Treatment of latent tuberculosis infections in the Darwin region

As it is estimated that one-third of the world population have a latent tuberculosis infection (LTBI), treatment to prevent active tuberculosis is an essential component of the World Health Organization “End TB Strategy”.1

To inform and evaluate practice, we undertook a cohort study of people in the Darwin region (estimated population, 140 000; 25% Indigenous Australians, 25% overseas-born residents) diagnosed with LTBI according to Northern Territory guidelines2 during June 2013 – July 2014. Diagnosis was based on a positive Mantoux test result2 and the absence of radiological and clinical evidence for active tuberculosis. Demographic and treatment acceptance and compliance data were collected from the sole treatment centre serving the region. The recommended therapy was 9 months’ treatment with isoniazid, or 4 months’ treatment with rifampicin if isoniazid was contraindicated.2 Treatment adherence was assessed monthly on the basis of clinic attendance, self-reported adherence, and collection of the medication.

During the study period, 573 people were diagnosed with LTBI, of whom 422 (74%) were overseas-born, 81 (14%) were Indigenous Australians, and 70 (12%) were non-Indigenous Australians. The age range was 0–77 years (median, 32 years); 61% were male. The proportions of people diagnosed with LTBI who were offered, accepted and completed treatment are shown in the Box. Uncertainty on the part of the physician about an individual’s ability to complete treatment was the most common reason for not offering treatment, including to members of transient populations, such as those with short prison sentences and immigration detainees. Most patients who did not complete therapy had been lost to follow-up, either moving interstate (31%) or defaulting without a reason being recorded (25%). Outcome data for people moving interstate were not collected, as there are no mechanisms for routinely sharing such data between Australian states, and forwarding addresses were unavailable. The 55% completion rate therefore probably underestimates the proportion of those who completed treatment.

Parents and guardians of all 28 children under 6 years of age accepted treatment for their children, 12 of whom (43%) completed treatment, including six of 11 who were contacts of people with active tuberculosis, four of 16 immigration detainees, and three of seven refugees. Five children did not, however, commence treatment (three immigration detainees, two refugees), and 11 moved interstate without completing treatment. Nine of those moving interstate were immigration detainees, highlighting the transiency of this population and the uncertainty of outcomes arising from a lack of feedback between states about LTBI treatment compliance.

Indigenous Australians were significantly more likely to accept treatment than overseas-born people (odds ratio [OR], 4.46; 95% CI, 1.55–12.8) or non-Indigenous Australians (OR, 7.69; 95% CI, 2.33–25.4). Overseas-born patients were less likely to complete treatment than Indigenous (OR, 1.34; 95% CI, 0.66–2.72) or non-Indigenous Australians (OR, 1.38; 95% CI, 0.56–3.41). This finding, however, was not statistically significant, and potentially confounded by the fact that all 36 patients who moved interstate were overseas-born, so that completion for this population was possibly higher.

Similar to the findings of other Australian studies, 45% of patients who accepted treatment did not complete it, representing missed opportunities for preventing disease.3,4 Uncertainty about treatment adherence by overseas-born people moving interstate indicates that national data sharing and collaboration between tuberculosis services should be improved. LTBI treatment could then be evaluated according to WHO recommendations, and targeted measures to improve treatment outcomes for this high-risk population implemented.1,3 Further, the reasons for not completing treatment were often unknown; communicating with non-adherent patients would identify problems and enable targeted interventions for improving compliance.

Encouragingly, we found high uptake of treatment by Indigenous Australians, which may help reduce the disproportionately high incidence of active tuberculosis in this population, compared with non-Indigenous Australians.

Box –
The proportions of people diagnosed with latent tuberculosis infection who were offered, accepted and completed treatment, Darwin, June 2013 – July 2014

	Total	Age group (years)
	Total	0–5	6–15	16–35	> 35

People diagnosed with a latent tuberculosis infection (LTBI)	573	32	56	244	241
Reasons for LTBI screening: asylum seeker/refugee (24%); health care worker (19%); tuberculosis contact (17%); (pre-)immunosuppression (7%); school student (overseas-born) (6%); medical referral (6%); incarcerated (6%); immigration health undertaking (3%); defence force personnel (3%); other (9%)
Offered treatment	374 of 573 (65%)	28 (88%)	48 (86%)	153 (63%)	145 (60%)
Reasons for not offering treatment: short term detention/prison sentence (physician uncertain about future adherence) (37%); low risk (35%); excessive alcohol use or liver disease (6%); prior LTBI treatment (4%); pregnant/lactation (4%); depression (2%); other (14%)
Accepted treatment	265 of 374 (71%)	28 (100%)	38 (79%)	103 (67%)	96 (66%)
Completed treatment	147 of 265 (55%)	12 (43%)	26 (68%)	56 (54%)	53 (55%)
Reasons for incomplete treatment: moved away from treatment centre (31%); no reason given/defaulted (25%); did not commence treatment (20%); elevated liver enzyme levels (5%); peripheral neuropathy (3%); patient died of disease other than tuberculosis (3%); rash (2%); other (12%)

Dealing with Bad Health News Masterclass – Limited Places Only

Don’t miss out on the opportunity to attend the 2017 AMA National Conference at the Sofitel on Collins, Melbourne, from 26– 28 May for a rare and unique glimpse into medico-politics, global health issues and contentious contemporary health policies.

One of the key highlights at this year’s Conference is a pre-conference masterclass facilitated by Professor Stewart Dunn. This hands-on experiential one day workshop will focus on developing doctors’ communication skills in breaking bad health news, dealing with bad health news and end of life conversations through interactive role plays. The workshop will help you understand and interpret human behaviour by recognising, identifying and responding to the most common emotional reactions.

Pre-conference masterclass – details

Time: 9:30 – 5:00
Date: Thursday, May 25, 2017
Venue: Sofitel, 25 Collins Street, Melbourne, VIC 3000
Tickets: Conference attendees – $660, AMA members – $770, non-AMA members – $880

Click here to find out more about the AMA National Conference, or contact the Conference organisers at natcon@ama.com.au.

This is an RACGP accredited activity for Category 1 ACRRM Core PDP points. Discounts on registration for AMA members.

Has healthcare’s Uber moment arrived?

House calls used to be at the very heart of a GP’s practice, but at some point in the past few decades economic forces made them largely obsolete. Now they may be back, thanks to what many are calling the “uberisation” of medicine.

In several large cities in the United States, new app-based services have made calling in a doctor or nurse to your house or workplace as easy as getting an Uber ride.

Take, for example, the Los Angeles-based start-up Heal, which says it has treated as many as 12,000 patients since its launch in 2015.

Heal came about after its co-founder, nephrologist Dr Renee Dua, found it impossible to get hold of a paediatrician at short notice and ended up waiting eight hours in emergency to get medical attention for her son.

Dr Dua and her tech entrepreneur husband saw a gap in the market, combining old-style home visits with new-fangled mobile technology. Patients in need of medical attention can whip out their smartphone, fire up the app, and in a few short taps have a doctor or nurse winging their way to wherever they are.

The New York-based Pager operates on the same principles, and even features an Uber-like map in its app to show users where the closest doctors are. Pager guarantees to get a doctor to wherever you are within two hours, or in the case of an emergency an immediate video hook-up with a nurse.

Then there’s 98point6 in Seattle, MedZed in Atlanta, DispatchHealth in Denver, or the New York-based FRND, which is a nurse-only callout service. Uber itself has dipped its toe in healthcare provision, piloting a flu-shot and “wellness pack” service called UberHealth.

Can this model work in Australia, with its very different healthcare and funding structures? The answer seems to be yes and no.

Home-visit apps in the style of Heal or Pager have yet to make an impact here, but after-hours services with an app component have proliferated. Examples abound, and include the likes of HomeDoctor, HouseCallDoctor, DoctorToYou, DoctorOnDuty and DoctorDoctor.

But these services are based on a business model that could yet prove flimsy. They offer bulk-billed visits, taking advantage of after-hours Medicare items that allow doctors to bill the government up to $153, if the visit is considered urgent.

Critics, including the Royal Australian College of General Practitioners, say companies may be exploiting these Medicare items, billing visits as urgent even when they’re just a case of a child with a bad cold.

There have been rumours, not denied by health minister Greg Hunt, that after-hours doctors may be targeted in the May budget, putting a serious hole in these services’ business models.

But even in the US, there are those who are not so sure that the “uberisation” of medicine is a model that actually adds up.

It comes down to the same reasons that home calls went out of fashion in the first place. They take up vastly more time – and are therefore much more expensive – than getting the patient to visit the doctor’s surgery.

A GP may get through 30 patients at her surgery, but would only be able to make seven or eight home visits, at most, in the same timeframe. At the moment, services like Heal and Pager are charging $100 to $200 per visit, but in the long term it doesn’t seem like that will sufficiently cover costs.

And yet only the wealthiest are likely to cough up the $400 to $500 that’s probably needed to make these services truly viable. That may mean that unlike Uber, which generally undercuts traditional taxi services, house call apps may end up having to appeal to a wealthy, niche audience.

One way to get around the travel factor, and another route to medicine’s Uber moment, is telemedicine. And here in Australia, there are plenty of entrepreneurs trying to make that work.

ReadyCare, for example, offers video consults with doctors at any time of the day or night for a fee of $69, and can also provide medical certificates, prescriptions and specialist referrals. GP2U, DoctorsOnDemand and Qoctor all have similar offerings, for similar prices.

None of these services is eligible for a Medicare rebate and they all have to be paid out of the patient’s pocket.

Again, these services have their critics. The Uber model is a transactional one, the critics say, whereas healthcare is about a long-term relationship between the patient and the healthcare provider.

AMA vice-president Dr Tony Bertone says that although there’s no doubt digital platforms will play an increasing role in healthcare delivery, he’s worried about the fragmentation of care they may engender.

“There’s really no replacement for an examination in person,” he says.

Resorting to video consults just because it’s the convenient option “may end up being more costly down the track, delaying the diagnosis, or even missing opportunities for preventative care”, he adds.

With Uberised medicine starting to make inroads in our own healthcare delivery system, now may be time to reframe the question from whether it’s a viable economic proposition to whether it’s actually good for patient outcomes.

Click here for Doctorportal’s comprehensive Find A Doctor tool.

Diagnostic triage for low back pain: a practical approach for primary care

One in seven Australians (13.6%) will suffer from back pain on any day,1 which makes this condition the largest contributor to the burden of disease in Australia, according to the Global Burden of Disease Study.2 In Australia, low back pain (LBP) is the most common musculoskeletal condition for which patients consult general practitioners.1 Back problems are more common in older people, and with an ageing Australian population, the 3.7 million GP encounters for LBP in 2012–20131 are likely to escalate. Given this context, GPs need a practical approach to assess and treat their patients with LBP.

A key step in the primary care management of LBP involves a diagnostic triage that classifies patients into three broad categories (Box 1). Based on a focused clinical assessment, patients are classified as having a specific spinal pathology (< 1%), radicular syndrome3 (ie, nerve root pathology including spinal canal stenosis; ∼ 5–10%), and non-specific LBP ([NSLBP]; 90–95%). The triage approach informs decisions about the need for further diagnostic workup (eg, imaging or laboratory tests), guides the care the GP needs to provide and helps the GP identify the patients who require referral to allied health or medical specialists.4

This article aims to outline the diagnostic triage approach in greater detail than that found in clinical practice guidelines,3–5 and to show the clinical utility of the approach for the primary care management of LBP. We identified relevant current English language clinical guidelines and publications from the Cochrane Library and PubMed in February 2016, our existing records, and citation tracking. We used search terms for LBP and key concepts in our article (eg, differential diagnosis, low back pain, sciatica and spinal stenosis).

Diagnostic triage for primary care management of low back pain

The goal of the diagnostic triage for LBP is to exclude non-spinal causes of LBP and to allocate patients to one of three categories that subsequently direct management (Box 1). A focused history and a physical examination of the patient form the cornerstone to the diagnostic triage classification; moreover, diagnosis of the largest NSLBP group is by exclusion of the other two categories (Box 1).

We describe the approach endorsed in the latest clinical practice guidelines and suggest some updates based on research published subsequent to the guidelines. Limited but essential background information is provided for stepwise application of the diagnostic triage.

Specific spinal pathology

The initial step is to recognise that in primary care, LBP is occasionally the initial symptom of a number of more serious specific spinal pathologies (Box 1), the most common of which is vertebral fracture (Box 2). A range of clinical features or red flags (eg, age > 50 years or presence of night pain) have been proposed to help clinicians identify patients with a higher probability of specific pathology, who require further diagnostic workup to allow a definitive diagnosis. While there are scores of red flags endorsed in texts and guidelines, many are of limited or no value. A good illustration is the red flag “thoracic pain”, which has both a positive and negative likelihood ratio of 1.0 (for cancer), meaning that both a positive and negative test result are uninformative.8 Based on two recent Cochrane reviews, only a small subset of red flags (ie, older age, prolonged corticosteroid use, severe trauma and presence of a contusion or abrasion) are informative for detection of fracture, and a history of malignancy is the only red flag increasing the likelihood of spinal malignancy.8

For patients with suspected specific spinal pathology, the condition itself dictates the next steps the GP should take (Box 2). Patients with rapidly deteriorating neurological status or a presentation suggesting cauda equina syndrome require urgent (same day) referral to a neurosurgeon. Where there is suspicion of infection (such as a spinal epidural abscess that may have important medico-legal implications if missed) or strong suspicion of cancer or fracture, the GP should initiate further diagnostic workup to confirm the diagnosis. When there is less convincing evidence of cancer or fracture, a trial of therapy with review in 1–2 weeks may be considered. In the same way, watchful waiting and a trial of therapy may be appropriate for suspected axial spondyloarthritis (axSpA). However, axSpA is often missed, with most patients typically diagnosed many years after the initial symptoms; therefore, scheduling a review is crucial to avoid this problem. Guidelines for rheumatology referral of axSpA are summarised in Box 2, together with the prevalence, alerting features (ie, risk factors), diagnostic workup and tertiary referral pathways for each of the specific spinal pathologies.

Radicular syndrome

The next step is to recognise, from the focused history and clinical examination, the clinical features that distinguish three subsets of nerve root involvement: radicular pain (sometimes called sciatica), radiculopathy and spinal stenosis (Box 1). Grouped together as radicular syndrome, the source of the clinical features lies in lumbosacral nerve root pathology associated with disc herniations,14 facet joint cysts, osteophytes, spondylolisthesis and acquired or degenerative canal stenosis.15 Severe pathoanatomy, including spinal tumours, may result in deterioration of radicular syndrome and crossover to cauda equina syndrome,16 which demands urgent management (Box 2).

Differential diagnosis is complex. Definitions seldom match the highly variable manifestations seen in clinical practice.17–20 For this reason, distinctive clusters of characteristic history cues and positive clinical examination signs, particularly the neurological assessment, provide a guide to diagnose radicular syndrome and to differentiate the subsets of this category, which is essential for clinical utility of the diagnostic triage (Box 3).

There are three important subsets to consider when diagnosing radicular syndrome:

Radicular pain: in primary care, LBP-related leg pain is common with about 60% of patients with LBP reporting pain in the legs;31 however, the subgroup with true radicular pain is much smaller. A prospective cohort study of radicular pain in the Dutch general practice 10-year follow-up20 found that the mean incidence was 9.4 episodes per 1000 person-years. Radicular, neurogenic leg pain, for which there is no gold standard diagnosis,18 is distinct from and more debilitating than somatic referred leg pain, and is associated with greater GP consultations,18 functional limitations, work disability, anxiety, depression and reduced quality of life,32 as well as imaging and surgical health care costs. Cues about the severity, asymmetry and radiating quality of leg pain from the history (Box 3) suggest radicular pain; however, specific dermatomal-dominant pain location has the greatest single-item diagnostic validity.23 Positive nerve tension tests for upper lumbar roots (prone knee bend) or lower roots (straight leg raise and crossed straight leg raise) are common physical examination signs that guide diagnosis.33
Radiculopathy: caused by nerve root dysfunction and defined by dermatomal sensory disturbances, weakness of muscles innervated by that nerve root and hypoactive muscle stretch reflex of the same nerve root,22 frequently co-exists with radicular pain. However, a patient with L4 radiculopathy may present with footdrop — which is a severely compromised or absent concentric foot dorsiflexion due to marked weakness of the tibialis anterior muscle, the strongest dorsiflexor of the foot — or paraesthesia without radicular pain, suggesting that the two are separate diagnostic entities. A single positive symptom or sign of sensory (soft) or motor (hard) deficit confirms the diagnosis (Box 3); nevertheless, myotomal weakness is the most diagnostic hard sign.23
Spinal stenosis: both degenerative in older patients and acquired or congenital in younger patients. Spinal stenosis has key clinical features such as neurogenic claudication34 relieved in forward flexion or sitting15,35 (Box 3). Neurological examination is often normal36 — in contrast to radicular pain or radiculopathy.

Recent research shows a favourable prognosis for all three radicular syndrome subsets when managed conservatively.18,20,36 Referral to a spinal surgeon should be reserved for patients for whom conservative care has proven insufficient and who have disabling symptoms that have persisted for longer than 6 weeks,37,38 for patients who have severe or progressive neurological deficit, and for patients with cauda equina syndrome.39 A recent trial showing similar outcomes for decompression surgery and conservative management — physiotherapist-delivered education combined with flexion-bias and conditioning exercises — provides support for conservative management of spinal stenosis.36 Another study found no clinically important improvement in symptoms and function after surgery in 57% of patients.40 Moreover, recent research has found no association between magnetic resonance imaging radiological findings and the severity of buttock, leg and back pain, even when analysis was restricted to the level of the spine with the most prominent radiological stenosis.41

Matching primary care treatment for radicular syndrome to the individual patient requires clinical acumen. There is also some uncertainty in management, as there are less clinical trials evaluating radicular syndrome than NSLBP. First line primary care comprising reassurance and advice, pain medication, physiotherapy treatment or rehabilitation (matched to muscle deficits and the reduced envelope of function), and “watchful waiting” would be indicated, for example, for recent onset radicular pain with mild L5 radiculopathy and associated motor deficit of the extensor hallucis longus muscle. This can present as a subtle, audible foot slap noted during gait because the eccentric control of lowering the foot after heelstrike is compromised on the affected side. In contrast to footdrop, foot slap has a relatively minor impact on gait. Second line care may progress to more complex medications, including neuropathic pain medication and oral steroids; however, the efficacy of both interventions is unclear.42–44 Moreover, epidural injections of corticosteroids are considered controversial.45 In a recent systematic review and meta-analysis of epidural corticosteroid injections for radiculopathy and spinal stenosis, the researchers concluded that epidural steroid injections for radiculopathy were associated with immediate reductions in pain and improvements in function.11 The benefits, however, were small and not sustained, and there was no effect on long term surgery risk. For spinal stenosis, limited evidence suggested no effectiveness for epidural steroid injections.33

Non-specific low back pain

NSLBP is the third triage group and represents 90–95% of patients with LBP in primary care. It is a diagnosis by exclusion of the first two less prevalent categories (Box 1). In contrast to these categories, there are no identifying features for NSLBP on currently available clinical tests to determine a definitive link between a pain-sensitive structure, such as annulus fibrosus or ligament, and the patient’s pain.27 NSLBP is managed conservatively and no imaging or pathology is recommended.46

There are two common approaches to staging NSLBP to help direct primary care management (Box 4). The traditional approach was to first stratify by duration of symptoms and then begin with simple care and progress to more complex care if insufficient progress was made. A more recent approach is to use validated risk stratification tools — such as the STarT Back Screening Tool (SBST)47 or the Örebro Musculoskeletal Pain Screening Questionnaire48 — to stream patients into different care pathways (Box 4). The SBST is a brief prognostic screener to direct stratified primary care management (Appendix), and which quantifies psychosocial risk for levels of pain, disability and distress as low, medium or high.47 A different treatment package is then matched to the patient depending on their risk category. For example, a low risk category indicates a highly favourable prognosis. Therefore, the matched treatment, aimed at enabling self-management, focuses on dealing with patient concerns and providing information. The medium risk category builds on the low risk package, but adds strategies to improve primary outcomes of pain and function (including work) and to minimise disability (even if pain is unchanged). For high risk scores, matched treatment builds on both the low and medium packages, but additionally includes psychologically informed physiotherapy, provided by a physiotherapist trained in cognitive behavioural therapy (Box 4).

For all patients — to reduce symptoms, activity limitation and participation restriction — management should be guided by a biopsychosocial understanding of LBP, targeting biological, psychological and social contributors to the condition.49 Biological components may be addressed with exercise and ergonomic education (eg, a standing desk to avoid prolonged sitting), whereas psychological therapies and modifications or pacing within sporting participation may be necessary to deal with the psychosocial components of LBP. The recognition that problems — other than the pain intensity — may need to be managed is important in the biopsychosocial model of LBP. Key examples would be the distress and disability associated with LBP; comorbidities, such as sleep disturbance or depression; and disruptions to the patient’s normal work and social roles. The general practice management of NSLBP will thus vary to reflect the clinical presentation of the individual patient. For example, an uncomplicated acute episode may only require education, reassurance and simple pain medicines, whereas a patient with chronic LBP that is persistently debilitating may require complex pain medicines, assessment of psychosocial risk factors, mental health screening and referral for cognitive behavioural therapy (Box 4). For some patients, it would be best practice for the GP to use a chronic disease management plan to manage the patient in a team care arrangement with two other health professionals, such as a rheumatologist, physiotherapist, dietitian50 or psychologist. Management in an intensive interdisciplinary rehabilitation program may be considered for patients who do not respond to primary care management, or where the initial presentation reveals many complex barriers to recovery.

The use of the terms “ordinary backache”51 or “mechanical back pain” has advantages, as the term “non-specific low back pain” may not engender patient confidence in the GP to identify a reason for their pain. The diagnostic triage can guide patient education: “ordinary backache” is extremely common (90–95%), and the patient’s clinical assessment has not revealed any evidence of specific pathology (< 1%) or spinal nerve involvement (5–10%; Box 1). Using the triage in this way removes “pain” from NSLBP nomenclature, and potentially minimises imaging requests and catastrophising. Education of patients on evidence around LBP is important to dispel myths and counter anxious or demanding requests for unwarranted imaging, which can often reveal incidental findings. Radiological signs of disc wear and tear (eg, degeneration [91%], bulges [56%], protrusion [32%] and annular tears [38%]) are common in pain-free patients.52 It is also worth noting that the radiation level of a lumbar spine computed tomography scan is equivalent to that of 300 chest x-rays.53 Reassurance that LBP settles and responds well to staying active, together with advice regarding simple safe symptom control (eg, heat or analgesia), continuing normal daily activities and staying at work (with modification if needed) foster appropriate patient attitude and self-management.46

In summary, most patients presenting to primary care with LBP do not require imaging or laboratory tests, and a focused clinical assessment is sufficient to direct management. Part of the consultation should be used to gauge the patient’s understanding of their back pain, so that GPs are better equipped to provide relevant education and advice to their patient. This important aspect of care, ensuring that patients are active participants in their recovery from LBP, has been well described in a recent article.54

Conclusion

Back pain, like headache, is a symptom requiring differential diagnosis. Diagnostic triage, based on a focused history and physical examination, anchors LBP diagnosis in primary care. It guides the GP to triage each patient into one of three LBP categories. Specific spinal pathology and radicular syndrome are the two distinct LBP triage categories that need to be excluded before a diagnosis of NSLBP, or ordinary backache, can be made for most patients.

In this article, we have outlined a practical approach for a stepwise application of diagnostic triage in primary care. Accuracy in the initial LBP triage category requires clinical acumen and strongly affects subsequent clinical decision making. Therefore, clinically relevant diagnostic pointers, together with recent research evidence across the three domains, have been synthesised to sharpen diagnosis of the three categories and to guide subsequent clinical pathways in primary care.

The first imperative is prompt identification and referral of specific spinal pathology. The second is to identify and appropriately manage the wide clinical variability within patients presenting with radicular syndrome, that is, radicular pain, radiculopathy and lumbar spinal stenosis. Collaborative conservative care and evidence-based referral for imaging and spinal surgery are important for this group of patients. Third, the triage process equips GPs to confidently educate and reassure 90–95% of patients with LBP that there is no evidence of specific pathology or nerve root involvement. This paves the way for a biopsychosocial model of care for patients presenting with NSLBP: to manage pain intensity, but also to quantify risk for disability so that patients can be directed to appropriate pathways of care.

Diagnostic triage of LBP empowers GPs in their role as gatekeepers of LBP in primary care. Practical application of this tool is essential to anchor LBP diagnosis in primary care and to deal with the complexity of a presenting symptom that is vexing, costly and too prevalent to be ignored.

Box 1 –
Diagnostic triage for low back pain (LBP)

GP = general practitioner. * For diagnostic features, see Box 2. † For diagnostic features, see Box 3. ‡ Diagnosis by exclusion of the first two categories.

Box 2 –
Specific spinal pathologies presenting in primary care

Prevalence in primary care

Alerting features

Diagnostic workup

Tertiary referral

Vertebral fracture

1.8–4.3%6

Older age (> 65 years for men, > 75 years for women)7
Prolonged corticosteroid use
Severe trauma
Presence of contusion or abrasion

Imaging:

immediate (for major risk);
delay (for minor risk, 1-month “watch and wait” trial); and
laboratory test: ESR7

Spine surgeon

Malignancy

0.2%8

History of malignancy*
Strong clinical suspicion
Unexplained weight loss, > 50 years (weaker risk factors)

Imaging:

immediate (for major risk);
delay (for minor risk); and
laboratory test: ESR7

Oncologist

Spinal infection

0.01%9

Fever or chills
Immune compromised patient
Pain at rest or at night
IV drug user
Recent injury, dental or spine procedure

Imaging:

immediate (MRI); and
laboratory tests: CBC, ESR, CRP10

Infectious diseases specialist

Axial spondyloarthritis11

0.1–1.4%12,13

Chronic back pain (> 3 months’ duration), with back pain onset before 45 years of age and one or more of the following:

inflammatory back pain (at least four of: age at onset 40 years or younger, insidious onset, improvement with exercise, no improvement with rest, and pain at night — with improvement when getting up);
peripheral manifestations (in particular arthritis, enthesitis or dactylitis);
extra-articular manifestation (psoriasis, inflammatory bowel disease or uveitis);
positive family history of spondyloarthritis; and
good response to non-steroidal anti-inflammatory drugs

Refer to rheumatologist if strong suspicion of axial spondyloarthritis

Rheumatologist (where a rheumatologist is not available, consider another medical specialist with expertise in musculoskeletal conditions)

Cauda equina syndrome

0.04%9

New bowel or bladder dysfunction
Perineal numbness or saddle anaesthesia
Persistent or progressive lower motor neuron changes

Imaging: immediate MRI

Spine surgeon

CBC = complete blood count. CRP = C-reactive protein. ESR = erythrocyte sedimentation rate. IV = intravenous. MRI = magnetic resonance imaging. * A history of malignancy is the only proven single alerting feature (red flag) for suspected malignancy.8

Box 3 –
Differential diagnosis of radicular syndrome: key clinical features of three subsets*

Condition

History

Physical examination

Radicular pain^†

Leg pain typically worse than back pain18,21
Leg pain quality — sharp, lancinating or deep ache increasing with cough, sneeze or strain22
Leg pain location — unilateral, dermatomal concentration (below knee for L4, L5, S1)23,24

Positive provocative tests for dural irritation: straight leg raise (L4, L5, S1, S2) and prone knee bend (L2, L3, L4)14,25
Lumbar extension and ipsilateral side flexion may exacerbate radicular pain (Kemp sign)
Sometimes accompanying radiculopathy signs

Radiculopathy^‡

Numbness or paraesthesia (typically in distal dermatome)26
Weakness or loss of function (eg, footdrop)22,27

Sensory: diminished light touch or pinprick in dermatomal distribution,27 paraesthesia intensifies with lumbar extension
Motor: myotomal weakness27
Reflexes: reduced or absent knee jerk or ankle jerk14,25

Lumbar spinal stenosis^§

Neurogenic claudication limiting walking tolerance15,28
Older patient, bilateral leg pain or cramping with or without LBP15,29
Bilateral leg pain exacerbated by extended posture (eg, standing)30 and relieved by flexion (eg, sitting, bending forward and recumbent posture)15

Normal neurological assessment during rest (sometimes mild motor weakness or sensory changes)29
Antalgic postures (stooped standing and walking), straightened posture can amplify leg pain or numbness28
Wide based gait28

LBP = low back pain. * Radicular pain and radiculopathy frequently coexist.19 † Radicular pain is caused by nerve root irritation and there is a focus on symptom-related eligibility criteria from the history.22 Because of dermatomal overlap, pain radiation is a more reliable guide than sensory loss for localising the root involvement.27‡ Radiculopathy is due to nerve root compromise; therefore, there is a focus on sign-related eligibility criteria from the physical examination.22 § Lumbar spinal stenosis is a clinical diagnosis where neurogenic claudication is the cardinal diagnostic symptom from the history.15 Neurogenic claudication is defined as the progressive onset of pain, numbness, weakness and tingling in the low back, buttocks and legs, which is initiated by standing, walking or lumbar extension.15 Imaging to determine structural pathology is reserved for when surgery is being considered.15

Box 4 –
Primary care management of non-specific low back pain (LBP)

CBT = cognitive behavioural therapy. STarT Back = STarT Back Screening Tool.47 The Appendix contains more information on the STarT Back approach.

AMA awards: nominations are open

Do you have a colleague who has done truly exceptional work in the medical community? If so, you may want to see their contribution is recognised by nominating them for a prestigious AMA Public Health Award.

These honours provide well-deserved recognition for the work doctors and health groups do to improve our healthcare and public health.

This year, the AMA is calling for nominations for five awards:

AMA Excellence in Healthcare Award
Woman in Medicine Award
Women’s Health Award
Men’s Health Award
Youth Health Award

You can access full descriptions of selection criteria here; nominations will remain open until Wednesday, 19th April.

Among last year’s recipients was Associate Professor Diana Egerton-Warburton, who is Director of Emergency Research and Innovation at Monash Medical Centre Emergency Department. She was honoured with the Woman in Medicine Award for her exceptional contribution to emergency medicine and her passion for public health.

Also honoured in 2016 were Associate Professor John Boffa and Ms Donna Ah Chee, whose contributions to improving early childhood outcomes for Aboriginal children were recognised with the AMA Excellence in Healthcare Award.

Nominations, including all required documentation, should be submitted to awards@ama.com.au.

Aussie research results go missing

A disturbingly high number of publicly-funded medical trials never publish results, representing millions of wasted research dollars, say Queensland researchers.

Their study of 77 randomised trials funded by Australia’s National Health and Medical Research Council found that 28% of them had no published results within eight years of receiving funding.

That alone represents nearly $30 million of wasted money, and is no doubt the tip of an iceberg of wasted research funds in the Australian funding system, say the study authors from the Queensland University of Technology.

For published studies, the median time it took for the main results to be published was 7.1 years after funding, even though the funding only supports up to five years of research.

Even protocol papers, which are supposed to come out soon after a project is greenlighted, were hard to come by, appearing at a median of 6.4 years after funding.

In a linked comment, senior author Professor Adrian Barnett (PhD) says researchers avoid publishing results for several reasons. One common reason is when the results are negative, as these are harder to publish, and have less cachet.

But regardless of the reason, researchers should report what happened, Professor Barnett says.

Otherwise, not only is the research money wasted, but patients miss out as well.

“Sufferers of diseases being studied are being denied information which could have informed a better treatment,” Professor Barnett points out.

He says the ball on this issue is in the court of the funders. They have tremendous power over researchers and they should create stronger incentives to publish results, regardless of outcome.

Funders could make a funding contract contingent on a commitment to publish results, he says. Researchers who miss reporting deadlines could be fined or have further funding withheld.

“Too many scientists take public money without delivering on that investment,” Professor Barnett concludes.

You can access the study here.

Neuropathic pain drug no good for sciatica

The increasingly popular painkiller pregabalin (Lyrica) is no better than placebo for sciatica, say Australian researchers.

Their study of 209 patients randomised to pregabalin or placebo over eight weeks showed that not only was the drug ineffective for pain, it also caused almost twice as many adverse events.

Senior author Associate Professor Christine Lin from Sydney’s George Institute says there’s been an exponential rise in the amount of pregabalin scripts written for sciatica since its PBS listing in 2013, but that until now there’s been no solid evidence that the drug actually works.

“Our results have shown pregabalin treatment did not relieve pain, but did cause side effects such as dizziness.”

She says that ironically, most people in both groups reported satisfaction with their treatment. Indeed, over the course of the trial levels of pain did lessen, but the decreases were the same in both arms.

“It seems people associate a drop in pain being due to taking a capsule, rather than something that would happen entirely naturally over time.”

Dr Lin says there are currently no drugs proven to work for sciatica, and even epidural injections only provide a small benefit in the short term.

“What we do know is that most people with sciatica recover over time. It’s also important to avoid bed rest and to stay as active as possible.”

However, pregabalin’s maker Pfizer has pushed back against the study’s findings.

A Pfizer spokesperson told trade publication Pharma In Focus that less than a third of study participants had the characteristics of neuropathic pain.

The spokesperson added that the vast majority of patients were being treated for acute rather than chronic sciatica, even though the acute form generally clears without the need for treatment.

The study findings comes amidst alarm at the high rate of pregabalin prescribing in Australia, a large proportion of which is likely to be off-label.

Last year, a Pharmaceutical Advisory Board report found that around half a million people were given the drug between March 2014 and February 2015, considerably more than had been predicted.

Nearly half of patients discontinued pregabalin after just one prescription, suggesting that the drug was being prescribed for acute rather than chronic neuropathic pain as indicated.

Around 45% of patients started pregabalin without being on a prior drug regimen, although the drug is not indicated as a first line treatment.

You can read the study abstract here.

Australia’s Health Care Homes: laying the right foundations

The Health Care Home is a central component of our national health reforms, and refining the model for broader implementation is essential

It seems a long time since April 2016, when the then federal Health Minister accepted all 15 Primary Health Care Advisory Group recommendations to improve care for Australians with complex, chronic health conditions. Recommendations included a mix of initiatives in system integration, care targeting, outcome measurement, change management and payment redesign.1 Central to this reform was the Health Care Home (HCH) — a change in traditional arrangements between patients and their general practices or Aboriginal community controlled health services.1

The major professional and consumer groups greeted the Minister’s announcement enthusiastically,2–4 and the Council of Australian Governments (COAG) agreed to support from all jurisdictions. The Commonwealth agreed to provide enabling infrastructure to support a national pilot of the HCH model. The states agreed to work with HCHs and Primary Health Networks (PHNs) at local provider level regarding regional planning, collaborative commissioning of services, shared patient information and pooled funding arrangements.5

Under the proposed model, patients will be invited to enrol with a nominated clinician within their practice who will coordinate all their chronic disease management, face-to-face or virtual, within and outside the practice.1 Rather than the myriad Medicare chronic care and planning items currently available for doctors and nurses, practices will receive a single payment of between $591 and $1795 per patient per annum, based on assessment of the patient’s complexity via a risk stratification tool.6 Participating practices will also receive a one-off grant to support training and establishment.6 Practices will be free to work with the patient and family to tailor the care to the patient’s circumstances, clinical need and preference. Opportunities for more innovative use of e-health, both in-hours and after-hours, will be encouraged. Health care — like online banking and shopping — can be uncoupled from traditional in-practice face-to-face delivery, based on patient and clinician agreement.6

The outcomes for 65 000 consenting patients from 200 participating practices within 10 chosen PHN regions will be evaluated over 2 years to determine the impact of the new approach on patient outcomes, hospitalisations and costs;6 in addition, Australia’s remaining 21 PHNs will be encouraged to make HCH-related innovation a priority for their practice development programs.

In November 2016, the Department of Health released HCH expression of interest documentation, including an overview of the COAG-approved model, the process to become involved, and further funding details.6 Final practice selection will occur in the first half of 2017.

Although consumer support for the initiative has been strong,7 professional organisations including the Australian Medical Association8 and the Royal Australian College of General Practitioners9 have voiced concern, against the background of a longstanding Medicare rebate freeze and review of the Practice Incentives Program. Concerns include the size of the payment bundle, recompense for practice change, the urgency to have stage one implemented by 1 July 2017, and the paucity of detail regarding the business costs in moving to the new model.10 The Department of Health has responded with further information regarding payment assumption modelling.11

As the year commences, Australia’s 7000 accredited general practices are considering the risks and benefits of HCH involvement. The initial HCH rollout is described as stage one,11 suggesting that participation in the process would be of benefit for longer term business planning (Box). Practices face difficult choices between the desire to shape the future for their communities, and the business and reputational risks of embarking into the unknown.

So, what are the take-home messages for HCHs in 2017?

COAG has identified the HCH as a central component of our national health reforms, and integral to improved care for the 10% Australians who currently consume 45% of health resources.5 Refining the model for broader implementation in the Australian health care context is therefore vitally important.

International experience suggests that clinician leadership will be critical for success at national and practice levels. Managing change in care delivery, practice innovation and workforce training is challenging, but is pivotal to making our practices and system function better for needy Australians. This change requires active clinician involvement and patient engagement at every stage.12

Finally, engagement in digital transformation is essential to inform and activate our patients, to share personalised care plans across teams, and to collect information to underpin quality improvement and resource allocation.13

We must understand and embrace the commitment of numerous practices, patients and state-funded support initiatives as they test the HCH model. They are allowing us the opportunity to move a valued and heavily used service sector into a future built on service integration, patient engagement and digital change. Working together they will allow us to learn, adapt and upgrade to the COAG HCH of 2018 — progressive, functional and hopefully cyclone proof.

Box –
Health Care Homes: stage one requirements6

A general practice or Aboriginal community controlled health service taking part in stage one will:

participate in the Practice Incentives Program eHealth Incentive
participate in the stage one Health Care Homes training program
use the patient identification tool to identify eligible patients in their practice, and stratify their care needs
ensure that all enrolled patients have a current My Health Record
develop, implement and regularly review each enrolled patient’s shared care plan
provide care coordination for enrolled patients using a team-based approach
provide enhanced access for enrolled patients through in-hours and after-hours telephone support, email or video-conferencing, where clinically appropriate
ensure that enrolled patients are aware of how to access after-hours care
collect data for the evaluation of stage one and for internal quality improvement processes

To be ill is human: why normalising illness would make it easier to cope with

Why are we so shocked when we, or someone we know, becomes ill? Why are many people scared of illness and unable to support their loved ones when illness strikes? And why do so many people still think “it won’t happen to me”?

These questions strike at the heart of our relationship between sickness and health and our reluctance to confront illness as part of our everyday lives.

Many people do not talk openly about illness because they fear it will make them seem weak or self-indulgent.

People also keep illness a secret because they worry they will be blamed or judged for developing it, which is surprisingly common. For example, think about the stigma patients and their families experience if they are affected by lung cancer, obesity-related illness or mental illness.

This fear of being judged or blamed may also contribute to people hiding their symptoms, even from health professionals, delaying diagnosis and proper management.

Perhaps we don’t talk about illness because of the global multi-billion dollar health industry reinforcing a message that we must be healthy if we consume the right food and drinks.

Or perhaps we don’t talk about our illness because we believe modern medicine will cure us.

All of these factors mean remaining quiet about illness becomes normal, illness is often hidden and many people cope with illness alone. While it may be acceptable to talk about having a common cold, it seems that speaking about more serious illness is not. Sometimes we hide away our health troubles behind a mask of wellness.

About a quarter to a third of people with serious physical illnesses hide their illness from colleagues and even family and friends. The data is even more striking when considering mental health problems, with studies suggesting more than two-thirds of people would conceal a mental illness from their co-workers or classmates.

So, it is hardly surprising people are not prepared when they, or a loved one, become ill; they can find it hard to cope psychologically with, and adjust to, their and other people’s illness.

Serious and chronic disease is common

Society seems in a state of denial that illness is a fact of life for most families. It is part of the human condition.

Serious and chronic illness is becoming more common. At any one time, about half of us will be managing a serious health condition and around one in five of us will be experiencing two or more serious illnesses at once.

No family is immune: serious illness can affect people of all ages, wealth, professions and education levels. Celebrities also develop serious illnesses (although many likely keep their health problems private).

Look around you. Who in your family is ill? Who is off work because they are sick with something other than a common cold? Who has been diagnosed with a life-threatening condition (cancer, diabetes and heart disease spring to mind) or with a chronic condition such as inflammatory bowel disease, arthritis or depression?

Living with illness

We are now coming to understand that many life-threatening diseases are in reality long-term conditions rather than a death sentence. Many people are managing multiple serious illnesses at once, while others are told they are at risk of developing a serious illness in the future. If your family, friendship circle and workplace is anything like ours, then being ill is surprisingly common.

There are a number of different psychological approaches to help us cope with these long-term health problems.

So-called third wave psychological therapies promote the idea of accepting rather than avoiding illness, and the pain and suffering that often accompanies it. These types of therapies may help us to cope when illness strikes. They can help patients to clarify their values and make choices that align with them.

Other more traditional psychological approaches (such as cognitive behaviour therapy) may also help people who are struggling with their health to re-frame their illness as part of the normal experience and identify effective coping strategies. They may also help people to identify their needs and seek help to meet these needs.

For young people who are ill, more modern approaches, using internet-delivered support may meet their needs well, for instance this online intervention for young cancer survivors.

And when an illness becomes terminal, psychological therapies and bereavement counselling can help patients, families and friends to face the end of life.

These forms of support may help people thrive with illness rather than despite their illness. But society also needs a “therapy” to cope with people being ill.

For starters, we need to see people who are not 100% healthy represented in the government, workplace and media, in fact in all areas of social life. This should lead to greater acceptance of illness and position ill health as the new normal.

If this article has raised issues for you or if you’re concerned about someone you know, call Lifeline on 13 11 44.

Gill Hubbard, Reader in Cancer Care, University of Stirling and Claire Wakefield, Associate Professor, UNSW

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

Other blogs:

Why we’re wasting money on medical tests

How doctors should talk to anti-vaxxers

Women don’t always get what they want from labiaplasty

Professional and psychosocial factors affecting the intention to retire of Australian medical practitioners

The known The number of doctors who work beyond the age of 65 is growing. Studies of retirement intention have focused on single factors, such as health and income, and have generally been limited to single specialties.

The new 38% of doctors aged 55 or more were unsure about retiring or did not intend to retire. Both professional and broader psychosocial factors (including financial resources, work centrality, emotional resources, anxiety about ageing) influenced the intention to retire.

The implications Education programs facilitating retirement planning are needed for late career doctors, including advice on financial planning and developing non-professional interests.

In the absence of a mandatory retirement age in Australia, many doctors work beyond the age of 65.1 In 2014, 9.9% of the medical workforce were 65 or older, and the total number of doctors over 65 years of age has increased by 80% since 2004,1,2 consistent with an ageing society.

Older practitioners who prolong their careers are important for providing medical care as well as for teaching and mentoring younger colleagues.3 These benefits, however, must be weighed against a complex array of factors associated with ageing, including physical and cognitive changes that may hinder optimal practice.4

The challenges associated with retiring from a career in medicine were highlighted by the finding that only 61% of older Australian psychiatrists had commenced planning their retirement.5 Anticipated reasons for retirement reported in single specialty studies include deteriorating health and family or personal reasons;5 self-perception of one’s skill levels, rather than age;6 and financial aspects and the inability to find a suitable replacement.7

Whether the broader retirement literature is directly applicable to the medical profession is unclear.8 The largest reported effect sizes for factors favouring retirement planning have been for work involvement and job satisfaction. We similarly suggest that being a doctor is so closely linked with self-identity9 as to make retirement threatening. If so, it would be expected that work centrality — the extent to which work is of primary personal importance compared with other life roles; that is, an indicator of a person’s affective commitment to work10 — would be higher in doctors who are less inclined to retire. Further support for this hypothesis would be that doctors are less likely to retire if work is perceived as a calling (the work itself is fulfilling and perceived as contributing to the greater good), rather than a career (achievement is defined by advancement and promotion) or job (defined purely by financial success).11

Other psychological factors that may affect retirement planning include positive emotions, such as adaptability and optimism. Anxiety about ageing — the tendency to fear anticipated threats and losses associated with advancing age12 — may also be involved.

The factors that are weighed when considering retirement have not been explored in specific subgroups of doctors, such as international medical graduates (IMGs). Working in a rural or remote area may hinder retirement planning, given the lower replacement rates in such locations.

The aim of our survey was to determine the professional and personal factors associated with the intention to retire (ITR) among older medical practitioners. Significant correlations between retirement intention and subsequent retirement behaviour have been reported in the general literature on retirement.13

Methods

We undertook a cross-sectional self-report survey of doctors aged 55 or more, using a commercial database rented from the Australasian Medical Publishing Company (AMPCo). A pilot study (among doctors in the Australian Capital Territory and South Australia) verified the questionnaire items and data collection methodology. The main study was conducted in October 2015: 6000 doctors received an email from AMPCo (independently of the study authors) with an embedded link to the survey, twice within 2 weeks. Participants were offered the chance to win one of ten $50 gift vouchers. Data from the pilot study were not included in the data analysed in this article.

Questionnaire

The questionnaire (see online Appendix) included questions about demographic and professional details, such as country in which the primary medical degree was obtained, specialty, geographic location, and hours and type of practice. Representative items from the social resources and financial resources subscales of the Retirement Resources Inventory (RRI)14 were included. Health was measured on a 5-point self-rating scale of overall physical health, and also with the Self-Administered Comorbidity Questionnaire (SACQ),15 which asked whether the participant experienced, received treatment for, or was limited by any of 12 common medical problems.

Psychological variables were assessed with the K10, a validated screening instrument for measuring psychological distress.16 Items from the emotional resources subscale of the RRI that measure positive emotion, mastery, self-esteem, and self-perception of cognitive functioning14 were applied. The Anxiety about Ageing Scale17 was administered, including items reflecting each of four previously validated dimensions: fear of old people, psychological worries, concerns about physical appearance, and fear of losses.

A doctor’s self-identification with medical practice was assessed by two methods. The Work Centrality Questionnaire measures the primacy of work in a person’s life.18 Participants were also asked to state (on a 7-point Likert scale, ranging from “strongly agree” to “strongly disagree”) whether they viewed medical practice as a “job,” a “career”, or a “calling”.

Participants were asked to indicate whether they intended to retire (options: “I do not intend to retire”; “I do not know whether I will retire”; “I do intend to retire”). Those who intended to retire were asked to indicate a retirement age, and to rate the salience of factors that would determine its timing (on a Likert scale). Similarly, those who did not plan to retire or were unsure were asked about factors determining their decision. These factors were derived from previous research on older doctors, and from the general literature on retirement.19,20

Statistical analyses

As there was significant skew in the distribution of continuous variables (determined in one-sample Kolmogorov–Smirnov tests), descriptive statistics are reported as medians and interquartile ranges (IQRs). For categorical and dichotomous variables, numbers and percentages are reported. Skewed continuous data for dichotomous groupings were compared in Mann–Whitney U tests; χ² tests and linear-by-linear association tests for ordinal variables were applied in univariate analyses of variables with respect to age, sex and ITR. Please note when interpreting results that it is possible for groups to have different rank sums that are statistically significant in non-parametric tests, but to also have identical or nearly identical medians.

Potential predictors with a significant relationship with ITR (univariate analysis, P < 0.2) were included in logistic regression models, with dichotomised ITR as the dependent variable. The first model included all participants, the second and third models assessed each age group separately (55–64 years, 65 years and over), and the fourth and fifth models each sex. A sixth model included medical specialties for which there were at least 50 respondents.

A two-block variable entry procedure was applied; block 1 included demographic factors (age, sex, location of practice, country of qualification), with forced entry. In block 2, forward conditional likelihood ratio entry was used for survey scores.

All analyses were conducted in SPSS 22 (IBM). P < 0.05 was deemed statistically significant.

Ethics approval

The study was approved by the Human Research Ethics Advisory Panel of the University of New South Wales (reference, 2014-7-68).

Results

Of the 6000 doctors invited to participate, 1049 responded; one participant was excluded because they had recently retired, leaving a final cohort of 1048 (response rate, 17.5%). The proportion of respondents by state and territory was similar to the proportion of registrants aged 55 and older located in the respective jurisdictions:1 37.1% from New South Wales, 26.2% from Victoria, 20.7% from Queensland, 11.6% from Western Australia, 2.6% from Tasmania, and 1.2% from Northern Territory; five respondents (0.5%) were from the ACT and SA.

The demographic characteristics of the participants are summarised in Box 1. The median age was 65 years (IQR, 59–69 years; range, 55–89 years). The medical specialties with at least 50 respondents were general practice (439 doctors, 41.9% of sample), internal medicine specialists (122, 11.6%), anaesthesia (72, 6.9%), surgery (71, 6.8%) and psychiatry (56, 5.3%). Compared with national data, the sample was similar with regard to the proportion of female doctors aged 55 or more and general practitioners aged 55 or more, but there were fewer IMGs.1

Six hundred and fifty respondents (62.0%) intended to retire; the others (combined as one group in further analyses) either had no intention of retiring (11.4%) or were unsure (26.6%). There were no differences in ITR according to age or sex (Box 2). There were, however, statistically significant differences between the five specialties with more than 50 respondents (P = 0.001): anaesthetists were the most likely to affirm an ITR (76%), followed by surgeons (69%), internal medicine specialists (67%), GPs (56%), and psychiatrists (50%).

Of the doctors who intended to retire, 33% did not nominate a specific retirement age. The anticipated retirement age for those who did increased progressively with age: for those aged 55–64 years, the median anticipated retirement age was 65 years (IQR, 65–68 years); for those aged 65–74, it was 71 years (IQR, 70–75 years); for those aged 75–84, it was 80 years (IQR, 78–83 years); and for those aged 85 or more, it was 86 years (IQR, 86–88 years). The median anticipated retirement age was 70 years (IQR, 65–73 years) for men and 68 years (IQR, 65–71 years) for women.

There were significant differences by age in the anticipated reasons for retirement. Those aged 55–64 years were more likely than older doctors to nominate achieving financial security, being able to access superannuation, a desire for more personal or leisure time, and a partner or spouse retiring. Further, the younger group was more likely to plan transition to retirement by reducing working hours. Women were more likely to nominate a partner retiring as an anticipated reason for retirement (Box 2).

Among doctors who did not intend to retire or were unsure about retirement, there were significant differences by age in the reasons for continuing to work. Doctors aged 65 or older were more likely to indicate that continuing to work was motivated by the wishes of their partner or family, the cognitive stimulation afforded by work, their maintaining a sense of purpose, or their good physical health. Men were more likely to nominate a partner’s or family’s wishes as a reason for continuing to work (Box 3).

Factors associated with intention to retire

For the entire sample of respondents, the odds of ITR were lower for IMGs, and for those with a higher work centrality score and greater emotional resources. The odds of ITR were higher for doctors with better financial resources and greater anxiety about ageing (Box 4, model 1). It is notable that factors such as location of practice, social resources, and objective health were not significant factors.

For doctors aged 55–64 years, the odds of ITR were higher for those with better financial and social resources, and lower for IMGs and for those with greater work centrality. For doctors aged 65 or more, the odds of ITR were higher for doctors with better financial resources and greater anxiety about ageing, and lower for those with greater work centrality and greater emotional resources (Box 4, models 2 and 3).

The factors significant for ITR in male doctors were the same as for the whole sample. For women, the odds of ITR were higher for doctors with better financial resources, and lower for those with greater work centrality score and greater emotional resources (Box 4, models 4 and 5).

When regression analysis was restricted to doctors from the five specialties with more than 50 respondents (Box 4, model 6), the odds of ITR were lower for doctors who were IMGs, psychiatrists, GPs, and for those who reported greater work centrality and greater emotional resources. The odds of ITR were also higher for doctors with better financial resources and greater anxiety about ageing (Box 4, model 6).

Discussion

This is the first study of the broader professional and psychosocial factors associated with retirement intention among doctors in different specialties. Planning retirement has benefits for the continuity of patient care and service provision, and is likely to assist the medical practitioner’s adjustment to retirement.21

Our sample of doctors were less likely to retire than people aged 45 and over in the general population: male doctors planned to retire 4 years later (at age 69.7 v 65.7 years) and female doctors 3.6 years later (age 68.1 v 64.5 years) than people in the general community, while fewer doctors reported an ITR (62% v 79%).19 Only two-thirds of doctors who intended to retire nominated a retirement age, and the anticipated age increased progressively with each successive 10-year age bracket.

There were a number of differences between age groups in the reasons for either anticipating retirement or continuing to work. The responses of doctors aged 65 or more who intended to continue to work suggested that this group was financially independent, enjoyed good physical health, and valued a sense of purpose in life more than leisure time.

Women were more likely than men to accompany a spouse into retirement, and a greater proportion of women nominated responsibilities as a carer as a reason for retiring (although the difference was not statistically significant), consistent with data for the general community.19,22 Men were more likely to continue working because of the wishes of a partner or family.

Two factors, work centrality and financial resources, consistently predicted ITR in all regression models. It is unclear whether the association of greater work centrality with reduced odds of retiring is related to the self-identity of people attracted to medicine and, if so, whether this effect is limited to the current sample or generally applies to doctors over 55. Alternatively, the nature of medical practice may lead to work becoming the pre-eminent feature of one’s life. That greater emotional resources and greater anxiety about ageing were also associated with reduced odds of retirement is another indication of the importance of personal characteristics in determining retirement intentions.

Financial security was the other consistent factor when considering retirement, in keeping with data for the general community.19 Retirement intentions were informed by the views of a broader community, not just the practitioner themselves; for one-third of doctors the wishes of partners and family were a key consideration in the decision to keep working.

The desire of IMGs to delay retirement is unsurprising, given their later entry into the medical workforce in Australia. Interpretation of ITR in different specialties was limited by the fact that only five provided sufficient responses for statistical analysis. The odds of GPs and psychiatrists intending to retire were the lowest of the five specialties; this may reflect the respective salience for these two groups of financial rewards and physical demands in decision making about retiring. Although being a surgeon or anaesthetist were not significant factors in regression model 6, the proportions of respondents in these two specialties who planned to retire was greater than in the other three; this was perhaps related to the systemic approaches to ageing and retirement undertaken by their respective colleges.23

There are limitations to our study. These include the modest response rate to our survey of 17.5%. Although comparable with similar surveys,24 the low rate limits our ability to generalise our findings about subgroups of doctors. In addition, there are potential sources of bias, such as sample skewing toward doctors who were already contemplating retirement, the lack of demographic data on respondents apart from age, sex, and the proportion of practitioners in a specialty compared with their overall state/territory proportion, the under-representation of IMGs, and the electronic format of the survey. Although our sample was not fully national, its demographic data were comparable with national data on the proportions of women, GPs, and the states of practice. Finally, the cross-sectional nature of the survey did not allow retirement intention to be analysed as a dynamic process, although significant correlations between retirement intention and behaviour over 5 years have been reported.13

Our findings are relevant to developing education and support programs for assisting late career medical practitioners to transition to retirement. Retirement is potentially an emotional question for many doctors; learning about their colleagues’ experiences may be helpful. Such programs should include general advice (including about financial and emotional resources), recognise work as part of self-identity, and target specific groups, such as IMGs and GPs. Programs should be provided within continuing professional development programs, and receive funding from the medical colleges.

Box 1 –
Demographic characteristics of the 1048 respondents to the survey on intention to retire

	Total	55–64 years old	65 years old or more	P	Men	Women	P

Number of doctors	1048	520 (49.6%)	528 (50.4%)		807 (77.0%)	241 (23.0%)
Married (de jure/de facto)	921 (87.9%)	458 (88.1%)	463 (87.7%)	0.85	745 (92.3%)	176 (73.0%)	< 0.001
Work less than 40 h/week	558 (53.2%)	206 (39.6%)	352 (66.7%)	< 0.001	403 (49.9%)	155 (64.3%)	< 0.001
International medical graduate	205 (19.6%)	75 (14.4%)	130 (24.6%)	< 0.001	157 (19.5%)	48 (19.9%)	0.87
Live in a capital city	646 (61.6%)	317 (61.0%)	329 (62.3%)	0.77	491 (60.8%)	155 (64.3%)	0.33
Solo practitioner*	197 (19.9%)	74 (14.8%)	123 (25.0%)	< 0.001	154 (20.1%)	43 (18.9%)	0.69
Self-rated health
Excellent/very good	718 (68.5%)	355 (68.3%)	363 (68.8%)	0.87	546 (67.7%)	172 (71.4%)	0.28
Poor to good	330 (31.5%)	165 (31.7%)	165 (31.3%)		261 (32.3%)	69 (28.6%)
SACQ score, median (IQR)	2.0 (0.0–4.0)	2.0 (0.0–3.0)	2.0 (1.0–4.0)	< 0.001	2.0 (0.0–4.0)	2.0 (0.0–3.0)	0.031
K10 score, median (IQR)	12.0 (11.0–15.0)	13.0 (11.0–15.0)	12.0 (11.0–14.0)	< 0.001	12.0 (11.0–15.0)	12.0 (11.0–15.0)	0.68
Perception of work
Job	59 (5.6%)	37 (7.1%)	22 (4.2%)	0.11	49 (6.1%)	10 (4.1%)	0.013
Career	423 (40.4%)	203 (39.0%)	220 (41.7%)		342 (42.4%)	81 (33.6%)
Calling	566 (54.0%)	280 (53.8%)	286 (54.2%)		416 (51.5%)	150 (62.2%)
Work centrality score, median (IQR)	23.0 (21.0–25.0)	23.0 (20.0–25.0)	23.0 (21.0–25.0)	0.001	23.0 (21.0–25.0)	23.0 (20.0–25.0)	0.16
Anxiety about ageing score, median (IQR)	29.0 (26.0–32.0)	29.0 (25.0–32.0)	29.0 (26.0–32.0)	0.24	29.0 (26.0–32.0)	30.0 (25.0–32.0)	0.48

SACQ = Self-Administered Comorbidity Questionnaire. * Excludes 56 practitioners not engaged in patient care.

Box 2 –
Factors determining the timing of retirement among 650 doctors who intend to retire

	Total	55–64 years old	65 years old or more	P	Men	Women	P

Intend to retire (proportion of 1048 respondents)	650 (62.0%)	335 (64.4%)	315 (59.7%)	0.11	497 (61.6%)	153 (63.5%)	0.59
Intend to transition to retirement	540 (83.1%)	296 (88.4%)	244 (77.5%)	< 0.001	416 (83.7%)	124 (81.0%)	0.44
Factors affecting timing of retirement*
Financial security	371 (57.1%)	220 (65.7%)	151 (47.9%)	< 0.001	294 (59.2%)	77 (50.3%)	0.054
Physical illness/disability	364 (56.0%)	190 (56.7%)	174 (55.2%)	0.70	275 (55.3%)	89 (58.2%)	0.54
Cognitive impairment	354 (54.5%)	177 (52.8%)	177 (56.2%)	0.39	272 (54.7%)	82 (53.6%)	0.81
Work-related burnout	255 (39.2%)	141 (42.1%)	114 (36.2%)	0.12	192 (38.6%)	63 (41.2%)	0.57
Act as carer	178 (27.4%)	92 (27.5%)	86 (27.3%)	0.96	127 (25.6%)	51 (33.3%)	0.06
Desire more personal/leisure time	438 (67.4%)	243 (72.5%)	195 (61.9%)	0.004	336 (67.6%)	102 (66.7%)	0.83
Ability to access superannuation	225 (34.6%)	134 (40.0%)	91 (28.9%)	0.003	178 (35.8%)	47 (30.7%)	0.25
Spouse/partner retiring	139 (21.4%)	94 (28.1%)	45 (14.3%)	< 0.001	97 (19.5%)	42 (27.5%)	0.036

* Responses for each factor were dichotomised into “strongly agree”/“agree” v other responses.

Box 3 –
Factors determining decision to continue working for 398 doctors not intending to, or unsure about, retirement

	Total	55–64 years old	65 years old or more	P	Men	Women	P

Do not intend to retire, or unsure (proportion of entire sample)	398 (38.0%)	185 (35.6%)	213 (40.3%)	0.11	310 (38.4%)	88 (36.5%)	0.59
Factors affecting timing of retirement*
Relationship with patients	232 (58.3%)	101 (54.6%)	131 (61.5%)	0.16	179 (57.7%)	53 (60.2%)	0.68
Cognitive stimulation	349 (87.7%)	154 (83.2%)	195 (91.5%)	0.012	273 (88.1%)	76 (86.4%)	0.67
Finances	229 (57.5%)	115 (62.2%)	114 (53.5%)	0.08	174 (56.1%)	55 (62.5%)	0.29
Fulfilling professional relationships	254 (63.8%)	114 (61.6%)	140 (65.7%)	0.40	196 (63.2%)	58 (65.9%)	0.64
Good physical health	312 (78.4%)	134 (72.4%)	178 (83.6%)	0.007	239 (77.1%)	73 (83.0%)	0.24
Family’s/partner’s wishes	136 (34.2%)	49 (26.5%)	87 (40.8%)	0.003	118 (38.1%)	18 (20.5%)	0.002
Sense of purpose/goals	322 (80.9%)	140 (75.7%)	182 (85.4%)	0.013	248 (80.0%)	74 (84.1%)	0.39

*Responses for each factor were dichotomised into “strongly agree”/“agree” v other responses.

Box 4 –
Logistic regression analyses of factors significantly influencing the intention to retire by 1048 medical practitioners in Australia

Intend to retire

No intention/don’t know

Adjusted odds ratio (95% CI)

Model 1: Whole sampleP < 0.001; variance accounted, 9.5%

n = 650

n = 398

International medical graduate

99 (15.2%)

106 (26.6%)

0.61 (0.44–0.85)

0.004

RRI score: cognitive, emotional and motivational resources, median (IQR)

47 (44–50)

48 (45–51)

0.96 (0.93–0.98)

0.001

RRI score: financial resources, median (IQR)

7 (6–8)

1.31 (1.18–1.44)

< 0.001

Work centrality, median (IQR)

22 (20–24)

24 (22–26)

0.89 (0.85–0.92)

< 0.001

Anxiety about ageing, median (IQR)

30 (26–32)

28 (25–32)

1.05 (1.02–1.09)

< 0.001

Model 2: 55–64 years oldP < 0.001; variance accounted, 10.1%

n = 335

n = 185

International medical graduate

33 (9.9%)

42 (22.7%)

0.47 (0.28–0.80)

0.005

RRI score: social, median (IQR)

15 (13–17)

15 (12–17)

1.07 (1.01–1.14)

0.017

RRI score: financial resources, median (IQR)

7 (6–8)

1.38 (1.18–1.60)

< 0.001

Work centrality, median (IQR)

22 (20–24)

23 (21–25)

0.89 (0.83–0.94)

< 0.001

Model 3: 65 years or olderP < 0.001; variance accounted, 10.2%

n = 315

n = 213

RRI score: cognitive, emotional and motivational resources, median (IQR)

46 (43–49)

48 (45–50)

0.94 (0.91–0.98)

0.001

RRI score: financial resources, median (IQR)

7 (6–8)

1.22 (1.06–1.39)

0.004

Work centrality, median (IQR)

23 (20–25)

24 (22–26)

0.87 (0.82–0.93)

< 0.001

Anxiety about ageing, median (IQR)

30 (27–32)

29 (25–32)

1.06 (1.02–1.11)

0.004

Model 4: MenP < 0.001; variance accounted, 8.8%

n = 497

n = 310

International medical graduate

75 (15.1%)

82 (26.5%)

0.59 (0.41–0.86)

0.006

RRI score: cognitive, emotional and motivational resources, median (IQR)

47 (44–50)

48 (45–50)

0.97 (0.94–0.995)

0.021

RRI score: financial resources, median (IQR)

7 (6–8)

1.26 (1.13–1.41)

< 0.001

Work centrality, median (IQR)

22 (20–24)

24 (22–26)

0.89 (0.85–0.94)

< 0.001

Anxiety about ageing, median (IQR)

30 (26–32)

28 (25–31)

1.06 (1.02–1.10)

0.001

Model 5: WomenP < 0.001; variance accounted, 13.8%

n = 153

n = 88

RRI score: cognitive, emotional and motivational resources, median (IQR)

46 (44–49)

48 (45–51)

0.92 (0.86–0.98)

0.014

RRI score: financial resources, median (IQR)

7 (6–8)

6 (5–8)

1.48 (1.18–1.85)

0.001

Work centrality, median (IQR)

22 (20–24)

24 (21–26)

0.87 (0.79–0.96)

0.004

Model 6: Medical specialties with more than 50 responsesP < 0.001; variance accounted, 12.9%

n = 462

n = 298

International medical graduate

74 (16.0%)

84 (28.2%)

0.67 (0.45–0.99)

0.044

General practitioner

248 (53.7%)

191 (64.1%)

0.54 (0.34–0.87)

0.012

Psychiatrist

28 (6.1%)

28 (9.4%)

0.40 (0.20–0.79)

0.009

RRI score: cognitive, emotional and motivational resources, median (IQR)

47 (44–50)

48 (45–50)

0.95 (0.92–0.98)

0.001

RRI score: financial resources, median (IQR)

7 (6–8)

1.31 (1.17–1.48)

< 0.001

Work centrality, median (IQR)

22 (20–25)

24 (22–26)

0.87 (0.82–0.92)

< 0.001

Anxiety about ageing, median (IQR)

30 (27–32)

29 (25–32)

1.07 (1.03–1.11)

< 0.001

RRI = Retirement Resources Inventory. For all models, demographic variables were entered in a first block (eg, age groups, sex, international medical graduate, location of practice, specialty), before questionnaire data were entered in a second block (eg, RRI subscale, Self-Administered Comorbidity Questionnaire, work centrality, and Anxiety About Ageing scores). Note that it is possible for groups to have different rank sums that are statistically significant in non-parametric tests, but identical or nearly identical medians.