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Preference: Administration and Health Services

2

Co-creation: a new approach to optimising research impact?

Bold new world offers researchers opportunity and challenge

Traditionally, academics benchmarked their success with metrics of publication such as journal impact factors or their personal h-index (a citation measure). Increasingly, researchers are required to demonstrate impact beyond academia.

In these challenging times, research funding is seen as an investment, and funders expect demonstrable returns in both monetary and societal terms (including morbidity, quality of life and economic benefit). The United Kingdom’s Research Excellence Framework now allocates 20% of its score, and linked public funding to universities, on the basis of demonstrated research impact. Australia’s recent Strategic Review of Health and Medical Research contained recommendations to “embed research in the health system” and “[strengthen] partnerships between researchers, healthcare professionals, governments and the community”.

The applied traditions of knowledge translation, research utilisation and implementation science have developed rapidly in recent years to inform how we achieve, measure and monitor research impact.1 But do they truly assist researchers to embed research into practice?

For traditional science-based enquiry, such approaches make sense. But they work less well for applied research, because their focus is on taking previously completed research and “translating” it for real-world consumption. In doing so, they make the assumption that the original research is destined for a close eventual fit with society, and that the real world is both ready for, and engaged with, their research “product”. All too often this is not the case, and we are trapped, trying to massage the Ugly Stepsister’s large foot into Cinderella’s smaller shoe. The eventual uptake and impact of our lengthy and expensive research is often disappointingly small.

This mismatch is well illustrated within the applied discipline of health services research. The aims and approach of carefully conducted trials may not fit the competing demands of busy clinical practice. Despite a lexicon of new terminology and mixed-methods study designs (“complex interventions”, “normalisation”, “mediators/moderators”, “process evaluations”, “Phase IV”) to understand and operationalise implementation processes and causal influences, the reality is that the health service delivery world often fails to generalise our research product.

The reason for this is not (as is often assumed) disinterest, lack of understanding or poor leadership on the part of our service colleagues. Conventional analytic frameworks describe barriers to implementation such as readiness to change, perceived relevance and incentive frameworks. A more contemporary conceptual framework depicts new service models as “complex interventions”.2 We thus need to move from approaches based on industrial metaphors (develop a universal intervention package, overcome barriers, and then “roll it out” at scale) to ecological ones (solutions must be locally grown and owned, and fit materially, historically and culturally with the particularities of context).

An approach rapidly gaining currency in addressing this mismatch, is research “co-creation” or “co-production”.3,4 Similar paradigms emerged decades ago in both the management world and development studies. They emphasise ongoing, collaborative “value creation processes” between multiple stakeholders — to understand and agree desired outcomes, create real innovation and deliver better performance. In health service research, co-creation draws researchers and end users together far earlier and more powerfully than in traditional research translation. Academics, consumers, clinicians, and service organisations (across public, private and third sectors) work together from the outset to frame relevant research questions, create research designs that map real-world environments, and commit to implementing the research and its findings in the broader health service community (Box).

Co-creation is not a new concept, nor is it a panacea. But it aligns in particular with four recent developments in applied health services research: (a) the emerging science of pragmatic randomised controlled trials, developed and executed in real-world conditions;9 (b) the increasing sophistication of efforts to embed complex interventions in a local organisational context and the wider health care ecosystem;10 (c) the growth of multistakeholder research collaborations;11 and (d) the call to go beyond tokenism when involving patients and the public in the research process.12

Co-creation methodology is informing the work of multistakeholder collaborations to generate research with rather than on local health services in the United Kingdom,13 Canada,14 the Netherlands15 and Australia.11 These new partnerships are not without their management and governance challenges, and we still have much to learn about how to run them effectively. But to do so, and truly “embed” research meaningfully within the health system, researchers need to revisit the methodology of research impact and their own relational connection with end users.

Rather than “Here is one I have cooked earlier, now eat it”, researchers may increasingly say: “Here’s the kitchen, let’s choose the ingredients and method, make the meal, sample and refine it together, and shoot for Masterchef”.

Box –
Developing culturally congruent research and services for a multi-ethnic community in London, United Kingdom

  • In the deprived and multi-ethnic East End of London, United Kingdom, the prevalence of diabetes is high, health outcomes are often poor, and attendance at conventional health education sessions is usually low. Systematic reviews and randomised controlled trials published in academic journals seemed to have limited relevance, perhaps because most described “clean” scientific samples in which important variables (comorbidity, poverty, low health literacy, limitations of local health systems) had been excluded or controlled for.
  • Led by a consultant diabetologist and academic general practitioner, a dynamic and evolving network of partners (including community-based social services, faith-based organisations and academics linked to a local university) worked collaboratively to define a research agenda, seek funding from a range of sources (research councils, charities, the National Health Service, the European Commission) and strive for the twin goals of local service improvement and high-quality research outputs.
  • Projects have included development and evaluation of an innovative peer support program for black and minority ethnic groups through oral storytelling,5,6 mapping diabetes risk with aggregated data from electronic patient records in general practice,7 and an analysis of the complex sociocultural barriers to behaviour change in South Asian immigrants.8

Every year eventually becomes the year for the older person

Case conferences demand a degree of organisation that does not occur easily in general practice

Does anybody remember that 1999 was the International Year of Older Persons? Does anybody remember the statement made by Bronwyn Bishop, as the Minister for Aged Care at that time, titled “Our commitment to Australia’s seniors”?1

There were two pages on enhanced primary care and three pages on residential care, much of which was devoted to aged care challenges in rural Australia. Individually, some of the proposed recommendations were very sensible. However, the problem with so much of government rhetoric is in joining up the points to form a coherent whole.

Medicare payments are based on general practice being a one-to-one episodic consultation. Chronic medical conditions in an increasingly ageing population demand reliable communication between health care professionals. “Multidisciplinary” is one of those words beloved by the ministerial scribes; however, in the way primary care is structured, it is difficult to organise because general practice is based around doctors not multidisciplinary teams.

The Medicare item for case conferences, introduced in 2000 by then Minister for Health and Aged Care, Michael Wooldridge, for general practitioners and consultant physicians acknowledged that teamwork is an essential part of chronic disease management. However, case conferences demand a degree of organisation that does not occur easily in general practice. Interestingly, they do provide a means of supporting teaching as part of the service commitment.

In 2000, Wooldridge also established the Medical Specialist Outreach Assistance Program (MSOAP) with the aim of broadly increasing visiting specialist services in rural and remote areas and in so doing increasing and maintaining the skills of the local health professionals.

The traditional method of communication to the specialist is the referral letter from the GP, who waits for a response. The case conference demands a consulting specialist and a GP with a variety of carers being in the one place at the one time, either face to face or by video or telelink; importantly, the doctors must see sufficient value to set time aside for such conferences, insulated against other pressures.

Wooldridge had provided a funding mechanism for the Bishop rhetoric.

However, it was about joining the dots.

Richard Whiting is a consultant geriatrician who, until recently, headed the aged care services at Western Health, Melbourne, with a commitment to multidisciplinary treatment of the elderly. In North East Victoria, after a significant lack of an effective visiting consultant geriatrician service was identified, MSOAP funding was secured so that Dr Whiting could visit both Cobram and Yarrawonga, two towns in the Moira Shire in North East Victoria, each of which had health services and nursing homes.

Dr Whiting was able to test the value of the case conference and several of the GPs were prepared to participate. As for the nursing staff, case conferences with allied health professionals are a normal part of patient care, and their participation was relatively easy to maintain. However, after a promising beginning in 2007, this stand-alone program with one specialist who had a full-time responsibility elsewhere ultimately became unsustainable.

The incoming federal government in 2007 introduced funding for “superclinics” — funding buildings in the expectation that they would provide a complete one-stop primary health care service. This initiative attracted controversy because, although it seemed a good idea in its conception, it was little more than a “thought bubble” in its execution.

However, Cobram was well placed to take advantage of this program as the health service already owned its medical clinic. The chief executive officer and the Board were prepared to invest in the federal government model, yet without being recognised or rewarded by government funding for Cobram’s foresight — at least initially. However, with the relevant services under the one roof, working together was made easier, thus providing a base for the geriatric service.

In any program, it is helpful if the local doctors have a sense of ownership. In the case of aged care, the assumption of many government grants is that GPs universally have an interest in geriatrics; and that is not so. Local doctors with nursing home patients often just want the difficult patients referred or transferred to the local regional hospital for treatment of acute episodes because dealing with multiple comorbidities and determining how far to pursue a particular symptom is a challenge to any clinician without formal training in geriatrics.2 Being required to attend at a nursing home for such episodes interferes with the GPs’ other commitments. The consultant geriatric service inter alia aimed to significantly reduce the number of acute episodes and provide more formal geriatrician backup for the local clinicians.

Thus, there were barriers that had to be confronted when the decision was made by the Moira Health Services to apply for a grant from the Victorian Department of Health in 2011 to establish a visiting geriatric service on a firmer basis than the first iteration. At the time, there was no regular geriatric visiting service and the consultant geriatrician position at Goulburn Valley Health had been vacant for several years.

The previous program, which involved only Dr Whiting, was thus placed on a firmer footing after the Moira Health Services’ successful application for the program grant in 2011. The opportunity was taken to define the terms of agreement for participation of Western Health to provide visits by another consultant geriatrician, in addition to Dr Whiting. During the 3-day, 6-weekly visits, the particular visiting geriatrician — often accompanied by the registrar — also provided a lunchtime lecture at each health service venue. These lectures, on topics as diverse as “hoarding” and “polypharmacy”, were particularly appreciated by the nursing staff.

In 2011, a UK-trained consultant geriatrician, Dr Arup Bhattacharya, was appointed to the vacant Goulburn Valley Health position and he immediately saw the value of providing a visiting service and the benefits of combining teaching with service.

Therefore, when the funding from the Victorian Department of Health ceased at the end of 2014, the program has not only been maintained in 2015, but expanded. Dr Bhattacharya visits three of the Moira Health Services regularly. Dr Whiting continues to visit Yarrawonga Health and the three campuses of Alpine Health have now been added to the program. Funding for the consultant geriatrician visits is derived from the modified visiting medical specialist assistance program and from Medicare. The level of acceptance in the program has been shown to work for the local medical profession, such that (a) the original scepticism has been allayed and (b) the program has been received enthusiastically by the nursing staff.

This program has not been part of any grand design — hence my narrative. Elements of government policy have been fashioned for needed services, which fit into the words expressed in the Bishop statement back in 1999. It is now time to take stock — so much effort has been put into getting this one regional service for the elderly. The question is, has it been worth it? Is it time to evaluate the program? Is it sustainable? What is the appropriate balance between service and education? With what can this program be compared?

Later this year in November, a symposium is being organised in Wangaratta where those who have been involved and those who have an interest in the success of such programs will be invited to answer these questions. The answer may be that this is a combined service and education model that should be rolled out.

In 1999, Bishop was not yet a senior; today at 72 years of age, former Speaker Bronwyn Bishop remains an active member of the workforce. However, the ability of the nation to fulfil the fine words in her statement 16 years ago will become of increasing relevance to her as it is for the 15% of the Australian population who are over the age of 65 years.3

The stability of rural outreach services: a national longitudinal study of specialist doctors

Outreach health care services by medical specialists, involving travel away from their normal practice to underserved areas, is a key strategy to promoting access to such services in rural Australia. Evidence shows that rural outreach clinics can improve access to specialist services, reducing hospitalisations1 and achieving similar clinical outcomes to metropolitan-based clinics.2,3 The degree to which specialists continue to visit the same town over time is important to sustaining access and supporting follow-up care. About one in five Australian specialists provides rural outreach services,4 but we do not know how stable these services are.

The available evidence about the continuity of rural outreach services is scant, localised to individual services, and descriptive in nature. One small-scale qualitative evaluation has shown how service structure and design can influence outreach sustainability, but it was restricted to a remote setting.5 Case studies of successful ongoing outreach services by a selected range of specialist types in both rural and regional settings have been reported.1,6,7

A parliamentary enquiry that appraised outreach services in regional Australia suggested that outreach health care might better balance the social and professional needs of practitioners than their being permanently located in a rural area.8 In one survey, visiting specialists reported less negative effects of rural practice than did resident specialists.9 However, an evaluation of several demonstration outreach services of at least 5 years’ duration indicated that diverse challenges can threaten ongoing service provision. In particular, the leadership of individual specialists was considered to play a strong part in sustaining outreach service delivery.6

Since 2000, the Australian government has provided subsidies for the costs of rural outreach work, most recently through the Rural Health Outreach Fund (RHOF).10 However, to effectively target the RHOF, more information is needed about the determinants of ongoing practice.

The factors influencing ongoing outreach service provision by specialists are yet to be established. The aim of this study was to explore the characteristics of specialists who provide ongoing outreach services, and to determine whether the nature of their service patterns contributed to ongoing service delivery.

Methods

Our study was based on a large national longitudinal survey of Australian doctors, the Medicine in Australia: Balancing Employment and Life (MABEL) study (mabel.org.au). The MABEL study commenced in 2008 by inviting all Australian doctors listed on the Australasian Medical Publishing Company directory (AMPCo Direct), the most comprehensive listing of medical practitioners in Australia at the time, to complete a print or online copy of a survey between June and November 2008. Doctors who responded were re-surveyed on an annual basis, between June and November each year, and doctors who were new to the AMPCo database (returning to the workforce or new graduates) were also surveyed. The participants were broadly representative of Australian doctors in general.11,12

Study cohort

We included specialist doctors who had completed advanced training to gain accreditation from a specialist medical college, who were working clinically, and who, when they first completed the survey in 2008 or 2009, had indicated that they had travelled to provide services in other geographic locations and had reported at least one rural location to which they had travelled (up to three could be listed). Locations were geocoded using the Australian Standard Geographical Classification — Remoteness Areas categories.13 Specialists not reporting a residential location (12 doctors) or a specific location that they had visited (35 doctors) were excluded from the study.

Outcomes

The series of annual surveys allowed us to observe whether specialists continued to travel to provide services to rural locations. Ongoing outreach was defined as providing outreach service to the same rural or remote town for at least a 3-year period (from 2008 or 2009, up to 2011). Ongoing outreach service delivery was assumed when data were missing if the specialist had provided outreach to the same town over at least two time points spanning at least a 3-year period, and in the interim year, (1) they did not respond to the survey, or (2) they continued to work clinically, with no indication that they had ceased travelling or had travelled to different communities.

The alternative outcome, ad hoc outreach, included specialists who responded to the survey over at least two time points, but who provided rural outreach service to the same community for less than 3 years, or ongoing outreach service was interrupted by a year of non-clinical work, not travelling, or visiting other towns.

Variables

Predictive variables were assessed when the specialist first completed the survey (2008 or 2009).

Age was categorised to reflect career stages: early career, < 45 years; mid-career, 45–64 years; and near-retirement, ≥ 65 years.

The definition of practice sector was based on weekly hours worked in public hospitals, private hospitals, private consulting rooms, or “other” (aged care, education and other). Three categories were applied: “public sector” (public hospital only), “private sector” (private consultation rooms and/or private hospital, not public hospitals) and “mixed sector” (both public sector and “private sector). “Mixed sector” was further disaggregated to “mainly public” if the specialist spent more than the median hours (equivalent to more than 31% of their total work time) in a public hospital, or “mainly private”. Specialists who reported most of their work hours in the “other” setting and less than 10 hours’ work in public or private sectors or both public/private (if a mixed sector specialist) were excluded from this study.

The main specialty was self-selected from a list of 48 accredited specialties.

Four service patterns were defined according to the specialist’s residential location (metropolitan or rural) and service destination (inner regional or outer regional/remote). The most remote service pattern was used if more than one rural location was visited.

Locations were approximated using town centroids, and straight-line distances (in kilometres) were calculated between the residential and outreach location. Distance was categorised as “local” (< 300 km) or “distant” (≥ 300 km), reflecting the probability that the specialist drove to the location. The most distant service was used if more than one rural location was visited.

Town size was categorised into four groups that were relatively homogenous according to professional and non-professional indicators: < 5,000; 5000–15 000; 15 001–50 000; > 50 000 people.14 The most remote town visited was applied if more than one rural town was visited.

The number of rural locations visited was re-coded as 1 or 2–3.

Analysis

Data were analysed using Stata version 11.2 (StataCorp). First, bivariate associations of four covariates (age, sex, residential location and practice sector) were tested by logistic regression, odds ratios (ORs) and 95% confidence intervals (CIs) to explore the characteristics of specialists who provided ongoing outreach. Interactions were tested in the adjusted model using the Wald test. A single multiple logistic regression model included all these covariates.

A second, separate logistic regression tested the association between specialist type and ongoing outreach, expressed as ORs and 95% CIs. Deviation contrasts compared each category of specialist type with the grand mean.

Finally, the association between the specialist’s service patterns and ongoing outreach was tested by bivariate associations (ORs and 95% CIs) for the remoteness of outreach service provision from metropolitan or rural locations, distance travelled, town size and number of rural locations visited.

The study was part of a research program with ethics approval from the University of Melbourne (Ref. 0709559) and Monash University (Ref. CF07/1102 – 2007000291).

Results

A total of 4596 specialists (22.3% of those invited) completed the MABEL survey in 2008, and 348 specialists new to AMPCo (44.1%) responded in 2009. After exclusions, the cohort providing rural outreach services included 953 specialists (893 in 2008, 60 in 2009). Of these, 105 (92 in 2008, 13 in 2009) did not respond to subsequent surveys or were not working clinically after entry to the survey. No attrition bias based on age (P = 0.30) or sex (P = 0.08) was detected.

We compared the characteristics of the final cohort of 848 specialists with those of the medical specialist workforce in Australia, and found that they were similar with respect to age, hours worked and specialist group (Box 1). The exception was that the proportion of older and rural doctors in the study cohort was approximately double that for the national specialist workforce; rural-based male specialists are more likely to participate in outreach work.4

Specialist characteristics

A total of 440 of 848 specialists (51.9%) provided regular outreach to the same community. The data in Box 2 show that ongoing outreach was associated with being male, mid-career and working in mixed but mainly private practice. Working in private-only practice was associated with lower levels of regular outreach service. Metropolitan and rural-based specialists were equally likely to provide ongoing outreach service. There was no evidence of interaction in the multivariate analysis.

Specialist type

General surgeons (30/40, 75.0%; P = 0.005) and otolaryngologists (14/18, 77.8%; P = 0.035) were more likely to provide regular outreach service, whereas laboratory specialists (15/45, 33.3%; P = 0.01), anaesthetists (22/65, 33.9%; P = 0.003) and emergency physicians (6/25, 24.0%, P = 0.005) were less likely. A range of other specialist types also provided a higher than average rate of ongoing outreach service, such as cardiologists (14/19, 73.7%), general physicians (18/29, 62.1%) and paediatricians (37/66, 56.1%), but these was not significantly different from the overall mean.

Service patterns

Box 3 shows that visiting more towns and visiting smaller towns (< 5000 people) was associated with ongoing outreach service, but travel distance and visiting remote locations had no effect.

A sensitivity analysis confirmed that the assumptions for missing data were reasonable. Restricting the ongoing group to specialists for whom no assumption was made (n = 364) did not affect the results.

Discussion

Around half of all medical specialists providing rural outreach service in our study provided it to the same town on an ongoing basis. This suggests that the stability of rural outreach services could be improved. The characteristics of specialists, including their career stage, practice conditions, specialty type and aspects of their service patterns, influence the ongoing provision of outreach services.

Career stability

Male specialists at a more stable career stage were more likely to provide ongoing rural outreach services. Early career specialists could be restricted by the amount of time needed to develop their main practice or to fulfil hospital-based roles. One way to address their lower rate of regular outreach provision may be to structure outreach services to complement their commitments at their main practice. Team-based rotational arrangements require less time commitment by individuals, and including telehealth in the service platform can also reduce the number of visits needed. The attitude of employers to the participation of staff in outreach work also needs further investigation.

Specialists nearing retirement may not consider rural outreach work as part of their retirement work plan. However, it is possible that succession planning could provide a structure for late career specialists to maintain some involvement with a reduced workload.

Previous research found that women were less likely to participate in rural outreach work,4 and our study found that they are also less likely to provide ongoing outreach services. The influence of sex on outreach workforce dynamics requires specific investigation.

Conditions at the main practice

Specialists working in the public and mixed, mainly public sectors in their normal practice provided similar rates of ongoing rural outreach services. Despite the potential security of salaried remuneration for outreach work, the workload of public sector employment and the financial constraints of the public system may restrict regular participation in outreach services.

Specialists working in mixed practice with a higher component of private work may have a greater sense of ownership and enthusiasm, considered important for ongoing outreach service delivery.6 However, there appears to be a tipping point: working in a fully private model reduced the likelihood of ongoing outreach services. We speculate that private-only specialists are hindered by the costs and the demands that ongoing outreach work can place on their normal practice.7 Financial subsidies for the costs of travel and travel time may help facilitate ongoing rural outreach by specialists working privately. Australia’s RHOF policy plays an important role supporting this. However, only some specialist types and a restricted number of doctors can gain subsidies through this fund, and other long-term financial incentives may be required to encourage ongoing outreach practice by private-only specialists.

Specialist type

To some extent, generalist specialists were more likely to provide ongoing outreach services. But at the other end of the spectrum, otolaryngologists, who are procedurally based and have high equipment demands, were also likely to provide ongoing service. This might be driven by the demographic and disease profiles of different rural communities. Further, it could be enabled by specialists widening their normal scope of practice during outreach work.15 Meanwhile, the RHOF, which targets sustained outreach in chronic diseases, and in maternal and child, ear and eye, and mental health,16,17 may need to be reinforced by other approaches targeting specialists working in priority areas of care, including intersite staff sharing, and hub-and-spoke models from major public hospitals.

Location and nature of service patterns

The specialist’s location did not influence the rate of ongoing outreach services. Mobilising specialists from metropolitan areas, where 85% of specialists live, could contribute to sustained service access in rural and remote locations. Although the distance the specialist travelled made no difference, it is still possible that the time spent travelling, which more closely determines any loss of income, may influence choices about ongoing outreach services.

Outreach services delivered to smaller towns are likely to be structured differently and driven by different personal motivations to outreach services to larger towns, but this remains to be investigated. Smaller towns are less likely to have any resident specialist services. We propose that the nature of planning for outreach services in larger towns is worth exploring, to identify factors that could increase service stability.

This research did not study other parameters of sustainable outreach, such as the regularity of visiting, the quality, relevance and responsiveness of clinical and professional support, and the availability of a succession plan. Further, a range of factors with the potential to affect service maintenance, such as short-term contracting6,7 and inadequate or inflexible funding,6,18 remain to be investigated.

Ongoing outreach was defined in our study on a conservative basis, being limited doctors to visiting the same town, whereas some specialists visited more than one rural location on a regular basis, while others visited different nearby towns. Rotational or team-rostered outreach was also not considered. Self-administered survey methods mean there is some potential for under-reporting of participation. There was also a small degree of survey dropout and movement in and out of the annual survey. Finally, we were limited to analysing 4 years’ data.

A small proportion of specialists in our cohort moved from a metropolitan to a rural location or vice versa during the study. However, moving location should not, theoretically, alter the ability to continue visiting a town. Further, we did not account for changes to practice sector, because the hours worked in different settings are very sensitive to change over time; we could not be sure whether any change reflected a definite change in practice.

In summary, a range of strategies is needed to promote more stable rural outreach services, taking into account the individual specialist’s career stage, practice conditions and specialty. Financial incentives are likely to increase ongoing outreach services only by specialists working privately. Our research indicates that outreach services to smaller communities are more stable.

Box 1 –
Characteristics of medical specialists providing rural outreach services, compared with those of the general Australian medical specialist workforce

Specialist doctors providing rural outreach (n = 848)

Australian specialist workforce (n = 24 290)∗

Male

Female

Male

Female

Number (% of group)

656 (77.4%)

192 (22.6%)

18 132 (74.6%)

6158 (23.4%)

Age

< 45 years

171 (20.2%)

76 (9.0%)

6284 (25.9%)

3334 (13.7%)

45–64 years

331 (39.0%)

103 (12.1%)

9596 (39.5%)

2569 (10.6%)

≥ 65 years

154 (18.2%)

13 (1.5%)

2252 (9.3%)

255 (1.0%)

Mean age, years

51.4

46.8

50.6

45.2

Location (main place of work)

Metropolitan

423 (49.9%)

141 (16.6%)

13 340 (68.1%)

3646 (18.6%)

Rural

231 (27.2%)

49 (5.8%)

2203 (11.3%)

389 (2.0%)

Specialist group

Internal medicine

218 (25.7%)

68 (8.0%)

4968 (20.5%)

1743 (7.2%)

Pathology

20 (2.4%)

8 (0.9%)

707 (2.9%)

430 (1.8%)

Surgery

116 (13.7%)

13 (1.5%)

4298 (17.7%)

500 (2.1%)

Other specialists

299 (35.3%)

102 (12.0%)

8159 (33.6%)

3484 (14.3%)

Mean hours worked per week

48.5

42.2

45.9

37.3

There were four missing observations for specialist group and location (main place of work) for the outreach group, and one was missing for the Australian specialist workforce specialist group. ∗Data on the Australian specialist workforce were obtained from the Australian Medical Labour Force Survey, 2009,19 except the data on location (main place of work), which were obtained from the 2008 Australian Medical Directory dataset (n = 19 578).

Box 2 –
Univariate and multivariate analysis of association between specialist characteristics and ongoing rural outreach services (n = 848)

Covariates

Number reporting continuity of outreach∗

Univariate analysis

Multivariate analysis

OR (95% CI)

P

OR (95% CI)

P

Total

440 (51.9%)

Sex

Female

79 (41.2%)

1

1

Male

361 (55.0%)

1.75 (1.26–2.43)

0.001

1.82 (1.28–2.60)

0.001

Age

< 45 years

115 (46.8%)

1

1

45–64 years

288 (55.0%)

1.39 (1.02–1.88)

0.03

1.44 (1.04–1.99)

0.029

≥ 65 years

36 (46.8%)

1.00 (0.60–1.67)

0.99

0.99 (0.57–1.74)

0.99

Location of residence

Metropolitan

300 (52.5%)

1

1

Rural

140 (50.7%)

0.94 (0.70–1.25)

0.65

0.81 (0.60–1.11)

0.19

Practice sector

Public only

120 (49.2%)

1

1

Mixed, mainly public

114 (50.7%)

1.06 (0.74–1.52)

0.75

0.95 (0.66–1.38)

0.80

Mixed, mainly private

145 (64.7%)

1.90 (1.31–2.75)

0.001

1.73 (1.18–2.53)

0.005

Private only

42 (36.5%)

0.58 (0.37–0.92)

0.02

0.51 (0.32–0.82)

0.006

OR = odds ratio. The number of respondents included in the final model was reduced to 807: there was one missing observation for age, and 40 observations for weekly hours worked in different settings either missing or involving work in “other” sectors. ∗Percentages are based on corresponding figures for specialist doctors providing rural outreach in Box 1.

Box 3 –
Univariate analysis of association between patterns of service and ongoing rural outreach services (n = 848)

Covariates

Number reporting continuity of outreach

Univariate analysis: OR (95% CI)

P

Remoteness of service

Metropolitan to inner regional

172 (50.7%)

1

Rural to inner regional

60 (43.8%)

0.76 (0.51–1.13)

0.17

Metropolitan to outer regional/remote

128 (54.9%)

1.18 (0.85–1.65)

0.32

Rural to outer regional/remote

80 (57.6%)

1.32 (0.88–1.96)

0.18

Distance travelled

Local (< 300 km)

282 (52.8%)

1

Distant (≥ 300 km)

158 (50.3%)

0.91 (0.68–1.20)

0.48

Size of town

> 50 000

55 (46.2%)

1

15 001–50 000

167 (48.1%)

1.08 (0.71–1.64)

0.72

5000–15 000

97 (51.9%)

1.25 (0.79–1.99)

0.34

< 5000

121 (62.1%)

1.90 (1.20–3.02)

0.006

Number of rural locations visited

1

247 (48.1%)

1

2–3

193 (57.8%)

1.48 (1.12–1.95)

0.006

OR = odds ratio.

A comparison of the stages at which cancer is diagnosed in physicians and in the general population in Taiwan [Research]

Background:

Previous investigations have reported that physicians tend to neglect their own health care; however, they may also use their professional knowledge and networks to engage in healthier lifestyles or seek prompt health services. We sought to determine whether the stage at which cancer is diagnosed differs between physicians and nonphysicians.

Methods:

We conducted a nationwide matched cohort study over a period of 14 years in Taiwan. We accessed data from two national databases: the National Health Insurance Research Database and the Taiwan Cancer Registry File. We collected data on all patients with the 6 most common cancers in Taiwan (hepatoma, lung, colorectal, oral, female breast and cervical cancer) from 1999 to 2012. We excluded patients less than 25 years of age, as well as those with a history of organ transplantation, cancer or AIDS. We used propensity score matching for age, sex, residence and income to select members for the control (nonphysicians) and experimental (physicians) groups at a 5:1 ratio. We used 2 tests to analyze the distribution of incident cancer stages among physicians and nonphysicians. We compared these associations using multinomial logistic regression. We performed sensitivity analyses for subgroups of doctors and cancers.

Results:

We identified 274 003 patients with cancer, 542 of whom were physicians. After propensity score matching, we assigned 536 physicians to the experimental group and 2680 nonphysicians to the control group. We found no significant differences in cancer stage distributions between physicians and controls. Multinomial logistic regression and sensitivity analyses showed similar cancer stages in most scenarios; however, physicians had 2.64-fold higher risk of having stage IV cancer at diagnosis in cases of female breast and cervical cancer.

Interpretation:

In this cohort of physicians in Taiwan, cancer was not diagnosed at earlier stages than in nonphysicians, with the exception of stage IV cancer of the cervix and female breast.

Patients face potentially lethal delays as hospitals struggle

Emergency physicians have warned the public hospital system is at “breaking point”, with thousands of patients being forced to wait hours for a hospital bed, clogging emergency departments and preventing ambulances from unloading.

A survey by the Australasian College of Emergency Medicine of all the nation’s 121 accredited emergency departments has found that 70 per cent of emergency department patients are being delayed more than eight hours as they wait for beds in other parts of the hospital to become available, adding to evidence of enormous strain in the system.

The survey’s author, Associate Professor Drew Richardson, said the result highlighted the extent of the “access block” problem, when a dearth of free beds in the main body of a hospital prevents patients moving out of emergency. The knock-on effect is to clog the emergency department, which in turn means ambulances cannot unload patients.

“These figures…show that too many patients are waiting too long to receive the proper care,” A/Professor Richardson said. “They reflect a hospital system that is critically overburdened and that is putting patients into the firing line.”

More than half the hospitals in the survey reported that at least one patient had to wait for more than 12 hours for a bed, an outcome A/Professor Richardson said was “completely unacceptable”, and should be ringing alarm bells for health authorities across the country.

Evidence indicates that the longer patients are forced to wait in emergency, the worse their health outcome is likely to be. A Canberra Hospital study found that older patients forced to wait more than four hours for a ward bed were 51 per cent more likely to die than those who suffered shorter delays.

The survey’s results underline AMA warnings of an impending crisis in the public hospital system as a result of the Federal Government’s decision to rip $57 billion from its funding over the next 10 years.

The Federal Government has walked away from the National Health Reform Agreement with the states, cut incentive payments, dump activity-based funding and reduce indexation of its public hospital funding to inflation plus population growth.

AMA President Professor Brian Owler has warned the cuts will have a profound effect on the hospital system, warning that “public hospitals and their staff will be placed under enormous stress and pressure, and patients will be forced to wait longer for their treatment and care”.

“Rather than funding the necessary hospital capacity, the Commonwealth has withdrawn from its commitment to sustainable public hospital funding and its responsibility to meet an equal share of growth in public hospital costs,” Professor Owler said earlier this year. “Funding is clearly inadequate to achieve the capacity needed to meet the demands being placed on public hospitals.”

The AMA’s annual Public Hospital Report Card, released in April, showed that although there had been marginal improvement in public hospital performance against Government benchmarks, no State or Territory met the target to see 80 per cent of emergency department Category 3 urgent patients within clinically recommended triage times.

Professor Owler said access block was a particularly concerning issue.

He said that emergency departments were able to meet performance targets for patients who did not require admission to hospital.

“But when they have to be admitted, that is where performance suffers. That is an issue of the capacity of our public hospital system,” he said.

Professor Owler warned the system would be hit by “a perfect storm” when lower indexation funding arrangements kick in in 2017-18.

“This will lock in a totally inadequate base from which to index future funding for public hospitals,” he said. “State and Territory governments, many of which are already under enormous economic pressures, will be left with much greater responsibility for funding public hospital services. Performance against benchmarks will worsen and patients will suffer. Waiting lists will blow out.”

Adrian Rollins

Families pick up the tab as Commonwealth health spending slows

Government spending on health has slowed dramatically while the health bill for households has increased sharply as the Commonwealth pushes more of the burden of care on to individuals and families.

In a result that undermines Federal Government claims that health funding is ‘out of control’, an Australian Institute of Health and Welfare report shows that Commonwealth spending grew by just 2.4 per cent in 2013-14 – below the rate of inflation – and its share of total health spending has plunged from almost 44 per cent to 41.2 per cent in just five years.

At the same time, individuals and families are shouldering more of the burden, Institute spokesman Dr Adrian Webster said – non-government funding grew by 5 per cent after inflation.

“Over the decade, funding by individuals was the fastest growing type of non-government funding, growing by an average of 6.2 per cent a year in real terms, compared with 5.3 per cent for all non-government sources,” he said.

The figures are in line with other data showing only moderate growth in government health expenditure.

“The sky is not falling in when it comes to Federal Government funding for health,” AMA Vice President Dr Stephen Parnis said.

The Commonwealth’s Commission of Audit had predicted that Medicare spending would grow by 7.1 per cent per year until 2023-24, but Dr Parnis said the AIHW report and recent Medicare data showing that MBS expenditure increased 5.6 per cent in 2014-15 and just 3 per cent the previous financial year cast doubt on this projection.

“Costs are not escalating in the way that some have suggested,” Dr Parnis said. “There is an ethical obligation on health professionals to improve efficiency wherever we can, but this should not be at the expense of undermining the pillars of the health system which have served us so well.”

But the Coalition Government appears set to continue with health cuts despite last week’s change of leader.

In his first major press conference as Treasurer, Scott Morrison indicated he would maintain the focus of his predecessor Joe Hockey on cutting Commonwealth expenditure, declaring that “we have a spending problem, not a revenue problem”.

The Abbott Government implemented major cuts to health spending, including ripping $57 billion from public hospital funding in the next decade and freezing Medicare rebates until mid-2018, contributing to one of the sharpest slowdowns in health spending on record.

Dr Parnis said this was the wrong prescription for Australia’s health system.

“The answer is not to cut away at Commonwealth funding for health. It is to ensure that Commonwealth funding achieves greater benefit, and the way we can do that is by having a more modern Medicare Benefits Schedule, and having an understanding that the Commonwealth has a central role in supporting the states on hospital funding,” he said.

Earlier this week, AMA President Professor Brian Owler warned the Government’s MBS reviews needed to ensure patients had access to the best evidence-based services and procedures, rather than simply being a cost-cutting exercise.

Dr Parnis said the Government also needed to ensure it got maximum value for its support for the private health insurance industry.

“We need to ensure that Commonwealth funding for private health insurance extracts maximum benefit for patients in the health system, rather than policies that are designed simply to avoid premium surcharges,” he said.

The AIHW found that total spending on health, including from governments, families and private organisations, grew by just 3.1 per cent in real terms in 2013-14, faster than the 1.1 per cent growth recorded the previous financial year, but well below the annual average of 5 per cent recorded in the past decade.

As the Institute figures show, most of this growth was driven by spending by individuals and private organisations, with the Commonwealth’s share dropping and that of State, Territory and local governments holding steady.

Adrian Rollins

 

NSW prison smoking ban allows staff to continue with the habit

New Zealand started it, Northern Territory followed and now most of Australia has banned smoking in prisons. New South Wales is the latest to have joined the ranks to ban smoking in correctional facilities. However, NSW’s recently introduced ban isn’t without controversy, as prison officers are exempt.

An Australian Institute of Health and Welfare report ‘The health of Australia’s prisoners 2012’, released mid-2013, found that four out of five prisoners reported that they smoke, with 78 per cent saying they smoked daily.

Smoking bans in prisons are complex, and around the world have been controversial and difficult to implement. New Zealand introduced a blanket ban on smoking in correctional facilities in July 2011, but the New Zealand High Court ruled that the ban was unlawful in December 2012. After a lengthy legal battle, Correctional Services amended legislation which reinstated the blanket ban.

New Zealand Corrections Department Chief Executive Ray Smith said that, since the introduction of smoke-free prisons the work environment had improved for staff and prisoners with better air quality and fewer fires.

“Implementing smoke-free prisons was always going to be a serious challenge, and it has gone incredibly well and without major incident. We are the first national prison service to achieve this,” Mr Smith said.

Prisoners were given 12 months to quit smoking before the blanket ban was introduced in July 2011.

Northern Territory prisons have been smoke-free since July 2013, modelling their approach closely on New Zealand’s successful introduction of smoke-free prisons. The Northern Territory introduced a 12 month plan prior to the ban to encourage staff and inmates to quit smoking. Better access to services to help staff and inmates to quit smoking was provided and a comprehensive rather than a partial, smoking ban was introduced.

Much of the rest of Australia followed in Northern Territory’s footsteps with Queensland, Tasmania, and Victoria introducing total bans on smoking in correctional facilities. South Australia is trialling bans at the Adelaide Remand Centre later this year while the ACT has committed to phasing out smoking in prisons, but continues to be elusive with a timeline for the ban. Western Australia currently has no intention to ban smoking from correctional facilities, but they have banned smoking indoors.

NSW’s ban on smoking at correctional facilities was introduced mid-August, but a loophole in the legislation allows staff who live in correctional centres to smoke in designated areas, a move likely to be resented by many prisoners who are being forced to quit.

Inmates’ families have been told by NSW Corrective Services that they won’t be permitted to smoke anywhere on the grounds of a correctional centre which includes car parks or inside their cars during visits.

The smoking ban legislation was amended to allow smoking areas to be declared for staff living in NSW’s 84 prison residences by the Minister for Corrections David Elliot a week before the implementation.

A Corrective Services spokesman told the Sydney Morning Herald that staff who live on Corrective Service NSW sites will be able to smoke while off duty in a designated area outside their accommodation and not visible from any correctional centre.

Monarch University researcher Anita Mackay, who has studied smoking bans in prisons around the world, said that she hasn’t come across a situation where there is a complete ban for imprisoned people, while staff are able to smoke. Given that the justification is to protect the health of staff, it doesn’t really align.

Kirsty Waterford

 

Empowering General Practice

The AMA Submission to the Government’s Primary Health Care Review highlights the robustness of the Australian health system, particularly the crucial role of general practice, and stresses the need to build on the proven track record of general practice with significant new investment.

AMA President Professor Brian Owler said that the Review must focus on strengthening the parts of the system that deliver quality, accessible, and affordable care to the community, most notably general practice.

“This is not the time to throw the baby out with the bathwater,” Professor Owler said.

“In terms of both cost and health outcomes, the Australian health system is performing very well by world standards, and general practice delivers outstanding public health outcomes from modest Government investment.

“We must avoid radical change for change’s sake.

“Some of the potential reforms raised in the Primary Health Care Advisory Group’s (PHCAG) discussion paper have been tried or are in place in other countries, and there is only very limited evidence about any significant positive impact.

“General practice in the UK, for example, has been the subject of several rounds of funding reforms, and the GP workforce in the UK is now being reported as demoralised and suffering from extreme shortages.

“We do not want or need to repeat the same mistakes here. It is concerning that some of the failed UK experiments are still on the table here for PHCAG consideration.

“For the Review to have genuine credibility, the Government must change its reform language – it must start talking about primary care reform as an investment, not a cost or a saving to the Budget bottom line.

“There is no doubt that extra investment in general practice will deliver long term savings to the Government, and improve the sustainability of the health system.

“The Government needs to take a long term view and make this investment now, in the knowledge of savings in later years, better patient outcomes, and less pressure on our hospital system.

“Significant new investment in general practice and the urgent need to lift the current freeze on the indexation of Medicare patient rebates must be priorities for the Review, or they will be priority issues for voters at the next election,” Professor Owler said.

With the growing burden of chronic disease and the long term impact this will have on the health system, the AMA is encouraging the PHCAG to consider reforms that will better support these patients in accessing high quality GP-led care.

The AMA Submission highlights a number of areas for change, including:

  • provided there is no overall reduction in funding, reform of existing Medicare chronic disease items to strengthen the role of the patients usual GP, cut red tape, streamline access to GP referred allied health care services and reward longitudinal health care;
  • the adoption of pro-active models of care-coordination for patients with higher levels of chronic disease and who are at risk of unplanned hospitalisation – similar to the Coordinated Veterans’ Care program that has been established by the Department of Veterans’ Affairs;
  • the introduction of an incentive payment through the Practice Incentives Program to support quality improvement, informed by better data collection;
  • the introduction of non-dispensing pharmacists in general practices to help improve medication management, particularly for patients with chronic disease;
  • an enhanced role for private health insurers to fund targeted programs that support general practice in caring for patients with chronic disease;
  • the utilisation of Primary Health Networks to support GPs in providing care for patients, particularly in improving the connection between primary and hospital care; and
  • better use of technology, including the use of point of care testing.

While the AMA Submission promotes a number of reforms, it also emphasises that fee-for-service should remain the primary source of funding for General Practice.

Professor Owler said that the fee-for-service model works well for the majority of patients in the Australian context.

“Fee-for-service provides patients with autonomy and choice, and access to care based on clinical need as opposed to the potential for rationed care that arises under some other funding models,” Professor Owler said.

“It also supports the doctor-patient relationship, with patients receiving a Medicare rebate to support them in accessing GP services.”

The AMA Submission to the Primary Health Care Review is at submission/ama-submission-primary-health-care-review

John Flannery

AMA slams Medicare misinformation

AMA President Professor Brian Owler has questioned comments from the Health Minister about the latest Medicare data that suggested the Government is setting the scene for Health budget cuts through the Medicare Benefits Schedule (MBS) Reviews, which are due to report to the Minister by the end of the year.

Professor Owler said the Health Minister is being alarmist about health expenditure.

“The Government is misleading the public by talking about the number of Medicare services per patient as if they are all separate visits to doctors, which is wrong,” Professor Owler said.

“A single visit to a doctor can result in several services being provided to the patient on the day.

“Contrary to the Minister’s view that the Medicare data paints a complex picture, it is really quite simple. Growth in health expenditure will always occur, as the population increases and ages.

“A first world country like Australia should embrace the fact that it can offer its citizens timely and affordable access to a full range of healthcare services.

“This is essential to a productive nation. Good health keeps people in jobs. And good health keeps people actively contributing to their communities, which contributes to a strong economy.

“Rather than focusing on the number of items on the Medicare Benefits Schedule, the Government should be celebrating the positive health outcomes that the MBS delivers to the nation.

“Many of the items that have recently been added to the Schedule are a direct result of Government policies.

“The MBS should and must reflect modern medical practice.

“The medical profession is participating in the MBS Reviews that the Minister has commissioned.

“The profession will take the lead in identifying waste and inefficiency in the healthcare system.”

Professor Owler said that it was the AMA’s understanding that the MBS Reviews were not set up as a Budget cost-cutting exercise, but the Minister’s recent media release contains language that suggests otherwise.

“By using terms such as ‘Medicare usage had continued to skyrocket’ and ‘the cupboard needed a good clean’, the Minister has clearly indicated that the ‘blueprint’ for the MBS Reviews will inevitably have a focus on the budget bottom line rather than a funding mechanism for supporting good health care,” Professor Owler said.

“The Australian public would prefer the Government to set the strategic vision and direction for Australia’s healthcare system, which in turn will guide the MBS Reviews.”

Professor Owler said it is wrong for the Government to claim that health funding is out of control.

“Medicare expenditure increased by 5.6 per cent in 2014-15. Over the last seven years, this is the second lowest annual increase in Medicare expenditure. Last year (2013-14), was the lowest, at 3 per cent.

“The Government’s Commission of Audit report stated that Medicare expenditure was expected to grow by 7.1 per cent per year until 2023-24, and continue growing. Yet the last two years have been well under that projection.

“The Commonwealth Government’s total health expenditure is reducing as a percentage of the total Budget. In the 2014-15 Budget, health was 16.13 per cent of the total, down from 18.09 per cent in 2006-07. 

“It reduced further in the 2015-16 Budget, representing only 15.97 per cent of the total Commonwealth Budget.

“The Reform of the Federation White Paper estimates ‘that 10 per cent of patients account for around 45 per cent of MBS expenditure’.

“This shows that the MBS is working as intended.”

John Flannery

How changes to the Medicare Benefits Schedule could improve the practice of cardiology and save taxpayer money

The Australian Medicare system is a government-funded fee-for-service system that is highly regarded by the general public. A major advantage of the system is that low-income non-insured patients have ready access to approved ambulatory medical services at little or no cost to them, with public inhospital care provided at no charge. However, a disadvantage is the potential for over servicing. This may occur when new technology or new knowledge lessens or eliminates the indications for a test, without such a development being reflected by a change in the criteria for the particular Medicare Benefits Schedule (MBS) item number. In these circumstances, a medical practitioner may disregard advances in the medical evidence base and continue to practice in the same way, particularly if it is financially advantageous to do so. The examples we discuss in this article reflect this phenomenon. Computed tomography coronary angiography (CTCA), a new, safer and much less expensive technology, should replace invasive coronary angiography (ICA) for the diagnosis of coronary artery disease (CAD), but based on Medicare item reports for 2010–2014,1 this is happening only slowly. Measurement of the fractional flow reserve (FFR) clearly improves the practice of percutaneous coronary intervention (PCI) and saves both money and lives; however, the uptake in Australia has been slow.1 A nuclear stress test has a high radiation burden and is 3.4 times more expensive than a stress echocardiogram,2 yet under the current MBS system it can be ordered by any medical practitioner who may or may not be aware of the cost or the radiation risk.

Invasive coronary angiography

ICA is an expensive procedure ($5187–$6289 per procedure; Appendix 1), with substantial cost to the taxpayer (Box 1). It carries a small risk of serious complications and a radiation burden (5–7 mSv).3 It is a guideline-recommended investigation for patients presenting with troponin-positive acute coronary syndrome.4 In these circumstances, ICA and PCI, if necessary, should be performed by an interventional cardiologist at the same sitting.

ICA is also indicated in symptomatic patients with known stable CAD or with a high probability of CAD who have evidence of myocardial ischaemia of sufficient severity to justify revascularisation with PCI or coronary artery bypass grafting.5 In these circumstances, initial ICA is often performed by a non-interventional cardiologist, and a second ICA and a PCI, if indicated, is then carried out by an interventional cardiologist. This practice is inefficient; the patient and the Medicare system will be billed for two ICAs and a PCI, whereas if the initial ICA had been performed by an interventional cardiologist, only one ICA (and one PCI) would have been charged. Further, in most cases, the decision of a non-interventional cardiologist to refer a patient for PCI after the baseline ICA will be made on visual (anatomical) assessment of the coronary lesion(s), whereas it should be guided by both anatomical and functional assessment.6 The diagnostic accuracy of ICA based on diameter stenosis alone to predict functionally significant coronary artery stenosis (ie, lesions causing ischaemia) is poor.7,8 In the FAME (Fractional flow reserve versus Angiography for Multivessel Evaluation) study, 35% and 80% of coronary lesions seen on ICA with diameter stenosis between 50%–70% and 70%–90%, respectively, were functionally significant by FFR measurement.8 The implication of these findings is that if a patient with stable CAD undergoes ICA for the purpose of assessing suitability for revascularisation, the operator should be capable of performing FFR measurement. As FFR measurement involves instrumentation of the coronary artery with a pressure wire, interventional training is required for its safe performance. This lends further support that ICA is best performed by an interventional cardiologist.

ICA is no longer an appropriate test for the diagnosis of CAD, because it is associated with a low rate of obstructive CAD warranting intervention, even when preceded by an abnormal stress test result.9 It accurately examines the lumen of the coronary artery but does not detect non-obstructive atherosclerotic lesions in the coronary wall that could be a nidus for future coronary events.10 That is, a “normal” ICA finding does not always exclude coronary atherosclerosis.

We suggest that the item numbers for ICA should only be payable if the procedure is performed by an accredited interventional cardiologist in a hospital with accredited PCI facilities.

In cardiology, there is already a precedent for a procedural item number to be available only to an accredited cardiologist. For example, the item number for extraction of a permanent pacemaker lead is only available to cardiologists accredited for that procedure on the advice of the Cardiac Society for Australia and New Zealand. To our knowledge, all public and private hospitals performing PCI have an accreditation process to allow cardiologists to carry out the procedure in their hospital. For new applications, accreditation approval in these hospitals requires evidence that the candidate has undergone specialised training in interventional cardiology and is regarded as competent by his or her supervisors. We suggest that all interventional cardiologists currently accredited to perform PCI be allowed to charge the item numbers for ICA, and that new applications for accreditation be vetted by the Cardiac Society for Australia and New Zealand.

Operator compliance with the indications for ICA could be monitored by examination of an individual cardiologist’s Medicare statistics or, alternatively, by a national cardiac procedures registry. For example, if ICA was only being performed in the setting of troponin-positive acute coronary syndrome or for patients with known CAD and objective evidence of ischaemia not sufficiently controlled with medical therapy, one would expect most patients to require a revascularisation procedure such as PCI or coronary artery bypass grafting. On this basis, the ratio of ICA to revascularisation should be at least less than 2.0 : 1 and preferably in the order of 1.5 : 1. If an individual cardiologist’s statistics fall well outside this range (eg, greater than 2 SDs from that of his or her peers), that cardiologist could be asked to justify the discrepancy.

Computed tomography coronary angiography

Compared with ICA, CTCA is a safer, less invasive and less expensive (the cost to the taxpayer is $622 per angiogram) outpatient investigation and carries a lower radiation burden. The costs of equipping and running a CTCA service in terms of equipment and personnel are far less than those for a cardiac catheterisation laboratory. In regional hospitals without cardiac catheterisation and PCI facilities, the presence and appropriate use of CTCA would allow many patients to be treated locally without the need for transfer to larger centres.

CTCA should be considered as a logical first-line investigation in patients with suspected CAD.11–13 There are three possible outcomes to a CTCA investigation. First, the angiogram may show completely normal results. In such a patient, the likelihood of a coronary event occurring within the next 5 years is extremely low.14,15 Second, the angiogram may show non-obstructive coronary atherosclerosis. In this instance, the patient’s symptoms are unlikely to be caused by myocardial ischaemia. Nevertheless, such patients are at increased risk of future cardiovascular events and require lifestyle advice and possibly anti-atherosclerotic therapy.14,16,17 Third, the angiogram may show obstructive intramural coronary atherosclerotic lesions (or non-evaluable segments as a result of heavy calcifications). Symptomatic patients with these lesions require lifelong anti-atherosclerotic therapy and may benefit from a stress test to determine the presence of ischaemia. CTCA alone is of little or no diagnostic value in patients with pre-existing CAD, because with current technology, routine CTCA is not capable of reliably detecting ischaemia.18

We suggest that the item number for CTCA be payable only if performed in patients without known CAD. For patients whose initial CTCA results are normal, a second CTCA investigation should only be rebatable if it is performed at least 5 years after the first. The imposition of these restrictions would undoubtedly reduce over servicing and help stem the dramatic rise in the use of CTCA.

Stress testing

Stress testing (electrocardiogram based, echocardiogram based or nuclear based) is the non-invasive test of choice for detection of myocardial ischaemia but is a less suitable test for the diagnosis of CAD.19 A standard electrocardiogram stress test is less accurate than either a nuclear stress test or a stress echocardiogram to determine the site and extent of ischaemia. A stress echocardiogram and a nuclear stress test have similar sensitivity for detecting ischaemia but the former has a higher specificity.20 Stress echocardiography is not associated with any radiation exposure but may be technically difficult in patients with unfavourable body habitus. On the other hand, a stress nuclear test is 3.4 times more expensive ($756 v $222) and carries an average radiation burden of 9–11 mSv.3 For these reasons, we suggest that the item number for a nuclear stress test be payable only if ordered by a physician and only if a stress echocardiogram is considered unsuitable for technical reasons.

Percutaneous coronary intervention

ICA with a view to PCI at the culprit lesion, if technically suitable, is a guideline recommendation for patients with acute coronary syndrome.4 In stable CAD, the benefit from PCI with optimal medical therapy is less certain compared with medical therapy alone.21 Furthermore, stenting of non-ischaemic coronary lesions leads to higher rates of mortality and myocardial infarction.22 A coronary lesion can be assumed to be causing ischaemia only if there is > 90% stenosis in a major coronary artery or if it is a single lesion in a coronary vessel supplying an area of myocardium identified as ischaemic on stress testing. All other coronary lesions should not be stented in stable CAD unless the FFR is less than 0.8. Use of FFR in this manner has been shown to reduce stent insertions, improve outcomes and lower health costs.23,24 According to Medicare item reports for 2013–2014,1 only 16% of cases of PCI were associated with FFR. The implication of this finding is that, in Australia, many patients must be undergoing PCI procedures that are potentially detrimental to their health.

We suggest separate MBS item numbers for PCI for troponin-positive acute coronary syndrome and for PCI for stable CAD, thus allowing easier evaluation of the Medicare statistics of an individual practitioner. The item number for PCI for stable CAD should only be payable if one of three conditions is satisfied: (i) a stenosis >90% in a coronary vessel >2 mm in diameter; (ii) a single lesion in a vessel supplying an area of myocardium identified as ischaemic on stress testing; or (iii) a coronary lesion associated with an FFR less than 0.8.

Overall savings resulting from our proposed changes

The overall savings resulting from these changes are summarised in Box 2. Medicare statistics along with data from the Australian Commission on Safety and Quality in Health Care25 were used to calculate the ratio of ICA to revascularisation and the cost to the taxpayer of unnecessary ICA (defined as in excess of a ratio of 1.5 : 1; Appendix 2). Applying this ratio to the four patient groups discussed, taxpayers could have saved $233.5 million and private health insurance companies $139.8 million in 2013–2014.

If our suggested changes to PCI were to occur, the annual savings to the Australian health budget would be in the order of $4 million.24 Changes for CTCA would be cost neutral in the short term but would save costs in the long term (Appendix 2).

In 2013–2014, 77 564 nuclear stress tests were charged to Medicare (cost per test, $756). It is likely that at least 75% of these patients could have had a less expensive stress echocardiogram (cost per test, $222) as an alternative. Doing so would have saved over $30 million of the Medicare budget.

We believe that these relatively simple changes to the MBS would improve the practice of cardiology (Box 3) and result in substantial savings to the health budget (Box 2). Undoubtedly, some cardiologists will consider the suggested changes to be an unwelcome interference with their practice. The counter argument is that as funders of Medicare, the government has a right and a duty to spend public money prudently.

In 2013–2014, the ratio of ICA to revascularisation was substantially higher in the private compared with the public system (3.1 v 2.3; Appendix 2). The likely explanation relates to the effect of fee-for-service on the provision of ICA.

A potential disadvantage of performing PCI at the same sitting as the initial ICA is that the patient will be denied the opportunity for surgical consultation. However, in light of recent evidence indicating the clear superiority of coronary artery bypass grafting over PCI for patients with complex multivessel disease or with diabetes with multivessel disease,26,27 we believe the need for multidisciplinary discussion to determine the best revascularisation option will be infrequent. We consider our recommended ratio of ICA to revascularisation of 1.5 : 1 or less to be sufficiently elastic to accommodate this possibility without compromising patient care.

In summary, we believe these relatively simple changes to the MBS would result in improved evidence-based cardiology practice and substantial savings to the health budget in an ever-increasingly constrained fiscal climate.

1 
Cost to the taxpayer of unnecessary invasive coronary angiography (ICA), 2013–2014

ICA to revascularisation ratio

No. of unnecessary cases

Cost per unnecessary case

Cost per year

Public inpatient

2.3 : 1

23 060

$5773

$133.13m

Private in public

2.7 : 1

2986

$4964

$14.82m

Private inpatient

3.1 : 1

38 259

$2199

$84.13m

Non-insured outpatient

2.4 : 1

1871

$759

$1.42m

Total cost

$233.5m

2 
How much money could be saved?

Measure

Potential annual savings

Reducing invasive coronary angiography to revascularisation ratio to 1.5 : 1

$233.5m

Limitations to computed tomography coronary angiography

Cost neutral

Reducing nuclear stress tests

$30.1m

More use of fractional flow reserve

$4.0m

Total

$267.6m

3 
How our proposed changes to the Medicare Benefits Schedule could improve cardiology practice

  • More judicious use of invasive coronary angiography = less complications, less radiation exposure, less waste of catheter laboratory resources.
  • More judicious use of computed tomography coronary angiography = earlier diagnosis of coronary artery disease, better prognostic assessment, lifestyle modifications and medical therapy where appropriate.
  • More judicious use of nuclear stress test = less radiation burden.
  • Greater use of fractional flow reserve-guided percutaneous coronary intervention = less inappropriate percutaneous coronary intervention and less myocardial infarction and death.