFESSOR SUSAN NEUHAUS, CHAIR, AMA HEALTH FINANCING AND ECONOMICS COMMITTEE

Under its terms of reference, public hospital funding is a key focus for Health Financing and Economics’ work. How funding arrangements affect the operation of public hospitals and their broader implications for the health system has always been an important consideration for HFE, and for Federal Council and the AMA overall.

The AMA Public Hospital Report Card is one of the most important and visible products for AMA advocacy in relation to public hospitals.

The 2017 Report Card was released by the AMA President on 17 February 2017. The launch and the Report Card received extensive media coverage.

The Report Card shows that, against key measures relating to bed numbers, and to emergency department and elective surgery waiting times and treatment times, the performance of our public hospitals is virtually stagnant, or even declining.

Inadequate and uncertain Commonwealth funding is choking public hospitals and their capacity to provide essential services.

The Commonwealth announced additional funding for public hospitals at the Council of Australian Governments (COAG) meeting in in April 2016. The additional funding of $2.9 billion over three years is welcome, but inadequate.

As the Report Card and the AMA President made very clear, public hospitals require sufficient and certain funding to deliver essential services.

“Sufficient and certain” funding is also the key point in the AMA’s submission to the Productivity Commission’s inquiry into Reforms to Human Services, in relation to public hospitals. The Commission is expected to report in October 2017.

As part of this inquiry, the Productivity Commission published an Issues Paper seeking views on how outcomes could be improved through greater competition, contestability and informed user choice.

While the AMA believes there is clearly potential to improve outcomes of public hospital services, its submission highlighted that there are significant characteristics of Australia’s public hospitals that must be taken into account.

Health care is not simply a “product” in the same sense as some other goods and services. Public hospitals are not the same as a business entity that has full or even substantial autonomy over their customers and other inputs, processes, outputs, quality attributes, and outcomes.

Public hospitals work on a waiting list basis, usually defined by acuity of need, to manage demand for public hospital services. Private hospital services typically use price signals. There is limited scope to apply mechanisms for patient choice (such as choice of treating doctor) to access arrangements in public hospitals that are governed by waiting lists.

Public hospitals also operate within a highly developed framework of industrial entitlements for medical practitioners and other staff that are tightly integrated with State/Territory employment awards. These measures are intended to encourage recruitment and retention of medical practitioners to the public sector, offering stable employment conditions, continuity of service and portability of entitlements. They support teaching, training and research in the public sector as well as service delivery.

The freedom to choose between public and private hospital care, and the degree of choice available to patients in public hospitals as distinct from private patients, is an integral part of maintaining Australia’s balanced health care system. The broad distinction between public and private health care is generally understood by the community as a basic feature of the health system and part of Medicare arrangements, even though detailed understanding of how this operates, including what they are actually covered for in specific situations, is often lacking for many people.

Introducing private choice and competition elements into public hospital care will tend to blur the distinction between public and private health care, and reduce the perceived value of choice as a key part of the incentive framework for people choosing private health care.

The Commission’s Issues Paper proposes that increased competition will address equitable access for groups including in remote areas, benchmarking and matching of best practice, and greater accountability for performance. These are all worthwhile and important objectives in their own right. As such, they are already the focus of a range of initiatives.

Public hospitals are already subject to policies and requirements that address the same ends of improved efficiency, effectiveness and patient outcomes, including:

Hospital pricing, now supported by a comprehensive, rigorous framework of activity based funding and the National Efficient Price;
Safety and quality, supported by continuously developing standards, guidelines and reporting, including current initiatives to incorporate into pricing mechanisms;
Improved data collection and feedback on performance including support for peer-based comparison.

The single biggest factor that will increase the returns from such initiatives is the provision of sufficient and certain funding. Increased competition, contestability and user choice will not address this need.

The AMA Public Hospital Report Card 2017 is at ama-public-hospital-report-card-2017

Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials [Research]

BACKGROUND:

Telemedicine, the use of telecommunications to deliver health services, expertise and information, is a promising but unproven tool for improving the quality of diabetes care. We summarized the effectiveness of different methods of telemedicine for the management of diabetes compared with usual care.

METHODS:

We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials databases (to November 2015) and reference lists of existing systematic reviews for randomized controlled trials (RCTs) comparing telemedicine with usual care for adults with diabetes. Two independent reviewers selected the studies and assessed risk of bias in the studies. The primary outcome was glycated hemoglobin (HbA_1C) reported at 3 time points (≤ 3 mo, 4–12 mo and > 12 mo). Other outcomes were quality of life, mortality and episodes of hypoglycemia. Trials were pooled using randomeffects meta-analysis, and heterogeneity was quantified using the I² statistic.

RESULTS:

From 3688 citations, we identified 111 eligible RCTs (n = 23 648). Telemedicine achieved significant but modest reductions in HbA_1C in all 3 follow-up periods (difference in mean at ≤ 3 mo: –0.57%, 95% confidence interval [CI] –0.74% to –0.40% [39 trials]; at 4–12 mo: –0.28%, 95% CI –0.37% to –0.20% [87 trials]; and at > 12 mo: –0.26%, 95% CI –0.46% to –0.06% [5 trials]). Quantified heterogeneity (I² statistic) was 75%, 69% and 58%, respectively. In meta-regression analyses, the effect of telemedicine on HbA_1C appeared greatest in trials with higher HbA_1C concentrations at baseline, in trials where providers used Web portals or text messaging to communicate with patients and in trials where telemedicine facilitated medication adjustment. Telemedicine had no convincing effect on quality of life, mortality or hypoglycemia.

INTERPRETATION:

Compared with usual care, the addition of telemedicine, especially systems that allowed medication adjustments with or without text messaging or a Web portal, improved HbA_1C but not other clinically relevant outcomes among patients with diabetes.

The AMA Indigenous Medical Scholarship Becomes Tax Deductible

The number of Aboriginal and Torres Strait Islander people attending university is sharply increasing; and more Indigenous people are choosing to study medicine.

There are now well over 200 Indigenous doctors practicing medicine across Australia, but barriers remain that prevent many Aboriginal and Torres Strait Islander people from completing a medical degree. Factors, such as cultural differences, racism, high expectations, financial hardship, and lack of academic support all play a role in preventing students from realising their dream of being a medical professional.

The AMA has a scheme in place to support more Indigenous students to pursue their dream of becoming a doctor – the Indigenous Medical Scholarship. Each year, the AMA offers a Scholarship to an eligible Aboriginal or Torres Strait Islander student, providing financial support for the full duration of a medical degree.

Since its inception in 1994, the Indigenous Medical Scholarship has helped more than 20 Indigenous men and women become doctors, many of whom may not have otherwise had the financial resources to study medicine. Despite this success, the AMA hopes to expand the number of Scholarships on offer each year to meet the increasing demand for the Indigenous Medical Scholarship. The number of applicants for the Indigenous Medical Scholarship is increasing each year, and we expect this this to increase even more in the future.

It can cost between $10,400 and $15,000 to attend one year of university to study medicine and students typically undertake four to six years to complete their degree to become a registered medical practitioner.

There is evidence that Aboriginal and Torres Strait Islander people have improved health outcomes when they are treated by Indigenous doctors and health professionals. Indigenous doctors have a unique ability to align their clinical and sociocultural skills to improve access to services, and provide culturally appropriate care for Aboriginal and Torres Strait Islander people. Yet, Aboriginal and Torres Strait Islander doctors comprise less than 1 per cent of the entire medical workforce.

The AMA is seeking contributions towards the Indigenous Medical Scholarship to increase our support for Indigenous medical students, and to help grow the Indigenous medical workforce. All contributions can be claimed as a tax deduction.

By supporting an Indigenous medical student throughout their medical training, you are positively contributing to improving health outcomes for Aboriginal and Torres Strait Islander people.

If you are interested in making a donation to the Indigenous Medical Scholarship, please contact Ms Sandra Riley at the AMA via email at indigenousscholarhip@ama.com.au or phone (02) 6270 5400.

Further information about the Indigenous Medical Scholarship can also be found online at: advocacy/indigenous-peoples-medical-scholarship.

The Scholarship was established in 1994 with a contribution from the Australian Government.

The AMA would like to acknowledge the contribution of the Reuben Pelerman Benevolent Foundation and also the late Beryl Jamieson’s wishes for donations towards the Scholarship

DONATE TO THE AMA’S INDIGENOUS MEDICAL SCHOLARSHIP TODAY!

Northern Territory Remote Aboriginal Investment: Ear and Hearing Health Program—July 2012 to June 2016

This report presents data on the Indigenous children and young people who participated in the audiology, ear, nose and throat (ENT) teleotology and Clinical Nurse Specialist (CNS) services delivered under the National Partnership Agreement on Northern Territory Remote Aboriginal Investment. During 2012–16, 9,221 outreach audiology services were provided to 5,357 children and young people, and 3,799 ENT teleotology services to 2,434 children and young people. A total of 2,612 children participated in the CNS services and presented for 3,085 visits. Of the children and young people who received audiology services in 2015–16, 31% had a hearing impairment.