[Articles] Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis

Our study shows that homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals experience extreme health inequities across a wide range of health conditions, with the relative effect of exclusion being greater in female individuals than male individuals. The high heterogeneity between studies should be explored further using improved data collection in population subgroups. The extreme health inequity identified demands intensive cross-sectoral policy and service action to prevent exclusion and improve health outcomes in individuals who are already marginalised.

[Comment] Nutrition in the ICU: sometimes route does matter

The NUTRIREA-2 trial by Jean Reignier and colleagues1 in The Lancet provides an important piece in the puzzle of intensive-care unit (ICU) nutrition management. This pragmatic multicentre study done at 44 French ICUs randomly assigned patients aged 18 years or older requiring invasive mechanical ventilation and vasopressors (median 0·5 μg/kg per min) to receive either enteral nutrition (n=1202) or parenteral nutrition (n=1208), both targeting normocaloric goals (20–25 kcal/kg per day), within 24 h after intubation or ICU admission.

The horror of waking up during surgery

The fear of waking up while you’re being operated upon is almost up there with the fear of being buried alive. But while the latter never happens any more, if it ever did, the former is more common than you might think. A newly published review reveals that accidental awareness during general anaesthesia (AAGA) may occur in one in every 800 interventions, depending on how you define the term. And some level of responsiveness during surgery could happen in as many as one in 25 cases.

Waking up during surgery is often, understandably, a traumatic experience. Take the case of Sandra, who as a 12-year-old suffered an episode of AAGA during a routine orthodontic operation.

“Suddenly, I knew something had gone wrong,” Sandra wrote in the foreword to NAP5, a recent UK report on AAGA. “I could hear voices around me, and I realised with horror that I had woken up in the middle of the operation, but couldn’t move a muscle… while they fiddled, I frantically tried to decide whether I was about to die.”

Like many other victims of AAGA, Sandra suffered from PTSD-like symptoms for years after the event. She described nightmares in which “a Dr Who-style monster leapt on me and paralysed me.” The nightmares continued for more than 15 years before she realised the link: “I suddenly made the connection with feeling paralysed during the operation; after that I was freed of the nightmare and finally liberated from the more stressful aspects of the event.”

The account underlines a key factor in AAGA, which is the use of neuromuscular blocking agents as part of the anaesthetic mix. They paralyse the muscles, which means that if a patient wakes up for any reason, he or she cannot signal to the surgeon that anything is wrong. It can render AAGA a truly terrifying experience, during which patients can hear voices and equipment, and vainly try to move to alert staff as a feeling of dread and powerlessness sweeps over them.

The NAP5 report found that anaesthesia awareness was most common in obstetrics, and specifically in caesarian interventions. This could be because caesarians often require rapid induction of anaesthesia, with anaesthetists occasionally erring too greatly on the side of caution with doses that are too low.

Cardiothoracic surgeries also had a higher rate of AAGA, at around twice the rate of other surgeries.

Female gender, youth, obesity, a junior trainee anaesthetist and the use of neuromuscular blockades were found to be the key risk factors for AAGA.

Around 40% of victims of AAGA reported ongoing adverse effects, including nightmares, flashbacks and other PTSD-type symptoms.

The review authors say that although in many cases the cause of AAGA is obvious, involving technical failure or error, there remain cases where no rational explanation can be found. But although case reports of AAGA can make for harrowing reading, litigation is relatively rare. In the UK between 1995 and 2007, only 99 claims were made for intraoperative paralysis or brief awake paralysis.

When AAGA is reported, the authors recommend three stages of management: a meeting and interview with the patient; analysis of what went wrong; and follow-up interviews 24 hours and two weeks after the event.

It’s important that the interviewing clinician shows empathy, accepts the AAGA story as genuine, expresses regret, and offers psychological support to the patient.

You can read the review here.

Repeated influenza vaccination for preventing severe and fatal influenza infection in older adults: a multicentre case-control study [Research]

BACKGROUND:

The effectiveness of repeated vaccination for influenza to prevent severe cases remains unclear. We evaluated the effectiveness of influenza vaccination on preventing admissions to hospital for influenza and reducing disease severity.

METHODS:

We conducted a case–control study in 20 hospitals in Spain during the 2013/14 and 2014/15 influenza seasons. Community-dwelling adults aged 65 years or older who were admitted to hospital for laboratory-confirmed influenza were matched with inpatient controls by sex, age, hospital and admission date. The effectiveness of vaccination in the current and 3 previous seasons in preventing influenza was estimated for inpatients with nonsevere influenza and for those with severe influenza who were admitted to intensive care units (ICUs) or who died.

RESULTS:

We enrolled 130 inpatients with severe and 598 with nonsevere influenza who were matched to 333 and 1493 controls, respectively. Compared with patients who were unvaccinated in the current and 3 previous seasons, adjusted effectiveness of influenza vaccination in the current and any previous season was 31% (95% confidence interval [CI] 13%–46%) in preventing admission to hospital for nonsevere influenza, 74% (95% CI 42%–88%) in preventing admissions to ICU and 70% (95% CI 34%–87%) in preventing death. Vaccination in the current season only had no significant effect on cases of severe influenza. Among inpatients with influenza, vaccination in the current and any previous season reduced the risk of severe outcomes (adjusted odds ratio 0.45, 95% CI 0.26–0.76).

INTERPRETATION:

Among older adults, repeated vaccination for influenza was twice as effective in preventing severe influenza compared with nonsevere influenza in patients who were admitted to hospital, which is attributable to the combination of the number of admissions to hospital for influenza that were prevented and reduced disease severity. These results reinforce recommendations for annual vaccination for influenza in older adults.

Christmas message from AMA President

It has been a very busy and very successful year for the Federal AMA. Your elected representatives and the hardworking staff in the Secretariat in Canberra have delivered significant achievements in policy, advocacy, political influence, professional standards, doctors’ health, media profile, and public relations.

We have worked tirelessly to ensure that health policy and bureaucratic processes are shaped to provide the best possible professional working environments for Australian doctors and the highest quality care for our patients.

Our priority at all times is to provide value for your membership of the AMA.

As 2017 draws to a close, I would like to provide you with a summary of the work we have undertaken on behalf of you, our valued members.

General Practice and Workplace Policy

Our strong advocacy led to a decision to lift the freeze on Medicare patient rebates.
AMA coordination of Doctors’ Health Services around the country, with funding support from the Medical Board of Australia.
Launched the AMA Safe Hours Audit Report, giving added focus to the issue of doctors’ health and wellbeing.
Maintained a strong focus on medical workforce and training places, with the National Medical Training Network significantly increasing its workforce modelling and projection work following sustained advocacy by the AMA.
Secured a number of concessions in the proposed redesign of the Practice Incentive Program (PIP), as well as a delay in the introduction of changes.
Lobbied at the highest level for a more durable solution to concerns over Pathology collection centre rents, focusing on effective compliance, and achieving a fair balance between the interests of GP members and pathologist members.
Led the Reforms to After-hours GP services provided through Medical Deputising Services (MDSs) to ensure that these services are better targeted and there is stronger communication between the MDS and a patient’s usual GP.
Successfully lobbied the ACCC to renew the AMA’s existing authorisation that permits GPs to engage in intra-practice price setting, potentially saving GPs thousands of dollars annually in legal and other compliance costs.
Ensured a proportionate response from the Government in response to concerns over the security of Medicare card numbers, avoiding more draconian proposals that would have added to the compliance burden on practices, and added a barrier to care for patients.

Medical Practice

Fundamentally altered the direction of the Medical Indemnity Insurance Review, discussing its importance to medical practice at the highest level, helping to ensure the review is not used as a blunt savings exercise, and saving doctors and their patients millions of dollars in increased premiums.
Led a nationally co-ordinated campaign with the State AMAs and other peak bodies to uphold the TGA’s decision to up-schedule Codeine.
Campaigned against an inadequate, poorly conceived, and ideological National Maternity Services Framework, which has now been scrapped.
Campaigned on the issue of Doctors’ Health and the need for COAG to change mandatory reporting laws, promoting the WA model.
Launched the AMA Public Hospital Report Card.
Pressed the case for vastly improved Private Health Insurance products through membership of the Private Health Ministerial Advisory Committee (PHMAC), my annual National Press Club Address, an appearance before a Senate Select Committee, and regular and ongoing media and advocacy.
Launched the AMA Private Health Insurance Report Card.
Successfully convinced the Government to address concerns with the MBS Skin items, and will continue to do so with the MBS Review more broadly.
Successfully lobbied for changes to the direction of the Anaesthesia Clinical Committee of the MBS Review.
Launched a new AMA Fees List with all the associated benefits of mobility and regular updates.
Saw a number of our Aged Care policy recommendations included in a number of Government reviews.
Lobbied against the ill-thought-out Revalidation proposal, which resulted in a vastly improved Professional Performance Framework based around enhanced continuing professional development.
Successfully held off the latest attempt to have a non-Medical Chair of the Medical Board of Australia appointed.

Public Health

Launched the AMA Indigenous Health Report Card, which this year focused on ear health, and specifically chronic otitis media, in conjunction with the Minister for Indigenous Health, The Hon Ken Wyatt AM.
Led the medical community by being the first to release a Position Statement on Marriage Equality, and advocated for the legislative change that eventuated in late 2017.
Released the updated AMA Position Statement on Obesity, following a policy session at the AMA National Conference, which brought together representatives from the medical profession, sports sector, food industry, and health economists.
Launched the AMA Position Statement on an Australian Centre for Disease Control (CDC), which was welcomed by experts in communicable diseases.
Released the AMA Position Statement on Female Genital Mutilation, which provided a platform for the AMA to engage in advocacy on preventing this practice.
Released the AMA Position Statement on Infant Feeding and Maternal Health.
Released the progressive and widely-supported AMA Position Statement on Harmful substance use, dependence, and behavioural addiction (Addiction).
Successfully lobbied against the proposal to drug test welfare recipients, including a strongly worded submission to a Parliamentary Inquiry on the proposal, which resulted in defeat of the proposed measure in the Parliament.
Released the AMA Position Statement on Firearms, generating considerable media coverage and interest, in Australia and overseas. Most importantly, it is a factor in Australia maintaining its tough approach to gun control.
Released the AMA Position Statement on Blood Borne Viruses (BBVs), which called for needle and syringe programs (NSPs) to be introduced in prisons and other custodial settings to reduce the spread of BBVs. This policy has been promoted by other health organisations and saw the AMA create strong ties within the sector.
Ongoing and prominent advocacy for the health and wellbeing of Asylum Seekers and Refugees, including a meeting with the Minister for Immigration and Border Protection, The Hon Peter Dutton MP, and lobbying on behalf of individual patients behind the scenes.
AMA lobbying of manufacturers saw a change to the sale of sugar-sweetened beverages in some remote Aboriginal communities, which will improve health outcomes.
Promoted the benefits of Immunisation to individuals and the broader community. Our advocacy has contributed to an increase in child and adult vaccination rates.
Provided strong advocacy on climate change and health.
Consistently advocated for better women’s health services.
Lobbied for the establishment of a No-Fault Compensation Scheme for people adversely affected by vaccines.

We promoted our carefully-constructed Position Statement on Euthanasia and Physician Assisted Suicide during consideration of legislation in Tasmania, Victoria, NSW, and WA.

I would like to thank Dr David Gillespie for his contribution to the Rural Health portfolio, and hope that his legacy will be seen in the success of the new Rural Health Commissioner, a position the AMA lobbied for and supports.

In the New Year, we will release new Position Statements on Mental Health, Road Safety, Nutrition, Organ Donation and Transplantation, and Rural Workforce.

As your President, I have had face-to-face meetings with Prime Minister Malcolm Turnbull, Opposition Leader Bill Shorten, Health Minister Greg Hunt, Shadow Health Minister Catherine King, Greens Leader Dr Richard Di Natale, and a host of Ministers and Shadow Ministers.

We also organised lunch briefings with backbenchers from all Parties to promote AMA policies.

In July, our advocacy was publicly recognised when the Governance Institute rated the AMA as the most ethical and successful lobby group in Australia.

I have met regularly with stakeholders across the health sector, including the Colleges, Associations, and Societies, other health professional groups, and consumer groups.

As your President, I have been active on the international stage, representing Australia’s doctors at meetings in Zambia, Britain, Japan, and the United States.

The highlight of the international calendar was the annual General Assembly of the World Medical Association. Outcomes from that meeting included high level discussions on End-of-life care, numerous ethical issues, Doctors’ health, and an editorial revision of the Declaration of Geneva.

But our focus remains at home, and your AMA has been very active in promoting our Mission: Leading Australia’s Doctors – Promoting Australia’s Health.

We have had great successes. We have earned and maintained the respect of our politicians, the bureaucracy, and the health sector. We have won the support of the public as we have fought for a better health system for all Australians.

We have worked hard to add even greater value to your AMA membership.

May I take this opportunity to wish you, your families, and loved ones a safe, happy, and joyous Christmas, and a relaxing and rewarding holiday season. I hope you all get some quality private and leisure time – you deserve it.

Dr Michael Gannon
Federal AMA President

AMA Fees List finalised

The AMA has enhanced a key member benefit, with the launch of the AMA Fees List online in October. The new website has replaced the previous book and CD-ROM formats, making setting medical fees faster and more user friendly than ever before.

The new Fees List includes the annual 1 November 2017 indexation rates.

Since 1973, the Fees List has been a critical aid for AMA members by providing an important reference guide on medical fees. The Fees List is an original work owned and administered by the AMA Secretariat.

In moving online this year, the Fees List has been enhanced with number of features in to make referencing AMA Fees fast and easy for any medical discipline. This includes:

Interactive dashboard to find, search and save AMA fees
Search function that links directly to AMA and MBS item descriptions
Customised user profile with options to save, download or print favourite items
Fee calculator tools including a new Anaesthesia fee calculator
Ability to print parts of, or full PDFs of the Fees List
Online tutorials and help tools
Mobile and tablet compatible
Full PDF and CSV downloads.

The move to the online format has also enabled the Fees List to be updated throughout the year, as ongoing changes are made to the MBS as a result of the MBS Reviews.

All financial AMA members will continue have free, unlimited access to the Fees List online and its many features. We have also introduced new purchasing options and licensing arrangements for select third party groups, such as hospitals, workers compensation agencies and health insurers who reference the AMA fees or provide assistance to AMA members with their billing.

The Fees List is primarily an AMA member benefit and whilst the AMA’s aim is to provide guidance on fair and reasonable medical fees, the AMA does not permit the unauthorised use of the Fees List by billing agencies and software companies for clients who have not purchased the list themselves – due to the risk of copyright infringement of AMA intellectual property.

Of course, many members use these agencies to support their billing operations, which may require providing the AMA rates to these services for their individual billing purposes.

The new Fees List website has been launched at a time when medical fees are under increasing medical and mainstream scrutiny. Medical practitioners are currently challenged with setting appropriate medical fees, amidst the backdrop of a frozen Medicare schedule. The result is that the MBS has not kept pace with the realistic costs of running a viable, quality practice.

The AMA encourages medical practitioners to use their own judgement to charge an appropriate fee for a medical service. Medical practitioners should satisfy themselves in each individual case as to a fair and reasonable fee, having regard to their own practice cost experience and the particular circumstances of the case and the patient.

More information on how the AMA Fees List can assist in setting, licensing and Terms of Use can be found on the Fees List website feeslist.ama.com.au

The next Fees List update is scheduled for 1 December and will include the 1 November MBS changes.

For login assistance please contact Member Services on memberservices@ama.com.au or 1300 133 655. For all other queries, please contact feeslist@ama.com.au

Eliisa Fok
Policy Adviser, Medical Practice

[Correspondence] A global perspective on the history of anaesthesia

The overview of the development of anaesthesia by Thomas Schlich in The Lancet (Sept 9, p 1020)1 provided fascinating insight into the changing relationship between surgeons, physicians, and the patient’s body in western medicine. A more global view of medical history affords the opportunity for other sensibilities. The first recorded use of a general anaesthetic in Japan was by Hanaoka Seishu in 1804,2 and it is possible that a similar approach was used by Hua Tao, a Chinese surgeon, in second-century CE.

MBS Reviews – A long way to go, and a lot of improvement needed

BY DR ANDREW MULCAHY CHAIR, MEDICAL PRACTICE COMMITTEE

Members will recall that the AMA cautiously welcomed the MBS reviews in 2015, noting it was a far-reaching exercise with an ambitious two-year timeline.

The AMA’s support for the MBS reviews has always been contingent on the review being clinician-led and having direct and early involvement of the specialist colleges, associations and societies (CAS). The AMA has called for the review to be fully transparent from decision making through to implementation, and be underpinned by a scientific approach. There must also be scope to add new items to achieve the overall aim of ‘modernising’ the MBS.

In March, the AMA entered into a compact agreement with the Government for a shared vision for Australia’s health system. We committed to support in principle the ongoing operation of the MBS Review Taskforce, including a transparent, consultative clinician-led approach to high-value care and future-proofing the system. During that time the Government extended the review another three years to 2020.

Under the compact, the AMA is committed to work with the Department of Health to deliver on agreed recommendations arising from the MBS Review in conjunction with the relevant sectors. The AMA will continue to identify areas to improve the review process and recommendations.

The AMA’s approach to the MBS review has always been to defer recommendations relating to specialty items to the relevant CAS groups, and comment on the broader policy.

Now two years into the review, the AMA is continuing to press the Government to ensure that reviews remain more than just a cost-cutting exercise, or a mechanism to meddle with the scope of clinical decision making.

In this context, the AMA reviews concerning recommendations against a set of key principles to determine if a response to the Taskforce is necessary. This work is undertaken through stakeholder consultation with an AMA Working Group drawing from the broader membership, and the Medical Practice Committee. AMA also facilitates an annual CAS meeting for stakeholders to air concerns and receive information as the reviews progress.

Based on these feedback mechanisms, the AMA has responded to every single MBS review consultation – raising issues from across our membership, while stressing where systematic improvements need to be made. The AMA Secretariat and the President have done this through direct representations with the Health Minister, the Department of Health and in writing to the Chair of MBS Review Taskforce.

In our latest submission to the MBS Review Chair, the AMA highlighted a number clear deficiencies and significant variations in the process adopted by the MBS Review Taskforce and the Clinical Committees.

Noting the commitment made by the profession to sit on the Clinical Committees and Working Groups, the AMA has continued to stress that there must remain absolute transparency of the review process.

In particular: where a decision is being made in contradiction to the advice of the profession, there should be clear evidence and data to support such a decision.

We also called for early engagement of CAS on each of the Clinical Committees to ensure recommendations are practical and consistent. We have called for complete transparency, starting with how Clinical Committee members are selected and details of the Committees’ scope of work. Finally, the AMA has strongly recommended the Clinical Committees engage early with other Department areas including the Medicare Compliance and Professional Services Review to ensure that any changes to the schedule are practical for clinicians and do not result in sub-optimal care for patients. We all know a poorly worded MBS item can set up a practitioner to fail.

What we don’t want to see is a confusing MBS schedule, with medical practitioners as scapegoats.

With more than half the Clinical Committees yet to be established, there is still a long way to go. The next round of public consultations is expected to occur in February, 2018, commencing with the anaesthesia and oncology reports. The AMA continues to monitor with interest, and encourages the profession and the CAS to engage in the consultation and review process early. The full schedule of MBS reviews can be found on the Department of Health website: http://www.health.gov.au/internet/main/publishing.nsf/content/MBSR-about

In the meantime, the AMA has and will continue to hold up our end of the compact with a commitment to a stronger MBS review. Government must ensure the Review does the same through a significant improvement in the way they conduct it.

[Articles] Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial

Use of CGM during pregnancy in patients with type 1 diabetes is associated with improved neonatal outcomes, which are likely to be attributed to reduced exposure to maternal hyperglycaemia. CGM should be offered to all pregnant women with type 1 diabetes using intensive insulin therapy. This study is the first to indicate potential for improvements in non-glycaemic health outcomes from CGM use.

[Correspondence] Comment on the PODCAST study

The Prevention of Delirium and Complications Associated with Surgical Treatments (PODCAST) study (July 15, p 267)1 analysed whether application of ketamine after anaesthesia induction would result in a lower incidence of postoperative delirium in elderly patients. Contrary to expectations, ketamine treatment did not result in a lower incidence of postoperative delirium. We think this result might partly be because of the varying depths of anaesthesia in the PODCAST study. At least, the study does not mention by what means a similar depth of anaesthesia was established or guaranteed.