Cheaper drugs a path to better health

Medicines save lives and improve health and wellbeing when they are available, affordable, and properly used.

With Aboriginal and Torres Strait Islander people experiencing double the rate of chronic illnesses than their non-Indigenous peers, access to affordable prescription medicines is essential. Unfortunately, Aboriginal and Torres Strait Islander people are not accessing medicines at a level that is appropriate to their needs, with cost being reported as a major barrier.

As evidenced by the Closing the Gap (CTG) Pharmaceuticals Benefits Scheme (PBS) Co-payment measure, reducing out-of-pocket costs for medications increases access to, and use of medications, ultimately resulting in improved health outcomes.

Since its inception in 2010, the CTG PBS Co-payment measure has increased access to medicines for more than 280,000 Aboriginal and Torres Strait Islander people in urban and rural areas, by reducing or removing the patient co-payment for PBS medicines. Substantial reductions in hospitalisations have also been seen in areas with the greatest uptake of the CTG PBS Co-payment incentive.

While the outcomes under this measure have been encouraging, there is still a long way to go until we achieve equality in access to medicines for Aboriginal and Torres Strait Islander people.

A good starting point is to promote the CTG PBS Co-payment more widely to all prescribing doctors across Australia, to increase awareness and uptake of the initiative and build on its success.

In August 2012, Australian Doctor reported that, alarmingly, thousands of doctors were unaware of the existence of the CTG PBS Co-payment measure – an important initiative that has the potential to make a real contribution to closing the gap.

With chronic diseases being one of the main reasons for the life expectancy gap between Indigenous and non-Indigenous people, it is unacceptable that so many Australian doctors are unaware of such an important scheme.

Doctors working in Aboriginal and Torres Strait Islander Community Controlled Health Services are generally aware of this initiative, and regularly prescribe medications covered by the CTG PBS Co-payment measure for the benefit of their patients. However, many doctors working in mainstream general practice may not be aware of this scheme.

To participate in the CTG PBS Co-payment measure, practices must be able to first identify eligible Aboriginal and Torres Strait Islander patients. All patients across Australian medical practices should be asked whether they identify as being of Aboriginal and Torres Strait Islander origin by asking the National Standard Identification question – ‘Are you of Aboriginal or Torres Strait Islander origin?’ Once Indigenous patients are recognised, they are eligible to be registered for co-payment assistance.

Improved access to medicines is critically important if we are to see generational change in health outcomes for Aboriginal and Torres Strait Islander people.

The Australian Medical Association encourages all medical practitioners to increase their awareness of the CTG PBS Co-payment measure to improve health outcomes for Aboriginal and Torres Strait Islander patients.

Freeze a white-hot election issue

The Medicare rebate freeze is set to become a top issue in the Federal Election following the launch of a nationwide AMA campaign targeting Coalition MPs and candidates over the issue.

In a blow for Malcolm Turnbull as he seeks to win his first election as Prime Minister, the nation’s peak medical organisation is mobilising doctors and patients, accusing the Government of cutting Medicare and trying to sneak through a tax that would hit every Australian household.

AMA President Professor Brian Owler said that ever since Budget night the AMA has been flooded with complaints from medical practitioners and members of the public outraged by the Government’s decision.

“The Medicare freeze is not just a co-payment by stealth – it is a sneaky tax that punishes every Australian family,” Professor Owler said. “It will hit working families with kids really hard. It will hit people with chronic illness, and it will hit the elderly.”

The Budget decision to extend the Medicare rebate freeze through to 2020, at a saving of almost $1 billion over four years, has undermined Government attempts to neutralise health as an issue in the Federal Election.

Prime Minister Malcolm Turnbull acted to get public hospital funding out of the headlines by giving the states and territories an extra $2.9 billion at a Council of Australian Governments meeting last month, and Health Minister Sussan Ley has been accused of trying to deflect public attention by mounting attacks on the professionalism and integrity of doctors and other health workers.

But the Government, which has previously been forced to back down on plans to introduce patient co-payments in the face of widespread doctor and patient fury, faces a similar outcry over the extended Medicare freeze.

Professor Owler said the decision placed GPs and other specialists under enormous financial strain and left them no choice but pass their increased costs onto their patients.

“The costs of running a medical practice – rents, staff, technology and equipment, indemnity insurance, accreditation – continue to rise year-on-year,” the AMA President said. “Many doctors have absorbed the impact of the freeze until now, but the two-year extension has pushed them over the edge. Their businesses are now struggling to remain viable.”

Professor Owler has warned that for practices that have traditionally bulk billed their patients, moving to a model in which they begin to charge some will be expensive.

To recoup the outlay and cover associated costs, patients faced being charged up to $30 or more a visit, he said.

Combined with the Government’s decision to axe bulk billing incentives for pathology and diagnostic imaging services, it meant that patients would “face higher costs for their health every step of their health care journey – every GP visit, every specialist visit, every blood test, every x-ray”.

Posters supporting the #nomedicarefreeze campaign are being distributed to 30,000 GPs and other medical specialists around the country, and doctors and patients are being provided with the contact details of MPs and candidates in every electorate.

Professor Owler said the medical profession was united in its efforts to put an end to the Medicare freeze, and the AMA campaign would complement those of other medical organisations.

For information and to download campaign materials, visit: ama.com.au/nomedicarefreeze

Adrian Rollins

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Stepwise expansion of evidence-based care is needed for mental health reform

One of the greatest opportunities in Australian public health is to reduce the mortality and morbidity caused by mental illness. In contrast to cancer and cardiovascular disease, there have been no improvements in rates of death or disability from mental illness in recent decades. Indeed, rates of suicide have increased,1 and mental illness is the largest and fasting growing source of disability.2 Prevention, early diagnosis and sustained access to evidence-based treatment have underpinned health gains in other diseases, yet these are poorly provided by a mental health system that is characterised by a self-perpetuating focus on acute care and welfare payments.3

With mental illness projected to have the greatest impact on global economic output of all non-communicable diseases,4 there is an economic imperative to replicate what has been accomplished for other diseases. The mental health reforms announced by the Prime Minister and the Minister for Health on 26 November 2015 outlined new directions,5 two of which, in particular, are highly congruent to achieving this goal. However, the reform package is constrained by a focus on cost containment and will need further strengthening if it is to be successful.

The first welcome aim of reform is to shift the focus of mental health care towards early intervention. The National Mental Health Commission highlighted the enormous avertable personal, social and economic burden imposed by underprovision of prevention and early intervention in mental health.3 It is therefore welcome that the government has endorsed this aim,6 but notable that it has not committed the funding to make it happen. This crucial plank of reform may remain more rhetoric than reality. For example, acting on the advice of its Mental Health Expert Reference Group,7 the government announced a measure to develop much-needed new responses to young people with serious, non-psychotic mental illnesses. This is to be financed from funds that are already fully committed to an evidence-based, cost-effective model of early intervention for young people with a first episode of psychosis.8–12 Spreading already modest resources a mile wide and an inch deep would be an unpromising financing model for such a major reform objective. It would be safer and more logical to pilot a small number of novel approaches to young people with serious non-psychotic mental illness and to then provide new investment for those approaches that have most promise in terms of cost-effectiveness.

The second notable aim of reform is to move mental health services more towards providing stepped and person-centred care. This means supports must be targeted and weighted (right care, right intensity, right time) and more holistic. Achieving the goal of better targeting and weighting of support will depend on the government’s preparedness to also finance more intensive interventions, not just divert people with milder illnesses to lower intensity interventions. More holistic care may help overcome the excess burden of chronic physical illness that contributes to a median of 10 years of life lost for people with mental illness.13

The current funding constraints within which direct mental health care is provided mean that treatment, especially expert, specialised care, is heavily rationed and overly restricted to late presentations, with a duration frequently insufficient for remission and recovery. Of Australian adults with depression and anxiety, 16% receive only “minimally adequate treatment”,14 and the situation for those with psychotic illnesses reflects similar poor access to and variable quality of care.15 Unless something changes, the problem may get even worse, as federal support for state hospitals is set to reduce and state mental health services within these structures are already soft targets for hospital administrators.

Although largely neglecting the financing issue, the government has outlined potentially important actions at national and regional levels. National actions will include two national initiatives brought about by consolidating several school mental health programs that support promotion and prevention activity, and an array of digital mental health platforms. Flagged future national actions include Medicare reforms, the details of which are yet to be announced, and coordination of cross-departmental and intergovernmental activity. In a move away from centralised planning and contracting, primary health networks (PHNs) will now undertake local needs assessment and mapping, use pooled flexible funds to plan and commission a range of service responses for their regions, and work in partnership with local health networks to better integrate these services with state-funded mental health care.

These national and regional strategies to achieve earlier intervention and better targeted, stepped and more holistic care are consistent with the Commission’s recommendations3 and the advice of the government’s Mental Health Expert Reference Group,7 and have been cautiously welcomed by much of the mental health sector, which has been destabilised by chronic uncertainty.

In addition to more adequate funding, a key success factor for these reforms will be whether the PHN model of commissioning the mental health services needed in each local area functions well — and equally so in all regions. International experience suggests that devolving commissioning is not a magic bullet to improve health outcomes, that it creates predictable risks and that the impact of such measures depends on a range of supporting policy levers and environmental factors.16

Appropriate national structures, supports and oversight will be required to ensure PHNs can tailor programs to local circumstances, while maintaining fidelity to evidence-based practice and models of care. The virtue of regional planning flexibility cannot overshadow the need to invest in programs that work. Any new investment, and the repurposing of existing resources, must be channelled through commissioning of evidence-based interventions and proven models of care. It is at present unclear how this will be assured. It is essential that all major aspects of program innovation are appropriately trialled and evaluated before being codified in frameworks and guidelines that shape the development of services throughout all PHNs. International commissioning guidelines suggest that PHNs may be more likely to progress reform goals if they commission integrated, accessible, effective and holistic service platforms17 and appropriately engage consumers and carers in measurement and evaluation processes.18

Much of the funding allocated to the PHNs is focused on youth and early intervention. For young people, integrated, holistic, multicomponent primary care platforms achieve better results than do standard primary care platforms.19 The headspace platform3 will be central to how PHNs progress the reform aims of early intervention and stepped, holistic care, consistent with the Commission’s recommendation that this platform continue to be funded as a fundamental pillar of the youth mental health service system.3 As with other programs devolved to PHNs, there remains a need for strong national functions in areas such as data collection, evidence dissemination, model fidelity and workforce development. In the case of headspace, the Commission recommended these should be unified under a single national youth mental health umbrella.3

Other areas of national responsibility in the reform process, such as the digital mental health and Medicare reform agendas, also require an evidence-based and evidence-generating approach. Particular care is required in progressing the government’s plan to promote use of low-intensity and self-help strategies for people with milder forms of mental illness and to encourage general practitioners to be more sparing in referral of patients to face-to-face psychological services. Implicit in this plan is an assumption that many of the people currently accessing mental health care through primary care and the Better Access initiative could be more cost-effectively managed by e-health intervention strategies. This may well be true, at least in part, and the Better Access initiative represents a tempting target for funding cuts as it is seen as large, and is expanding. However, as an early step in the universal care pathway, a threshold of proof of safety and cost-effectiveness should be met before access to a GP and allied health professional is further constrained. E-health can be an excellent complement to all steps in the care pathway, not only the first, and it would be safer to offer it initially as a choice, rather than as a triage strategy or barrier.

The government has begun to acknowledge that we must do much better for the “missing middle” group of patients — those people with complex disorders who need to access the expert care that they are unlikely to ever receive from state-funded public mental health services.6 Care for this group should involve a step up in expertise from the initial GP and allied health professional, and ideally should involve a team approach, with input from a psychiatrist. In the case of non-response to this first step, more of the same may not be what is required for many people with complex and persistent disorders. This should be a federal responsibility, and a new model of care needs to be designed and tested in a defined subset of regions before any sweeping changes are made.

The other major group requiring consideration is older adults with persistent and disabling illnesses, particularly schizophrenia. Traditionally, being the target group for the asylums of old, they have been the major adult group eligible for state public mental health services. Yet, even they are underserved and have insecure access to care and sufficient duration of treatment, and outcomes — both physical and mental — remain well short of what is possible.15 This shortfall in care was the motivation behind the federal Partners in Recovery initiative (http://www.pirinitiative.com.au), which was formulated in 2011. This initiative, while popular, lacked a real evidence base or “road testing”, and the variability in the models of care that resulted conversely underlines the value of national templates that are based on best-available evidence and are properly tested before being scaled up. Federal funding to fill the service gaps for these patients would be better focused on more practical needs, such as family support, housing and specialised employment programs — all highly evidence-based but inadequately funded. Of great concern is that only a small proportion of these patients (estimated at about 10%) will be able to access the National Disability Insurance Scheme,20 yet it is feared that mental health funding may be lost in the process. The irony is that mental illness, by far the largest source of disability and for so long the poor cousin of the health system, is being forced into the same position within the new disability system. This must be dealt with as a matter of priority. The states should also be required to care much more adequately for their traditional core patient population.

Finally, there is an important role for new research funding programs that include, but are additional to, the National Health and Medical Research Council, and which are more directly tied to specific reform objectives. Potential reforms to Medicare Benefits Schedule items, such as incentives for GPs to provide longer consultations and for psychiatrists in private practice to integrate much better with primary care and other disciplines, as well as new and alternative uses of digital mental health strategies and systematic expansion of vocational recovery models, are areas that would benefit from such targeted funding schemes. The Medical Research Future Fund looms as an appropriate vehicle for funding some of this activity.

Australians now have a greatly increased awareness and understanding of the scale and impact of mental illness on their lives and society. The challenge is to transform this into targeted investment so that access, quality and outcomes in mental health care match those seen in physical health care.

A campaign to improve the mental health of medical students

Australian medical students responded swiftly and effectively to the increased burden of mental illness in the medical profession, which was highlighted by the 2013 beyondblue National Mental Health Survey.1 In 2012, medical student representatives from Australia’s 20 medical schools passed a health and wellbeing policy,2 then in 2013, voted student mental health as a top advocacy priority for the Australian Medical Students’ Association (AMSA), choosing to advocate for the mental health of all tertiary students through development of the AMSA Mental Health campaign.

The four key aims of the campaign were to: (i) decrease stigma and increase awareness and mental health literacy among students; (ii) promote preventive measures to improve coping strategies and resilience; (iii) enable and empower students to look out for their peers and take positive action; and (iv) facilitate improved access to and uptake of mental health services.

Our advocacy strategy targeted the general public through broadcast and print media, the medical community through medical literature and conferences, and students through social media and on-campus events.

University campuses are geographical foci for at-risk young people and are therefore ideal sites for implementing effective preventative and early intervention strategies.

A “National Vice-Chancellor Tour” involved meetings of AMSA representatives with Vice-Chancellors (or their nominated representatives) from 12 of the 20 Australian universities housing a medical school. The purpose of these meetings was to explore the experiences and attitudes of the universities towards mental health. University mental health strategies varied greatly in their scope, complexity, student consultation, evidence base, and investment.

Blue Week, a grassroots component of the campaign, aimed to destigmatise and catalyse conversations about mental illness by engaging students on university campuses and in hospitals with blue-themed events and activities. In 2014, Blue Week ran at 17 medical schools, and over 5000 students participated. Activities varied, and included comedy, yoga, meditation classes, massages, guest speakers, and blue-themed parties. Although events were held throughout the year, a national online Blue Week was held during Mental Health Week (6–12 October). During this week we shared and distributed infographics, such as the poster shown in the Box, and over 200 people shared personal experiences and advice on social media. The online Blue Week reached over 90 000 people and engaged over 11 000 in at least one of its components.

AMSA also produced the second edition of the medical student wellbeing guide, Keeping your grass greener;3 coordinated the AMSA Mentor Network; ran Academy of the Mind, an online short course available to medical students internationally; and ran numerous student mental health workshops nationally and at conferences internationally.

The AMSA Mental Health website (mentalhealth.amsa.org.au/) and social media are ongoing focal points for students to access existing resources and information, blog articles,4 relevant news, and a comprehensive database of mental health services.

Although evaluation is difficult due to limited resources, the AMSA Mental Health campaign has engaged thousands of students and medical professionals in Australia and around the world. The campaign continues to grow and evolve, building momentum in the interests of student mental health.

Box –
An infographic distributed to participants during Mental Health Week

Better Access and equitable access to clinical psychology services: what do we need to know?

Critical data on the delivery, outcomes and out-of-pocket expenses of services are lacking

The Australian Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative aims to improve access to evidence-based mental health care in the community.1 Providing rebates for private services appears to be improving treatment uptake,2 yet the equity of Better Access has been questioned, with a recent study showing that specialised Better Access mental health services were disproportionately concentrated in affluent areas.3 This effect was particularly visible for clinical psychology services, with more than 2.5 times the volume of these services provided in the most, versus least, affluent areas. Within Better Access, clinical psychology services are intended for “the treatment of patients with complex and/or chronic mental health disorders, quite often with comorbid drug and alcohol problems”.4 As these patients are also more likely to experience financial distress and live in socio-economically disadvantaged areas,5 there is a pressing need to identify why clinical psychology services may be particularly vulnerable to inequitable service distribution.

Cost as a factor in inequitable access to clinical psychology services

Potential causes proposed for this inequitable service distribution include higher-paid professionals choosing to live in more affluent areas and work closer to home, or patients’ out-of-pocket expenses for these services being prohibitive.3 The differential impact of out-of-pocket expenses on access to specialist health services is widely recognised.6 Such expenses include those associated with attending treatment sessions, with incidental costs (eg, lost income, childcare, travel) averaging $57 per treatment session for face-to-face psychological interventions.7

Copayments, often used as a cost-sharing mechanism to distribute health care burden and encourage more judicious use of health services,8 are another common cost. Within Better Access, copayments are the responsibility of patients and cannot be covered by private health insurance rebates or other schemes, although they may be reduced through Medicare safety net arrangements after a specific threshold of expenses has been reached.9 Although copayments may place a financial burden on patients, they are often essential for supplementing non-remunerated tasks, including administration, professional development and supervision, to ensure sustainable private practice.10,11

Why comorbidity may be more important than copayments

However, there is evidence to suggest that copayments for clinical psychology services cannot fully account for inequitable service provision. Roughly 35% of Better Access clinical psychology services are bulk-billed (no copayment), with this rate similar to that for consultant psychiatry services (36%) and lower than that for services provided by other allied health professionals (43%).12 However, average copayment amounts are lower for clinical psychology services ($32) than for other allied health professionals ($37) or consultant psychiatry services ($82).12 So, while Better Access services are associated with higher out-of-pocket expenses overall — compared with schemes such as Access to Allied Psychological Services (ATAPS), where one in 20 sessions incurs a copayment averaging $13.5913 — these costs are not unique to clinical psychology services. Instead, epidemiological and treatment outcome studies suggest that comorbidity is a more likely contributor to inequitable Better Access clinical psychology service distribution.

Currently, there is no routine data collection on the number of treatment sessions provided by health professionals once Better Access allowances (ten individual and ten group sessions per calendar year) have been exhausted. Yet, several factors suggest that, if clinical psychology services are being used for more complex and comorbid presentations as intended, these services will extend beyond ten individual sessions. Comorbidity between mental disorders can signal more severe and treatment-resistant presentations and is often the norm, rather than the exception, in those with mental illness.14 Current best-practice guidelines for managing comorbid mental and substance use disorders include providing empirically supported treatments for each disorder, either sequentially or concurrently.15 Clinical practice guidelines synthesising high-quality clinical and health economic research literature, such as the guidelines developed by the United Kingdom’s National Institute for Health and Care Excellence,16 highlight that these empirically supported treatments are likely to extend beyond ten individual sessions, even for single disorders treated in isolation (Box). Although there is some debate about whether comparable treatment outcomes can be achieved in fewer sessions,17 it is unlikely that combinations of empirically supported treatments for multiple disorders (even in reduced formats) can be contained to ten individual sessions.

The financial impact of mismatched policy and practice

It is important to consider the financial impact of this mismatch between Better Access allowances and empirically supported treatment guidelines. Any sessions beyond Better Access allowances are not supported by alternative initiatives, such as ATAPS, or the Medicare safety net. Private health insurance rebates may also be less available to this population, as increased mental disorder has been linked to both limited financial resources5 and reduced private health insurance coverage.18 Currently, there is little guidance about how to adapt therapy for people with complex presentations who cannot afford treatment beyond ten individual sessions. The Australian Psychological Society recommends adjusting usual intervention techniques to “ensure an outcome is achieved” within available sessions,19 but it is unclear how this is to be achieved or what impact these modifications will have on the effectiveness of treatment.20 There is also little guidance about how to use combinations of Better Access individual and group sessions to best support people with comorbid disorders.

After exhausting Better Access allowances, people who cannot afford ongoing care may be referred to other services, such as consultant psychiatrists (up to 50 individual consultations subsidised by Medicare per year1) or community mental health services. Yet, limited availability of these services may result in long waiting periods, reflecting the “missing middle” of the mental health system.21 It is also unclear whether referral to consultant psychiatrists or community mental health teams for delivery of psychological interventions reflects the most cost-effective or efficient use of scarce health resources. Extending Better Access clinical psychology allowances from ten to 16 sessions, as has been proposed,21 may help bring health policy more in line with empirical evidence.

However, the reduced provision of Better Access clinical psychology services in less affluent areas may not necessarily reflect poor treatment coverage in these areas. Better Access is only one component of federal mental health investment, representing 9.5% ($907.9 million) of federal government spending on mental health in 2012–13.21 It is complemented by a range of programs (eg, ATAPS) targeting hard-to-reach and disadvantaged populations. Lower Better Access coverage in some areas may not be inequitable if general practitioners are instead referring a comparable proportion of people to alternative schemes. This highlights how complex networks of funding arrangements make it hard to assess the overall equity of services.

Implications for mental health policy

Exploring discrepancies between clinical practice guidelines and reimbursement structures highlights the importance of empirical evidence in the design of health care financing. Although finite resources are a constraint in any health care system, without thoughtful consideration of empirically supported treatments, short-term cost-saving measures may have longer-term financial consequences. For example, capping Better Access sessions may contain costs in the short term but may also result in ineffective treatment, increasing rates of drop-out, relapse or reluctance to engage in treatment.22 This may then result in increased costs such as welfare payments, lost productivity and increased use of other health care services. The most recent estimate of the costs of mental disorders in Australia reaches up to $40 billion each year,21 highlighting the importance of identifying cost-effective methods for reducing this burden.

Rather than capping the number of sessions, more creative approaches to achieving efficiencies in the mental health system, while also potentially enhancing the quality of clinical care, could be explored. An example of this could include replacing the review of GP Mental Health Treatment Plans after six sessions with innovative technologies for tracking clinical trajectories. Recent estimates show that patients seek an average of 4.8 Better Access sessions,23 but it is unclear whether these brief treatment courses reflect successful treatment outcomes or treatment drop-out. This means the six-session review may occur too late to identify people at risk of poor outcomes. Anecdotally, requiring a review after six sessions can also have the unintended effect of setting unrealistic expectations about progress that demotivate patients or create treatment delays that negatively affect momentum of change. An alternative may be replacing the six-session review with the use of standardised assessment measures to monitor trajectories of symptom change, identify at-risk patients, provide clinically useful information to practitioners and generate real-time service use data.24

The importance of measurement for management

There is a critical lack of data on the delivery of mental health services under Better Access,21,25 including limited data on how practitioners adapt therapies to fit session constraints, the impact of these modifications, relapse rates, average out-of-pocket costs (not just copayments), the influence of the Medicare safety net on copayments and how various populations may be differentially affected by all these factors. A full understanding of the effectiveness and equity of Better Access requires information about the number of sessions completed once Better Access allowances have been exhausted, the utility of separating Medicare Benefits Schedule items for individual and group psychological therapy and how people transition through services over time.

With the most recent Australian population survey of mental disorders and service use conducted almost a decade ago,26 it is essential to develop a plan to ensure the collection of timely and meaningful data to inform current mental health reforms. It is also essential to take a multidisciplinary approach to mental health policy, to ensure policies facilitate the delivery of best-practice care to those who need it most.

Box –
Number of sessions for psychological interventions recommended by NICE clinical guidelines for mental disorders16

CBT = cognitive behavioural therapy. NICE = National Institute for Health and Care Excellence. * These figures do not include initial assessment sessions, which are typically required to confirm and refine diagnosis.4 † Signifies the current cut-off of Better Access sessions. ‡ Some sessions longer than 60 minutes recommended. § Recommended in conjunction with pharmacotherapy for moderate to severe presentations.

How can we ensure that people with lung cancer living in rural and remote areas are treated surgically when appropriate?

We have the will to improve cancer services for patients outside major cities but, thus far, not the way

In 2012, 30% of the Australians newly diagnosed with cancers other than non-melanoma skin cancer lived in rural and remote areas. Some rural locations have visiting cancer specialists or outreach services, others have telemedicine available to assist local clinicians, but many subspecialty surgical services are located only in major cities. Therefore, to have their cancers adequately staged and, if suitable, to have potentially curative surgery, most rural and remote cancer patients will have to travel to see an appropriately specialised surgeon. It is necessary to centralise cancer care to make it possible to give patients access to the full range of clinical expertise and to provide the surgical services needed to achieve the best outcomes.1,2 This desired level of centralisation is rarely available except in major cities.

Using linked New South Wales cancer registry and admitted patients’ data and death records for the years 2000–2008, with geocoded residential and institutional addresses, we showed that patients with potentially curable non-small-cell lung cancer (NSCLC) who lived farthest from the nearest accessible hospital with a thoracic surgical service were the most likely to be admitted to a general rather than to a specialist hospital and, as a result, the least likely to have potentially curative surgery.3 Similar findings have been reported in other regions, for example, the East Anglian region of England. Moreover, in NSW, lack of surgical treatment fully explained the lower rate of survival from lung cancer observed in patients living farthest from an accessible thoracic surgical service.4 Thus, distance from specialised surgical services puts NSCLC patients at a significant disadvantage.

There is policy-level awareness of the disadvantage experienced by rural and remote cancer patients. Australia’s “National Strategic Framework for Rural and Remote Health” states that the goal of cancer care is to ensure that rural patients have increased access to diagnostic testing, coordinated care, multidisciplinary team review, patient accommodation, and appropriate medical oncology and radiotherapy services locally. To achieve this goal, the federal government has dedicated $1.3 billion in its budget not only to building two comprehensive cancer centres in Melbourne and Sydney but also to enhancing or building ten regional cancer centres. These developments should greatly improve cancer diagnosis in rural and remote areas and some aspects of cancer treatment, but they will not remove the need for some patients to travel for specialised surgical assessment and surgery.

In recognition of this need as it relates to lung cancer, the National Health Pathways initiative5 has, since 2013, included a detailed lung cancer referral pathway that provides general practitioners with up-to-date advice on the closest specialist cancer services so that rural patients are referred early and to the right place. While welcome, it will require much more than just publishing and promoting information to ensure reliable rapid referral of patients with NSCLC to specialist assessment and care. The NSW Ministry of Health’s planning for surgical services in greater Sydney6 and Rural Surgery Futures7 recommend that surgery be collocated with other specialist cancer services. While action on these recommendations may improve access to multidisciplinary care in general, it is unlikely to make highly specialised surgical care, such as thoracic surgery for lung cancer, more readily available in rural and regional areas, because of the large populations required to sustain such services.

There are guidelines and programs aimed at increasing early and appropriate surgical referral for cancer patients and some evidence that they work. For example, guidelines for recognition of and referral for suspected lung cancer of the United Kingdom’s National Institute for Health and Care Excellence (updated in 2015) recommend immediate referral if a chest x-ray suggests cancer or if someone aged 40 years or older has unexplained haemoptysis; and urgent chest x-ray if a person has two or more of, or has smoked and has one of, cough, fatigue, shortness of breath, chest pain or weight loss.8 Potentially more discriminating algorithms for urgent chest x-ray than these are being developed and evaluated.9 Recent evaluations of urgent referral initiatives in the UK suggest that they increase cancer detection rates, reduce delays in diagnosis and reduce the risk of death from cancer.10,11

In summary, available evidence suggests that people living remotely in Australia have poorer outcomes from NSCLC because they are often not referred to specialist thoracic surgical centres where their disease will be adequately staged and, if appropriate, they will be offered potentially curative surgery.

Australian health policy supports rapid referral of patients with suspected lung cancer for expert assessment. However, at present, there is a substantial lack of well organised processes to ensure that such patients are referred and assessed appropriately. This must change.

The National Emergency Access Target (NEAT) and the 4-hour rule: time to review the target

The National Emergency Access Target (NEAT) stipulates that a pre-determined proportion of patients should be admitted, discharged or transferred from Australian emergency departments (EDs) within 4 hours of presentation. Targets that varied from state to state were set for all Australian EDs by the National Partnership Agreement in 20121 in response to evidence that ED overcrowding and prolonged length of stay were associated with increased in-hospital mortality.2,3 The original aim was to incrementally increase the target to 90% in all jurisdictions by 2015, in line with the “4-hour rule” target set in the United Kingdom in 2010.

Despite the potentially major impact of the NEAT upon patient care, there was no prospective standardised framework for monitoring outcomes for patients admitted to hospital from EDs. Measuring patient outcomes is difficult, and no approach is beyond criticism. The hospital standardised mortality ratio (HSMR) is an objective screening tool designed to alert clinicians to potentially avoidable harm, and it has been accepted as a core indicator of hospital safety.4 The HSMR compares the numbers of observed and expected deaths; unlike raw mortality statistics, it excludes the deaths of palliative care patients, and attempts to adjust for clinically relevant risk factors, such as age, sex and principal diagnosis. The HSMR has been clinically useful in Australia, where it has helped guide the clinical re-design of ED admission processes,5,6 and in the UK, where elevated HSMRs helped identify potentially avoidable adverse clinical events in Mid Staffordshire Trust hospitals.7

Retrospective studies in large hospitals in Brisbane,5 Melbourne8 and Perth9 have shown that clinical restructuring induced by the NEAT has been associated with reduced ED crowding, improved patient flows through the ED, and reduced in-hospital mortality. In one study, a rise in NEAT compliance rates from 30% to 70% was strongly correlated with a reduction in HSMR for patients specifically admitted from the ED (eHSMR), from 110 to 67 (R = 0.914, P < 0.001).6

However, certain factors may have confounded these findings. Following the introduction of the NEAT, more low acuity patients, who are less likely to die, may have been admitted to short-stay wards instead of being discharged from the ED more than 4 hours after presenting. This would introduce a bias if risk adjustment were to overestimate the mortality risk of these low risk patients. In addition, increased coding of patients as receiving palliative care after acute admission would increase the number of expected deaths, while the number of observed deaths would remain unchanged, again reducing the eHSMR.10

Putting these interpretive considerations to one side, no hospital in Australia, apart from small rural institutions, has consistently reached 4-hour targets greater than 85%.11 Moreover, despite evidence associating ED overcrowding with increased in-hospital mortality, and reduced mortality in some jurisdictions after introducing a time-based target, uncertainty persists as to whether such targets consistently improve patient outcomes in most hospitals.

Overzealous pursuit of stringent time-based targets may actually compromise quality of care and endanger patient safety. This was seen in the Mid Staffordshire experience in the UK, where elevated HSMRs suggested that avoidable patient harm may have increased after introducing time-based treatment targets.7 A focus on the NEAT must be coupled with patient-centred outcome measures that balance the dual needs for hospital efficiency and safe, effective care.2,3,6,8,9,12,13 The ideal NEAT compliance rate maximises the benefits of decongesting EDs while minimising the potential harms of rushed and suboptimal management of acutely ill patients, and has not yet been determined on the basis of empirical data. A recent literature review of 4-hour targets in Australia and the UK noted that all were arbitrary and lacked validation.14 Another review concluded that the introduction of the 4-hour rule in the UK, undertaken at considerable financial cost, had not resulted in consistent improvements in care, with markedly varying effects between hospitals reported.15 In Australia, the need to determine the optimal NEAT has increased because of the opportunity costs involved in achieving high compliance rates and the loss of financial incentives following dissolution of the National Partnership Agreement in 2014.16,17

The aims of our study were to explore the relationship between eHSMR and NEAT compliance rates using a large dataset from several Australian hospitals, and to assess the effects on this relationship of potential confounding by the inclusion of palliative care and short-stay patients.

Methods

Study design, participating sites and data sources

This retrospective observational study covered the 4-year period from 1 July 2010 to 30 June 2014, spanning the introduction and subsequent focus on the NEAT by Australian governments after signing the National Partnership Agreement on Improving Public Hospital Services in February 2011.1

De-identified data on hospital admissions during the study period were obtained from The Health Roundtable (HRT) in accordance with its academic research policy. The final dataset comprised data from 59 Australian hospitals; all 33 New Zealand hospitals, which were working towards a 6-hour target, were excluded, as were 26 sites in Australia with no general EDs, two specialist hospitals with an atypical mortality profile, and 48 hospitals for which the ED data for the study period were incomplete. With approval from the HRT, the de-identified dataset was independently analysed by investigators from the Commonwealth Scientific and Industrial Research Organisation (CSIRO) e-Health Research Centre.

Episodes of care and patient cohorts

All patients who presented to an ED of one of the study hospitals and were either admitted to or discharged from the hospital were included in the analysis. For admitted patients, the unit of analysis was the entire hospital stay, preserving any changes in care type during the admission. Elective patients, patients coded as dead on arrival and who had a principal diagnosis of sudden unexplained death or had died in the ED, organ donation episodes, non-acute and geriatric evaluation and management episodes, and all episodes involving neonates were excluded. Patients coded as palliative and short-stay patients (defined as being an inpatient for less than 24 hours) were also excluded from the primary analysis.

In addition, three additional patient cohorts were analysed:

patients coded as palliative care patients at the time of death;
patients with short stays (defined as a length of hospital stay of less than 24 hours), this cohort serving as a proxy group for patients admitted to short-stay observation wards or clinical decision units, and thereby compensating for inconsistencies between hospitals in coding transfers to these wards as inpatient admissions; and
these two cohorts combined.

NEAT compliance rates

The NEAT compliance rate was defined as the proportion of patients with an ED length of stay of less than 4 hours. The rate was calculated separately for all patients (total NEAT) and for patients admitted to inpatient units and designated short-stay units (admitted NEAT).

Main outcome measure

The main outcome measure was the relationship between NEAT compliance rates and inpatient mortality for emergency admissions, as expressed by the eHSMR. The eHSMR was preferred to raw mortality rates for two reasons:

The HSMR is the risk-adjusted ratio of the observed to the expected numbers of deaths, which helps account for variations in the acuity of presentations and in hospital activity.
The HSMR has been validated in other clinical studies for monitoring patient outcomes.

Statistical analysis

Regression models of eHSMR

Several models were used to calculate the expected number of deaths for the denominator of the eHSMR. In keeping with standard practice,18,19 the data on all included patients were separated into two parts: episodes coded with the top 68 diagnostic codes, which account for 80% of in-hospital deaths (part 1), and episodes accounting for the remaining 20%, whereby the number of individual International Classification of Diseases, revision 10 (ICD-10) codes was reduced from about 1000 to ten broad categories based on the raw proportions of deaths associated with each code (part 2). Model selection for each part consisted of an elastic net model with tenfold cross-validation, with the chosen penalty parameter being the largest λ within one standard deviation of the minimum.20 All models initially included two-way variable interactions. Additional information about the modelling process is available in Appendix 1. Area under the curve measures assessed the predictive ability of the model, with values of 0.85 found for the part 1 model and 0.89 for part 2. Similar values were found for models of the three additional cohorts described above.

Relation between NEAT compliance rates and eHSMR

Emergency presentation data, and observed and expected in-hospital mortality rates were aggregated at monthly levels for each hospital and for each hospital peer group over the study period. Overall NEAT and admitted NEAT compliance rates and eHSMR were then calculated. Exploratory data analysis with linear regression models suggested a complex relationship between NEAT and eHSMR, and non-linear relationships were assessed using a restricted cubic spline with knots at 50%, 60%, 70%, 80%, 85%, 90% and 95% NEAT compliance rates.

The primary analysis of the NEAT–eHSMR relationship excluded palliative care and short-stay patients; the effects on this relationship of including these patient cohorts were explored in sensitivity analyses of the total cohort and each hospital peer group. Statistical analyses were undertaken in R (R Foundation for Statistical Computing); P < 0.05 was defined as statistically significant.

Ethics approval

An ethics approval exemption was provided by the Metro South Health Human Research Ethics Committee (reference, HREC/15/QPAH/233).

Results

Participating sites

Emergency presentation and admissions data and operating characteristics of the participating hospitals are summarised in Appendix 2, Table 1. ED and inpatient data were aggregated for 12.5 million ED episodes of care and 11.6 million inpatient episodes of care.

NEAT compliance rates

Over the 4-year study period, there was a progressive increase in mean monthly NEAT compliance rates for admitted (25% to 45%), total (56% to 70%) and non-admitted patients (70% to 80%) (Appendix 2, Figure 1).

Relationship between eHSMR and NEAT compliance rates

The primary analysis of monthly plots of eHSMR v total NEAT compliance rate (Box 1) and of eHSMR v admitted NEAT compliance rate (Box 2) for all hospitals combined showed similar and significant (P < 0.001) inverse linear relationships until an inflection point was reached. Wide confidence intervals beyond these points reflect the fact that limited data were available.

The eHSMR declined by an average of 5.5% for each five percentage point change in total NEAT compliance rate, reaching a nadir of 73 at a compliance rate of about 83% (range [distance between the two knots in the spline analysis], 80–85%). For admitted NEAT compliance, which included short-stay ward admissions, the eHSMR declined by an average of 4.5% for each five percentage point change in the compliance rate, reaching a nadir of 73 at a compliance rate of about 65% (range, 60–70%).

Sensitivity analyses

When the primary analysis was repeated but including either palliative care or short-stay patients, or both, the previously noted relationships between eHSMR and total NEAT compliance were largely unchanged (Box 3).

Discussion

Overview of findings

With the recent abolition of the NEAT, the future of time-based targets for emergency care is unclear. Ours is the first multisite study to assess the relationship between NEAT compliance rates and risk-adjusted in-hospital mortality. An inverse linear relationship was seen as NEAT compliance rates increased to approximately 83% for total NEAT compliance and to 65% for admitted NEAT compliance. Differences between hospitals in the coding of palliative care patients or in the numbers of short-stay patients did not affect the eHSMR–NEAT compliance rate relationships.

Strengths and limitations of the study

Our study has several strengths. First, the analysis involved a very large number of episodes of care over 4 years from a large, representative sample of Australian hospitals, including the 79% of all tertiary hospitals that account for more than 85% of all ED admissions. Second, we were able to use an objective measure of mortality for emergency admissions to hospital and to assess patient outcomes over the period in which the NEAT was introduced. This study helps inform the debate about whether time-based targets should be retained, and, if so, what they should be.

Limitations of the study include the fact that this was an observational study. We identified a reduction in eHSMR as NEAT compliance rates increased to certain values, but this does not prove causality. However, the relationship was highly significant, even in sensitivity analyses that accounted for potential confounders, and we are unaware of any other national hospital quality and safety initiative implemented during the study period. Our omission of some hospitals limits the generalisability of our findings to all institutions. As the primary outcome measure, the eHSMR does not encompass other outcomes important to patients, such as morbidity or quality of life. Further, the use of HSMRs as the basis for cross-sectional, inter-hospital comparisons is controversial.21 Our final models cannot account for errors associated with estimating HSMRs; the denominator is estimated by modelling, and will therefore be imprecise.19 However, the HSMR is objective, accepted as a national measure,4 and serves as a useful indicator of potentially avoidable mortality within individual hospitals when tracked over time, provided there are no major changes in coding practices or admission policies; this applied to our study.21 Finally, the 95% confidence intervals around the mean eHSMR values corresponding to higher NEAT compliance rates broadened as the number of hospitals achieving such rates decreased, so that it is possible that mortality may further decline at higher NEAT compliance rates.

Implications for clinical practice and policy

We found that there is no robust evidence regarding a clinically significant mortality benefit associated with total and admitted NEAT compliance rates above 83% and 65% respectively. Further, as the identified reduction in mortality for admitted patients was associated with increasing total and admitted NEAT compliance rates, it can be argued that both compliance rates should be monitored. Finally, consideration should be given to embedding time-based NEAT compliance rates within a suite of patient-focused outcome measures that can quickly signal any unintended adverse consequences of pursuing ever higher NEAT compliance rates.

Box 1 –
Total National Emergency Access Targets (NEAT) compliance and hospital standardised mortality ratio for patients admitted from emergency departments (eHSMR) for 59 Australian hospitals, 1 July 2010 – 30 June 2014

P < 0.001 for regression (F-test). Pale lines, 95% confidence intervals; graph labels, change in eHSMR per five percentage point change in NEAT.

Box 2 –
Admitted National Emergency Access Targets (NEAT) compliance and hospital standardised mortality ratio for patients admitted from emergency departments (eHSMR) for 59 Australian hospitals, 1 July 2010 – 30 June 2014

P < 0.001 for regression (F-test). Pale lines, 95% confidence intervals; graph labels, change in eHSMR per five percentage point change in NEAT.

Box 3 –
Effects of potential confounders (palliative care and short-stay patients) on relationship between total National Emergency Access Targets (NEAT) compliance and hospital standardised mortality ratio for patients admitted from emergency departments (eHSMR) for 59 Australian hospitals, 1 July 2010 – 30 June 2014

[Correspondence] Blood shortages and donation in China

China has a relatively low blood donation rate compared with the mean global rate, resulting in long-term blood shortages. Blood shortages are fairly common in regions in which the demand for blood for health-care services is high, such as Beijing, and are seasonal, such as during the winter and summer when college students and migrant workers (the main blood donors) are on holiday. To address the challenges of ensuring that sufficient blood is available, the Chinese Government has released a series of incentive policies, such as priority services, which give donors non-monetary compensation and prioritise them to receive blood during shortages, and mutual help donation, which encourages patients undergoing elective surgeries to persuade their family members, relatives, and friends to donate blood in blood centres in exchange for the same amount of blood for them to use during their surgery.

Vote #1 Health

The AMA has called on whoever wins the Federal Election to bring an immediate end to the Medicare rebate freeze, boost public hospital funding and retain bulk billing incentives for pathology and diagnostic imaging services.

Launching the AMA’s policy manifesto for the election at Parliament House today, AMA President Professor Brian Owler said health will be at the core of the contest between the major parties, and whoever forms government “must significantly invest in the health of the Australian people”.

“Elections are about choices. The type of health system we want is one of those crucial decisions,” Professor Owler said.

The Turnbull Government is facing a backlash from patients and the medical profession over a series of controversial funding cuts, including the Budget move to extend the Medicare rebate freeze to 2020, to slash billions from the future funding of public hospitals, and to axe bulk billing incentives for pathology services.

The Medicare rebate freeze, initially introduced by Labor in 2013 and extended twice by the Coalition since, has been condemned as a policy to introduce a patient co-payment “by stealth”, with warnings it threatens the financial viability of many practices and will force many GPs to abandon bulk billing and begin to charge their patients.

“The freeze on MBS indexation will create a two-tier health system, where those who can afford to pay for their medical treatment receive the best care and those who cannot are forced to delay their treatment or avoid it altogether,” the AMA’s Key Health Issues for the 2016 Federal Election document said.

Professor Owler said the freeze will mean “patients pay more for their health care. It also affects the viability of medical practices.”

The AMA President has also warned that massive cuts to public hospital funding were likely to stymie improvements in their performance and increase the delays patients face.

In 2014, the Coalition Government announced it would scale back growth in hospital funding, savings $57 billion over 10 years, provoking a storm of protest from State and Territory governments. To try to placate them ahead of the Federal Election, Prime Minister Malcolm Turnbull thrashed out a deal to provide an extra $2.9 billion over the three years to 2020.

But Professor Owler said the funds were an inadequate short-term fix that fell “well short of what is needed for the long term”.

The AMA has called on the major parties to commit to adequate long-term public hospital funding, including an annual rate indexation that provides for population growth and demographic change.

The Government is also under pressure over its decision to save $650 million over four years by scrapping bulk billing incentives for pathology services and reducing them for diagnostic imaging services, with loud warnings it will deter many patients, particularly the sickest and most vulnerable, from undertaking the tests they need to manage their health and stay out of hospital.

The AMA said the move was a “short-sighted policy that will ultimately cost future government and the Australian community much more in having to treat more complicated disease – disease that could have been identified or avoided through good access to pathology and diagnostic imaging services”.

It said the major parties should commit to maintaining the current subsidies.

In addition, the AMA is calling for all those contesting the Federal Election to commit to:

advancing the care of patients with chronic illnesses by providing adequate funding of the Government’s Health Care Homes trial;
ensuring the medical workforce meets future community need by boosting GP and specialist training programs and completing workforce modelling by the end of 2018;
increasing funding for Indigenous health services and strengthen programs to address preventable health problems;
improving the GP infrastructure grants program;
increasing investment in preventive health initiatives;
cracking down on the marketing and promotion of e-cigarettes, including banning their sale to children; and
adopting a National Physical Activity Strategy to improve health and reduce the incidence of obesity, heart disease, diabetes, stroke and other illnesses.

“The next Government must significantly invest in the health of the Australian people,” Professor Owler said. “Investment in health is the best investment that governments can make.”

The AMA’s Key Health Issues for the 2016 Federal Election document is available at article/key-health-issues-federal-election-2016

Adrian Rollins

‘Elements’ of racism in how health system treats Indigenous

Indigenous life expectancy in some parts of Australia is 26 years below that of the national average, and there is an “element” of racism in how the health system treats Aboriginal and Torres Strait Islander people, according to AMA President Professor Brian Owler.

Speaking at the launch of a document in which the AMA called for an end to the under-funding of Indigenous health services, Professor Owler said that although people who worked in the health system were not racist, the way the system itself treated Aboriginal and Torres Strait Islander people was often culturally inappropriate.

“Racism is a word that needs to be used cautiously, but there is no doubt that there is an element in terms of how we deal with Indigenous people,” the AMA President said. “Now, it’s not to say that the people in the system are racist, it is about the way that we recognise and provide culturally appropriate care.”

Professor Owler, who visited Alice Springs and several Aboriginal communities in the Northern Territory earlier this year, said the Alice Springs Hospital was much more culturally sensitive in the way it dealt with Indigenous people compared with other hospitals and health centres, including those with a significant number of Indigenous people as patients.

“I think in that way…there is an element of racism, and those are the sorts of things that we need to deal with,” he said. “I don’t think people should understand that the people in the system itself are racist, it’s the way that the system needs to change and develop to make sure that we look after Indigenous people in the way that is more appropriate, safer in terms of culture, and that is likely to engage them more and deliver much better outcomes.”

Nationally, the life expectancy of Aboriginal and Torres Strait Islander people lags 10 years behind that of the rest of the community. But in parts the gap reaches 26 years, and Professor Owler said Indigenous children as young as seven years old were developing type 2 diabetes – probably the youngest of anyone in the world.

Indigenous health services have been hit by Government spending cuts and uncertainty over future funding, and the AMA, in its Key Health Issues for the 2016 Federal Election document, has called for an end of what it said was chronic under-funding of the sector and an investment boost in Aboriginal and Torres Strait Islander community controlled health organisations.

“Having toured central Australia and the Northern Territory, and spoken to people that work in this field, they have seen a cut in Indigenous health over the past few years,” Professor Owler said. “While we’ve made ground in Indigenous health, there is so much more to do. But when you go and talk to people, when you see the realities on the ground, the issues that are being faced by Indigenous people, particularly in remote and rural communities and regional Australia, you can see that there’s so much more that needs to be done.”

The AMA’s Key Health Issues for the 2016 Federal Election document is available at article/key-health-issues-federal-election-2016

Adrian Rollins