Optimal Cancer Care for First Nations Australians

An Australian-first Optimal Care Pathway for Aboriginal and Torres Strait Islander People with Cancer, released in August by Cancer Australia, charts new approaches to cancer care for First Nations people, to boost their cancer treatment experience and results.

Indigenous Health Minister Ken Wyatt AM said this Optimal Care Pathway aims to tackle the growing gap in cancer outcomes between First Nations people and other Australians, by supporting the delivery of tailored, culturally safe and competent care.

“First Nations people are more likely to be diagnosed at a more advanced stage and are, on average, 40 per cent more likely to die from cancer than non-Indigenous Australians,” Minister Wyatt said.

“Cancer is the second leading cause of death and one of the biggest challenges for Aboriginal and Torres Strait Islander people, not just for those diagnosed, but also for families, carers, Elders, and communities.”

Minister Wyatt said that for services to be effective in improving Aboriginal and Torres Strait Islander health, they must operate with a fundamental understanding of, and respect for, First Nations culture.

“The new pathway provides health services and health professionals across Australia with principles and guidance to ensure that cancer care is culturally safe and responsive,” the Minister said.

“Being aware of how a person’s culture, values, and motivations can influence their decisions and preferences relating to the delivery of their care is an essential component in creating a culturally competent workforce. It is critical to better outcomes.”

The Optimal Care Pathway for Aboriginal and Torres Strait Islander People with Cancer – endorsed by the Australian Health Ministers’ Advisory Council – is accompanied by information and resources for Aboriginal and Torres Strait Islander people who may have or do have cancer, as well as for their carers, families, and communities.

Pic: Inidigenous Health Minister Keny Wyatt

Racial diversity of physicians in the USA

In the United States, racial and ethnic minorities have higher rates of chronic disease, obesity, and premature death than white people.

Black patients, in particular, have among the worst health outcomes, experiencing higher rates of hypertension and stroke. And black men have the lowest life expectancy of any demographic group, living on average 4.5 fewer years than white men.

The Harvard Business Review says that a number of factors contribute to these health disparities, but one problem has been a lack of diversity among physicians.

African Americans make up 13 per cent of the US population, but only four per cent of US doctors and less than seven per cent of US medical students. Of active US doctors in 2013, 48.9 per cent were white, 11.7 per cent were Asian, 4.4 per cent were Hispanic or Latino, and 0.4 per cent were Native American or Alaska Native.

Research has found that physicians of colour are more likely to treat minority patients and practise in underserved communities. And it has been argued that sharing a racial or cultural background with one’s doctor helps promote communication and trust.

A new study from the National Bureau of Economic Research looked at how changing this ratio might improve health outcomes – and save lives.

Researchers set up an experiment that randomly assigned black male patients to black or non-black male doctors, to see whether having a doctor of their race affected patients’ decisions about preventive care.

They found that black men seen by black doctors agreed to more, and more invasive, preventive services than those seen by non-black doctors. And this effect seemed to be driven by better communication and more trust.

Increasing demand for preventive care could go a long way toward improving health. A substantial part of the difference in life expectancy between white and black men is due to chronic diseases that are amenable to prevention.

By encouraging more preventive screenings, the researchers calculate, a workforce with more black doctors could help reduce cardiovascular mortality by 16 deaths per 100,000 per year – resulting in a 19 per cent reduction in the black-white male gap in cardiovascular mortality and an 8 per cent decline in the black-white male life expectancy gap.

Exams rigged against female applicants in Japan

One of Japan’s leading medical schools has been automatically reducing the entrance exam scores of female applicants by 20 per cent for at least 12 years to graduate more male doctors, an independent inquiry has found.

The case has been examined in a report in the British Medical Journal (BMJ).

According to the BMJ, Tokyo Medical University’s acting president, Keisuke Miyazawa, admitted to the exam rigging at a press conference on 7 August after the release of a damning report by external lawyers.

“For those people whom we have caused tremendous hardship, especially female candidates whom we have hurt, we will do everything we can,” he said.

Miyazawa said that the school was considering options including financial compensation and retroactive admission of some women who would have passed without the automatic deduction. He said that he had not known of the score manipulation.

Tetsuo Yukioka, the school’s executive regent and chair of its diversity promotion panel, stood beside him.

Both men spent much of the press conference with their heads bowed in an attitude of shame.

“Society is changing rapidly and we need to respond to that, and any organisation that fails to utilise women will grow weak,” Yukioka said. “I guess that thinking had not been absorbed.”

Kenji Nakai, a lawyer who led the inquiry, said that the rigging had been ordered by the former chair of the board of regents, Masahiko Usui, 77, with the approval of the former president, Mamoru Suzuki, 69.

Both men resigned last month amid allegations that they had inflated the exam score of the son of Futoshi Sato, a health ministry official, in return for increased research funding. Usui, Suzuki, and Sato have all since been charged with bribery.

As well as discriminating against women, the school secretly penalised men who had failed the entry test more than twice before. The school had far more applicants than places – only one in 11 men and one in 33 women who tried for a place succeeded in 2018 – so multiple attempts were common.

A computer algorithm automatically deducted 20 per cent from the score of everyone taking the first multiple choice segment of the entrance exam.

Men taking the test for the first or second time were then re-awarded 20 per cent, men taking it for the third time were given back 10 per cent, and men taking it for the fourth time – plus all women – were given back 0 per cent.

The investigators also found 18 instances of applicants’ scores being inflated in return for donations to the school or bribes to its officials. In one case, a student’s mark had been raised by 49 per cent in return for a donation to the school.

Investigators examined records dating back to only 2006 so that they could report their findings earlier, said Nakai.

The principal motive for the discrimination, he said, was the perception that female doctors are more likely to quit the profession young to have children, exacerbating a doctor shortage.

Because medical graduates in Japan typically work in hospitals affiliated to their medical school, this would be a problem for the institution itself, not just for society at large.

‘Profound sexism’ among the school’s leadership also played a role, said Nakai.

The revelations have released a torrent of online criticism, much of it under the hashtag, “It’s okay to be angry about sexism”.

Female doctors in Japan have complained that staying in the profession is almost impossible after having children because childcare services are lacking and because women are expected to perform all household tasks while also working the extremely long hours demanded of male doctors.

The number of Japanese children waiting for kindergarten places this year rose to 55 000. The health ministry, which is also responsible for welfare programs, has announced plans to add 320,000 childcare places by 2021.

Suspicion is now widespread in Japan that exam rigging against women is not limited to one medical school. The education minister, Yoshimasa Hayashi, said yesterday that he plans to examine entrance procedures at schools around the country.

He will also decide what action to take against Tokyo Medical University after studying the report, he said.

[Editorial] India’s mega health reforms: treatment for half a billion

Technocrats and functionaries are hastily putting the final touches to India’s mega health insurance scheme following Prime Minister Narendra Modi’s announcement that the programme will be launched nationwide on Sept 25. The scheme aims to provide up to 100 million poor families with approximately INR500 000 (US$7100) in annual health insurance coverage to pay for secondary or tertiary hospital care. It is one of the components of a flagship initiative known in Hindi as Ayushman Bharat or “India blessed with long life”, which includes developments in primary health services and health promotion.

[Correspondence] The global health and equity imperative for safe consumption facilities

The first safe consumption facility (SCF) opened its doors in 1986, in Bern, Switzerland, intending to curb drug overdose-related deaths and prevent other drug-related harm in people who inject drugs (PWID).1 Since then, communities who have adopted the SCF approach have seen decreases in HIV incidence, injection-related litter and disorder, and drug overdose.2,3 Use of SCFs is also associated with uptake of treatment for drug use and other recovery assistance services.4

What use is the high moral ground when you are being eaten alive?

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA

GPs’ livelihood and ability to practise are being attacked on many fronts. Dubious role substitution creep from usurper health care practitioners must stop. Does the fight need to come to their doorstep instead of doctors always being in defence?

The Acting President of the Pharmacy Guild recently likened the AMA to a “salivating and barking dog,” following a perceived “onslaught of abuse and derision,” in a response to broader scope of practice for pharmacists. The hyperbole was rousing!

It was suggested that prescribing medications, being able to capably understand and diagnose a patient’s medical problems without appropriate training or ability to garner a full history and examine, and to provide health prevention advice is within the scope of pharmacy training? Clearly not true. The aircraft engineer doesn’t pilot the plane, serve the drinks, or unload the luggage. Being able to work a sphygmomanometer and having a basic understanding of physiology does not make you a doctor or capable of giving medical advice while standing in the middle of a retail pharmacy. The benefits of an enduring, familiar family doctor who knows you well and can provide wide-ranging advice and treatment is well evidenced and the appropriate cornerstone of our health care system. Pharmacists are not required to do any part of this job.

It was also asserted that self-defined broader scope of practice for pharmacists will also save money and time for patients. Not really if outcomes are inferior. Where is the evidence that pharmacists behaving as quasi-doctors achieves anything? Regular interactions with general practitioners is crucially important in developing an enduring bond, discussing risk factor modification, and so on. Government cannot ‘de-fund’ general practice, then attempt to remove the more simple work, and expect the system will still work given growing patient complexity and potential risk.

If you want to be a doctor – go to medical school. Australia is graduating just under 4000 doctors this year – there’s no lack of space! Please, do not abandon doing the job you are actually trained to do. Patients need direction in how to use their inhalers every few months (or their technique degrades), explain the purpose of medications (both prescribed and over the counter), clarify dosing regimens for patients, make sure warfarin interactions with diet are understood by patients, sort out pill boxes or Webster packs to reduce medication errors, and so on. This unequivocal in-scope pharmacy activity is performed far less than it should. If it was done frequently and properly, it would be far more useful to patients and contribute more robustly to the safety and quality of the system, compared to the constant attempts to do a doctor’s job in a rudimentary and inferior way.

The AMA has always decided it is morally and ethically more appropriate for doctors to not dispense medications as a system- wide policy (bearing in mind it has usefully occurred in rural areas for a long time). It would actually be very convenient to patients if doctors did dispense medications (to use one of the Guild’s main arguments for role substitution), and we could make it cheaper to the system as a whole if the costs reflected the dispensing fees only, without profit being generated, and/or any profit being retained within the practice for other patients’ services. If doctor dispensing of medications became a reality, individuals would not have to do it, if they didn’t want to. If patient convenience and cost are paramount in the system, whereas training, evidence, and professionalism do not matter as much to decision-makers, then we perhaps need to recognise this.

Offence might serve us better than defence. Is the AMA position due for a re-think?

Shared Responsibility

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

New amendments to the Health Insurance Act 1973, strengthening the Government’s debt recovery powers and seeking to tackle the role of corporate entities in billing under Medicare, have recently been passed by Parliament.

Practitioners may have a debt to the Commonwealth raised against them due to receipt of incorrectly, inappropriately, or fraudulently claimed Medicare benefits. However, according to the Government, a large proportion of these debts has proven difficult to collect. New powers will allow the Department of Human Services to off set a portion of future bulk billed claims against debts. If the practitioner doesn’t bulk bill, the new arrangements will allow garnisheeing of other funds owed to them.

So, more than ever, it is in practitioners’ interests to get their claiming right from the outset.

The problem, as many of you have no doubt found, is trying to get clarity when you are unsure of how to interpret an item or an applicable rule. The Department of Human Services ‘ask MBS’ email for billing enquiries was supposed to provide this. However, the answers are often very unclear or non-committal.

What you are likely to get today, at best, is the regurgitation of either the item descriptor, rules, or legislation back in response to a query. At worst, you will get a misinterpretation and advice that is contrary to the rules. The incorrect advice recently provided to a GP Registrar that GPs could not claim a consultation when providing a vaccination, where the vaccine is funded under the National Immunisation Program, is a prime example.

This is not good enough and must be addressed! The AMA Council of General Practice recently made this point to the head of compliance at the Department of Health. If the Department hopes to increase compliance through education, it needs to have on staff medical advisers who understand the legislative requirements and have experience in their application. The Department of Health should also consider bringing ‘ask MBS’ within its realm of responsibility.

The other legislative change, which will take effect on 1 July 2019, is provision for a Shared Debt Recovery Scheme. To date, all the liability for a Medicare debt has been with the individual practitioner, except in cases where another party has engaged in fraud. The new change provides that, where contractual or other arrangements exist between a practitioner and an employer or corporate entity, both may be held responsible for the repayment of the debt.

What the percentage split of the liability between the employing/ contracting organisation and the individual practitioner is, is still to be finalised. Although it is likely it will be similar to the average of current billing splits. Both sides will have the opportunity, where a shared debt determination is made, to make a case for a review of assigned liability.

The objective of this measure is for a fairer assignment of liability and to facilitate greater billing assurance from a practice level as well as from the practitioner level. This is a proposal that the AMA strongly supported as part of improving debt recovery arrangements.

We are still to see how these new compliance arrangements will play out in practice. Most GPs seek to do the right thing, and the AMA be watching the implementation of these measures with interest to ensure its fairness and appropriate application

Drugs use the source of one in four new hepatitis C infections

Two in five people who have injected illicit drugs in the past year are living with hepatitis C, highlighting the urgent need for prevention and treatment, new Australian research shows.

Researchers from the Kirby Institute at the University of New South Wales and the National Drug and Alcohol Research Centre (NDARC) estimate that 6.1 million people who inject drugs are living with hepatitis C globally, with one-quarter of new infections occurring in people who inject drugs.

It is the first time that researchers have estimated the global, regional, and national numbers of people who inject drugs who are living with hepatitis C.

Lead author, Associate Professor Jason Grebely, said that, in Australia, almost 40,000 people who have recently injected drugs are living with HIV. However, Australia is one of only four countries worldwide with high coverage of both needle and syringe programs and opioid substitution therapies.

“Australia has been an international leader in its response to hepatitis C,” Associate Professor Grebely said.

“The fact that hepatitis C treatments are available for all individuals, without restrictions based on current or previous drug use, means that we are likely to achieve the World Health Organization goal to eliminate hepatitis as a major public health threat by 2030, including among people who inject drugs.”

However, the outlook is not so bright globally, with only one per cent of people who inject drugs living in countries where needle and syringe programs and opioid substitution programs are widely available.

The greatest number of people with hepatitis C who have recently injected drugs live in eastern Europe, east and south- east Asia, and North America, and more than half of them live in just four countries – Russia, the United States, China, and Brazil.

“It is concerning that more than half of all hepatitis C infections among people who have recently injected drugs occur in countries with inadequate coverage of harm reduction services,” Judy Chang, from the International Network of People Who Use Drugs, said.

“The global elimination of hepatitis C as a public health threat will not be achievable unless we improve access to harm reduction services, de-stigmatise drug use and drug users, and improve the overall health of people who use drugs.”

The researchers estimate that about 71 million people world- wide are living with hepatitis C.

The research was published in Addiction on 24 July.

Studies spell double trouble for women

There’s been a double whammy of bad health news for women, with one study finding that women with diabetes are more likely to develop cancer, and a second finding that women are twice as likely as men to be under-treated for heart attack.

In the first study, researchers from The George Institute for Global Health reviewed the health outcomes of almost 20 million people involved in 47 studies.

They discovered that having diabetes – type 1 or type 2 – significantly raises the risk of developing cancer, with a significantly higher risk for women.

Women with diabetes were 27 per cent more likely to develop cancer than women without diabetes. For men, the risk was 19 per cent higher.

Overall, women with diabetes were six per cent more likely to develop any form of cancer than men with diabetes.

“The link between diabetes and the risk of developing cancer is now strongly established,” lead author, Dr Toshiaki Ohkuma, said.

“We have also demonstrated, for the first time, that women with diabetes are more likely to develop any form of cancer, and have a significantly higher chance of developing kidney, oral, and stomach cancers, and leukaemia.

“The number of people with diabetes has doubled globally in the past 30 years, but we still have much to learn about the condition.

“It’s vital that we undertake more research into discovering what is driving this, and for both people with diabetes and the medical community to be aware of the heightened cancer risk for women and men with diabetes.”

The George Institute research was published in Diabetologia, the journal of the European Association for the Study of Diabetes.

In the second study, published in the Medical Journal of Australia, University of Sydney researchers found that women admitted to 41 Australian hospitals with ST-Elevation Myocardial Infarction (STEMI) in the past decade were half as likely as men to receive appropriate diagnostic tests and treatment.

They were also less likely to be referred for cardiac rehabilitation, and prescribed preventive medications, at discharge.

Death rates and serious adverse cardiovascular events among these women were more than double the rates seen in men six months after discharge.

“The reasons for the under-treatment and management of women compared to men in Australian hospitals aren’t clear,” lead author and cardiologist, Professor Clara Chow, said.

“It might be due to poor awareness that women with STEMI are generally at higher risk, or by a preference for subjectively assessing risk rather than applying more reliable, objective risk prediction tools.

“Whatever the cause, these differences aren’t justified. We need to do more research to discover why women suffering serious heart attacks are being under-investigated by health services, and urgently identify ways to redress the disparity in treatment and health outcomes.”

[Correspondence] A Brexit miscalculation

I read with concern Nick Fahy and colleagues’ Health Policy (Nov 4, p 2110)1 about how Brexit might affect health and health-care services in the UK. I argue that their Health Policy has a logical flaw and a potential miscalculation (appendix). Fahy and colleagues’ key anti-Brexit argument is that EU membership, protective legalities from the Court of Justice of the EU (CJEU), and free movement, tax, and childcare rights are essential to attract and retain much of the UK’s National Health Service (NHS) workforce.