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Preference: Administration and Health Services

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AMA critical of Qld Pharmacy Inquiry recommendation

The Queensland Pharmacy Inquiry has recommended that options be developed for what it is describing as “low-risk” prescribing by pharmacists.

The AMA has condemned the recommendation, saying patients will lose out if it is adopted.

Recommendations are listed in the Queensland Parliament’s Health, Communities, Disability Services, and Domestic and Family Violence Prevention Committee Report into the Establishment of a Pharmacy Council and Transfer of Pharmacy Ownership

Chairman of the Inquiry, Aaron Harper said: “We see potential for pharmacists to do more than they currently do – with some prescribing of medications in low-risk situations and subject to a range of safeguards.”

But AMA President Dr Tony Bartone said that and some other recommendations add up to bad news for patients.

“The Report contains recommendations to expand the role of pharmacists, including in relation to the prescribing of medications,” Dr Bartone said.

“It is well known that the more that other non-medical health professionals are involved in prescribing, the higher risks of medication error and adverse reactions.”

Other recommendations include lowering the minimum age for pharmacist-administered vaccinations to 16, retaining current pharmacy ownership laws, and establishing a new pharmacy advisory council for the State.

Dr Bartone said GPs were only trained primary health professionals who have the skills needed to properly and comprehensively diagnose patients, prescribe the right medications, and refer patients to other health care providers as appropriate.

“These are skills that come from years of observing and examining patients, and understanding how text books and the real live patient overlap,” he said.

“Clinical training is an art that has its foundations over the centuries, and cannot be learnt by simply and solely reading texts.

“GPs currently work closely with their pharmacist colleagues on a daily basis, and respect the unique skills they bring to the care of patients, particularly with respect to the quality use of medicines.”

Dr Bartone said the AMA was in the middle of a real effort to introduce the medical home concept in Australia, where GPs are able to coordinate patient care, with full access to a patient’s medical history.

 “But let me be very clear about this Report, which completely overlooks the reality of quality primary health care,” he said.

“It totally ignores the well-understood need in our health system to strengthen the coordination of care, and the need to encourage patients to have a long-term relationship with a usual GP or general practice.

“The Report also opens up a serious conflict of interest for pharmacists who will gain commercially through prescribing of medications, and then being able to dispense them.

“We already know that pharmacies sell many complementary medicines that are not backed by clinical evidence. This highlights the retail pressure they are under to sell products to consumers regardless of patient need.

“The recommendations in this Report, if adopted, would set Australia on a dangerous course.”

Dr Bartone said Australia had a GP-led model of care that is the envy of the world, with GPs highly accessible in most parts of the country.

Australia has primary care outcomes that are second to none.

He said the Australian community deserved better than what was recommended in the Report. The focus of policymakers, he said, needed to be on building on the proven model of GP-led care, rather than undermining it by giving in to the retail interests of the pharmacy sector.

 “Any access concerns cannot be solved by providing a second-best alternative,” Dr Bartone said.

CHRIS JOHNSON

New unified systems for Peter Mac

Peter MacCallum Cancer Centre’s five Victorian sites have deployed a unified radiotherapy treatment planning and oncology informatic system.

In a partnership with research and developers Varian, the Peter Mac hospital locations will have new cloud-hosted treatment planning systems, as well as new oncology imaging informatics systems.

Nilgun Touma, Director of Radiation Therapy Services at Peter Mac, Melbourne, said the new systems will support the radiation oncology team to develop tailored treatment regimens – a task that requires absolute confidence in the accuracy of patient data and efficiency of planning workflows.

Until recently, Peter Mac ran multiple treatment planning systems across its five radiation therapy sites.

 

Terms of reference deliberately broad for aged care inquiry

Prime Minister Scott Morrison has unveiled the terms of reference for the Royal Commission into Aged Care Quality and Safety, saying he expected it to uncover some horror stories in the sector.

“I think the country is going to have to brace itself for some difficult stories, some difficult circumstances, some difficult experiences,” Mr Morrison said.

Flanked by Health Minister Greg Hunt and Aged Care Minister Ken Wyatt, the Prime Minister said the Royal Commission wasn’t just about the terrible incidents of abuse and neglect, but also about how to deal with “this problem and this challenge” into the future.

“We need to establish a national culture of respect for senior Australians and Australians as they age,” he said.

The PM has appointed Supreme Court Justice Joseph McGrath and former Australian Public Service Commissioner Lynelle Briggs to head up the Royal Commission.

The inquiry will travel the nation but will be headquartered in Adelaide, the epicentre of neglect in the aged care sector following the uncovering of shocking abuse in the Oakden nursing home there.

The terms of reference are “deliberately broad” and go to the investigation of mistreatment and all forms of abuse; how best to deliver services to people with dementia; and how to care for young disable people living in aged care facilities.

The Royal Commission has until April 2020 to complete its investigation and report to the Government, but must deliver an interim report in October next year.

CHRIS JOHNSON

 

Use of the emergency department as a first point of contact for mental health care by immigrant youth in Canada: a population-based study [Research]

BACKGROUND:

Emergency department visits as a first point of contact for people with mental illness may reflect poor access to timely outpatient mental health care. We sought to determine the extent to which immigrants use the emergency department as an entryway into mental health services.

METHODS:

We used linked health and demographic administrative data sets to design a population-based cohort study. We included youth (aged 10–24 yr) with an incident mental health emergency department visit from 2010 to 2014 in Ontario, Canada (n = 118 851). The main outcome measure was an emergency department visit for mental health reasons without prior mental health care from a physician on an outpatient basis. The main predictor of interest was immigrant status (refugee, non-refugee immigrant and non-immigrant). Immigrant-specific predictors included time since migration, and region and country of origin. We used Poisson models to estimate adjusted rate ratios (aRRs) and 95% confidence intervals (CIs).

RESULTS:

The cohort included 2194 (1.8%) refugee, 6680 (5.6%) non-refugee immigrant and 109 977 (92.5%) nonimmigrant youth. Rates of first mental health contact in the emergency department were higher among refugee (61.3%) and non-refugee immigrant youth (57.6%) than non-immigrant youth (51.3%) (refugee aRR 1.17, 95% CI 1.13–1.21; non-refugee immigrant aRR 1.10, 95% CI 1.08–1.13). Compared with non-refugee immigrants, refugees had a higher rate of first mental health contact in the emergency department (aRR 1.06, 95% CI 1.02–1.11). We also observed higher rates among recent versus longer-term immigrants (aRR 1.10, 95% CI 1.05–1.16) and immigrants from Central America (aRR 1.17, 95% CI 1.08–1.26) and Africa (aRR 1.15, 95% CI 1.06–1.24) versus from North America and Western Europe.

INTERPRETATION:

Immigrant youth are more likely to present with a first mental health crisis to the emergency department than non-immigrants, with variability by region of origin and time since migration. Immigrants may face barriers to access and use of outpatient mental health services from a physician. Efforts are needed to reduce stigma and identify mental health problems early, before crisis, among immigrant populations.

Paying for performance

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY

Assessing the quality of care in general practice can mislead if it is not based on observations of that care. Asking doctors what they have done and judging quality on the basis of medical records is not good enough. 

The perils of judging what happens in the clinical setting on the basis of what doctors record is obvious in a study of a health care funding agency, in this case the NHS, ceasing to pay doctors for providing additional services it regarded as so desirable that for which it had previously provided incentive payments. 

A paper in the September 5 issue of the New England Journal of Medicine by five authors from the National Institute for Health and Care Excellence in the UK [N Engl J Med 2018; 379:948-957 or  www.nejm.org/doi/full/10.1056/NEJMsa180149] used electronic medical records from 2010 to 2017 in UK general practices to assess the effects of removing, in 2014, 12 incentives linked to 12 indicators and compared the outcomes for six indicators where the incentives were maintained.

The study was set in 2,819 English general practices with more than 20 million registered patients. There were big drops – 62 per cent – in records of indicators ‘related to lifestyle counselling for patients with hypertension’ when the incentives were withdrawn.  

The authors noted that reductions in the documentation of clinical processes varied widely among conditions – from a 6 per cent reduction for smoking counselling to a 30 per cent decrease in documenting BMI of 30 per cent among patients with mental illnesses.

The authors observe: “Several studies show that what is gained on incentive introduction is essentially lost on incentive withdrawal.”

But – and here’s the rub – what was gained?  The authors note: “The uncertainty about whether changes in the documentation [my italics] of care represent true changes in patient care.”

We do not know to what extent the reduced documentation of the incentivised clinical behaviours reflected reduced clinical care.

Other than the automatically updated markers (like lab tests) in the records, frequencies of other interventions were measured purely on their action being documented.

It is quite possible that the desired actions were still taking place at a similar rate, but were simply not documented. Ask any busy clinician about how record keeping can diminish when the day is long or when there’s an emergency. It is hardly surprising that documentary markers decrease after removal of incentive.

An example of the disconnect between the record and the action given in the paper is that of prescription of long-term contraceptives. Although the records suggested a fall in prescriptions after the withdrawal of the incentive, actual use assessed from other sources increased.

I hold to the view, based on long observation, including a five-year stint chairing a district health board in Sydney, that our health system would grind to a halt were it not for the altruism of health professionals, including doctors. Yes, getting the right mechanism for paying for health care matters intensely, and doctors are well paid, but creating the conditions where doctors can express and apply more altruism in the system may offer the best yield in clinical care. Worth an experiment, anyway.

Recently I read Out of the Wreckage: A New Politics for an Age of Crisis by British journalist George Monbiot. It is an exciting and optimistic book despite the prevailing uncertainties in many democracies.

A major thesis is that the distinctive human attribute which has led humanity to its current zenith, and which Monbiot considers to be critical to our approach to the future, is altruism – by which he means people looking out for others and caring for them. You can assess the strength of his argument for yourself or watch him on YouTube www.youtube.com/watch?v=uE63Y7srr_Y

If you consider that more needs to be done in improving health care, proceed cautiously with the idea of incentive payments.

Do not be beguiled in assessing their effectiveness by the documentation of process. Rather, measure their effects on actual care and outcomes. And when considering what doctors and other health professionals do day by day and how this might be strengthened, remember that altruism – doing caring things without concern about reward – still ranks highly on the scale of what motivates them.  This is why they do what they do. Make it easier for them.

Invest in quality improvement: Have doctors got the PIPs?

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

While having tried to play a constructive role to date, growing concerns at level of funding that will be available for the Practice Incentives Program (PIP) Quality Improvement Incentive (QII) has seen the AMA Federal Council decide that the AMA cannot support the current cost neutral approach to the introduction of the incentive.

The AMA has delivered a blunt message to the Health Minister – the AMA’s support for this initiative is in peril unless the PIP receives a significant boost in funding.

While the AMA has backed the concept of an incentive to support practices in their quality improvement journey, we have consistently opposed the idea that some practices could finish up worse off. Instead of properly funding the new incentive, the Government has decided to rob Peter to pay Paul. Worthy incentives will be lost including the quality prescribing, cervical screening, asthma, diabetes and the Aged Care Access Incentive (ACAI).

The value of the ACAI must be considered in more than just monetary terms. The results of the recent AMA Aged Care Survey indicated that more than a third of doctors currently providing services to residential aged care facilities (RACFs) would either cut back or cease their visits over the next two years. I don’t think it is a stretch to suggest that the impending loss of the ACAI is a contributing factor.

For general practices struggling to remain viable in the face of seemingly unending cuts and the lingering impact of the MBS freeze, PIP is a vital funding source for general practices. The AMA estimates that an injection of about $44million per annum to the PIP is required to support a meaningful PIP QII so it can deliver on its objectives.

The AMA wants to see practices embrace the QII because it has potential to improve current funding arrangements by recognising the value of quality improvement. Value for the health system, value for the practitioners, value for the patient, and value to the population through better outcomes.

Our data is the key driver to meaningful quality improvement activities. We must collect it, understand what it tells us, and use it to inform our decisions about the quality initiatives that would most benefit our patients. Data-driven quality improvement is the second building block in the Bodenheimer’s 10 building blocks of high-performing primary care. By focusing on this area, we can strengthen the delivery of care to our patients and demonstrate the value of general practice in the health care system.

Good policy requires real foresight and, in cases like this, real investment. Continuing to short change the most cost-effective part of the health system will inevitably lead to downstream costs to the health system. The PIP QII is a good idea, but it is being poorly executed by a Government and Department that needs to stop paying lip-service to the importance of general practice and put their money where their mouth is.

Be better prepared to respond to disclosures of intimate partner violence

BY VICTORIA COOK, VICE PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

This year, like the ones before it, Australia has been shocked by stories of horrific violence against women reported in the media. Yet for every story that is reported, many go unmentioned. Women die by violence in Australia at a rate of more than one per week. The organisation Destroy the Joint which ‘counts dead women’ holds this year’s total at 47 women killed in Australia by September 14. There are another 13 weeks left in 2018, meaning we can expect that at least 13 more Australian women will be killed by the end of this year alone.

We know that healthcare professionals are often first responders in disclosures of domestic violence. Health professionals are the second most commonly sought source of support for women experiencing domestic violence, after family and friends. Of women experiencing domestic violence, 30 per cent will seek advice from a general practitioner and 20 per cent from another health professional. On average, eight women are hospitalised each day due to intimate partner violence, and the rate is rising. The person that a woman reaches out to, to disclose violence at home, will likely be one of us. Yet, medical students don’t feel as if medical school adequately prepares them to respond to disclosures of intimate partner violence.

Medical student representatives across Australia recently unanimously endorsed a position calling for improved access to education and training around intimate partner violence. In 2015, a study showed that the median time spent on intimate partner violence in Australian medical schools, across all years of the curriculum, was only two hours¹. One can only assume that access to education in this area after medical school is less again. Intimate partner violence is the greatest contributor to mortality and morbidity among women aged 18 to 44 in Australia. It outranks smoking, illicit drugs, and obesity. Yet the burden of illness is not reflected in the time dedicated in medical curricula or training.

Intimate partner violence is a complex and distressing topic, making it hard to teach but even more difficult for professionals to respond to without adequate training. Students must be taught to recognise intimate partner violence, assess risk, document disclosures, record evidence and understand legal implications. Medical practitioners are under-prepared to respond appropriately, which risks reinforcing women’s feelings of powerlessness and violation. This is a whole society issue, and action is needed not only from medical schools, but from medical training colleges, health services, Governments (Federal, State and Territory), and individual practitioners and students. When a woman reaches out she must find someone who is equipped to help. As future doctors we know we will be faced with disclosures, and when we are, we want to be prepared.

In the wake of the tragic death of Eurydice Dixon, students and young women reckoned with an awful paradox; despite entreaties to be safe and stay home, they often aren’t safer at home at all. One medical student told me she began university in Melbourne when Jill Meagher was murdered, and is graduating as Eurydice Dixon was killed. These seemingly random acts of violence remind us to fear what we do not know, whilst distracting us from the facts we do; most women who die by violence will be killed by a man that they know. Our medical education must prepare us to help prevent that.

 

References

  1. Valpied J, Aprico K, Clewett J, Hegarty K. Are future doctors taught to respond to intimate partner violence? A study of Australian medical schools. Journal of interpersonal violence. 2017;32(16):2419-32.

 

Night shift, naps and naysayers – not all hours are created equal

BY DR TESSA KENNEDY, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING

Night shift. It’s 4am, and the ward is finally quiet after a rush of clinical reviews. The lights are dim, patients are all in bed, the tea room chairs converted to makeshift stretchers for nurses napping on break. I sit staring bleary-eyed at the computer screen, raising my eyebrows to keep my lids from drooping shut. There’s nowhere to sleep, and if I do steal away to a couch in the office my absence will be noted. The head of department made it clear: you don’t get paid to sleep. Intermittently I startle as I nod off. This matters little sitting still at a desk – it matters a lot on the drive home, as sleep presses heavy on my arms, loosening my grip on the wheel.

There is increasing pressure to provide the same healthcare staffing and services 24 hours a day, seven days a week, in a bid to reduce hospital mortality associated with afterhours admission. This, combined with efforts to reduce unpredictable and onerous working hours associated with on-call arrangements means an increase in continuous cover provided by shiftworkers.

The dual aims of improving patient access to quality care and safer working hours for doctors are noble, but the changes made to practice in order to achieve them often create new problems by neglecting to acknowledge that not all hours are created equal, and should not be treated as such.

Working at night is fundamentally different to working during the day – two very different shifts can run ‘8 til 8’. It is clear to anyone who has worked night shifts or indeed parented a newborn that tasks completed in the middle of the night require much more effort and are much more prone to error than those performed in the middle of the day, as sleep deprivation and disrupted circadian rhythms conspire against our best efforts.

If we treat night shifts like just another day at the office, we place patients and practitioners alike at risk of harm.

Yet interns spend more time in orientation learning which bins take which kind of waste or how to operate a fire extinguisher than how to manage the challenges and risks inherent to shift work. How to best make use of sleep, caffeine and other strategies to perform the best they can at work, and make it safely home afterwards.

We think twice before waking the on-call team, but not for denying the night shift worker the cultural permission and facilities to sleep, trusting them to know when it’s the most appropriate use of their time.

Sadly, sleeping quarters traditionally utilised by doctors on call are getting absorbed by administrators who fail to realise that yes, I might be rostered ‘to work’, but I’m not a factory line worker for whom down time equates directly to reduced service. My job is far more complex, my cognitive powers my most important tool, and actually a nap in the 4am lull may provide the best chance of a successful resuscitation at 6am by offering more sound judgement and a steadier hand.

I’m in no way advocating for doctors who staff the wards overnight to sleep through everything but a Code Blue, but I am advocating for us to acknowledge the limits and mitigate the risks of humans operating in a high-risk field. Naps are not luxury or laziness, but akin to ensuring the defib is plugged in and fully charged so it’s ready to go. Ironically, sometimes the most productive thing a night shift worker can do is nothing.

We mustn’t move blindly towards a 24/7 model of healthcare without recognising and mitigating the associated risks for patient and practitioner, without taking care to decide which services are truly necessary to provide at any time, and which can be left til morning.

[Viewpoint] US Preventive Services Task Force recommendation statement regarding screening for peripheral artery disease with the ankle-brachial index: déjà vu all over again

On July 10, 2018, in the Journal of the American Medical Association, the US Preventive Services Task Force (USPSTF) published its 2018 update of the 2013 recommendation on screening for peripheral artery disease and cardiovascular disease risk assessment by measuring the ankle-brachial index (ABI).1 The conclusion is the same as in the 2013 report: “current evidence is insufficient to assess the balance of benefits and harms of screening for peripheral artery disease and cardiovascular disease risk with the ABI in asymptomatic adults.”1 This conclusion applies to asymptomatic adults without a known diagnosis of peripheral artery disease, cardiovascular disease, or severe chronic kidney disease.