On the road to value co-creation in health care: the role of consumers in defining the destination, planning the journey and sharing the drive

Internationally, there has been a growing focus on the governance and performance of health systems and health professionals, and a redefining of the role of the health consumer. Crises relating to increasing aged populations, the increasing burden of chronic and complex disease, the continuing challenges of quality and safety, and escalating health care costs have resulted in pressure to achieve a more productive and sustainable health system that is responsive to the needs and cognisant of the rights of health consumers.1

In Australia, the focus on partnership approaches between researchers, health professionals and the community has been seen as a central part of this transformational change.2 This partnership must extend the role of the consumer beyond engagement and participations and enable a more substantial contribution in all aspects of health system and health service activity — as co-participants and co-creators of health services and health system sustainability.1,3 It is this form of consumer value co-creation that is critical to improving health services, enhancing the quality of care, increasing patient and health care provider satisfaction, and contributing to primary health care reform in Australia.

Consumer involvement in value co-creation

The inclusion of consumers in health care has been variously described as patient participation, patient-centredness, shared decision making and patient engagement.4,5 While consumers continue to be involved as active participants in managing their own health,6 the focus is now moving forward to include the potential for consumers to be involved in innovation and value co-creation in health care.4,6

Consumer value co-creation is not a new concept and has been described in business management literature and practice since the 1970s.1 Payne and Frow7 described two dimensions of co-creation, namely co-production and co-creation relating to value-in-use. Co-production is defined as the engagement of consumers in a specific product development; examples of this in health care encompass the development of health care services such as proposed models for chronic care.4,7 In comparison, value co-creation is defined as collaborative activities that enhance customer lifetime value.7 In this definition, value is co-created if and when a consumer is able to personalise his or her experience in using an organisation’s services or products and in undertaking tasks the organisation gives them.8 Thus, consumers determine value based on their individual experiences as end users of health care, and have control over value co-creation in health care. The health care team participates in this process as co-creators.9

There is growing literature on health value co-creation and the benefits of consumer value co-creation in the health care sector.10–13 These include increased efficiencies in health services,14 improved health outcomes,15 increased trust in the health care team, reduced health care costs to the patient and the health system, increased value and use of medical research, and increased patient satisfaction and compliance with treatment regimens.12,16,17 Value can be co-created for the individual, clinical practices, health care organisations and providers, and government.12

Engagement opportunities for value co-creation

There are many co-creation opportunities where the health consumer can engage with the health system, health professionals and other stakeholders to co-create value. Engagement platforms vary in type (such as cognitive, emotional and behavioural engagement); in level (from non-engaged to highly engaged individuals); and in duration (one-off, recurring and continuous engagement).18 It is through purposefully designed co-creative interactions — such as face-to-face discussions, online information sharing, collaborative product development, physical spaces for knowledge exchange and problem solving, site visits, open forums or joint ventures19 — that health consumers share their resources and experiences, build relationships and so co-create value.20 The building blocks of interaction for value co-creation include dialogue, access, risks–benefits and transparency.20 For active dialogue to occur, health care organisations or health care providers and consumers must become equal partners, focused on the issues of interest to both.

A framework for consumer value co-creation in primary health care

The use of value co-creation in health care involves embedding this approach across entire health systems — from the microsystem level (individual practices) to the mesosystem (health care organisations) and the entire macrosystem (overall health system and government policy).1 The system thus needs to allow for the consumers to inject their views, experiences and expectations through ongoing dialogue on varying aspects of treatment options, health services delivery, health policy and the overall health system.1

In relation to health care, numerous models and approaches to value co-creation have been proposed. Drawing on both the theory and practice of value co-creation, Nambisan and Nambisan6 describe four models of value co-creation in relation to consumer and health care organisations. These are:

a partnership model for consumer co-creation in health care (ie, explicit knowledge acquired from consumers, such as innovative ideas, are combined with existing knowledge to develop new solutions or to improve existing services);
an open-source model of consumer value co-creation in health care (consumer and community led activities with a focus on new knowledge co-creation);
the support group model of consumer value co-creation in health care (consumer and community led forums for sharing specific knowledge and experiences related to disease and treatment); and
the diffusion model of consumer value co-creation (knowledge-sharing activities initiated and led by health care organisations, focusing on those services or products offered by the organisation).6

In the following section, we provide examples of how these models have been used or are expected to be adopted across the health system.

Use of consumer value co-creation across different levels of the health system

Health care in Australia has only just begun to regard consumers as integral to value co-creation. Frameworks such as the maturity matrix developed by KPMG Global Healthcare21 reinforce the need for comprehensive and transformative approaches to realise the benefits of patient involvement in health care improvement. In addition, they encourage health care organisations and providers and government to move beyond simply involving consumers on boards and committees towards ongoing genuine consumer involvement across the journey from the inception and development phases to the implementation and evaluation phases of health care.

There is, however, an emerging trend of co-creation models taking place at the micro-, meso- and macrosystem levels in the Australian context. This demonstrates a growing recognition that working with consumers to establish what matters most to people about the health care they receive can powerfully shape health status and outcomes through improved service and system development.

The support group and diffusion models of co-creation have been applied at the microsystem level in hospital settings. In 2013, the Patient Based Care Challenge of the New South Wales Clinical Excellence Commission was implemented to spur system-wide change to promote patient-centred care. Designed in collaboration with a patient advisory committee, it has been implemented in 13 local health districts. Each district had tailored partnerships with patients, families and carers to address the health service priorities of their local community, which included involving them in the design of processes, new facilities and staff interview panels. Patient experience surveys and patient complaints data will inform an assessment of the impact that this initiative has had on hospital culture, systems and practices.22

At the mesosystem level, we can expect to see the partnership model of co-creation systemically applied. Guidelines require Primary Health Networks (PHNs) to involve consumer experience intrinsically in their core strategic and operational practices.23 It will be critical that PHNs appreciate the various models of consumer value co-creation and that steps are taken to support them to systematically adopt and embed good practice in consumer participation in all phases of primary care commissioning. A standards-driven approach to commissioning that is person-centred and outcomes-focused has enormous potential to exercise a lasting impact on the triple aims of health care: better population health, better experiences of care and more cost-effective health care delivery.

In education and research settings, we see the application of partnership and open-source models to initiatives that enable consumer input in generating ideas for local service and system improvements and provide suggestions for direction in health and medical research. For example, the University of South Australia’s International Centre for Allied Health Evidence offers a Professional Certificate in Health Consumer Engagement co-designed with the Health Consumers Alliance of South Australia. Health professionals and consumers worked together to inform the objectives, curriculum, delivery and assessment. Course participants are health consumer representatives and professionals who learn together, and plan and conduct a joint workplace improvement-oriented intervention.

At the macro level, broadly reflecting the partnership model, national policy mandates consumer representation and engagement as an important factor in policy development and governance of national agencies. Consumer representation is evident at the highest level in key federal reviews including the Primary Health Care Advisory Group,24 which examined new ways to coordinate and fund care for people with complex and chronic conditions, the Expert Panel for the Review of Pharmacy Remuneration and Regulation,25 and the Medicare Benefits Schedule Review Taskforce.26 Consumer involvement in the implementation of government responses to these reviews will be important to the integrity of policy translation and to upholding policy intent. A peak consumer body, the Consumers Health Forum of Australia, is a key part of the health architecture and facilitates consumer input into policy and decision making and builds the capacity of the consumer sector overall in public participation.

Conclusion

Existing and emerging practice demonstrates the role and value of consumers in shaping health care in Australia. Such practice is starting to become better accepted and embedded at various levels across the system and is no longer a peripheral issue in policy, research, program and service development, and care delivery. However, shifting from the paternalistic caregiver–care receiver dynamic continues to be challenging.27 Embracing the way we conceive of patients and thinking of them less as “users and choosers” and more as “makers and shapers” of services offers a way of achieving a more collaborative dynamic.28 In the Australian context, this requires further investment in consumer leadership, in building the capacity of consumers and all relevant stakeholders as co-creators, and in the active promotion of patient–clinician alliances. Only then can consumers define the destination, plan the journey and share the drive.

Embracing value co-creation in primary care services research: a framework for success

There is a growing focus on the central role of primary care in providing high-quality, accessible, and cost-effective care for international communities. However, maximising the reach and uptake of evidence into primary care policy and practice continues to be a major challenge and a major focus in health reform.1–4 Research translation must ideally be directed in a bottom-up fashion from the community, through effective and consultative partnerships at every stage.5 This demands a “refocus” on the way we conduct health services research,6,7 requiring that strategic partnerships with influential end users are formed early in the research process and nurtured throughout the entire development and implementation journey.

In an effort to maximise investment in research, funding bodies and governments are increasingly working with the academic sector to strengthen partnerships with industry, society and end users of the research to improve the productivity of the sector.8–11 In response, researchers have increasingly adopted approaches such as translational research,12 implementation research,13 and community-based participatory methods14 to facilitate uptake of research findings into health policy and practice.15,16 Although these terms emphasise the use of research in “real-world” settings, they ultimately remain researcher-driven approaches. Thus they may fail to engage the end users of the research (patients, clinicians, and other key stakeholders within health care systems) adequately, may not recognise stakeholder and end user values, and so, may limit effective translation into policy and practice.12 In many cases, the researcher may lack insight into the end users’ specific needs and values in the all-important development phase, making the research outcomes difficult to implement and often unsustainable in the real-world setting.16

Over the past decade, the business sector has witnessed the transformation of multi-million dollar enterprises through the adoption of the “value co-creation paradigm”.17 This paradigm includes important concepts, innovative approaches and key principles, within an overarching framework. Value co-creation is focused on creating value with, and for, multiple stakeholding individuals through regular interactions and value-creating processes.17 These, in turn, create opportunities for increasing innovation, productivity and co-created outcomes of value for the end users, the community at large and the economy.17 This approach is now gaining momentum outside the business world, where it has been used to increase innovation within the public sector to create new joint value.18 There is also a growing literature on health value co-creation and the benefits of consumer value co-creation in the health sector.19–22

In 2011, our Centre of Research Excellence (CRE) in Building Primary Care Quality, Performance and Sustainability was established through a partnership between the University of Queensland and some of Australia’s most influential primary care organisations.23 We used the value co-creation approach to encourage innovation, unify partner capability and maximise the impact of our complex program of research.17,24 In this article, we describe the underpinning principles of value co-creation, the benefits of using this approach, lessons learned and strategies to achieve value co-creation in primary care services research.

A new vision for value co-creation

Value co-creation introduces a new vision of value creation through a shift in thinking about potential co-creators of value, the value networks, and the entire value of ecosystems.25 Value co-creation also requires a redefining of the way an organisation or group engages individuals internally (employees, teams, departments) and externally (suppliers, partners, and other stakeholders) through a process of value creation and engagement in enriched experiences to design new products and services, transform management systems, increase innovation, productivity and returns on investment.24 Strategy is the art of creating value26–28 and, in a co-creative research enterprise, the central focus of the strategy becomes making choices about where and how to co-create value with stakeholders and end users of the research (Box 1).

Co-creation expands the creation of value in three ways: (i) value as enacted through co-creative interactions; (ii) value as exemplified experiences; and, (iii) value as emerging from strategic stakeholder engagement through diverse collaborations across multiple sectors and evolvable ecosystems of capabilities (Box 2).17 Key steps and principles that capture the essence of implementing value co-creation are described below. In Box 3, we provide a case study that illustrates the application of the six key steps to the development of a quality improvement tool for primary care, one of the centrepieces of our CRE program.

Value co-creation steps

1. Strategically engaging stakeholders in creating value together

The first step in any co-creative initiative is to identify key stakeholders and end users who can take part in the co-creation efforts. Value co-creation demands that organisations and individuals reach out to different groups, enterprises or sectors so they can co-create new knowledge together, thus generating more value.17,24 A deeper collaboration with multiple influential stakeholders increases the pool of resources, competencies and capabilities, which accelerates value creation opportunities for all.17,29 With this in mind, the research team must identify and invite research stakeholders, including influential clinical organisations, policy makers, funders and other end users to take part in the co-creation journey from inception.

2. Identifying and supporting champions

Over time, influential co-creation champions need to be identified and supported within all involved enterprises, ecosystems and stakeholder organisations to increase the chance of success of the co-creative initiative.17,29 Change is challenging, and using new approaches to innovation can be confronting to those accustomed to following traditional processes. As the aim of value co-creation is to embed collaborative, ongoing, successful relationships between stakeholders, so champions of the new approach are essential to lever and maintain cultural change in both research, funding, policy and end user groups.

3. Purposefully designing co-creative interactions for stakeholder engagements

The value co-creation approach positions the source of value within the co-creation experience, which is actualised through the organisation–stakeholder or end user co-creative interactions. These interactions must be purposefully designed by strategically aligning people, processes and interfaces to co-create the value propositions and outcomes together17,29 while being mindful of stakeholders’ individual domains of experience and with the aim of building effective connections. Engagement platforms can be formal face-to-face meetings, online interactions (website, webinars, and blogs), private or public community forums, site visits or open forums. These platforms must also enable new experiences by ensuring opportunities for end users to co-create their own unique outcomes (products, services, and experiences).17,29

4. Expanding the circle of stakeholders and joint value creation opportunities

A co-creative enterprise must be cognisant of maximising the ecosystems of capabilities in the social, business, civic, and natural communities in which stakeholders exist to produce new co-creative capacities of value creation.17 It is important for the enterprise to assess value in order to verify that those involved have generated new value. Further to this, it is imperative to recognise that value is subjective and varies as a function of the co-creation experiences of stakeholders, both their experiences in interacting through the platform and the experiences of the co-created outcomes.17,29 There are many different kinds of value — economic or societal gains, organisational improvement, personal achievements, satisfied stakeholders just to name a few.17

Engaging stakeholders in private, public, and social sectors to expand benefit for all

It is important for an enterprise to be mindful that building ecosystems of capabilities together with other private, public, and social sector enterprises will expand the wealth–welfare–wellbeing all around. By strategically engaging stakeholders across the numerous industries and domains, co-creation enables more resourceful and sustainable growth opportunities which, in turn, benefit the stakeholders in the ecosystems, the economy and society as a whole.17,26

Deepening the impact and enable the viral spread of “win more–win more” value creation

In the co-creation paradigm, we work with others to continuously multiply and join the capabilities that exist across a variety of industries and business domains; across the private, public and social sectors. Succeeding together in growing value of many kinds, fuels a “win more–win more” environment, in which the number and scope of interested co-creation partners expands and the capability to spread and build on value co-creation approaches increases.17,26

Co-created outcomes of value

Embedding value co-creation across the CRE research program led to co-created outcomes of significant value which are described briefly below.

Robust and enduring partnerships

The approach encouraged the research team to build genuine multi-stakeholder relationships with influential partner primary care organisations, national and international researchers, clinicians, government, consumers, and relevant stakeholders to undertake collaborative research. From inception, the approach brought together influential primary care peak bodies including the Royal Australian College of General Practitioners; the Australian Association of Practice Managers; the Australian Primary Health Care Nurses Association; the Department of Health; Australian General Practice Accreditation Limited; the Improvement Foundation; Chronic Illness Alliance; and the Australian Commission on Safety and Quality in Health Care; and the Medicare Locals (now Primary Health Networks [PHNs]). These partner organisations collectively represent 40 000 primary care clinicians and managers delivering more than 100 million patient consultations per year, and organisations responsible for establishing policy, and the quality and safety benchmarks for Australian primary care.

Co-created research outcomes of value to end users

The involvement and input from the strategic partners throughout the entire research journey, that is, from the development of the research program to the implementation and evaluation phases, ensured that the co-created research outcomes were highly relevant and easily transferrable to the real world. One example of a co-created research journey is provided in Box 3, showing how value co-creation resulted in development of the Primary Care Practice Improvement Tool (PC-PIT), an on-the-ground quality improvement tool now embedded in practices Australia-wide. Another approach delivered a best-practice governance framework30 now in use in integrated care arrangements between PHNs and local hospital and health services.

Establishment of the International Implementation Research Network in Primary Care

Through co-creative networking and a focus on building value in service innovation internationally, the CRE and stakeholders began the International Implementation Research Network in Primary Care (IIRNPC). This collaboration of researchers and stakeholders shared a vision of advancing the field of implementation research with a specific focus on care transformation policy and practice.31 The IIRNPC, through multiple channels and interactions (such as e-newsletters, online forums, website interactions, a shared repository of publications and resources, and annual face-to-face meetings), stayed engaged, shared implementation research, developed expertise on implementation and translational research methods, and developed international collaborative primary care research.

Formation of the International Primary Health Reform Conference

The CRE’s approach in working with end users to co-create value in primary care research has expanded its national and international relationships and networks with influential partners. The CRE has been fortunate to co-host three successful International Primary Health Care Reform Conferences, bringing together primary care organisations, policy makers, consumers, researchers and clinicians, to continue the reform platform for primary care globally, and to further develop our international network for future growth.32

Strategies to achieve value co-creation in primary care services research

Leading theorists predict that value co-creation will become a primary source of an organisation’s competitive advantage.33 In our experience, value co-creation has drawn together strategic primary care organisations responsible for over 100 million consultations annually. As the case study (Box 3) illustrates, the key benefits of value co-creation lie in the development of relationships with stakeholders through meaningful engagement (co-creative interactions). It focuses on improving the experiences of stakeholders through the provision of strategic value creation opportunities. We propose that applying the principles of value co-creation in a way that strategically and genuinely considers all influential stakeholders from different ecosystems, maximises the productivity, creativity, utility and impact of the evidenced-based research outcomes and their translation to primary care policy and practice. To use this approach in primary care services research will require a commitment from the research enterprise to the value co-creation principles. It also requires creative research management processes and solutions and an effective leadership and governance framework.

The use and implementation of value co-creation will vary from one case to the next. Yet, there are key principles and strategies which are essential to successful value co-creation that leaders should consider as they follow the six steps and apply this approach in primary care services research. In Box 4, we provide these based on our experience of applying value co-creation. Underpinning these principles are four key lessons we learned, summarised below.

Partnership development requires an investment of time, effort and resources

The regular engagements required for research stakeholders to build effective long term relationships and co-create value takes effort, time and resources.19 Considering that most research programs or projects have limited time frames and funding, researchers must strategically factor in extended time, resources and budget to allow for successful value co-creation. In addition, funding bodies and university organisations continue to hold traditional views of research which require clearly articulated aims, set methodological processes and proposed outcomes that are largely inflexible and do not allow for the dynamic and evolving nature of value co-creation.

Management systems need to be “co-creative”

Creative research management solutions are needed to ensure that the benefits of a true co-creation approach can be achieved. This includes effective leadership and governance to manage multi-stakeholder relationships, and the design of appropriate platforms of engagement to yield useful co-created research outcomes. Traditional research teams do not typically have these skills, and may consider recruiting appropriate staff or providing training in the principles and application of the co-creation paradigm.

From the health system perspective, co-creative leadership entails the ability to embed a co-creation culture within the research enterprise, understanding the process of co-creation through its key building blocks (dialogue, access, risk assessment and transparency),34 embracing co-creative engagement, and designing co-creative management systems and processes with internal and external stakeholders.17 The research enterprise, as the organising agency, sets the overall strategic direction and defines the boundaries between what can and cannot be created.28 The governance structures, including the identification of the roles and responsibilities of people and projects, must be co-created by all involved. Research committees and boards must have representation from all stakeholders and end users of the research, and the management system should allow stakeholders to participate as co-creators throughout the entire enterprise (ie, co-creating value identification, strategy formulation and execution, fine tuning processes, involvement in problem solving, performance and risk management activities, and implementation).17

Openness and understanding is needed to work across different sectors and cultures

Working across the research–policy interface and care delivery systems can pose challenges related to differing cultures, priorities, preferred styles of communication, and time frames.23 The value co-creation approach must allow time for getting to understand stakeholder needs and values (which are subjective and can evolve in the course of the research journey) and thus ensure that the research team is in a position to better meet them (eg, designing more appropriate platforms of engagement, adjusting methods or deliverables, and producing co-created outcomes in a timely manner).

Flexibility, fairness and transparency is essential in value co-creation

It is widely accepted that value co-creation involves the free exchange of knowledge, information and contribution in different forms from external stakeholders. Therefore, issues of fairness, ethics, and intellectual property need to be considered, and in some senses reinvented, as part of an ongoing co-creation process. Once again, it is linked to a deeper understanding of stakeholder motives for involvement and engagement which can range from intrinsic (altruistic, free-worker) to extrinsic (economic rewards);35 and their perspectives of fairness, ethics, and values.36 From our experience, and supported by the literature,36 transparency and constant dialogue are the best solutions to ensure that these differing perspectives align. Clarifying expectations between stakeholders reduces potential perceptions of “free riding”, exploitation, or the perception that intellectual property is being used for the exclusive benefits of other participants or organisations. It includes mutually constructing rules of engagement, encouraging stakeholders to voice their needs, discuss their obligations, give their consent and identify perceived benefits as these evolve throughout the journey.

Conclusion

The value co-creation paradigm provides an effective framework to join researchers and the broader community in better creating end user value.23 It is an effective, sustainable approach to building and expanding long term research partnerships across multiple sectors, and increasing research productivity and the benefits of co-created outcomes for stakeholders, the health care economy and society as a whole.

As the example of the PC-PIT shows, the essence of the value co-creation is the development of long term, trusting relationships with and between key stakeholders and end users of the research, ultimately resulting in greater uptake of research outcomes into both policy and practice. This facilitates a shift in focus from traditional research processes and outcomes toward stakeholder or end user articulated processes and co-created outcomes. The “human experience”, forms the central focus of the co-creation strategy, leading to a cycle of ongoing, valuable and sustained relationships between researchers and end users.

Box 1 –
Traditional strategy versus a co-creative strategy in primary care services research*

Traditional research

Co-creative strategy

Value: Creates value by delivering defined outcomes to targeted research end users

Value: Creates value by constantly enhancing experiences for all stakeholders, so they remain engaged and involved in the co-creation of research outcomes

Goals: Establishes strategic goals at the outset and does not significantly change them

Goals: Uses the initial strategic goal as a starting point and lets the full strategy emerge over time (ie, be co-created with all stakeholders)

Key focus: Focuses on the interests of the research organisation or team and how the they can maximise their share or gains of the outcomes relative to the shares or gains of its research competitors and the other members of its value chain

Key focus: Focuses on the interests of all stakeholders and how the ecosystems can maximise the size of the pie; maximise the share of value captured by the research organisation as secondary

Advantages: Achieves advantage through completing research on time and within budget, and by publishing research in academic journals and obtaining further funding to do more research

Advantages: Achieves advantage through increased engagement of stakeholders and by continually building new interactions and experiences. These lead to co-created outcomes of value for all involved and ultimately increase uptake of research to inform policy and practice

* Adapted from Ramaswamy and Gouillart.28

Box 2 –
Value co-creation in primary care services research*

Adapted from Ramaswamy and Ozcan, 2014, figures 1–3, page 29.17

Box 3 –
Case study: the development and trial of the Primary Care Practice Improvement Tool (PC-PIT)*

Steps

Description

Strategically engaging varying stakeholders in creating value together

Partners included primary care peak bodies, the federal Department of Health, primary care clinicians and managers, Medicare Locals (quality improvement and practice support units), GPs (clinical leaders) and practice managers (organisational leaders) providing strategic input into the application of the tool. Initial implementation and evaluation of a pre-existing organisational improvement tool revealed extensive problems, namely jargonistic language; a complex and lengthy implementation process and the need for ongoing, expert external facilitation. Thus, a new, co-created aim was developed to co-design and trial a tool bespoke for Australian general practice.

Identifying and supporting champions

Champions included practice managers and practice nurses as well as principal GPs. Participants provided a strategic link to their organisational values and expectations. Trusting relationships developed across previously disparate groups. The research team was thus able to tie the research process back to strategic enterprises, for example, the design and implementation of the PC-PIT linked to the role, education and support for practice managers in organisational performance improvement.

Purposefully designing platforms (or co-creative interactions) for stakeholder engagements

Engagement platforms included formal partner meetings, one-on-one in-depth discussions, combined partner and stakeholder feedback sessions (formal presentations), end user advisory committees, teleconferences, social (online) and printed (newsletters) media. Stakeholders identified a list of desired attributes an improvement tool should encompass, along with a shared vision for a “one stop shop” of organisational improvement resources mapped to existing quality improvement programs.^†

Expanding the circle of stakeholders and joint value creation opportunities

All stakeholding individuals were able to influence processes and outcomes and be involved in collective problem solving. Increased trust led to data and resource sharing, creating new capacities and expediting strategic decisions. Focus on the role of practice managers as organisational leaders and practice nurses as facilitators of organisational development created a sense of satisfaction in these professional groups and a sense of ownership in relation to performance improvement programs. Medicare Locals and the Primary Health Networks ensured the PC-PIT could be embedded into existing quality improvement frameworks. The Department of Health ensured the PC-PIT was in line with system policies relating to practice performance incentives.

* Appendix 1 provides an illustration of PC-PIT co-creation. † Appendix 2 has additional information about engagement platforms developed for co-creating the PC-PIT.

Box 4 –
Summary of the key principles and strategies for achieving value co-creation in primary care health services research17,23,24,26,28,34

[Correspondence] HIV moments and pre-exposure prophylaxis

The PROUD study (Jan 2, p 53)1 recently reported confirmatory evidence that oral tenofovir disoproxil fumarate–emtricitabine pre-exposure prophylaxis (PrEP) protects men who have sex with men against HIV acquisition. The study showed unexpectedly high HIV incidence (9·0 infections per 100 person-years) in men who asked for PrEP and who were asked to defer. The HIV incidence in this group was three times what was expected on the basis of epidemic trends. This finding is consistent with our observations that people at higher risk for HIV infection were more likely to seek PrEP services, stay in care, and be adherent.

Blaming individual doctors for medical errors doesn’t help anyone

If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

In Australia, estimates suggest undesired harmful effects from medication or other intervention such as surgery, known as “adverse events”, occur in around 17% of hospital admissions. This results in up to 18,000 unnecessary deaths and 50,000 temporarily or permanently disabled patients each year.

Over 50% of adverse events are the result of medical error. Harms are physical, financial and psychological. Adverse events mean patients need to stay in hospital longer, have more treatment and incur financial loss.

Adverse events are the result of errors and violations (deviations from prescribed practice) of health-care professionals. Although the direct and most obvious causes of adverse events are errors and violations, the causes of adverse events we can control are the working conditions and organisational systems that cause people to make mistakes.

When the pace of work is too fast, health professionals can get distracted and feel under pressure. When supervisors turn a blind eye to non-compliance, teams aren’t functioning well, equipment is unavailable or opportunities for training rare, the willingness and ability of staff to perform reliably is reduced.

Safety cannot be assured by identifying the individuals who make an error. Safety can only be assured by creating conditions in which people can perform well.

Blame is unhelpful

Finding someone to blame and dealing with this person by assuming they are uniquely incompetent (a person-centred approach) is a comforting strategy for those managing risk and for society at large. Much less satisfying is the notion that the majority of health professionals, in the same situation, would make the same mistake and that perhaps the situation, not the professional, is to blame.

The human tendency to blame others’ mistakes on their personal characteristics (ability, personality, attitudes) is even stronger when the outcome of the mistake is more severe (such as a patient’s life being shortened). This makes it difficult to move away from blame even when there is no compelling evidence “person-centred” strategies reduce error rates.

A person-centred approach also exacerbates the feelings of guilt, shame and anxiety that plague health-care professionals in the aftermath of error. These negative emotions, in turn, can lead to denial, avoidance and a failure to learn about the causes of the error. The possibility of putting preventive strategies in place is then limited.

The health-care professional may feel defensive, and this doesn’t help patients or their families learn the truth about what has happened and, in many cases, compounds the distress they feel. Blame means a lost opportunity for learning and can be detrimental to open and honest patient-professional discussions.

What are the alternatives?

Although we can and should focus efforts to reduce the number of medical errors made, errors are inevitable and so we also need to prepare for them more effectively. Both health professionals and patients need better support.

For health professionals, building psychological resilience at an individual and team level may help. Psychological resilience is defined as an individual’s ability to adapt to stress and adversity; to be positive, optimistic and to learn from mistakes. Not everyone is equally resilient and this is where being part of a team or being able to access social support from others is important.

So, what can we do in health care to promote resilience? At present, there is no definitive answer to this question; there is little research evidence available and even fewer recommendations.

In the United States, rapid response teams have been established in acute hospital settings to provide individuals with the support they need after an error. Support is offered either informally within the unit, through trained peer supporters within the hospital or via referral to professional guidance.

Training staff in emotional resilience is one approach that has been reported as successful among nurses transitioning from being students to staff. Mentoring for physicians has also been promoted as a strategy to enhance individual resilience and reduce burnout and stress. Neither approach has yet been evaluated at sufficient scale.

Minimising power differences between team members is important in encouraging people, no matter what their professional status, to speak up, ask questions and check understanding.

Training health-care leaders how to invite and appreciate contributions from all team members may provide a basis for greater equality and openness in health-care teams. When things go wrong in health care, blame is a rife but unhelpful response. What we need now are evidence-based strategies that support staff and organisations to use adverse events as an impetus for change.

Reema Harrison, Lecturer & Research Fellow: Patient Safety, University of Sydney and Rebecca Lawton, Professor, Psychology of Healthcare, University of Leeds

This article was originally published on The Conversation. Read the original article.

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Old but not forgotten: Antibiotic allergies in General Medicine (the AGM Study)

The prevalence of antibiotic allergy labels (AAL) has been estimated to be 10–20%.1,2 AALs have been shown to have a significant impact on the use of antimicrobial drugs, including their appropriateness, and on microbiological outcomes for patients.3,4 Many reported antibiotic allergies are, in fact, drug intolerances or side effects, or non-recent “unknown” reactions of questionable clinical significance. Incorrect classification of patient AALs is exacerbated by variations in clinicians’ knowledge about antibiotic allergies and the recording of allergies in electronic medical records.5–7 The prevalence of AALs in particular subgroups, such as the elderly, remains unknown; the same applies to the accuracy of AAL descriptions and their impact on antimicrobial stewardship. While models of antibiotic allergy care have been proposed8,9 and protocols for oral re-challenge in patients with “low risk allergies” successfully employed,10 the feasibility of a risk-stratified direct oral re-challenge approach remains ill defined. In this multicentre, cross-sectional study of general medical inpatients, we assessed the prevalence of AALs, their impact on prescribing practices, the accuracy of their recording, and the feasibility of an oral antibiotic re-challenge study.

Methods

Study design, setting and population

Austin Health and Alfred Health are tertiary referral centres located in north-eastern and central Melbourne respectively. This was a multicentre, cross-sectional study of general medical inpatients admitted between 18 May 2015 and 5 June 2015; those admitted to an intensive care unit (ICU), emergency unit or short stay unit were excluded from analysis.

At 08:00 (Monday to Friday) during the study period, a list of all general medical inpatients was generated. Baseline demographics, comorbidities (age-adjusted Charlson comorbidity index11), infection diagnoses, and inpatient antibiotic medications (name, route, frequency) were recorded. Patients with an AAL were identified from drug charts, medical admission notes, or electronic medical records (EMRs). A patient questionnaire was administered to clarify AAL history (Appendix), followed by correlation of the responses with allergy descriptions in the patient’s drug chart, EMR and medical admission record. To maintain consistency, this questionnaire was administered by pharmacy and medical staff trained at each site. Patients with a history of dementia or delirium who were unable to provide informed consent were excluded only from the patient questionnaire component of the study. A hypothetical oral antibiotic re-challenge in a supervised setting was offered to patients with a low risk allergy phenotype (Appendix).

Definitions

An AAL was defined as any reported antibiotic allergy or adverse drug reaction (ADR) recorded in the allergy section of the EMR, drug chart, or medical admission note. AALs were classified as either type A or type B ADRs according to previously published definitions (Box 1):12,13

type A: non-immune-mediated ADR consistent with a known drug side effect (eg, gastrointestinal upset);
type B: immune-mediated reactions consistent with an IgE-mediated (eg, angioedema, anaphylaxis, or urticaria = type B-I) or a T cell-mediated response (type B-IV):
- Type B-IV: delayed benign maculopapular exanthema (MPE);
- Type B-IV* (life-threatening in nature): severe cutaneous adverse reactions (SCAR),14 erythema multiforme (EM), fixed drug eruption (FDE), serum sickness, and antibiotic-induced haemolytic anaemia.

Study investigators JAT and AKA categorised AALs; if consensus could not be reached, a third investigator (LG) was recruited to adjudicate.

An AAL was defined as a “low risk phenotype” if it was consistent with a non-immune-mediated reaction (type A), delayed benign MPE without mucosal involvement that had occurred more than 10 years earlier (type B-IV), or an unknown reaction that had occurred more than 10 years earlier. Unknown reactions in patients who could not recall when the reaction had occurred were also classified as low risk phenotypes. All low risk phenotypes were ADRs that did not require hospitalisation. A “moderate risk phenotype” included an MPE or unknown reaction that had occurred within the past 10 years. A “high risk phenotype” was defined as any ADR reflecting an immediate reaction (type B-I) or non-MPE delayed hypersensitivity (type B-IV*).

AAL mismatch was defined as non-concordance between a patient’s self-reported description of an antibiotic ADR in the questionnaire and the recorded description in any of the medical record platforms (drug charts, medical admission notes, EMR). Infection diagnosis was classified according to Centers for Disease Control/National Healthcare Safety definitions.15

Statistical analysis

Statistical analyses were performed in Stata 12.0 (StataCorp). Variables of interest in the AAL and no antibiotic allergy label (NAAL) groups were compared. Categorical variables were compared in χ² tests, and continuous variables with the Wilcoxon rank sum test. P < 0.05 (two-sided) was deemed statistically significant.

Ethics approval

The human research ethics committees of both Austin (LNR/15/Austin/93) and Alfred Health (project 184/15) approved the study.

Results

Antibiotic allergy label description and classification

The baseline patient demographics for the AAL and NAAL groups are shown in Box 2. Of the 453 patients initially identified, 107 (24%) had an AAL. A total of 160 individual AALs were recorded: 27 were type A (17%), 26 were type B-I (16%), 45 were type B-IV (28%), and 62 were of unknown type (39%) (Box 3). Sixteen of the type B-IV reactions (35%) were consistent with more severe phenotypes (type B-IV*). When the time frame criterion (more than 10 years v 10 years or less since the index reaction) was applied to phenotype definitions, this translated to 63% low risk (101 of 160), 4% moderate risk (7 of 160), and 32% high risk (52 of 160) phenotypes. The antibiotics implicated in AALs and their ADR classifications are summarised in Box 3; 34% of reactions were to simple penicillins, 13% to sulfonamide antimicrobials, and 11% to cephalosporins. Three AAL patients (2.8%) were referred to an allergy specialist for assessment (one with type A, two with type B-I reactions). No recorded AALs were associated with admission to an ICU, while eight either ended or occurred during the index hospital admission (two type A, five type B-I, and one type B-IV).

Antibiotic use

Ceftriaxone was prescribed more frequently for patients with AALs (29 of 89 [32%]) than for those in the NAAL group (74 of 368 [20%]; P = 0.02); flucloxacillin was prescribed less frequently (0 v 21 of 368 [5.7%]; P = 0.02). The rate of prescription of other restricted antibiotics, including carbapenems, monobactams, quinolones, glycopeptides and lincosamides, was low in both groups (Box 4).

Antibiotic cross-reactivity

Seventy patients had a documented reaction to a penicillin (a total of 72 penicillin AALs: 55 to penicillin V or G, eight to aminopenicillins, nine to anti-staphylococcal penicillins), including two patients with two separate penicillin allergy labels to members of different β-lactam classes. Of these, 23 (32.9%) were prescribed and tolerated cephalosporins (Box 5). Of the 55 patients with a penicillin V/G AAL, β-lactam antibiotics were prescribed for 19 patients (34%); one patient received aminopenicillins (1.8%), four first generation cephalosporins (7%), two second generation cephalosporins (3.6%), and 12 received third generation cephalosporins (21.8%). Conversely, 18 patients had documented ADRs to cephalosporins, with a total of 19 AALs (14 to first generation, one to second generation, two to third generation cephalosporins, and two to cephalosporins of unknown generation). Of these, five patients (27.8%) were again prescribed cephalosporins without any reaction, and a further five (27.8%) tolerated any penicillin (Box 5).

Eight patients with AALs (7%) were administered an antibiotic from the same antibiotic class. No adverse events were noted in any of the patients inadvertently re-challenged. Eighty-six AAL patients (77%) reported a history of taking any antibiotic after their index ADR event. Thirteen patients (12%) believed they had previously received an antibiotic to which they were considered allergic, 62 had not (58%), and 32 were unsure (30%).

Recording of AALs

Almost all AALs (156 of 160 [98%]) were documented in medication charts, but only 115 (72%) were documented in admission notes and 81 (51%) in the EMR. Twenty-five per cent of patients had an AAL mismatch. No patients received the exact antibiotic recorded in the AAL.

Hypothetical oral antibiotic re-challenge

Fifty-eight AAL patients (54%) were willing to undergo a hypothetical oral antibiotic re-challenge in a supervised environment, of whom 28 (48%) had a low risk phenotype, seven a moderate risk phenotype (12%), and 23 a high risk phenotype (40%). If patients had received and tolerated an antibiotic to which they were previously considered allergic, they were more likely to accept a hypothetical re-challenge than those who had not (9 of 12 [75%] v 3 of 12 [25%]; P = 0.04).

Discussion

The major users of antibiotics in community and hospital settings remain our expanding geriatric population.16 An accumulation of AALs, reflecting both genuine allergies (immune-mediated) and drug side effects or intolerances, follows years of antibiotic prescribing. This is reflected in the high AAL prevalence (24%) in our cohort of older Australian general medical inpatients, notably higher than the national average (18%) and closer to that reported for immune-compromised patients (20–23%).4,17

To understand the high prevalence of AALs and the predominance of low risk phenotypes in our study group requires an understanding of “penicillin past”, as many AALs are confounded by the impurity of early penicillin formulations and later penicillin contamination of cephalosporin products.18,19 Re-examining non-recent AALs of general medical inpatients is therefore potentially both a high yield and a low risk task, considering the low pre-test probability of a persistent genuine penicillin allergy.20–22 While the definition of a low risk allergy phenotype is hypothetical, it is based upon findings that indicate the loss of allergy reactivity over time,20,21,23 the low rate of adverse responses to challenges in patients with mild delayed hypersensitivities,20,22,23 and the safety of oral challenge in patients with similar phenotypes.24

The high rate of type A, non-severe MPE and of non-recent unknown reactions in our patients (74% of all AALs; 63% low risk phenotypes) provides a large sample size to explore further, while the higher use of antibiotics that are the target of antimicrobial stewardship programs (eg, ceftriaxone) in AAL patients provides an impetus for change. The increased use of restricted antibiotics (eg, ceftriaxone and fluoroquinolones) and the reduced use of simple penicillins (eg, flucloxacillin) in patients with an AAL were marked. The effects of AALs on antibiotic prescribing have been described in large hospital cohorts and in specialist subgroups (eg, cancer patients).3,4 Associations between AALs and inferior patient outcomes, higher hospital costs and microbiological resistance have also been recently noted.2–4,8,17,25 Re-examining AALs in older patients from an antimicrobial stewardship viewpoint is therefore essential, particularly in an era when multidrug-resistant (MDR) organisms are being isolated more frequently in Australia.26 The fact that third generation cephalosporins and fluoroquinolones are associated with MDR organisms and with Clostridium difficile infection generation further supports the need for re-examining AALs, especially in those with easily resolved non-genuine allergies.27–30

The high rate of potential patient acceptance of an oral re-challenge (54%), especially by those with low risk phenotypes (48%), suggests that this should be explored in prospective studies. The idea of an antibiotic allergy re-challenge of low risk phenotypes is a practical extension of the work by Blumenthal and colleagues,24 who found a sevenfold increase in β-lactam uptake and a low rate of adverse reactions. Another group found that oral re-challenge was safe in children with a history of delayed allergy.23 These are both important advances; while skin-prick allergy testing is sensitive for immediate penicillin hypersensitivity, skin testing (delayed intradermal and patch) lacks sensitivity for delayed hypersensitivities.8,22,31 Incident-free accidental re-challenge with the culprit antibiotic or a drug from a similar class had occurred in some of our patients, adding further support for exploring this approach. A structured oral re-challenge strategy is attractive, as skin-prick testing is potentially expensive and inaccessible for most people.8

Analysing the high rate of AAL mismatch may be a more pragmatic low-cost approach, as not only were AAL labels absent from a number of medical records, the EMR AAL often differed from patients’ reports. Incorrect and absent AALs in other centres have been raised as a concern from a drug safety viewpoint.6,7,10 Education programs aimed at improving clinicians’ (pharmacy and medical) understanding of allergy pathogenesis could also assist antibiotic prescribing in the presence of AALs.5,10 Interrogation of the patient and their relatives about allergy history and examination of blood investigations at the time of the ADR for evidence of end organ dysfunction or eosinophilia may also provide greater accuracy in phenotyping and severity assessment. Many accumulated childhood allergies reflect the infectious syndrome that resulted in the implicated antibiotic being prescribed, rather than an immunologically mediated drug hypersensitivity.21,23 Referral to allergy specialists at the time of drug hypersensitivity may also reduce over-labelling.

That a clinician questionnaire about antibiotic prescribing attitudes was not administered is a limitation of this study, as was the inability to obtain AAL information from all patients (eg, because of dementia or delirium) or to further clarify “unknown” reactions. Some AAL descriptions are also likely to be affected by recall bias; however, this reflects real world attitudes and prescribing in the presence of AALs. While the prevalence of AALs in younger patients is probably lower than found in this study, the distribution of genuine, non-genuine and low risk allergies may well be the same. In a group of paediatric patients with an AAL for β-lactam antibiotics following non-immediate mild cutaneous reactions without systemic symptoms, none experienced severe reactions after undergoing oral re-challenge.23

Conclusion

AALs were highly prevalent in our older inpatients, with a significant proportion involving non-genuine allergies (eg, drug side effects) and low risk phenotypes. Most patients were willing to undergo a supervised oral re-challenge if their allergy was deemed low risk. AALs were sometimes associated with inadvertent class re-challenges, facilitated by poor allergy documentation, without ill effect. AALs were also associated with increased prescribing of ceftriaxone and fluoroquinolone, antibiotics commonly restricted by antimicrobial stewardship programs. These findings inform a mandate to assess AALs in the interests of appropriate antibiotic use and drug safety. Prospective studies incorporating AALs into antimicrobial stewardship and clinical practice are required.

Box 1 –
Classification of reported antibiotic allergy labels into adverse drug reaction groups12,13

EM=erythema multiforme; FDE=fixed drug eruption; MPE=maculopapular exanthema; SCAR=severe cutaneous adverse reactions (includes Stevens–Johnson syndrome, toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptoms, and acute generalised exathematous pustulosis). *These adverse reactions are classified as type B-IV* in this study, denoting their potentially life-threatening nature.

Box 2 –
Baseline demographics for patients with and without antibiotic allergy labels

Characteristic	Patients with an antibiotic allergy label	Patients with no antibiotic allergy label	P

Number	107	346
Median age [IQR], years	82 [74–87]	80 [71–88]	0.32
Sex, men*	38 (36%)	194 (56%)	< 0.001
Immunosuppressed	25 (23%)	29 (8%)	< 0.001
Median age-adjusted Charlson Comorbidity Index score [IQR]	6 [4–7]	6 [4–7]	0.17
Ethnicity			0.38
European	106 (99%)	334 (97%)
African	0	2 (1%)
Asian	1 (1%)	10 (3%)
Infection diagnosis	50 (47%)	140 (41%)	0.25
Infections (205 patients)	56	151	0.002
Cardiovascular system	0	2 (1%)
Central nervous system	1 (2%)	3 (2%)
Gastrointestinal	9 (16%)	9 (6%)
Eyes, ears, nose and throat	0	3 (2%)
Upper respiratory tract	7 (13%)	30 (20%)
Lower respiratory tract (including pneumonia)	12 (21%)	54 (36%)
Skin and soft tissue	7 (13%)	14 (9%)
Urinary system	11 (20%)	21 (14%)
Pyrexia (no source)	3 (5%)	4 (3%)
Sepsis (unspecified)	5 (9%)	8 (5%)
Other	0	2 (1%)
Received antibiotics	45 (42%)	162 (46%)	0.43

* There were a total of 232 men and 221 women in the study.

Box 3 –
Spectrum of implicated antibiotics linked with reported antibiotic allergy labels according to adverse drug reaction classification

Implicated antibiotics	Antibiotic allergy labels: adverse drug reactions
	Type A	Type B			Unknown	Total
	Type A	Type B-I	Type B-IV	Type B-IV*	Unknown	Total

All antibiotics	27 (17%)	26 (16%)	29 (18%)	16 (10%)	62 (39%)	160
Simple penicillins*	7 (26%)	14 (54%)	16 (55%)	4 (25%)	14 (23%)	55 (34%)
Aminopenicillins^†	1 (4%)	2 (8%)	2 (7%)	1 (6%)	2 (3%)	8 (5%)
Anti-staphylococcal penicillins^‡	0	0	1 (3%)	5 (31%)	3 (5%)	9 (6%)
Cephalosporins	3 (11%)	1 (4%)	1 (3%)	2 (13%)	11 (18%)	18 (11%)
Carbapenems^§	0	0	0	0	1 (2%)	1 (0.6%)
Monobactam	0	0	0	0	0	0
Fluoroquinolones	2 (7%)	0	2 (7%)	0	3 (5%)	7 (4%)
Glycopeptides	0	0	1 (3%)	1 (6%)	1 (2%)	3 (2%)
Lincosamides	0	0	1 (3%)	0	2 (3%)	3 (2%)
Tetracyclines	4 (15%)	1 (4%)	0	1 (6%)	5 (8%)	11 (7%)
Macrolides	1 (4%)	2 (8%)	1 (3%)	1 (6%)	6 (10%)	11 (7%)
Aminoglycosides	0	0	1 (3%)	0	0	1 (0.6%)
Sulfonamides^¶	4 (15%)	4 (15%)	3 (10%)	1 (6%)	9 (15%)	21 (13%)
Others	5 (19%)	2 (8%)	0	0	5 (8%)	12 (8%)

All percentages are column percentages, except for the “all antibiotics” row. * Benzylpenicillin, phenoxymethylpenicillin, benzathine penicillin. † Amoxicillin, amoxicillin–clavulanate, ampicillin. ‡ Flucloxacillin, dicloxacillin, piperacillin–tazobactam, ticarcillin–clavulanate. § Meropenem, imipenem, ertapenem. ¶ Trimethoprim–sulfamethoxazole, sulfadiazine.

Box 4 –
Antibiotic use in patients with and without an antibiotic allergy label

Antibiotic class prescribed	Antibiotic prescriptions		P
Antibiotic class prescribed	Antibiotic allergy label group	No antibiotic allergy label group	P

Total number of patients	89	368
β-Lactam penicillins	14 (16%)	120 (35%)	0.02
Simple penicillins*	4 (5%)	32 (9%)	0.27
Aminopenicillins^†	8 (9%)	52 (14%)	0.22
Anti-staphylococcal penicillins^‡	2 (2%)	36 (10%)	0.02
Carbapenems^§	2 (2%)	5 (1%)	0.63
Cephalosporins (first/second generation)	8 (9%)	20 (5%)	0.22
Cephalosporins (third or later generation)	29 (33%)	82 (22%)	0.05
Monobactam	0	0	NA
Fluoroquinolones	5 (6%)	6 (2%)	0.04
Glycopeptides	3 (3%)	12 (3%)	1
Tetracyclines	6 (7%)	46 (13%)	0.14
Lincosamides	0	0	NA
Others	26 (29%)	109 (30%)	1

NA = not applicable. * Benzylpenicillin, phenoxymethylpenicillin, benzathine penicillin. † Amoxicillin, amoxicillin–clavulanate, ampicillin. ‡ Flucloxacillin, dicloxacillin, piperacillin–tazobactam, ticarcillin–clavulanate. § Meropenem, imipenem, ertapenem. Some patients received more than one antibiotic.

Box 5 –
Antibiotic use in patients with penicillin and cephalosporin antibiotic allergy labels


Patients with documented allergy to penicillins* (n = 70)
Antibiotics prescribed:
Any antibiotics	28 (40%)
More than one class of antibiotic	31 (44%)
Culprit group penicillins^†	1 (1.4%)
Non-culprit group penicillins	2 (2.9%)
First generation cephalosporins	4 (5.7%)
Second generation cephalosporins	2 (2.9%)
Third generation cephalosporins	17 (24%)
Carbapenems	2 (2.9%)
Fluoroquinolones	4 (5.7%)
Glycopeptides	2 (2.9%)
Aminoglycosides	2 (2.9%)
Lincosamides	0
Patients with documented allergy to cephalosporins (n = 18)
Antibiotics prescribed:
Any antibiotics	10 (56%)
More than one class of antibiotic	7 (39%)
Culprit generation cephalosporins	1 (5.6%)
Non-culprit generation cephalosporins	3 (17%)
Other^‡	1 (5.6%)
Any penicillins*	5 (28%)
Carbapenems	1 (5.6%)
Fluoroquinolones	1 (5.6%)
Glycopeptides	1 (5.6%)
Aminoglycosides	1 (5.6%)
Lincosamides	0

* Penicillins (benzylpenicillin, phenoxymethylpenicillin, benzathine penicillin); aminopenicillins (amoxicillin, amoxicillin–clavulanate, ampicillin), and anti-staphylococcal penicillins (flucloxacillin, dicloxacillin, ticarcillin–clavulanate and piperacillin–tazobactam). † Prescription of culprit group penicillin: received any penicillin from the same group as that to which the patient is allergic. ^‡ This patient had a documented allergy to an unknown generation of cephalosporin, and received ceftriaxone.

[Correspondence] Health equity for LGBTQ people through education

We applaud The Lancet Editors (Jan 9, p 95)1 for drawing attention to new initiatives to improve the health and wellbeing of lesbian, gay, bisexual, transgender, and queer (LGBTQ) people worldwide. Many challenges remain, but the US Department of Health and Human Services report presents a strategy for change that could inform the efforts of other nations. However, one important aspect is missing from the worldwide conversation on addressing the health needs of LGBTQ—educating ourselves.

[Editorial] UK PrEP decision re-ignites HIV activism

On March 21, NHS England announced that, contrary to expectation, it will not proceed with a scale-up of pre-exposure prophylaxis (PrEP) for prevention of HIV infection among at-risk populations. Saying it was “not responsible for commissioning HIV prevention services”, the agency effectively dropped plans to hold public consultations and instead tepidly said it would work with local health authorities to consider how to make the anti-HIV drugs more widely available. Few other details were offered.

National talks on remote area nurse safety

Improvements in the security of remote area nurses have been put off to a future meeting of Federal, State and Territory health ministers.

In a statement issued following a meeting with remote health service operators and representatives, Rural Health Minister Fiona Nash said there had been “a number of worthy, original and thoughtful ideas” which the she would carefully consider and raise with her State and Territory counterparts “over the coming weeks”.

The meeting was convened in the wake of the fatal attack on Gayle Woodford, 56, who was working as a nurse in the remote Fregon community in the Anangu Pitjantjatjara Yankunytjatjara (APY) lands of north-west South Australia. A 34-year-old man, Dudley Davey, has been charged with her murder.

The murder has ignited a campaign for improved security for nurses working in remote areas, including calls for the abolition of single-nurse posts and new rules requiring health workers attending call-outs and emergencies to operate in pairs. As at 8 April, almost 130,000 people had signed a petition calling for the changes.

The sector also faces the threat of a mass walkout of staff. A survey of 800 regional nurses cited by the Adelaide Advertiser indicates 42 would quit if single nurse posts are retained.

The fatal attack on Ms Woodford is but the latest in a series of incidents and assaults on remote area nurses. A University of South Australia study of 349 such nurses, undertaken in 2008, found almost 29 per cent had experienced physical violence, and 66 per cent had felt concerned for their safety.

The study found that there had been a drop in violence against nurses since 1995, coinciding with a reduction in the number of single nurse posts.

Senator Nash paid tribute to health workers in remote areas and acknowledged that they faced “unique and difficult challenges”, but held back from endorsing any particular course of action to improve security.

Part of the problem she faces is that the ability of Federal and State governments to act to improve health worker safety is constrained because remote area health services are independently run, often by Aboriginal communities.

Senator Nash said she would respect the independence of service operators.

“Whilst the Federal Government funds many of these remote services, they are, in fact, independently run, as they should be,” she said. “I will not break Australia’s long-standing multi-partisan commitment to Indigenous self-determination by telling these health providers how to run their services.

“Remote health services do the work on the ground and they know best, so I will be asking them for their ideas on this important issue.”

Adrian Rollins

[Comment] Lean economies and innovation in mental health systems

Poor access to mental health care is widely reported, although it differs according to sociopolitical and economic contexts. In emerging economies, including Brazil, Russia, India, China, and South Africa (BRICS), there has been increased public investment in recent years, but rapid economic growth in these countries has now slowed. Precarious global transitions affect both the burden of mental health problems and demand for services. Innovations prompted by these transitions, in both high-income and low-income countries, could help meet population needs during times of economic shock, whether scarcity or affluence.

Military should get annual check up

Australian Defence Force personnel would undergo annual mental health checks under plans backed by the AMA to tackle rates of depression, post-traumatic stress disorder and suicidal thoughts in the military.

A parliamentary committee inquiring into the mental health of soldiers, sailors and air force personnel found that although in the short term they were no more prone to mental health problems than the broader community, the nature of their work meant the types of problems they experience are not the same.

The 2010 ADF Mental Health Prevalence and Wellbeing Study found that 22 per cent of Defence personnel experienced a mental disorder in the previous 12 months, roughly similar to that found in a sample of general members of the community, while almost 7 per cent who suffered multiple problems.

But although, in the short term, the prevalence of problems was approximately the same, over their lifetime, ADF personnel were found to be more at risk of mental health problems.

Military personnel were found to be less prone to alcohol abuse, but they were more likely to suffer depression, and to think about and plan suicide. The most common mental health problem, however, was anxiety, particularly post-traumatic stress disorder.

AMA President Professor Brian Owler said this reflected the particular characteristics of their work, including experiences during deployment overseas and long absences from family and support networks.

Professor Owler said a recommendation from the Foreign Affairs, Defence and Trade References Committee for annual mental health screening was a welcome proposal.

“Annual screening would help ensure that mental health problems are identified at a much earlier stage, would support early intervention, and lead to much better mental health outcomes for affected personnel,” the AMA President said.

He also endorsed the Committee’s call for a unique identifier number for veterans linked to their service and medical records.

In 2013, the Federal Government gave in-principle support to a similar idea put forward by the Joint Standing Committee on Foreign Affairs, Defence and Trade, but Professor Owler said there appeared to have been little progress made on it since.

“A unique or universal identifier could help improve health outcomes for these patients,” Professor Owler said.

The AMA President said it would support the transition of personnel out of Defence Force-funded health services into those provided by the Department of Veterans’ Affairs or the mainstream health system, and would enable tracking of the health of former ADF personnel over time, which was critical to research.

He said there was strong support for the idea among veterans’ groups, and called on the Government and bureaucracy to fast-track the initiative.

Adrian Rollins