Guideline for the diagnosis and management of hypertension in adults — 2016

Blood pressure (BP) is an important common modifiable risk factor for cardiovascular disease. In 2014–15, 6 million adult Australians were hypertensive (BP ≥ 140/90 mmHg) or were taking BP-lowering medication.1 Hypertension is more common in those with lower household incomes and in regional areas of Australia (http://heartfoundation.org.au/about-us/what-we-do/heart-disease-in-australia/high-blood-pressure-statistics). Many Australians have untreated hypertension, including a significant proportion of Aboriginal and Torres Strait Islander people.1

Cardiovascular diseases are associated with a high level of health care expenditure.2 Controlled BP is associated with lower risks of stroke, coronary heart disease, chronic kidney disease, heart failure and death. Small reductions in BP (1–2 mmHg) are known to markedly reduce population cardiovascular morbidity and mortality.3,4

Method

The National Blood Pressure and Vascular Disease Advisory Committee, an expert committee of the National Heart Foundation of Australia, has updated the Guide to management of hypertension 2008: assessing and managing raised blood pressure in adults (last updated in 2010)5 to equip health professionals across the Australian health care system, especially those within primary care and community services, with the latest evidence to prevent, detect and manage hypertension.

International hypertension guidelines6–8 were reviewed to identify key areas for review. Review questions were developed using the patient problem or population, intervention, comparison and outcome(s) (PICO) framework.9 Systematic literature searches (2010–2014) of MEDLINE, Embase, CINAHL and the Cochrane Library were conducted by an external organisation, and the resulting evidence summaries informed the updated clinical recommendations. The committee also reviewed additional key literature relevant to the PICO framework up to December 2015.

Recommendations were based on high quality studies, with priority given to large systematic reviews and randomised controlled trials, and consideration of other studies where appropriate. Public consultation occurred during the development of the updated guideline. The 2016 update includes the level of evidence and strength of recommendation in accordance with National Health and Medical Research Council standards10 and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.11 No level of evidence has been included where there was no direct evidence for a recommendation that the guideline developers agreed clearly outweighed any potential for harm.

Most of the major recommendations from the guideline are outlined below, together with background information and explanation, particularly in areas of change in practice. Key changes from the previous guideline are listed in Box 1. The full Heart Foundation Guideline for the diagnosis and management of hypertension in adults – 2016 is available at http://heartfoundation.org.au/for-professionals/clinical-information/hypertension. The full guideline contains additional recommendations in the areas of antiplatelet therapy, suspected BP variability, and initiating treatment using combination therapy compared with monotherapy.

Recommendations

Definition and classification of hypertension

Elevated BP is an established risk factor for cardiovascular disease. The relationship between BP level and cardiovascular risk is continuous, therefore the distinction between normotension and hypertension is arbitrary.12,13 Cut-off values are used for diagnosis and management decisions but vary between international guidelines. Current values for categorisation of clinic BP in Australian adults are outlined in Box 2.

Management of patients with hypertension should also consider absolute cardiovascular disease risk (where eligible for assessment) and/or evidence of end-organ damage. Several tools exist to estimate absolute cardiovascular disease risk. The National Vascular Disease Prevention Alliance developed a calculator for the Australian population, which can be found at http://www.cvdcheck.org.au.

Treatment strategies for individuals at high risk of a cardiovascular event may differ from those at low absolute cardiovascular disease risk despite similar BP readings. It is important to note that the absolute risk calculator has been developed using clinic BP, rather than ambulatory, automated office or home BP measures.

Some people are not suitable for an absolute risk assessment, including younger patients with uncomplicated hypertension and those with conditions that identify them as already at high risk.14

Blood pressure measurement

A comprehensive assessment of BP should be based on multiple measurements taken on several separate occasions. A variety of methods are available, each providing different but often complementary information. Methods include clinic BP, 24-hour ambulatory and home BP monitoring (Box 3).

Most clinical studies demonstrating effectiveness and benefits of treating hypertension have used clinic BP. Clinic, home and ambulatory BP all predict the risk of a cardiovascular event; however, home and ambulatory blood pressure measures are stronger predictors of adverse cardiovascular outcomes (Box 4).15,16

Automated office BP measurement involves taking repeated blood pressure measurements using an automated device with the clinician out of the room.17,18 This technique generally yields lower readings than conventional clinic BP and has been shown to have a good correlation with out-of-clinic measures.

The British Hypertension Society provides a list of validated BP monitoring devices.19 Use of validated and regularly maintained non-mercury devices is recommended as mercury sphygmomanometers are being phased out for occupational health and safety and environmental reasons.

Treatment thresholds

Although the benefits of lowering BP in patients with significantly elevated BP have been well established, the benefit of initiating drug therapy in patients with lower BP with or without comorbidities has been less certain. A meta-analysis of patients with uncomplicated mild hypertension (systolic BP range, 140–159 mmHg) indicated beneficial cardiovascular effects with reductions in stroke, cardiovascular death and all-cause mortality, through treatment with BP-lowering therapy.20 Corresponding relative reductions in 5-year cardiovascular disease risk were similar for all levels of baseline BP.21

Decisions to initiate drug treatment at less severe levels of BP elevations should consider a patient’s absolute cardiovascular disease risk and/or evidence of end-organ damage together with accurate blood pressure readings.

Treatment targets

Optimal blood pressure treatment targets have been debated extensively. There is emerging evidence demonstrating the benefits of treating to optimal BP, particularly among patients at high cardiovascular risk.17,20

The recent Systolic Blood Pressure Intervention Trial investigated the effect of targeting a higher systolic BP level (< 140 mmHg) compared with a lower level (< 120 mmHg) in people over the age of 50 years who were identified as having a cardiovascular 10-year risk of at least 20%.17 Many had prior cardiovascular events or mild to moderate renal impairment and most were already on BP-lowering therapy at the commencement of the study. Patients with diabetes, cardiac failure, severe renal impairment or previous stroke were excluded. The method of measurement was automated office BP,18 a technique that generally yields lower readings than conventional clinic BP. Patients treated to the lower target achieved a mean systolic BP of 121.4 mmHg and had significantly fewer cardiovascular events and lower all-cause mortality compared with the other treatment group, which achieved a mean systolic level of 136.2 mmHg. Older patients (> 75 years) benefited equally from the lower target BP. However, treatment-related adverse events increased in the more intensively treated patients, with more frequent hypotension, syncopal episodes, acute kidney injury and electrolyte abnormalities.

The selection of a BP target should be based on an informed, shared decision-making process between patient and doctor (or health care provider), considering the benefits and harms and reviewed on an ongoing basis.

Recommendations for treatment strategies and treatment targets for patients with hypertension are set out in Box 5.

Box 1 –
Key changes from previous guideline

Use of validated non-mercury sphygmomanometers that are regularly maintained is recommended for blood pressure (BP) measurement.
Out-of-clinic BP using home or 24-hour ambulatory measurement is a stronger predictor of outcome than clinic BP measurement.
Automated office blood pressure (AOBP) provides similar measures to home and ambulatory BP, and results are generally lower than those from conventional clinic BP measurement.
BP-lowering therapy is beneficial (reduced stroke, cardiovascular death and all-cause mortality) for patients with uncomplicated mild hypertension (systolic BP, 140–159 mmHg).
For patients with at least moderate cardiovascular risk (10-year risk, 20%), lower BP targets of < 120 mmHg systolic (using AOBP) provide benefit with some increase in treatment-related adverse effects.
Selection of a BP target should be based on informed, shared decision making between patients and health care providers considering the benefits and harms, and reviewed on an ongoing basis.

Box 2 –
Classification of clinic blood pressure in adults

Diagnostic category*

Systolic (mmHg)

Diastolic (mmHg)

Optimal

< 120

and

< 80

Normal

120–129

and/or

80–84

High-normal

130–139

and/or

85–89

Grade 1 (mild) hypertension

140–159

and/or

90–99

Grade 2 (moderate) hypertension

160–179

and/or

100–109

Grade 3 (severe) hypertension

≥ 180

and/or

≥ 110

Isolated systolic hypertension

> 140

and

< 90

Reproduced with permission from the National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults — 2016. Melbourne: NHFA, 2016. * When a patient’s systolic and diastolic blood pressure levels fall into different categories, the higher diagnostic category and recommended actions apply.

Box 3 –
Criteria for diagnosis of hypertension using different methods of measurement

Method of measurement

Systolic (mmHg)

Diastolic (mmHg)

Clinic

≥ 140

and/or

≥ 90

ABPM daytime (awake)

≥ 135

and/or

≥ 85

ABPM night-time (asleep)

≥ 120

and/or

≥ 70

ABPM over 24 hours

≥ 130

and/or

≥ 80

HBPM

≥ 135

and/or

≥ 85

Box 4 –
Recommendations for monitoring blood pressure (BP) in patients with hypertension or suspected hypertension

Method of measuring BP

Grade of recommendation*

Level of evidence^†

If clinic BP is ≥ 140/90 mmHg or hypertension is suspected, ambulatory and/or home monitoring should be offered to confirm the BP level

Strong

Clinic BP measures are recommended for use in absolute cardiovascular risk calculators. If home or ambulatory BP measures are used in absolute cardiovascular disease risk calculators, risk may be inappropriately underestimated

Strong

–

Procedures for ambulatory BP monitoring should be adequately explained to patients. Those undertaking home measurements require appropriate training under qualified supervision

Strong

Finger and/or wrist BP measuring devices are not recommended

Strong

–

Reproduced with permission from the National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults — 2016. Melbourne: NHFA, 2016. * Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.11 † National Health and Medical Research Council standards;10 no level of evidence included where there was no direct evidence for a recommendation that the guideline developers agreed clearly outweighed any potential for harm.

Box 5 –Recommendations for treatment strategies and treatment targets for patients with hypertension, with grade of recommendation and level of evidence*

A healthy lifestyle, including not smoking, eating a nutritious diet and regular adequate exercise is recommended for all Australians including those with and without hypertension.

Lifestyle advice is recommended for all patients (grade: strong; level: –).
For patients at low absolute cardiovascular disease risk (5-year risk, < 10%) with persistent blood pressure (BP) ≥ 160/100 mmHg, antihypertensive therapy should be started (grade: strong; level: I).
For patients at moderate absolute cardiovascular disease risk (5-year risk, 10–15%) with persistent systolic BP ≥ 140 mmHg and/or diastolic ≥ 90 mmHg, antihypertensive therapy should be started (grade: strong; level: I).
Once decided to treat, patients with uncomplicated hypertension should be treated to a target of < 140/90 mmHg or lower if tolerated (grade: strong; level: I).
In selected high cardiovascular risk populations where a more intense treatment can be considered, aiming for a target of < 120 mmHg systolic BP can improve cardiovascular outcomes (grade: strong; level: II).
In selected high cardiovascular risk populations where a treatment is being targeted to < 120 mmHg systolic BP, close follow-up of patients is recommended to identify treatment-related adverse effects including hypotension, syncope, electrolyte abnormalities and acute kidney injury (grade: strong; level: II).
In patients with uncomplicated hypertension, angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs), calcium channel blockers and thiazide diuretics are all suitable first-line antihypertensive drugs, either as monotherapy or in some combinations unless contraindicated (grade: strong; level: I).
The balance between efficacy and safety is less favourable for β-blockers than other first-line antihypertensive drugs. Thus β-blockers should not be offered as a first-line drug therapy for patients with hypertension that is not complicated by other conditions (grade: strong; level: I).
ACE inhibitors and ARBs are not recommended in combination due to an increased risk of adverse effects (grade: strong; level: I).

Treatment-resistant hypertension

Treatment-resistant hypertension is defined as a systolic BP ≥ 140 mmHg in a patient who is taking three or more antihypertensive medications, including a diuretic at optimal tolerated doses. Contributing factors may include variable compliance, white coat hypertension or secondary causes for hypertension.Few drug therapies specifically target resistant hypertension. Renal denervation is currently being investigated as a treatment option in this condition; however, to date, it has not been found to be effective in the most rigorous study conducted.22

Optimal medical management (with a focus on treatment adherence and excluding secondary causes) is recommended (grade: strong; level: II).
Percutaneous transluminal radiofrequency sympathetic denervation of the renal artery is currently not recommended for the clinical management of resistant hypertension or lower grades of hypertension (grade: weak; level: II).

Patients with hypertension and selected comorbidities

Stroke and transient ischaemic attack:

For patients with a history of transient ischaemic attacks or stroke, antihypertensive therapy is recommended to reduce overall cardiovascular risk (grade: strong; level: I).
For patients with a history of transient ischaemic attacks or stroke, any of the first-line antihypertensive drugs that effectively reduce BP are recommended (grade: strong; level: I).
For patients with hypertension and a history of transient ischaemic attacks or stroke, a BP target of < 140/90 mmHg is recommended (grade: strong; level: I).

Chronic kidney disease:

Most classes of BP-lowering drugs have a similar effect in reducing cardiovascular events and all-cause mortality in patients with chronic kidney disease (CKD). When treating with diuretics, the choice should be dependent on both the stage of CKD and the extracellular fluid volume overload in the patient. Detailed recommendations on how to manage patients with CKD are available.23

In patients with hypertension and CKD, any of the first-line antihypertensive drugs that effectively reduce BP are recommended (grade: strong; level: I).
When treating hypertension in patients with CKD in the presence of microalbuminuria or macroalbuminuria, an ARB or ACE inhibitor should be considered as first-line therapy (grade: strong; level: I).
In patients with CKD, antihypertensive therapy should be started in those with BP consistently > 140/90 mmHg and treated to a target of < 140/90 mmHg (grade: strong; level: I).
Dual renin-angiotensin system blockade is not recommended in patients with CKD (grade: strong; level: I).
For patients with CKD, aiming towards a systolic BP < 120 mmHg has shown benefit, where well tolerated (grade: strong; level: II).
In people with CKD, where treatment is being targeted to less than 120 mmHg systolic BP, close follow-up of patients is recommended to identify treatment-related adverse effects, including hypotension, syncope, electrolyte abnormalities and acute kidney injury (grade: strong; level: I).
In patients with CKD, aldosterone antagonists should be used with caution in view of the uncertain balance of risks versus benefits (grade: weak; level: –).

Diabetes:

Antihypertensive therapy is strongly recommended in patients with diabetes and systolic BP ≥ 140 mmHg (grade: strong; level: I).
In patients with diabetes and hypertension, any of the first-line antihypertensive drugs that effectively lower BP are recommended (grade: strong; level: I).
In patients with diabetes and hypertension, a BP target of < 140/90 mmHg is recommended (grade: strong; level: I).
A systolic BP target of < 120 mmHg may be considered for patients with diabetes in whom prevention of stroke is prioritised (grade: weak; level: –).
In patients with diabetes, where treatment is being targeted to < 120 mmHg systolic BP, close follow-up of patients is recommended to identify treatment-related adverse effects including hypotension, syncope, electrolyte abnormalities and acute kidney injury (grade: strong; level: –).

Myocardial infarction:

For patients with a history of myocardial infarction, ACE inhibitors and β-blockers are recommended for the treatment of hypertension and secondary prevention (grade: strong; level: II).
β-Blockers or calcium channel blockers are recommended for symptomatic patients with angina (grade: strong; level: II).

Chronic heart failure:

In patients with chronic heart failure, ACE inhibitors and selected β-blockers are recommended (grade: strong; level: II).
ARBs are recommended in patients who do not tolerate ACE inhibitors (grade: strong; level: I).

Peripheral arterial disease:

In patients with peripheral arterial disease, treating hypertension is recommended to reduce cardiovascular disease risk (grade: strong; level: –).
In patients with hypertension and peripheral arterial disease, any of the first-line antihypertensive drugs that effectively reduce BP are recommended (grade: weak; level: –).
In patients with hypertension and peripheral arterial disease, reducing BP to a target of < 140/90 mmHg should be considered and treatment guided by effective management of other symptoms and contraindications (grade: strong; level: –).

Older people:

Any of the first-line antihypertensive drugs that effectively reduce BP can be used in older patients with hypertension (grade: strong; level: I).
When starting treatment in older patients, drugs should be commenced at the lowest dose and titrated slowly as adverse effects increase with age (grade: strong; level: –).
For patients > 75 years of age, aiming towards a systolic BP of < 120 mmHg has shown benefit, where well tolerated, unless there is concomitant diabetes (grade: strong; level: II).
In older people whose treatment is being targeted to < 120 mmHg systolic BP, close follow-up is recommended to identify treatment-related adverse effects including hypotension, syncope, electrolyte abnormalities and acute kidney injury (grade: strong; level: II).
Clinical judgement should be used to assess benefit of treatment against risk of adverse effects in all older patients with lower grades of hypertension (grade: strong; level: –).

Adapted with permission from the National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults – 2016. Melbourne: NHFA, 2016. * Grade of recommendation based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology;11 level of evidence according to the National Health and Medical Research Council standards10 — no level of evidence included where there was no direct evidence for a recommendation that the guideline developers agreed clearly outweighed any potential for harm.

Ankles jerk — yes, but how?

Eliciting an ankle jerk is not a trivial task. It requires the skills of an experienced bell-ringer, an expert golfer and a mechanical engineer. The experience of the examiner and the positioning of the patient are two factors contributing to the accuracy of reported findings.1,2 Accurate findings can provide invaluable clinical information.

When an ankle jerk is elicited, the response can be seen, felt and heard. When the response is present, the tendon produces an undamped oscillation heard as a “boing”, and when it is absent, the damped oscillation is heard as a dull “thud”.

Percussion on the Achilles tendon activates muscle spindles — specialised sensory receptors within the muscle that respond to stretch (lengthening) and vibration. Action potentials move centripetally via large diameter, myelinated, fast conducting fibres, and trigger responses in the spinal cord from α motor neurones that mediate muscle contraction. The magnitude and rapidity of the reflex response is modulated by both autonomic sympathetic tone and descending (upper motor neurone) inhibition.3

Reflex activation is faster and stronger when sympathetic nervous system tone is high. Patients who are anxious, thyrotoxic or withdrawing from alcohol will have stronger, brisker responses. Similarly, if descending inhibition from upper motor neurones is reduced by, for example, stroke, myelopathy or Jendrassik (reinforcement) manoeuvre, there will be stronger, brisker responses.

An intact ankle jerk response confirms normal function in the large diameter, myelinated, sensory fibres, in spinal cord integration at the L5-S1 level, and in the α motor neurones projecting to skeletal muscle. Symmetrical reduction or loss of ankle jerks occurs early in the course of large fibre sensory neuropathy (eg, in diabetes). Asymmetrical loss of the ankle jerk is a common sign of radiculopathy but may also occur with rarer conditions such as plexopathy. Symmetrical exaggeration of ankle jerks may simply reflect increased sympathetic nervous system activity. Whether symmetrically brisk responses are pathological or not depends on the “company they keep”. If the exaggerated ankle jerks are accompanied by clonus, spasticity, spread of reflexes, or an extensor plantar response, they will be judged to be pathologically exaggerated. Asymmetrical exaggeration of one ankle jerk indicates the presence of an upper motor neurone abnormality (either ipsilateral or contralateral, depending on how rostral the lesion is).

Absent ankle jerks are often due to faulty technique. If the tendon is too slack, it will not vibrate when struck, and if it is too taut, the response will be diminished or inevident. If the head of the reflex hammer strikes adjacent bone or connective tissue as well as the tendon, any response may be attenuated or lost. This is the bell-ringing skill. If the head of the hammer is pushed against the tendon, rather than allowed to swing freely against it and bounce off unimpeded, the response may be decreased or absent. This is the skill of the experienced golfer. Patient positioning can affect tendon length, sympathetic tone and the magnitude of descending inhibition. This is the mechanical engineering skill.

Unfortunately, most medical students have only a hazy notion of the required skill and are often taught the patient positioning that is least likely to offer early success. There are at least five different positions that can be used to elicit ankle jerks, each with advantages and disadvantages. The positions are illustrated, and their relative merits described, in Figures 1 – 5. Additional dynamic factors are discussed in the video at mja.com.au.

Figure 1 –
Patient kneeling backwards in a chair

In this position, the lower segment muscles are relaxed and the tendon is near optimal stretch. However, the examiner needs to be aware that gripping the back of the chair is a default Jendrassik manoeuvre, exaggerating the response. This is desirable if the ankle jerk is thought to be absent. This method is reported to have the lowest rate of false-negative results.

Figure 2 –
Patient with legs dangling over the edge of the bed

In this position, the examiner must gently position the ankle in the mid-position without the patient “helping” by contracting the ankle dorsiflexors and preventing the reflex plantar flexion.

Figure 3 –
Patient seated in a chair with the feet beneath the knees

This position almost automatically produces lower limb relaxation and optimal tendon stretch. However, it requires an examiner to “grovel” a little in front of the patient.

Figure 4 –
Patient supine in bed with legs relaxed

The technique illustrated here requires the examiner to strike his or her hand while it rests on the sole of the foot near the metatarsal heads. Patients will often become tense when first touched, and the examiner has to avoid excessive dorsiflexion at the ankle with this technique. It is said to be a more reproducible technique for general physicians, but it might also produce more false-negative results.

Figure 5 –
Patient supine with hip abducted and externally rotated, knee flexed and ankle dorsiflexed

This traditional positioning is easily the most problematic. Patients for whom this position is uncomfortable, unseemly or simply unfamiliar will experience excess muscle tension. In addition, if the patient is unable to hold the position unaided, the examiner is tempted to stabilise the limb by strongly dorsiflexing the foot at the ankle, thereby lengthening the tendon excessively and reducing the chance of obtaining any response. The effect is complete if the examiner, failing to elicit a response, exhorts the patient to relax. Feeling implicitly blamed, the patient inevitably becomes more tense.

Clinical examination: evidence and eminence

We introduce a new MJA series outlining essential clinical skills for generalists, doctors in training and medical students

Medicine is a science of uncertainty and an art of probability
– Sir William Osler1

All clinicians and medical students are excited when they make a diagnosis from taking a patient’s history or after a physical examination. Most diagnoses can be made by taking a full history followed by targeted clinical examination.2 If and when necessary, this can be followed by appropriate cost-effective investigations. A targeted and thorough physical examination can avoid the ordering of inappropriate tests that return results that are very difficult or impossible to interpret. Inappropriate tests often lead to further tests to try to clarify unexpected (and usually false-positive) results. In the past, investigations used to follow and complement, rather than replace, clinical examination.

We need to bring this philosophy back to medicine to save costs and connect with our patients. For example, if you hear a systolic murmur at the apex and are not sure whether it results from aortic stenosis or mitral regurgitation, by all means confirm the diagnosis with an echocardiogram. But be sure to refine your clinical acumen. For example, if you thought it was mitral regurgitation but the echocardiogram reported aortic stenosis, this is your opportunity to improve your clinical skills.

While the uninitiated may think investigations lessen the importance of clinical skills, good history taking and physical examination is the way to gain patients’ confidence and connect with them.3

Reliability and accuracy are two separate entities in a clinical examination. Reliability is how two clinicians agree on a finding, yet they may both be inaccurate when objectively assessed.4 Some physical signs were described decades ago, when disease patterns and population characteristics were different. Could some of these signs be obsolete now? What is the evidence base in 2016?

As David Sacket, a pioneer of evidence-based medicine, observed, there are many reasons for paucity of evidence in clinical examination.5 Sackett identified several reasons for this problem: the challenges of designing and undertaking studies of physical examination; the difficulty of analysing a single sign when a diagnosis is made up of constellations of symptoms and signs; academic staff showing little inclination to investigate the physical examination as they spend little time at the bedside; the realities and pressures of modern medicine discouraging a careful history and physical examination; and the unpopularity of research when it challenges authority and the “art of medicine”.5 The reduction of length of stay and teaching being mainly confined to tertiary hospitals are other modern problems.

When there is no evidence, what should the physician do?6 For example, should we still percuss the cardiac border for a pericardial effusion in an obese patient when we could get an echo in a few minutes? Is the ankle jerk absent because of poor technique or peripheral neuropathy? What is the best way to elicit shifting dullness during ward rounds to avoid the shifting dullness of ward rounds (from patient to patient)?

This MJA medical education series will outline some essential clinical skills for generalists, doctors in training and medical students. As series editors, we will invite eminent clinicians to write about clinical skills that are important but poorly done and to evaluate the current clinical relevance of those skills. The series begins with some common topics. We will be very interested to receive your feedback about the skills you think are important.

Along with Sapira,7 we believe that history taking and physical examination are an art and a science. This MJA series is for people “who consider medicine to be a human and humane endeavour, not an industry”.7 We are passionate about bringing the art and science back to clinical teaching. We hope that many of you are too.

Dr Google aims to become more medical

With 1% of all Google searches related to medical symptoms, chances are some of your patients have searched on Dr Google before arriving at your door.

However for many, searching for symptoms on the internet can be a hindrance and not particularly trustworthy, particularly when a ‘worried well’ patient finds themselves researching a serious and probably unlikely condition after searching for a fairly mild symptom.

With this in mind, Google has announced they’re streamlining medical based searches to help people navigate medical content on the web.

In the future, when people search for symptoms like ‘headache to one side’, they’ll be shown a list of related conditions (for example “headache,” “migraine,” “tension headache,” “cluster headache,” “sinusitis,” and “common cold”).

The information will show up as a summary at the top of the page so people don’t have to crawl through multiple sites and blogs to find what they need.

They will also be given an overview description as well as self-treatment option and when it might be time to visit the doctor.

Product Manager Veronica Pinchin writes on the official Google blog that all the information has been collated alongside medical doctors and experts at Harvard Medical School and Mayo Clinic.

Although at this stage, the new changes will only be seen on US mobile searches, the company anticipates it will be gradually released in other languages and markets.

“By doing this, our goal is to help you to navigate and explore health conditions related to your symptoms, and quickly get to the point where you can do more in-depth research on the web or talk to a health professional,” she wrote.

Latest news:

Simple processing and clever apps? Don’t hold your breath for a user-friendly Medicare IT system

The privatisation of Australia’s Medicare organisation has become a hot issue in this election with the Labor party accusing the Liberals of wanting to privatise Medicare.

The Liberal Government earlier this year earmarked A$5 million to fund consultants to review the digital payment services of Medicare. This was with a view to cutting costs on Medicare’s processing of A$50 billion in annual claims.

The “digital payments services taskforce”, which promised to examine how Medicare’s systems could be modernised, no longer seems to be running.

Prime Minister Malcolm Turnbull has also stated there are no plans to proceed with a privatisation of Medicare’s payment systems.

It is misleading to talk about Medicare’s payment system as if it was a single system that could be easily outsourced to a private company. Medicare’s IT systems are the product of an evolution of government policy that dictates who is to be paid for health service encounters and under what circumstances.

The payments service is further complicated by the fact it has to interface with thousands of different providers and millions of end users.

Medicare processes medical expense claims for potentially every encounter between an eligible Australian and a health professional or organisation. There are a series of rules that govern what can be claimed and whether the organisation, health professional or individual is responsible for making the claim.

Some of these payment claims are handled through software provided by any one of dozens of different vendors. These software companies have all gone through a process whereby their systems are certified to interface with those of Medicare’s.

Medicare also manages the issuing of cards, identifiers and runs a “public key infrastructure” which provides health professionals with cryptographic signatures that can be used in conjunction with the payments system.

From Medicare’s perspective, its major goal is to provide a reliable service so the entire system processes payments correctly and with an acceptable timeframe. The secondary role would be to provide a digital interface to its customers, especially the general public.

Medicare has certainly been very slow to fulfil this latter role. Its moves in this direction have missed the mark when compared to the slick and user-friendly apps most modern tech companies are now providing.

However, this is also true of some of the private companies that were put forward as possible providers of Medicare’s payment system. Companies such as Telstra and Australia Post are not that far behind Medicare in terms of the technology they have provided their own customers.

The problem all companies face, especially those that aren’t technology companies, is their internal IT is usually underfunded. It is also often set with expectations of reliability and security that run counter to being able to innovate and move quickly. Often, the technology produced by these departments is a reflection of how the companies do business, so clunky mobile apps reflect the same lumbering processes.

Changing culture in these departments is very difficult because new leaders have to make do with staff who have become “acculturated” to a specific way of doing things are done. They can therefore be reluctant to change their practice through fear of change or lack of ability.

When a system is as complex as Medicare’s, it is extremely expensive to rebuild. It is not possible to simply “retrofit” an off-the-shelf product from another company.

IBM’s attempts to redevelop Queensland’s payroll system, for example, were plagued with delays and budget blow-outs, resulting in a system that didn’t work very well. In large part this was caused by the complexity of the system’s arcane rules and a lack of real understanding of these rules by the people interfacing with IBM and others.

Attempts to privatise Medicare’s systems would be met with similar challenges.

IT is often a reflection of the underlying company business models and processes, so improvements to IT systems cannot happen unless there is a change to the underlying processes they implement.

Medicare has a much greater challenge. Not only are business processes an issue, the politics that drove these policies and processes would need to change. Given the politics of Medicare as a public good, it is very difficult to disassociate tackling any part of that service from being seen to be challenging Medicare’s role in public life.

As a result, it is unlikely very much will change to any significant extent in Medicare’s IT services, even if there was a technological way forward and a team of people, internal or otherwise, to implement them.

David Glance, Director of UWA Centre for Software Practice, University of Western Australia. This article was originally published on The Conversation. Read the original article.

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

Other doctorportal blogs

On assisted dying

The AMA National Conference hosted a special policy session on the highly contentious issue of assisted dying as part of an on-going AMA policy review.

The session, moderated by ABC presenter Tony Jones, brought together a panel of doctors, ethicists and lawyers with a range of views on whether doctors should be involved in assisted dying.

The debate began with an account of the death of an elderly patient who had had a breathing tube removed without anaesthetic because the treating doctor was fearful that if they administered a drug they might be charged with causing their death.

The scenario prompted discussion of the degree to which doctors were uncertain about the law around assisted dying and the so-called double effect doctrine.

Professor of Ethics at the University of Queensland, Malcolm Parker, said it was “widely understood the doctor knowledge of the law in all sorts of areas is not particularly good,” and many doctors were worried that if the treatment they provided had the effect of causing death, “they will get into trouble”.

Avant Head of Advocacy, Georgie Haysom, said the issue hinged around intent: “If you intend to cause someone’s death, that is murder”.

Dr Karen Hitchcock, who works in acute and general medicine at Melbourne’s Alfred Hospital and last year wrote a Quarterly Essay on caring for the elderly, said there needed to be much greater education around the double effects doctrine, under which the death of a patient is a side effect of treatment.

“Double effect is the bedrock of medicine, which is to treat symptoms,” Dr Hitchcock said. “We never treat life, we treat symptoms. So hastening death is not an issue. [Doctors] do not set out to kill; alleviating symptoms is the aim.”

Associate Professor Mark Yates, a geriatrician at Ballarat Health Services, said the double effects doctrine “is used on a day-today basis”, and rather than changing its position on assisted dying, the AMA should devote its efforts to promoting good palliative care.

But Emeritus Professor Bob Douglas from the Australian National University said the double effects doctrine was “a nonsense”, and was causing serious concern for both doctors and the broader community.

Professor Douglas agreed that there needed to be greater investment in palliative care and advance care planning, but said patients should have the choice of assisted dying.

“From the perspective of a patient, my concern is that when I get to the point of incurable illness and inevitable death, I don’t want to put all my relatives through the pain and suffering of an unnecessarily elongated process,” he said.

Professor Douglas said laws similar to those enacted in the US state of Oregon, which allow terminally ill adults to obtain and use prescriptions from their physicians for self-administered, lethal doses of medications, would “give a lot of people comfort”.

Dr Hitchcock said, however, that Oregon-style laws were unnecessary and could actually be harmful, by making the elderly and disabled feel pressured into seeking assisted dying, such as because of the fear of being a burden to their relatives.

“Every patient [already] has a right to choose to have treatment withdrawn,” she said. “The main reason people request physician-assisted suicide is because of feelings of uselessness and hopelessness. If we give people the choice, it will influence them.”

Dr Hitchcock disputed claims that Oregon-style laws put doctors at arms’ length from killing their patients, arguing it was “ridiculous” to pretend that writing a prescription for a lethal dose of medicine was not an act.

“What we are proposing is that instead of [a palliative care team], doctors can give a patient a prescription to go ahead and kill themselves,” she said. “We are talking about replacing the palliative care team with a script.”

But Professor Douglas countered that just knowing assisted dying was an option could bring people enormous comfort, and experience showed that far from all who acquired a prescription for lethal medication went on to use it.

Figures published by the Oregon Public Health Division show that from the time the laws were introduced in 1997 and the end of 2013, 1173 had obtained prescriptions and 752 had used them. During 2013, 122 people were provided a prescription, and 71 had killed themselves.

AMA President Dr Michael Gannon, who initiated the policy review as Chair of the AMA Ethics and Medico-legal Committee, said the National Conference session would, along with 3500 responses to an AMA member survey, be used to help inform the AMA Federal Council’s deliberations on the issue.

Adrian Rollins

Financial toxicity in clinical care today: a “menu without prices”

Out-of-pocket costs are rising rapidly and can influence treatment decisions and health outcomes

Australia delivers health outcomes that rank well internationally, with per capita spending demonstrably less than that of the United States. Of concern, Australia’s out-of-pocket costs for health care are sixth highest among Organisation for Economic Co-operation and Development countries,2 despite universal health insurance. These out-of-pocket expenses accounted for 57% of non-government health expenditure in 2011–12, or over 17% of all health care expenditure.3 Health care costs in Australia continue to rise well above the consumer price index. The net burden of costs are reported by clinicians to influence some decisions that patients make, with the potential for detrimental health outcomes for individuals and for Australia’s health as a whole.

The average equivalised weekly disposable household income in 2013–14 was $998, with a median of $844.4 About half of all households therefore have a weekly net income of less than $844, yet that income has to support out-of-pocket health expenses. There are also limits to what is covered under different aspects of the safety net. Further, many aspects of community-based care are associated with part or all of the cost being borne by the patient, in many cases with no safety net provisions (wound dressings, incontinence pads, community nursing and allied health visits).

In cancer care, patients often face tough decisions as new unsubsidised therapies become available. An ageing population, innovations (some with very marginal benefits) and the risk that some procedures are overused or harmful all contribute to unnecessary financial (and emotional) pressure on patients and their families. Procedures and interventions, at times with marginal health gains, are being promoted actively, frequently with high costs and little meaningful benefit in terms of quality of life or survival. In the context of ongoing outcome disparities based on socio-economic status, our aim must be timely access to world class care for all Australians, regardless of financial circumstances.

In the Australian context, financial disclosure is not only how much a procedure will cost but, crucially, whether there are alternatives that offer similar benefits at less cost to the patient. This may be as important to the patient as the side effects or risks of an intervention. Most starkly, the omission of information from a private clinician regarding options in the public sector reduces informed financial choice and increases the potential for significant financial and health disadvantages.

Failing to inform patients about comparative waiting times in public and private systems falls short of fully informed (financial) consent. Indeed, national data demonstrate that public surgical waiting times for a sample of cancers are very short.5 Publicly available data on waiting times and service quality are critical for supporting informed treatment decisions, especially when out-of-pocket expenses can vary from zero to tens of thousands of dollars for the same procedure.

Value in health care is defined as outcomes relative to cost.6 In considering this from a patient’s perspective, it is imperative to not only question outcomes but to understand the true cost for the whole episode of care — the out-of-pocket expenses, the contribution made by the community through Medicare, and any supplementary private insurance. Informed choice should be based on more than the costs charged by an individual practitioner and those incurred by related pathology, imaging and anaesthetics. Informed choice now needs also to account for the extreme variations in the prices charged by identically credentialed practitioners within Australia undertaking the identical procedure.7

International data suggest that the consequences of high out-of-pocket costs include the potential for poorer compliance with ideal care, including prescribed medications that are necessary for best outcomes.8,9 To make decisions about what is often a long treatment pathway across multiple modalities, patients need a comprehensive and early understanding of the financial impacts of treatment, time away from work and other costs, and the opportunity to seek financial advice and assistance early as needed. Indeed, in one survey, people only sought help when the financial burden was starting to cause significant difficulties.9

Arguably, failure by medical practitioners to disclose all of the financial costs affecting patients’ decisions is a cause of avoidable suffering for tens of thousands of households across Australia each year.10 A new standard for financial disclosure is required — a standard that moves beyond disclosure of the costs of a single procedure to one that accounts for the costs of a full pathway of treatment and all the alternatives open to the patient. The issue of financial toxicity in Australian health care requires open debate supported by population- and individual-level data on rapidly rising out-of-pocket costs, and advocacy that places patients’ outcomes at the centre of any debate about the profession’s increasing demands on patients’ wallets.

GPs take a stand on after-hours services

The Royal Australian College of General Practitioners believes after-hours doctor services shouldn’t advertise to the general public and should only be accessed through their general practice.

The recommendation is one of many in the college’s recently released position statement about after-hours services.

RACGP President Dr Frank R Jones wrote in the college’s ‘In Practice’ newsletter: “Many issues of concern were identified by practicing GPs, especially around quality clinical assessment and continuity of care, as the patients’ normal treating doctor often receives variable and limited information about their patients’ after-hours visit.”

After-hours visiting services have become increasingly popular in recent years, which the college says coincides with an increase in the use of after-hours MBS item numbers.

“The increase in the use of after-hours related MBS item numbers could be attributed to the emergence of new business models offering dedicated after-hours home visiting services,” the college wrote in its statement.

After-hours visits classified as ‘urgent’ receives a rebate of $130-$150 compared to a non-urgent visit of $55 and $36 for a standard visit in the GP surgery.

The RACGP’s position is:

Only vocationally registered GPs, non-VR GPs, doctors on a pathway to Fellowship or GP registers with appropriate supervision should provide after-hours doctor services that attract an MBS rebate.
Patients should only be able to access after-hours services through their GP practice
Practices should provide information about access after-hours services to patients.
After-hours visiting services should have a formal connection with the patient’s usual GP.
There should be a summary document detailing clinical management forwarded to the patient’s usual GP by the next morning.
After-hours services should only take appointments during after-hours periods.
There should be appropriate triage processes from GP, nurse or other properly trained professional to minimise the amount of home visits required.
After-hours services are more expensive to the tax payer and should be subject to specific regulation and accreditation.
After-hours services should avoid advertising directly to the public.

The National Association for Medical Deputising (NAMDS) says it agrees in principle with the RACGP’s statement.

President of NAMDS, Ben Keneally, said: “We strongly support the view that Medical Deputising Services should work in support of General Practice.”

However they believe deputising services should be able to raise their own awareness. NAMDS said until recently, many patients weren’t aware of after-hours services and would inappropriately present at emergency departments instead.

“It is true that there has been growth in both after-hours clinic consultation and after-hours home visits. Indeed, in terms of volume, the growth in after-hours clinic visits has been much greater. This growth reflects the success of deliberate government policy to improve availability of primary healthcare in the after-hours period.”

The NAMDS recently released their Definition of a Medical Deputising Service: Interpretation and Guidance document to provide clarity on the role of Medical Deputising Services in after-hours primary care.

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Don’t dismiss conflict-of-interest concerns in IVF, they have a basis

It’s estimated over 5 million children have been born worldwide as a result of assisted reproductive technology treatments. Assisted reproductive technology, an umbrella term that includes in vitro fertilisation (IVF), is a highly profitable global industry, and fertility clinics are increasingly regarded as an attractive investment option.

In 2014, two major IVF clinics – Virtus and Monash IVF — floated on the stock exchange. Excited financial analysts observed at the time that:

people will pay almost anything to have a baby.

Over the past 12 months, there have been numerous critical media analyses of the IVF industry in Australia, including Monday night’s ABC Four Corners program, The Baby Business. The episode suggested IVF doctors are recommending treatments that are expensive, unsafe and likely to be futile.

The following morning the Fertility Society of Australia rejected these assertions, saying:

Four Corners presented no evidence to support these claims.

One of the claims made in the program was that IVF doctors have a financial incentive to treat women with the more invasive practice of IVF. The program suggested this financial incentive conflicts with the doctor’s duty of care towards the patient.

Four Corners highlighted the conflicted nature of commercialised IVF, where some IVF doctors are more concerned about their own interests (making money for themselves or their clinics) than they are about their patients.

Not surprisingly, the Fertility Society of Australia strongly denied such conflicts of interest exist. It argued that the profession is both highly ethical and highly regulated.

Why might doctors be conflicted?

While it is certainly a big call to claim some IVF doctors may not be sufficiently committed to their patients, the possibility that practice is being shaped — at least in part — by conflict of interest cannot simply be dismissed. There are three key reasons individuals working in the IVF industry, and the industry more broadly, may be perceived to be conflicted.

First, every time a doctor advises patients to consider IVF treatment, he or she profits financially from the recommendation. While all Australian doctors receive fees for their services, many IVF doctors also own shares in assisted reproductive technology companies, so they receive passive income that reflects the amount of assisted reproductive technology the company sells.

It is also worth noting that, as employees of publicly listed companies, doctors at clinics such as Monash IVF, according to their code of conduct, must:

recognise that (their) primary responsibility is to the Company and its shareholders as a whole.

It is therefore not unreasonable for people to be concerned some clinicians may be motivated (perhaps unconsciously) by financial conflicts of interest to make decisions that may not be in the best interests of their patients.

Second, there appears to be a lack of transparency about IVF success rates. Success, as measured by a live birth, is very dependent on age and the reason for seeking assistance.

In the youngest age bracket in Australia and New Zealand in 2013, the live birth per cycle rate was 27%. In the oldest it was between 1% and 5%, depending on whether a fresh or frozen egg was used. It is more likely that a cycle will result in failure than not, and some argue there is a lack of transparency about the likelihood of a live birth.

A striking example of this was seen on Four Corners when Dr Gab Kovacs, ex-medical director of Monash IVF, claimed:

I know that if you hang in there you get pregnant, because one of my patients got pregnant after 37 cycles. And, ah, so I encourage people to stay on.

While it is quite possible this woman made a fully informed decision to undergo this number of cycles, Dr Kovacs’ subsequent claim that he couldn’t say “no” and had no choice but to continue to offer the woman what she wanted inevitably makes one wonder what she knew about her real chances of success.

A third reason for concern about conflicts of interest, and one that might distinguish conflicts of interest in IVF from those in other medical settings, is the potential for exploitation of strong personal and social values associated with reproduction.

A strong discourse of hope runs through the IVF industry, and people seeking assisted reproductive technology are often very vulnerable. The profit motive of these companies has the potential to exploit these cultural norms and social pressures for ends that are not necessarily in the best interest of patients.

There are now two positions being taken: by those who consider some IVF practices are exploitative and unethical, and by those who consider that conflicts of interest are inherent in medical practice and are sufficiently well managed.

Rather than simply dismissing concerns about conflicts of interest, as the Fertility Society of Australia has just done, IVF specialists, ethicists and other stakeholders need to create a forum in which these concerns can be discussed openly and constructively.

Jane Williams, Doctoral student at the Centre for Values, Ethics and the Law in Medicine (VELiM), University of Sydney; Brette Blakely, Post-Doctoral Research Fellow; Christopher Mayes, Post-Doctoral Fellow in Bioethics, University of Sydney, and Wendy Lipworth, Senior Research Fellow, Bioethics, University of Sydney

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

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New AMA President to ‘speak up fearlessly’

The Australian Medical Association’s new president has told reporters that he’d like to build a more constructive relationship with the Turnbull government if they’re re-elected, “but we will speak up fearlessly when they produce bad policy.”

Western Australian obstetrician and gynaecologist, Dr Michael Gannon was voted into a two year term as President at last weekend’s AMA National Conference in Canberra.

Dr Gannon is the outgoing president of the WA branch of the AMA and is the head of the Department of Obstetrics and Gynaecology at the St John of God Subiaco Hospital.

On ABC’s Radio National this morning, he said: “I think that the AMA should always try and be constructive when it criticises policy of governments or opposition to come up with alternatives.”

One particular campaign that the AMA won’t be backing down on is the Medicare rebate freeze, a policy of key debate prior to July’s federal election.

“What we’ve tried to say for many years now is that successive governments have under-invested in quality general practice. That is the cornerstone of the health system: GPs providing quality care in decent visits will give you a saving. So even if you want to make an economic argument, you will have less people requiring hospital admissions, which are a lot more expensive down the track. Quality general practice is an investment in our community, it’s not a cost,” he told the ABC.

Dr Gannon did say that he intends to tone down the criticism of the asylum seeker policy, an area that Brian Owler’s leadership often commented on.

“If you ever hear me talking about it I’ll be talking about the health of asylum seekers, I won’t be making any comments about broader policy,” he explained.

The AMA conference also saw Victorian GP and outgoing President of AMA Victoria, Dr Tony Bartone elected Vice President.

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