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Preference: General Medicine

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Primary Health Networks and Aboriginal and Torres Strait Islander health

One of six priorities set by the Australian Government is for Primary Health Networks (PHNs) to focus on the health of Aboriginal and Torres Strait Islander peoples.1 Announced in the 2014–15 federal Budget, PHNs aim to coordinate primary health care provision especially for those at risk of poor health outcomes. There are 31 PHNs across Australia with several formed from consortia of Local Hospital Networks (LHNs). Operational and flexible funding of up to $842 million was committed for PHNs over 3 years from 2015–16.2 It is timely for PHNs to consider how they will improve health care coordination in partnership with Aboriginal and Torres Strait Islander communities in their respective regions.

Efforts to reduce the high hospitalisation rates of Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) people will require PHNs to build formal participatory structures to support best practice service models. Comprehensive primary health care can then be shaped by the needs of the community rather than by ad hoc factors or reactions to financial incentives and health care funding arrangements.3,4 Collaborations with Aboriginal community controlled health services (ACCHSs) within PHN regions have been recommended.5,6

This article outlines how PHNs might support health services to systematically and strategically improve their responsiveness to Aboriginal people within their boundaries according to ten proposals. These best practice models and examples can assist PHNs to adapt their strategic plans to optimally respond to this priority.

1. Collaborate with ACCHSs

ACCHSs are authorities on comprehensive primary health care matters at the local level4,7 and do much more than just cure illness.8 As authentic representational advocates, they can guide PHN responsiveness to Aboriginal health issues and, with more than 150 services across Australia, there are ACCHSs within the regional boundaries of every PHN.

The predecessors of PHNs — the Medicare Locals — were expected to engage with ACCHSs for many Closing the Gap initiatives, such as the Indigenous Chronic Disease Package (ICDP), from 2008.9 Where meaningful partnerships between ACCHSs and Medicare Locals were established in the delivery of these programs, health outcomes for Aboriginal people substantially improved (Box 1).10

2. Establish an Aboriginal and Torres Strait Islander steering committee

PHNs can foster meaningful Aboriginal community engagement by establishing an Aboriginal and Torres Strait Islander steering committee (and Aboriginal representation on the PHN board) with membership led by ACCHSs representatives inclusive of other Aboriginal health service organisations. Similar partnership forums established between the ACCHS, general practice sectors, and state and territory governments have set Aboriginal health priorities at the jurisdictional and regional level for decades.11 The steering committee aims might be modelled on current partnerships between the LHN and ACCHSs (Appendix 1) to develop a strategic plan across the life course.

3. Establish formal agreements to support the strategic plan

PHNs should aim for partnerships to reorient health services from reactionary care to comprehensive primary health care. For example, in remote Western Australia, a partnership agreement between an ACCHS and state government health services was associated with a reversal of the increasing trend in hospital emergency department attendances among other substantial health improvements in only 6 years (Box 2).12

Partnership agreements between PHNs, ACCHSs and other agencies should support Aboriginal leadership, quality care, accountability and patient-centredness, and should be formalised from non-binding memoranda of understanding to binding contracts (Box 1 and Box 2) to support a long term vision for core activity that is flexible to local priorities.

4. Support health services to assess their systems of care

There are now health system assessment tools specifically adapted to optimise the primary health care of Indigenous Australians based on the Chronic Care Model.13 Over 200 Aboriginal primary health care services have used such tools (Appendix 2). Many ACCHSs self-audit their performance using clinical audit tools for chronic disease, maternal and child health and other health priorities, and undertake generic health systems assessment as part of continuous quality improvement (CQI).14

Health system assessment and audits of actual practice against best practice standards should be used to guide PHN (and LHN where there is conjoint responsibility) priorities to systematically enhance quality care within all primary care services in PHN boundaries. Barriers to and enablers for systems improvement, and gaps in health service responsiveness to Aboriginal health needs, will be clearer. These include improving systems for follow-up of patients, use of electronic registers and recalls, Aboriginal community engagement and leadership, the commitment of workforce and management, service infrastructure, and staff training and support.14,15

5. Embed quality assurance activity within primary health care services

A commitment to CQI is a key strategy for disease prevention (Appendix 3) and the prevention of avoidable hospitalisations (Appendix 4), and should be a universal feature of primary health care services providing care to Aboriginal and Torres Strait Islander peoples.15

A national Aboriginal and Torres Strait Islander CQI framework supported by the Australian Government will shortly be released to guide jurisdictions to assess and deliver better quality primary health care.16 PHNs should endorse and adapt this framework to coordinate efforts and develop CQI implementation plans. For example, most state and territory affiliates of the National Aboriginal Community Controlled Health Organisation provide support to ACCHSs for CQI activities; and in some jurisdictions (Queensland and the Northern Territory), CQI support programs are well developed.14

PHNs will need to engage with existing programs to identify strategies for and barriers to CQI. Supporting CQI within the network boundary will require regional facilitators, trained staff, the coordinated use of shared electronic medical records and use of local information management systems by all providers (including locums and visiting services), regular monitoring of CQI indicators, performance reporting, and agreements on data use, ownership and reporting.14

6. Expand primary health care performance reporting

All primary health care services within each PHN delivering care to Aboriginal people (and especially in receipt of financial grants or incentives specific to Indigenous Australians) should be required to undertake CQI, and to participate in regional or centralised performance reporting which can be disaggregated by Aboriginality. Primary health care performance should be a core responsibility of quality, safety and risk subcommittees of both PHNs and LHNs.3 Aggregated CQI data at PHN levels can identify health service gaps and areas that need to be improved.16

The Australian Government reporting framework for PHNs will include national, local and organisational performance indicators.17 National indicators for PHNs will include primary and community health indicators such as potentially preventable hospitalisations (these will be sourced from existing datasets such as the National Hospital Morbidity Database) not unlike what is currently reported for LHNs. Potentially preventable hospitalisations are an indirect measure of whether people are receiving adequate primary health care. The disproportionately high rate of illness affecting Aboriginal people and their poorer access to primary health care explains higher potentially preventable hospitalisation rates independent of age, sex and remoteness (Appendix 4). Age-standardised potentially preventable hospitalisation rates within PHN boundaries should be disaggregated by Aboriginality and incorporated as a performance indicator within PHN strategic plans.

The selection of local and organisational performance indicators by PHNs should be guided by the Aboriginal steering committee. Benchmarking PHN progress using Aboriginal and Torres Strait Islander national key performance indicators18 should be considered. National key performance indicators serve as both a CQI tool and performance measure in the provision of primary health care to Indigenous Australians. For example, ACCHSs are required to report on 19 key performance indicators through a standardised portal supported by the Australian Government.7 Organisational performance reporting of PHN activity should quantify the allocation of funds towards Aboriginal programs and contractors and identify whether these are ACCHSs or other services.

7. Align and endorse PHN and LHN strategic plans

Commitment to region-specific Aboriginal primary health care strategic plans should be the goal for both PHN and LHN boards so that actions are informed by both and integrated to avoid cross purposes.3 These linkages might be streamlined in regions where PHNs have been established by LHNs. However, it is unclear how many LHNs have established Aboriginal health subcommittees or effective and formalised Aboriginal community engagement mechanisms to facilitate endorsement of strategic plans.

All PHNs are expected to complete baseline needs assessment and strategies to respond to service gaps.19 If these submissions pertain to the Aboriginal and Torres Strait Islander population, they should be accompanied by evidence of endorsement by the Aboriginal representative bodies in their region.

8. Strengthen the primary health care service model

Many visiting health providers can overburden Aboriginal people in remote communities with overlapping and poorly explained services.20 A core priority for PHNs is to review the coordination of care and improve clinical pathways in all geographic regions. PHNs will need to review the efficiency of current services including generalist and specialist outreach if they are to avoid duplication, foster local or residential health services,21 and sustain local CQI systems.

Specialist outreach should complement local health services through a bottom-up approach integrated with primary health care. Specialist outreach services operating independently of existing primary health care services will need review. Service reforms might mean building hub-and-spoke models involving ACCHSs, supporting regional Aboriginal health networks (Box 1), using telehealth adapted for Aboriginal and Torres Strait Islander settings, renegotiating clinical pathways, empowering local outreach coordinators of hospitals to support primary health care models, substituting workforce tasks through nurse and Aboriginal and Torres Strait Islander health practitioners, rural generalists and physician assistants,22 and reorienting health services towards primary health care (Box 2, Appendix 5).

9. Enhance cultural competence of primary health care services

Strategies to merely increase the awareness of non-Indigenous health staff to Aboriginal cultural protocols are often recommended to reduce Aboriginal health disparities, but may not lead to cultural competence.23 Some staff still struggle with how to make services culturally responsive beyond the posting of Aboriginal artwork.20 The ICDP invested in cultural awareness training of over 6000 general practice staff but change in practice was not universally embraced.8,15

Enhancing the cultural competence of health services within PHN boundaries will require strategies best managed by the Aboriginal steering committee and may include subcontracting ACCHSs and expanding their outreach role, person-centred and family-oriented care, fostering a culturally identified workforce that reflects the patient population and health needs, staff training in cultural safety, performance measures for cultural competence, and future planning.

10. Transition primary health care services to Aboriginal community control

PHNs are to be the health “providers of last resort and their decision to directly provide services should require the approval of the Department of Health”.3 Agreement from local ACCHSs in the region should be required if a PHN opts to directly provide health services to Aboriginal communities rather than make purchasing arrangements with existing Aboriginal services (Box 1). ACCHSs should also be supported to choose their involvement in programs within the PHN boundary.

Coalitions of Aboriginal organisations have advised that future funding on Indigenous health programs be prioritised to ACCHSs being better placed to meet Aboriginal health needs with better returns on investment.24 For example, according to the ICDP evaluation, it was unclear whether Closing the Gap measures (such as financial incentives to general practices) increased the provision of services to Aboriginal people who are “hard to reach” or increased their access to primary health care.9,15 For PHNs, it makes sense to direct Aboriginal health strategies to health services with the desire and potential to provide quality care to Aboriginal patients, which is also more cost-effective.15

The Queensland and Northern Territory governments have commenced processes to transition certain health services in remote areas to Aboriginal community control.25,26 The aim is to reform remote area services from doctor-focused, illness-centred, acute hospital-based primary care services to community-engaged, comprehensive, preventive and responsive systems. Policy frameworks propose staged approaches and capacity building of existing ACCHSs. Strategic plans developed by PHNs should consider transitioning health services and responding to existing transition plans26 to ensure alignment with them.

Conclusion

These proposals offer policy makers and PHNs a framework for health service planning within newly established boundaries, and may inform PHN organisational performance reporting on efforts to close the gap in Aboriginal health disparity.

Australians report that our health system is not sufficiently patient focused. Primary care is reactive and episodic, funding structures support providers and not patients, and there is little accountability for health outcomes.4 Through existing and better targeted additional investments, PHNs can offer Aboriginal and Torres Strait Islander people some hope towards reforming access to and quality of primary health care in their localities, but only if programs and systems can better fit in with community needs. To close the gap, PHNs need to support Aboriginal communities towards greater participation in primary health care, ultimately through the expression of community control.

Box 1 –
Example: collaboration between Medicare Locals and Aboriginal community controlled health services

In 2008, to close the gap in Aboriginal health disparity, the Indigenous Chronic Disease Package funded the Care Coordination and Supplementary Services (CCSS) program. The program supports Aboriginal and Torres Strait Islander patients with complex care needs, by coordinating clinical care and providing supplementary funding for allied health, specialists, transport services and medical aids. Implementation required collaborations between Aboriginal and mainstream health services. In South-East Queensland, the Metro North Brisbane Medicare Local (MNBML) was funded to deliver the CCSS program on behalf of four other Medicare Locals in South-East Queensland. A consortium of ACCHSs — the Institute for Urban Indigenous Health (IUIH) — was subcontracted by the MNBML to implement the program in 2013–14. IUIH employed a manager to oversee the program delivered by 20.5 full-time equivalent care coordinators.

The IUIH reported that subcontracting delivered significantly more services to significantly more Indigenous Australians with complex chronic conditions than any other part of the country: “In 2013–14 IUIH and members [ACCHSs] delivered over 57 000 episodes of care via the CCSS Program. The delivery of intensive case management and access to a comprehensive range of specialist and allied health services and medical aides for this population has avoided costly hospital admissions for Government and significantly improved the health and wellbeing of some of our most vulnerable and unwell patients.”10

Box 2 –
Example: a partnership to reorient acute care to comprehensive primary health care

Clinic services in the very remote Fitzroy Valley in Western Australia are delivered by state government health services (Fitzroy Crossing Hospital and the Kimberley Population Health Unit for community health services). Non-clinical health services are delivered by the Aboriginal community controlled health service (Nindilingarri Cultural Health Services) to a population of 3500 (80% Aboriginal). These services comprise healthy lifestyle programs designed around Aboriginal culture. A formal agreement between the agencies was negotiated in 2006 to form a single governance structure to allocate funding, share an e-health record, and coordinate health promotion, cultural safety, acute inpatient care, primary care and specialist care, and population-based screening. Commonwealth funding supported the development of a shared e-health record for quality improvement and additional staff (through the Healthy for Life and Indigenous Chronic Disease programs), and provided Medicare rebates to patients for primary care services delivered at the hospital clinic (an exemption from section 19(2) of the National Health Insurance Act 1973). Medicare billings were reinvested to support this reorientation under the guidance of the partners.

This reorientation enhanced health promotion programs and was associated with a reversal of the increasing trend in emergency department attendances. In the primary care clinic, there was a substantial increase in the number of patients seen, the number of health checks, the detection of risk factors, the proportion of patients with diabetes having care plans, transport provision, cultural security and follow-up attendances in only 6 years.12

Improving health outcomes for linguistically diverse patients

Cardiovascular health for all in Australia requires language-sensitive health systems

Every day, most Australian clinicians treat patients whose first language is not English. Nearly four million Australians speak 350 non-English languages, and 17% rate their spoken English as poor.1 To date, there has been little large scale Australian research into the health impacts of not speaking the country’s dominant language.

Studies on the relationship between linguistic diversity and health outcomes are methodologically challenging. Many have been criticised for their failure to adjust for socio-economic status, education, or English language proficiency, or for using country of birth as a proxy for language spoken at home.2 The prospective cohort study by Juergens and his colleagues, published in this issue of the MJA,3 adds to research on cardiovascular disease and language by analysing mortality 6 months after discharge from hospital. The authors found that mortality was higher in patients whose first language was not English.

Two broad sets of explanations are offered when interpreting differences in health outcomes associated with language: explanations related to socio-epidemiological determinants in the affected population, and explanations related to failures of health service responsiveness.

Although Australia’s immigrant population is heterogeneous, the cardiovascular risk factors in some populations warrant intensive primary and secondary preventive care. The two leading source regions for immigrants to Australia at present — China and South Asia — face escalating epidemics of diabetes.4 So rapid is the increase in prevalence that many communities do not have established strategies for managing patients with diabetes.5 Although the smoking rates among people whose first language is not English are overall lower than those of other Australians, some subpopulations have markedly higher rates.6

Equally important is health literacy: the ability to obtain, read and understand health information. In the 2006 national health literacy survey, only 26% of those born in a non-English speaking country had adequate health literacy, compared with about 45% of those born in Australia or in an English-speaking country.7 Patients with low health literacy may struggle to read and interpret information on how and why to take their medications, the significance of new cardiovascular symptoms, and how to obtain emergency help when they need it. For patients who have experienced cardiovascular events, achieving parity in health literacy may require innovative methods of cardiovascular rehabilitation with language-competent health providers; for example, by employing remote technology, such as Skype, supported by written language information, such as that produced by the National Heart Foundation (http://heartfoundation.org.au/support/information-in-your-language).

Health literacy is the product of good communication between a clinician and their patient, and of health systems that are responsive to the needs of patients. Doctors frequently overestimate the language capacity of their patients,8 who may themselves incorrectly assess their capacity to understand. In the national health literacy survey, more than a quarter of patients with demonstrably poor health literacy rated their ability to read and write English as excellent.7

Despite being a largely migrant country, Australia is unusually monolingual. Four out of five of us can speak only English,1 making us the third most monolingual country in the world, after Brazil and Japan.9 There is as an urgent need to develop and sustain health systems that are responsive to the needs of non-English-speaking Australians. A language-sensitive health system would ensure that complex health information, such as that provided before discharge from hospital or when explaining health interventions, such as cardiac catheterisation, is delivered comprehensibly, using language support resources.

We are a long way from achieving this. So great is the linguistic diversity of Australia that even multilingual doctors rarely find themselves sharing the language of their non-English-speaking patients. Hospitals cannot rely upon on-site interpreters to meet all the language needs of their patients. The Translating and Interpreting Service offers the most extensive telephone interpreting system in the world, providing doctors and pharmacists with rapid, 24-hour access to interpreters; this service does not, however, include Indigenous languages. Further, it is used in less than 1% of consultations by private practitioners with patients with limited English proficiency.10 We should also be able to reliably assess whether or not family members have the competence to adequately interpret for their relatives, when desired.

The challenge of meeting the needs of non-English speakers is a permanent one for Australia. The proportion of people over 65 years who have limited English proficiency increases at each census,1 reflecting the phenomenon of second language attrition as we age.11 The age group at greatest risk of cardiovascular disease is thus the one that may be struggling with diminishing English competence. Effective solutions will require us to develop culturally sensitive health promotion programs for cardiovascular disease, with a particular focus on diabetes as a comorbidity, and whole-of-system approaches which ensure that Australians who do not speak English as their first language can communicate clearly and confidently with their health care providers.

Death not hastened for those who choose to die at home

A large Japanese study has found terminal cancer patients who choose to die at home tend to live longer than those who die in hospital.

The study, published in Cancer journal, reassures oncologists that patients aren’t worse off when choosing home-based palliative care.

Jun Hamano, MD, of the University of Tsukuba in Japan studied 2069 patients: 1582 patients received hospital-based palliative care and 487 chose to receive palliative care at home.

The survival of patients who died at home was much longer than those who died in hospital, even after patients’ demographic and clinical characteristics were factored in.

Related: MJA – Goals of care: a clinical framework for limitation of medical treatment

The authors note that the patients who were referred for home-based palliative care “might be inherently different from those referred for hospital-based care, although all known confounding factors were successfully adjusted.”

They also said that not all medical treatments were recorded. “An exploration of the potential effect of the place of death on survival needs further investigation.”

“The cancer patient and family tend to be concerned that the quality of medical treatment provided at home will be inferior to that given in a hospital and that survival might be shortened; however, our finding—that home death does not actually have a negative influence on the survival of cancer patients at all, and rather may have a positive influence—could suggest that the patient and family can choose the place of death in terms of their preference and values,” said Dr. Hamano.

Latest news:

Your season of birth is stamped on your DNA and can affect your risk of allergies

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

People born in autumn or winter are more likely to suffer from allergies than people born in spring or summer. Nobody is certain why this is, but there are several theories. These include seasonal variations in sunlight (which could affect vitamin D levels), levels of allergens such as pollen and house dust mite (which vary by season), the timing of the baby’s first chest infection (colds tend to be more common in winter), and maternal diet (price and availability of fruit and vegetables vary by season).

But no matter which of these exposures causes changes to the risk of developing an allergy, until now nobody knew how these early environmental influences were so long lasting.

Our study tested whether epigenetic marks on a person’s DNA could be a mechanism behind these birth season effects. Of course, your genome doesn’t change depending on which season you’re born in, but there are epigenetic marks attached to your DNA that can influence gene expression – the process where specific genes are activated to produce a certain protein. This may result in different responses to immune triggers and hence different susceptibility to diseases.

Unlike DNA, which is inherited from your parents, epigenetic marks can change in response to the environment and allow gene expression to respond to environmental exposures. And they can also be very long-lasting.

Epigenetic imprint

We scanned DNA methylation (one type of epigenetic mark) profiles of 367 people from the Isle of Wight and found, for the first time, that the season in which a person is born leaves an epigenetic print on the genome that is still visible at the age of 18. This discovery means that these marks on the genome could be how season of birth is able to influence the risk of having allergies later in life.

We went on to test whether these DNA methylation differences that varied by season of birth were also associated with allergic disease. We found that two of them appeared to be influencing the risk of allergy in the participants. As well as allergies, other studies have shown that season of birth is associated with a number of things such as height, lifespan, reproductive performance, and the risks of diseases including heart conditions and schizophrenia. It is possible that the birth season-associated DNA methylation that we discovered might also influence these other outcomes but this will need further investigation.

The marks that we found in the DNA samples collected from the 18-year-olds were mostly similar to the epigenetic marks found in a group of Dutch eight-year-olds that we used to validate our findings. But when we looked at another cohort – a group of newborn babies – the marks were not there. This suggests that these DNA methylation changes occur after birth, not during pregnancy.

There’s something about the seasons

We are not advising women to change the timing of their pregnancy, but if we understood exactly what it was about birth season that causes these effects, this could potentially be changed to reduce the risk of allergy in children. For example, if the birth season effect on allergies was found to be driven by sunlight levels experienced by the mother during pregnancy or breastfeeding, then the increased risk of allergies among babies born in autumn and winter might be lessened by giving the expectant or breastfeeding mother vitamin D supplements. You wouldn’t need to time births with the seasons to get the benefits.

Our study reports the first discovery of a mechanism through which birth season could influence disease risk, though we still don’t know exactly which seasonal stimuli cause these effects. Future studies are needed to pinpoint these, as well as to investigate the relationship between DNA methylation and allergic disease, and what other environmental exposures have an effect.

With the considerable burden allergic disease places not only on individual sufferers but also on society, any step towards reducing allergy is a step in the right direction.The Conversation

Gabrielle A Lockett, Postdoctoral research associate, University of Southampton and John W Holloway, , University of Southampton

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

Other doctorportal blogs

New recommendations for Hepatitis C treatment

New recommendations have been released for the management of hepatitis C virus (HCV) infection in a consensus statement.

The statement was drawn up by Gastroenterological Society of Australia, the Australasian Society of Infectious Diseases, the Australasian Hepatology Association, the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Hepatitis Australia and the Royal Australian College of General Practitioners.

A summary, published in the Medical Journal of Australia, says that the recommendations for Hepatitis C treatment were drawn up in the wake of the new direct-acting antiviral therapies that were added to the Pharmaceutical Benefits Scheme earlier this month.

Related: 5 things you need to know about the new Hepatitis C medicines on the PBS

“The introduction of DAA therapies for HCV that are highly effective and well tolerated is a major medical advance,” said Professor Alexander Thompson, director of gastroenterology at St Vincent’s Hospital in Melbourne.

“All Australians living with HCV should now be considered for antiviral therapy.”

Recommendations in the consensus statement include:

  • All individuals with a risk factor for HCV infection should be tested.
  • Annual HCV serological testing is recommended for seronegative individuals with risk factors for HCV transmission.
  • People with confirmed HCV infection should be tested for HCV genotype (Gt).
  • All concomitant medications should be reviewed before starting treatment, using the University of Liverpool’s Hepatitis Drug Interactions website.
  • The use of any DAA regimen during pregnancy is not recommended.
  • People who are not cured by a first-line interferon-free treatment regimen should be referred to a specialist centre.
  • All people with decompensated liver disease, extra-hepatic manifestations of HCV, HCV–HIV or HCV–HBV co-infection, renal impairment or acute HCV infection, as well as people who have had a liver transplant should be referred for management by a specialist who is experienced in the relevant areas.
  • All people living with HCV infection should have a liver fibrosis assessment before treatment to evaluate for the presence of cirrhosis.
  • People with no cirrhosis can be treated by general practitioners working in consultation with specialists.

Read the full recommendations on the Gastroenterological Society of Australia’s website.

Latest news:

Male neurosurgeons highest ATO earners, GPs in top 50

With an average income of almost 577,000, male neurosurgeons have topped the list of the highest income status of Australians released by the Australian Tax Office.

Other medical specialities round out the top five for men, with Ophthalmologist, Cardiologist, Plastic and reconstructive surgeon and Gynaecologist/Obstetrician being the most lucrative jobs.

Among women, it was a slightly different story. The job with the highest income wasn’t in medicine at all, but was the role of a Judge. Neurosurgeon, plastic and reconstructive surgeon and Vascular surgeon came in at two, three and five respectively however future trader was number four in the list.

The statistics found that male specialists earned roughly twice as much as their female counterparts, however it didn’t distinguish between full and part time.

With an average income of $184,639, male general practitioners came in at 48th on the list while female GPs were 40th with an average income of $129,834.

According to the ATO, the statistics don’t include some of Australia’s top earners due to privacy protection or because their career title was unavailable.

Those with the lowest incomes, under $20,000 per year were fruit and nut pickers, deer farmer and fast food cook.

Read the full list at the ATO’s website.

Top 50 average incomes for Men and Women

  1. Neurosurgeon $577,674 Judge – law $355,844
  2. Ophthalmologist $552,947 Neurosurgeon $323,682
  3. Cardiologist $453,253 Plastic and reconstructive surgeon $281,608
  4. Plastic and reconstructive surgeon $448,530 Futures trader $281,600
  5. Gynaecologist; Obstetrician $446,507 Vascular surgeon $271,529
  6. Otorhinolaryngologist  $445,939 Gynaecologist; Obstetrician $264,628
  7. Orthopaedic surgeon $439,629 Gastroenterologist $260,925
  8. Urologist $433,792 Magistrate $260,161
  9. Vascular surgeon $417,524 Anaesthetist $243,582
  10. Gastroenterologist  $415,192 Ophthalmologist  $217,242
  11. Diagnostic and interventional radiologist  $386,003 Cardiologist $215,920
  12. Dermatologist  $383,880  Urologist $213,094
  13. Judge – law  $381,323 Surgeon – general  $210,796
  14. Anaesthetist  $370,492 Medical oncologist $208,612 
  15. Cardiothoracic surgeon  $358,043 Specialist physicians – other  $207,599
  16. Surgeon – general  $ 357,996 Specialist physician – general medicine $207,225
  17. Specialist physicians – other  $344,860 Otorhinolaryngologist $200,136
  18. Radiation oncologist $336,994 Dermatologist $195,030
  19. Medical oncologist   $322,178 Diagnostic and interventional radiologist  $180,695
  20. Securities and finance dealer $320,452 Cardiothoracic surgeon  $175,500
  21. Thoracic medicine specialist  $315,444 Paediatric surgeon  $175,314
  22. Specialist physician – general medicine $315,114 Endocrinologist $174,542
  23. Intensive care specialist $308,033 Member of parliament  $173,331
  24. Renal medicine specialist $298,681  Rheumatologist $169,409
  25. Neurologist   $298,543 Intensive care specialist $169,369
  26. Financial investment manager $288,790 Emergency medicine specialist $165,786
  27. Investment broker  $286,530 Orthopaedic surgeon $159,479
  28. Paediatric surgeon  $282,508 Neurologist $155,217
  29. Clinical haematologist $271,738 Renal medicine specialist $155,133
  30. Futures trader  $264,830 Psychiatrist $152,437
  31. Endocrinologist  $258,972 Clinical haematologist $147,970
  32. Cricketer  $257,527 Paediatrician $147,347
  33. Rheumatologist $256,933 Securities and finance dealer $145,208
  34. Dental specialist $253,442 Dental specialist $140,505
  35. Magistrate $246,737 Actuary $136,819
  36. Equities analyst; Investment dealer $245,826 Radiation oncologist $135,678
  37. Paediatrician $239,405 Financial investment manager $134,481
  38. Stock exchange dealer Stockbroker $238,192  Petroleum engineer $133,315
  39. Psychiatrist  $234,557  Mining production manager $133,061
  40. Emergency medicine specialist $232,595  General medical practitioner $129,834
  41. Member of parliament $232,093   Thoracic medicine specialist $127,645
  42. Pathologist $224,378 Stockbroker $124,433
  43. Company secretary – corporate governance $218,432 Paving plant operator $123,281
  44. State governor  $212,652 Mining engineer $119,564
  45. Actuary  $196,144 Tribunal member $119,219
  46. Doctor – medical practitioner – other; Occupational medicine specialist; Public health physician; Sports physician $187,468 Doctor – medical practitioner – other; Occupational medicine specialist; Public health physician; Sports physician  $118,310
  47. Petroleum engineer $185,808  Geophysicist $117,575
  48. General medical practitioner $184,639  Chief executive officer; Executive director; Managing director; Public servant – secretary or deputy secretary $116,855
  49. Chief executive officer; Executive director; Managing director; Public servant – secretary or deputy secretary  $181,849  Engineering manager $116,732
  50. Mining production manager  $179,439 Metallurgist $110,359

Latest news:

Impact of HPV sample self-collection for underscreened women in the renewed Cervical Screening Program

Major changes will occur in the Australian National Cervical Screening Program (NCSP) from 2017, following an extensive review (“Renewal”).1 In addition to a re-designed mainstream program (5-yearly human papillomavirus [HPV]-based screening with partial genotyping; colposcopy referral for women testing positive for HPV16/18; liquid-based cytology [LBC] triage for other oncogenic HPV types), it was also recommended that HPV testing on self-collected cervico-vaginal samples (“self-collection”) be funded for unscreened and underscreened women.2 Self-collection must be facilitated by a clinician who also offers mainstream cervical screening, and is likely to be restricted to women aged 30–74 years who have never been screened or are overdue for cervical screening by 2 years or more.3

Offering self-collection has increased screening participation among unscreened and underscreened women in several settings,4 and is seen as a potentially useful strategy for extending cervical screening to previously hard to reach groups. It is being introduced for this purpose in several countries, including the Netherlands.5–7 Recent international reviews have reported that HPV testing on self-collected samples was somewhat less sensitive for high grade cervical abnormalities than testing on clinician-collected samples if signal-based tests are used; however, sensitivity was similar when using polymerase chain reaction (PCR)-based tests.8,9 These findings describe a range of possible test performances for self-collection, but they cannot be applied to specific technologies in the Australian context: here the performance measures and standards for HPV test platforms to be used as part of the population screening program will need to meet National Pathology Accreditation Advisory Council requirements.

Taking all of these factors into consideration, the aim of our study was to inform decision making by women offered self-collection in Australia by quantifying how different screening decisions affect the future risk of cervical cancer in previously unscreened women.

Methods

We used a dynamic model of HPV transmission and vaccination in conjunction with a cohort model of HPV natural history, cervical screening, diagnosis, treatment, and cancer survival. This model platform underpinned the Renewal review, and has been described in detail elsewhere.10 Dynamic models are considered the most comprehensive models of HPV epidemiology, as they incorporate the direct and indirect effects of HPV vaccination on the incidence of infection, and thus reflect its full impact on changes in risk. Model-predicted outputs have been extensively calibrated and validated against local cancer and pre-cancer outcomes by age and HPV type, resource use, and observed effects of HPV vaccination.10,11 Detailed clinical management pathways were informed by an expert advisory panel convened for the Renewal review.1,10

Model scenarios

We evaluated three choices that could be made by previously unscreened women:

  • a single round of HPV testing on a self-collected sample (“1 × self-collected”);

  • a single round of HPV testing on a clinician-collected sample (“1 × clinician-collected”); and

  • joining the mainstream screening program (5-yearly HPV-based screening with partial genotyping for HPV16/18 and LBC triage for other oncogenic HPV types; testing on clinician-collected samples) (“join the program”).

The comparator in all cases was choosing to remain unscreened. In the single screening round scenarios (the first two options), women were assumed to complete a single round of screening, but then to never re-attend for subsequently recommended rounds. We considered a round of screening to be completed if the women were HPV-negative on their primary screening test, or if they were HPV-positive but had subsequently undergone appropriate follow-up and had then been recommended to return to routine screening. The main analysis evaluated outcomes based on a decision taken at age 30 years, as this is the earliest age at which self-collection will be offered to most women, but we also considered the outcomes if the decision was deferred to age 40 or 50 years.

Since the intention was to provide information useful to women when making their decision, we assumed that those who elected to undergo screening would attend for all subsequently indicated tests and procedures, including LBC triage (an additional visit is required, as LBC cannot be performed on a self-collected sample), colposcopy, and treatment. In a sensitivity analysis, we examined imperfect compliance with the recommended follow-up (Appendix, section 3).

Test characteristics

The characteristics of HPV testing on self-collected samples (baseline and feasible range) were informed by a recent meta-analysis of performance relative to clinician-collected samples8 (Appendix, section 2.1). We took a conservative approach and considered a performance range based on international data relevant to various test technologies.7 In the baseline analysis, we assumed that self-collected samples would be tested for any oncogenic HPV type. In a sensitivity analysis, we evaluated the use of a clinical test with partial genotyping on these samples, allowing differential management of women who test positive for HPV16/18, consistent with the mainstream screening program and an Australian trial of self-collection.12 The characteristics of other tests used were informed by meta-analyses, and by colposcopy test data from Australia and England (Appendix, sections 2.2–2.4).

HPV vaccination

The baseline analysis estimated outcomes for women in the absence of HPV vaccination, which would be relevant for older women; however, in a secondary analysis we also considered outcomes for a cohort of women offered vaccination against HPV16/18 at age 12, as currently implemented in Australia. Estimates of the uptake of vaccination by these girls (72%) and by older females (included to capture the indirect effects of the catch-up program) were based on published data.13,14 National uptake data for males (included to capture the indirect effects of the program) were not yet available, so we assumed an age-specific uptake by those offered vaccination since 2013 equivalent to that achieved among females, based on initial state-based reports.15 Results for cohorts offered vaccination would be relevant to women in Australia who turn 30 years of age from around 2026 (who were offered HPV vaccination at age 12), but are also potentially useful for those who turn 30 from 2017 onwards (who were offered vaccination when aged 13–20 years; since some will have been exposed to HPV prior to vaccination, their absolute risks of developing cervical cancer will be slightly higher than for those offered vaccination at age 12).

Outcomes assessed

We estimated for a cohort of 100 000 previously unscreened women aged 30 years the cumulative numbers of incident cervical cancer diagnoses, cervical cancer deaths, and women ever treated for cervical pre-cancer to age 84 years. The number of women needing to be treated for cervical pre-cancer (NNT) to avert one cancer diagnosis (or one cancer death), compared with women who remained unscreened, was also calculated as a measure of the balance between the benefits and harms of screening.

Sensitivity analyses

In addition to those previously discussed, we also performed sensitivity analyses of several parameters that were previously found to be the most influential across a range of screening evaluations using our model, as well as of those parameters for which the value was most uncertain (Appendix, section 1).10,16 These included the accuracy of triage testing with LBC, the diagnostic accuracy of colposcopy, and the management of women who test positive for oncogenic HPV types other than 16/18 at the primary test and whose LBC triage test is low grade (“intermediate risk”; 12-month recall v colposcopy referral).

Ethics approval

This model-based study did not involve human participants, so ethics approval was not required. A number of de-identified datasets were used in the prior development and calibration of the model platform that was used for this evaluation. Ethics approval for the use and analyses of these datasets to inform the model was provided by the Cancer Council NSW Ethics Committee (references 232, 236) and by the University of New South Wales Human Research Ethics Committee (references HC13270, HC13349).

Results

Compared with remaining unscreened, a single screening round at age 30 substantially reduced cancer incidence and mortality, and the number of cancer cases or deaths averted continued to increase over a woman’s life (Box 1, Box 2). One round of self-collected sample HPV screening in 100 000 women aged 30 years would avert 908 cancer diagnoses and 364 cancer deaths by age 84 (NNT, 5.8). Over a lifetime, the number of cancer cases or deaths averted by joining the mainstream program at age 30 years was about double that associated with a single screen at the same age. Underlying these findings is the fact that cancer incidence and mortality both start to increase again about 10 years after a single screen at age 30 years, whereas the lower incidence rate is maintained for most of a woman’s life if they join the program (Box 3). Joining the program was associated with the lowest NNT to avert each cancer case or death over a lifetime.

When the screening decision was deferred until age 40 or 50, the reduction in cancer diagnoses and deaths remained greatest when a woman joined the mainstream screening program; even doing so at age 50 averted more cases than a single screening round at age 30 or 40 (1091 fewer diagnoses and 583 fewer deaths [NNT, 3.4] by joining the program at age 50 v 908 or 922 fewer diagnoses and 364 or 426 fewer deaths [NNT, 5.8 or 3.7] for a single round of self-collection at ages 30 or 40 respectively). For each sample type, a single round of screening at age 40 prevented more cervical cancer cases and deaths than a single round at either age 30 or 50 (for self-collection, a single round of screening at ages 30, 40 or 50 years resulted in 908, 922 and 684 fewer diagnoses and 364, 426 and 385 fewer deaths respectively; for a clinician-collected sample, in 1020, 1049 and 775 fewer diagnoses, and 406, 480 and 437 fewer deaths respectively) (Box 4). While having a first screen at older ages often reduced the number of cases averted, the NNT to avert a cancer case was also lower.

Relative reductions in the numbers of cervical cancer diagnoses and deaths were similar for women in cohorts offered HPV vaccination and those who were not offered HPV vaccination. These reductions were substantial even when only one screening round was undertaken; however, the absolute numbers of diagnoses and deaths averted in those offered vaccination was smaller (by 63–70%) because of their lower underlying risk. In women offered vaccination, joining the program at age 30 averted more than twice as many cancer diagnoses and deaths as a single screen at the same age, and was also associated with a lower NNT to avert each cancer case (Box 2). Joining the program at age 50 remained more effective than a single screen at ages 30, 40 or 50 years (Box 4). At age 30, joining the mainstream program had the most favourable balance between benefits and harms; at older ages, the NNT was similar for all screening decisions. The NNT to avert a cancer diagnosis was 44–64% higher for women who had been offered vaccination than for those who were not (Box 4).

Sensitivity analyses

No feasible assumptions considered in sensitivity analysis altered the estimate of the number of diagnoses averted by more than 5%, or the NNT to avert a diagnosis by more than 8% (supplementary figures 3 and 4 in the Appendix). Results for self-collection were most sensitive to the accuracy of the HPV test and the availability of partial genotyping for HPV16/18. The effectiveness of joining the mainstream program was most sensitive to women’s compliance with the recommended tests, whereas the effect of this on single screening round scenarios was smaller (further discussion in the Appendix, section 5).

Discussion

This study provides valuable information that can inform decision making by women and clinicians. Even a single round of HPV screening on a self-collected sample can reduce the lifetime risk of a cervical cancer diagnosis, by around 41% if performed at age 30 or 40 years. A single round of HPV testing on a clinician-collected sample may offer superior results, but it is possible that the difference in outcomes may be smaller if a sufficiently accurate HPV test is used and if partial genotyping is performed on self-collected samples. However, our results also indicate that joining the mainstream program, even at an older age, offers substantially greater protection. Our findings also help to quantify the benefit for women of joining the program rather than being screened only once. For example, the benefit for women who continue to attend for recommended screening after a first screen at the age of 30 years is about double that of undergoing a single round of screening at 30. The balance of benefits and harms associated with joining the mainstream program was more favourable than or similar to that for a single screening round at all ages we considered in this analysis.

Self-collection was recommended during the Renewal review in the context of several factors in Australia. First, the 2-yearly cervical screening participation rate had remained relatively stable at around 60% for more than a decade, and the proportion of women remaining unscreened after 3 (almost 30%) or 5 years (about 17%) had also not decreased. Second, cervical cancers were mostly diagnosed in women who were unscreened or had not been screened in the previous 3.5 years (45% and 23% respectively of diagnosed invasive cancers in 2012).17 Third, there were persistent disparities in screening participation, with lower participation rates in lower socio-economic groups, among Aboriginal and Torres Strait Islanders, and in some migrant groups, and these participation disparities were reflected in the incidence of cervical cancer.18–22 These factors suggested that infrequent or non-participation in screening was a major barrier to further reducing the incidence of cervical cancer (which had plateaued over the past decade), and was also driving some persistent inequalities in cervical cancer incidence. Consequently, ensuring that all Australian women have access to a program that is acceptable, as well as effective and efficient, was a fundamental aim of Renewal.11 Self-collection is specifically aimed at women who are unscreened or underscreened.2

Two recent studies in Victoria suggested that self-collection is likely to be acceptable among women who are not being screened regularly, although, as both involved a mail-out model, their findings are not directly comparable with the NCSP recommendations. The iPap trial compared participation by previously unscreened and underscreened women who were randomly assigned to receiving either a mailed-out self-collection kit or a screening reminder letter.12 Offering self-collection was more effective in increasing participation than a reminder; attendance for recommended follow-up tests was high among women who returned a self-collected sample in the iPap trial; and participants reported finding self-collection simpler, more comfortable and less embarrassing than their previous Pap test (personal communication, Dorota Gertig, Medical Director, Victorian Cervical Cytology Register, July 2015). Secondly, a telephone survey in which women were asked about the option of home-based self-collection found that almost two-thirds of women who were unscreened or underscreened preferred this option to clinician-collected samples.23 Time since the most recent cervical screening test was the only significant factor associated with a preference for self-collection, with women who were up to date with screening less likely to prefer self-collection (27%) than women who had never been screened (62%; odds ratio [OR], 4.16; P < 0.001) or had not been screened in the previous three years (65%; OR, 5.19; P < 0.001). Women who did not favour self-collection most commonly cited a preference for seeing a general practitioner and a lack of confidence in their ability to collect the sample properly. This suggests that the model proposed for the NCSP, where self-collection is facilitated by a practitioner who also performs mainstream screening, is appropriate, as women may be reassured about their ability to perform the test by the facilitating provider or elect to have their practitioner collect a sample. However, some of the women who are currently less likely to participate in screening, including Aboriginal and Torres Strait Islander women, migrants, and those from lower socio-economic groups, were under-represented in the survey.

One concern about self-collection is that women who currently attend the mainstream program may switch to self-collection, and this could lead to a less effective program overall. The proposed model of restricting self-collection through a screening provider to under- and unscreened women is designed to reduce this problem. The results from our study provide additional information for both the provider and the woman by quantifying both the benefit of self-collection for unscreened women and the additional benefit of remaining in the mainstream program. Findings from a recent modelling study in the Netherlands suggest that, to maintain the overall effectiveness of a program including targeted self-collection, it is crucial that women at the greatest risk are among those who adopt self-collection and that a sufficiently accurate test is used.24 Our results also underline the importance of using a sufficiently accurate test and partial genotyping for HPV16/18 for ensuring comparable long term cancer outcomes in self-collected and clinician-collected samples.

The strengths of this study include the use of a robust model that has been calibrated against a large number of program outputs, and that clinical management pathways incorporated detailed local expert input.10 Another strength is that it included estimates for women offered vaccination during early adolescence, meaning the results will remain informative into the future. When self-collection first becomes available for unscreened women aged 30–74 years in 2017, the youngest women eligible will have been 20 years old when the HPV vaccination program commenced. A sizeable proportion of these women will have been vaccinated (30–63% with three doses),14 although possibly with lower effectiveness than in the cohorts modelled here.25 The absolute benefit of screening in these intermediate cohorts will potentially be slightly higher than for those offered vaccination at age 12, but our results suggest that the relative reductions are similar in both unvaccinated cohorts and those offered vaccination. Our results for cohorts offered vaccination will be fully applicable to women turning 30 from 2026.

As our results are intended to provide guidance for women and clinicians when making decisions, a limitation to our study is that compliance with recommended follow-up tests and procedures was assumed to be perfect. This assumption means our results cannot be directly interpreted as population-wide results; this was beyond the scope of the current study. However, trial data support the strong benefits we found from even a single screening round (further discussion in the Appendix, section 7), and these benefits did not vary substantially across the range of compliance assumptions examined. Self-collection at regular intervals was not evaluated, given the greater uncertainties in the evidence concerning the use of self-collection for routine screening, and because self-collection is not intended as a regular replacement for clinician-collected samples.

Our results support offering self-collection to women who are unscreened and reluctant to join the mainstream screening program, including older women, for whom the balance between benefits and harms remains very favourable. However, the level of protection achieved by joining the mainstream program and thereafter undergoing regular screening, even at older ages, is far greater. Engaging women and redressing barriers to their participation in the mainstream program must remain a primary focus.

Box 1 –
Impact of screening decision at age 30 years on the future risk of cervical cancer diagnosis and death, and treatment for pre-cancer, for a cohort of 100 000 previously unscreened women aged 30 years (unvaccinated cohort)

Number of women affected by cervical cancer, by age:

40 years

50 years

60 years

Lifetime*

Cervical cancer diagnosis

Join program†

99

120

139

205

1 × clinician-collected

104

245

476

1187

1 × self-collected

140

316

572

1299

Remain unscreened

312

811

1299

2207

Relative risk reduction compared with remaining unscreened, by age:

40 years

50 years

60 years

Lifetime*

Cervical cancer death

Join program†

22

26

30

45

1 × clinician-collected

22

46

117

490

1 × self-collected

28

62

145

531

Remain unscreened

53

177

367

895

Died from other causes

488

1655

4195–4202

39 509–39 780

Cervical cancer diagnosis

Join program†

68%

85%

89%

91%

1 × clinician-collected

67%

70%

63%

46%

1 × self-collected

55%

61%

56%

41%

Cervical cancer death

Join program†

58%

85%

92%

95%

1 × clinician-collected

58%

74%

68%

45%

1 × self-collected

47%

65%

61%

41%

Women ever treated for cervical pre-cancer, by age:

40 years

50 years

60 years

Lifetime*

Join program†

7373

8498

9143

9894

1 × clinician-collected

5973

6018

6019

6019

1 × self-collected

5235

5277

5278

5279

* Until (and including) 84 years of age. † Five-yearly human papilloma virus (HPV)-based screening with partial genotyping; colposcopy referral for women testing HPV16/18 positive; liquid-based cytology triage for other oncogenic HPV types.

Box 2 –
Cumulative numbers of cervical cancer diagnoses (A, B) and deaths (C, D) averted in women screened for human papillomavirus (HPV) at age 30 (compared with remaining unscreened), by attained age, in unvaccinated women (A, C) and women offered vaccination at age 12 (B, D)

Box 3 –
Cervical cancer incidence and mortality in women screened or unscreened for human papillomavirus (HPV), by attained age

Box 4 –
Cervical cancer diagnoses averted to age 84 by one screening round (A, B) and number needed to treat to avert a cancer diagnosis (NNT) (C, D), compared with remaining unscreened, in unvaccinated women (A, C) and women offered vaccination at 12 years of age (B, D)

Identifying low-value care: the Royal Australasian College of Physicians’ EVOLVE initiative

Challenges and lessons arising from early adoption of a new approach towards determining what is good clinical practice

In March 2015, 41 medical specialties of the Royal Australasian College of Physicians (RACP) came together as part of the College’s EVOLVE initiative. The main aim of EVOLVE is to drive safer, higher-quality patient care through identifying and reducing low-value medical practices.1 In EVOLVE, “low-value” practices are defined as tests, procedures or interventions that are overused, inappropriate or of limited effectiveness (and, in extreme cases, potentially harmful). The name of the initiative reflects the dynamic and evolving nature of evidence-based medicine. EVOLVE is modelled on the Choosing Wisely initiative in the United States and similar initiatives underway in Canada, Italy and the United Kingdom.2

In EVOLVE’s first year, more than 20 specialties have completed or commenced work on lists of “top-five” low-value clinical practices in their respective fields. Here, we examine the approaches of three early adopter EVOLVE specialties — geriatric medicine, palliative medicine and rheumatology. We also share insights that have arisen so far that are relevant to the Medicare Benefits Schedule (MBS) Review Taskforce.

The EVOLVE approach

EVOLVE recognises the breadth of physicians’ practice, uniting specialties through their commitment to reducing low-value care. It is a partnership between specialty societies and the RACP. EVOLVE is clinician-led, with each specialty responsible for developing lists, engaging with its members and providing feedback to the RACP on systemic barriers to adoption of each list’s recommendations. The RACP is the umbrella body, developing common frameworks and a robust methodology, coordinating across and between specialties, connecting EVOLVE with associated initiatives such as Choosing Wisely Australia, and communicating about and advocating for high-value care.

To avoid the early mistakes of Choosing Wisely in the US, where some participating specialties identified “low-impact” practices on their lists and singled out clinical practices performed by other specialties,3 EVOLVE’s participating specialties agreed to robust principles and methods. These included:

  • Practices under consideration by each specialty should be “within or significantly impact their domain of practice”. This can be interpreted as including practices involving shared decision making with other health care specialties and those that are the subject of referral to and from other specialties. Specialties also have broad discretion to consider practices that they consider can “make a difference” in reducing low-value care (eg, rheumatologists and geriatric medicine specialists examined practices that affected people with conditions they commonly treated).

  • Practices under consideration should be either growing in use or currently commonly used. Some specialties interpreted “commonly used” as encompassing cost, not just volume (eg, rheumatologists excluded from consideration practices that were not very costly to the health care system).

  • Use of the Delphi method4 as the overarching methodology for identifying a top-five list.

The three specialties reviewed the US and Canadian Choosing Wisely lists as part of their development process, but this was not a substitute for formulating their own lists, as not every international practice is relevant to Australia. For example, performing whole-body bone scans (eg, scintigraphy) for diagnostic screening for peripheral and axial arthritis is included in the Canadian rheumatology list but is not material to Australia.

Three Delphi method case studies

EVOLVE recommends use of the Delphi method for identifying low-value care practices, in keeping with initiatives elsewhere.5 This survey-based approach derives consensus based on purposive sampling of experts in the field of interest, panellist anonymity and iterative questionnaire presentation.4

There were three subtle differences in the way the method was applied by the specialties:

  • Both geriatric medicine and palliative medicine working groups consulted their memberships early in the process to seek comment on provisionally identified practices and suggest new ones. Only after processing membership feedback and refinement of the provisional list was an evidence review conducted.

  • Both geriatric medicine and palliative medicine working groups shortlisted their identified practices by requiring respondents to assign scores to each practice based on multiple criteria. Geriatric medicine used seven criteria, while palliative medicine used three. “Strength of evidence”, “significance” and “opportunity to make a difference” were criteria common to both.

  • Rheumatology recruited additional members (including three trainees) into the working group so they could invest effort in building on the RACP’s initial evidence review. With this larger working group, they could break into smaller teams and assign to each team a practice for further research. The evidence was summarised in an online survey distributed to the broader membership, with links to a full discussion of the evidence embedded in the survey questions.

Remaining challenges

Notwithstanding EVOLVE’s established principles and methods, some challenges remain.

First, without a requirement for compulsory participation, there is an element of self-selection in participation in specialty working groups and surveys. It is unclear whether this will lead to bias in the list of practices compiled for investigation and final shortlisting.

Second, there may be a risk of limited buy-in by specialty members if survey participation rates are low or if consensus cannot be reached, potentially reducing the impact of EVOLVE lists on clinician behaviour. The rheumatology working group aims to overcome this by encouraging high survey participation and by requiring that each top-five list practice be selected by at least 70% of survey respondents, in the hope that this represents a sufficiently high threshold for buy-in.

Third, ensuring that practices being considered are commonly used or increasing in use is difficult. For some practices, regularly collected publicly available data are incomplete (eg, MBS data that do not cover all hospital-provided services or do not provide sufficiently detailed breakdowns by indication). In other cases, the judgement of survey respondents or working group members (most of whom are in active clinical practice) was relied upon to remove practices considered irrelevant because of low levels of use.

Fourth, due to the clinical expertise required to formulate EVOLVE lists, the process is specialist-dominated. Nevertheless, achieving buy-in from consumers and non-RACP clinicians is critical, as sustaining changes in clinical practice requires cooperation from these groups. This task will benefit from support from Choosing Wisely Australia, led by NPS MedicineWise, to which EVOLVE is a contributor.

Finally, implementation of the EVOLVE recommendations into practice will be the greatest challenge. A recent study of the Choosing Wisely campaign in the US found significant declines being achieved in only two of seven low-value services identified by the campaign.6 Translating the EVOLVE recommendations into clinical practice requires both consumer and clinician education and a systemic cultural shift towards high-value care. This might be achievable if there is a systematic and coordinated approach, but a substantial investment in time and support may be required to ensure that the aims of EVOLVE are achieved and are sustainable over time.

Insights relevant to the MBS Review Taskforce

The MBS Review Taskforce’s early work has focused on identifying “obsolete” MBS items.7 EVOLVE’s focus is on reducing low-value care. Use of the 23 obsolete items identified by the Taskforce will, by definition, be declining, so aiming to reduce their use will have minimal impact. By contrast, one of the EVOLVE criteria is that the practice examined is commonly used or growing in usage.

A critical EVOLVE insight is that few practices are unambiguously low value for all clinical indications, and low-value care is contextual. Hence, there will be few genuinely low-value clinical practices that could be reduced by deleting particular MBS items.

Clinical practice is more likely to be improved by ensuring tests and treatments are targeted at people with appropriate clinical indications. The following low-value practices identified by the three specialties illustrate the importance of this:

  • use of ultrasound imaging to guide glucocorticoid injections into the shoulder or lateral hip compared with non-image-guided injections (rheumatology)

  • use of antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia (geriatric medicine)

  • use of oxygen therapy to treat non-hypoxic dyspnoea in the absence of anxiety and as routine treatment at the end of life (palliative medicine).

Although these three practices identify low-value applications of ultrasound imaging, antipsychotics and oxygen therapy for specific indications or groups, this does not justify withdrawing subsidies entirely from these tests and treatments, as they are valuable in other clinical contexts.

While some clinical change can be induced by restricting conditions under which particular MBS items are covered, our examples also illustrate the limits of this approach. First, there are tests and treatments that are at risk of being misused but are not funded by the MBS. Second, imposing additional restrictions on the use of MBS items does not guarantee adherence unless proof of correct indication is required.

Financial incentives have been found to have limited effectiveness in driving sustained changes in clinical practice.8 Thus, it is likely that a systems-based approach employing multiple complementary strategies is needed. Initiatives like EVOLVE, that create endorsed and recognised peer judgements on what is good clinical practice, combined with other strategies such as the current MBS Review and mechanisms to improve clinician and consumer understanding of what constitutes low-value care, are needed. Working together, such strategies may shift clinician behaviour and consumer preference towards opting for the most appropriate evidence-based tests and treatments.

Recording consultations: a win–win situation for physicians and patients

Encouraging patients to record consultation summaries may improve health outcomes

Technology plays a significant role in medicine, and technological advances are constantly changing how medicine is practiced. Technology is also widely used by patients, who are now able to apply it in a medical setting. For example, the rapid adoption of smart phones, tablets and other personal electronic devices has made audio or visual recording of consultations relatively straightforward.

The recording of consultations is not a new concept. A 1990 study investigated the effect of video recording consultations on physician behaviour.1 The benefits of recordings for oncology patients have been well established.2–4 The technology available for recording has expanded dramatically over the past 25 years; however, it is unknown if doctors are aware of the potential clinical usefulness of recording consultations.

Physicians can enhance patient care by using personal electronic devices in their practice. A recent study showed that 69% of respondents wanted to record consultations, motivated by the desire to improve their care experience and share the information with others.5

Benefits of recording consultations

There are several benefits of encouraging patients to record consultations, and particularly to record a management summary at the end of a consultation.

Patient recollection

Compliance with management plans and subsequent health outcomes depend on a patient’s ability to recall the management plan in the first place. To promote patient recollection of a consultation, physicians can encourage patients to record the discussion of the management plan at the end of the consultation. This would allow patients to review the crucial information provided later in a familiar environment and without time constraints. The benefit of recording a consultation has been demonstrated in an oncology setting, where the use of audiotapes has been reported to improve patient recall and satisfaction.2 One patient from a non-English-speaking background commented that an audiotape allowed for slower review of the information, which may not have been fully understood when first discussed. A review examining the effect of providing recordings to people with cancer and their families recommended that physicians consider offering recordings as most patients find them useful,3 or even prefer4 recordings. Using recording devices with the aim of improving patients’ understanding and compliance with management may result in better health outcomes.

Patient empowerment

Patient autonomy should always be considered and prioritised in medicine. Patients have the right to share decision making with their physicians. One study identified patient empowerment as the prime benefit of recording consultations.5 Additionally, patients have used recordings to share information with family and friends.4 By offering patients the opportunity to record the management plan at the end of a consultation, physicians may provide patients with a sense of control.

Ease of use

Both audio and video devices can be used to record consultations. Audio devices are readily available as independent voice recorders and on mobile phones, and allow patients to easily review medical information. Video recordings might be particularly useful when practical techniques, such as the use of an inhaled medication, are being demonstrated.

Creative integrity of the physician

Providing patients with an opportunity to record the management plan at the end of a consultation maintains a physician’s ability to carry out the majority of the consultation without feeling pressured or scrutinised. Although one study showed no evidence that video recording altered a physician’s consultation behaviour, there were several factors that were not considered, and the authors noted that decision making could be degraded or enhanced.1

Avoiding surreptitious recording

Concerns about secret recording of consultations have recently been raised.6,7 In Australia, it is illegal to make voice or video recordings of private conversations without the other party’s permission except in Queensland, Northern Territory and Victoria. Furthermore, it is illegal to communicate or publish the recording to any third party without the other party’s permission in every state and territory.7 Despite this legislation, medical practitioners are still at risk of being involved in legal action as a result of surreptitious recording.8 Physicians may derail secret recording that is already occurring, or reduce the likelihood of secret recording, by offering patients the chance to record a consultation summary. The additional benefit is that the responsibility to initiate this opportunity is removed from patients, who may feel uncomfortable about asking to record consultations, or be concerned that their motives will be questioned.5

Risks of recording consultations

Although encouraging the recording of consultations may be beneficial, there are also risks to be considered.

How the recording is used

Perhaps the most important consideration is how the recording will be used, and by whom. Despite most states requiring permission from both parties to record interactions and all states requiring permission from both parties to share recorded information with a third party, there are situations in which the agreement of privacy may need to be broken. In the Surveillance Devices Act 2007 (NSW), for example, the prohibition to communicate information obtained by a listening device does not apply in the case of an offence against the Act, or if there is imminent risk of serious harm to persons or of substantial property damage (the Act, Section 11).

Documentation

In the case of a recorded consultation summary, a physician may consider keeping a copy of the recording for the medical record, which raises a number of potential difficulties. Physicians may ask patients to forward the recordings to be added to their medical records or may have to also record consultations. There is then the matter of how the recording might be stored. If an electronic records system is available, it may be possible to upload recordings to patients’ medical records. If not, other methods of secure storage of recordings would have to be found.

Time management

One critic argues that recording may lead to consultations taking longer.9 While one study investigating the effect of video recording on a physician’s consultation behaviour did find a 1 minute increase in consultation time, the increase was not significant.1 However, in that study, the recording equipment was already set up, whereas in a standard consultation, it may take additional time for the patient, physician or both to prepare recording devices. Furthermore, to ensure the recording has been successful, the physician may request that it is replayed, which would take time.

Conclusions

The decision by physicians to encourage the recording of consultation management plans is an individual one. If a physician does decide to allow recordings, there are several factors to consider. For example, which patients should be offered recordings? It may be appropriate to start with long term patients, with whom the physician has established a trusting doctor–patient relationship, those with chronic disease and subsequent complex management plans, or patients who have received bad news. It may also be necessary to highlight the intended use for recordings. Importantly, it may benefit the patient to discuss confidentiality and when the recording may be required to be produced.

The use of recording devices for oncology patients improves recollection and satisfaction. However, it is not known if physicians outside the field of oncology have used recordings in their practice, and to what extent both physicians and patients are aware of the potential value of recordings. There are benefits and risks to be considered, and the decision to encourage the recording of consultations will be made on a physician-by-physician basis. Overall, given the benefits for patients, we recommend that physicians should encourage patients to record a management summary at the end of a consultation.

Clinical practice guidelines for dementia in Australia

Dementia is a National Health Priority Area in Australia. As our population ages, the number of people with dementia will increase.1 People with dementia have deficits in one or more of the areas of memory, communication, attention, thinking and judgement.2

The quality of clinical practice in dementia care in Australia is variable. The availability of high-quality services to support workforce training, diagnosis and ongoing care, advance care planning and support for families to provide care is inconsistent.

Clinical practice guidelines can improve uptake of research findings by identifying, synthesising and disseminating evidence to clinicians.3 Most importantly, adherence to clinical practice guidelines can improve the quality and consistency of care.4

The National Health and Medical Research Council (NHMRC) Partnership Centre for Dealing with Cognitive and Related Functional Decline in Older People was established in 2013 with funding support from the NHMRC, HammondCare, Alzheimer’s Australia, Brightwater Care Group and Helping Hand Aged Care. One of the activities of the Partnership Centre was to develop Australian clinical practice guidelines for dementia. The guidelines were adapted from existing guidelines5 using ADAPTE methodology6 to reflect the Australian context and the latest evidence. A multidisciplinary guideline committee, which included consumers, was appointed to refine the scope of the guidelines and form recommendations based on systematic reviews of the evidence.

The purpose of the guidelines is to provide recommendations for an agreed standard of practice for the diagnosis and management of people with dementia in Australia. The guidelines address care of people with dementia in community, residential care and hospital settings and are relevant to medical practitioners, nurses, aged care workers and allied health professionals. They are also useful for researchers, educators, policy makers and decision makers.

The full guidelines can be accessed via the Australian Clinical Practice Guidelines portal (https://www.clinicalguidelines.gov.au).

Main recommendations

The guidelines provide 109 recommendations, categorised as evidence-based recommendations (formulated after a systematic review of the evidence), consensus-based recommendations (formed where a systematic review has failed to identify sufficient studies to inform a recommendation) and practice points (based on expert opinion). Key recommendations prioritised by the committee for implementation are presented in the Box.

Changes in management

Delays between the onset of symptoms and diagnosis of dementia are widely acknowledged.7 There is currently a lack of information regarding the benefits and harms of population screening for cognitive impairment.8 The guidelines focus on timely diagnosis by recommending that symptoms are explored when first raised by the person experiencing the symptoms and/or their carer or family and are not dismissed as “just a part of ageing”. People with a possible diagnosis of dementia should be referred to a service or specialist in dementia diagnosis (eg, a memory clinic, neurologist, geriatrician or psychiatrist).9

The guidelines recommend a systematic approach to diagnosing dementia; this includes patient and informant history taking, cognitive assessment, medication review, blood tests and computed tomography or magnetic resonance imaging to exclude other cerebral pathologies. The use of single-photon emission computed tomography is not recommended.10 More recent diagnostic techniques using biomarkers (including the use of positron emission tomography) are not recommended for routine use.11

Clinical cognitive assessment should include examination with a screening tool with established reliability and validity. A number of tools are recommended in the guidelines including the Mini-Mental State Examination. The Kimberley Indigenous Cognitive Assessment tool for remote living Aboriginal and Torres Strait Islander populations and the Rowland Universal Dementia Assessment Scale for people from non-English speaking backgrounds are recommended for use where illiteracy, language or cultural considerations deem their use appropriate.

The committee recommended review of people with mild cognitive impairment after 6–18 months. This recommendation was formulated based on an existing systematic review which found that, in a clinic setting, the annual conversion rate of mild cognitive impairment to Alzheimer disease was close to 10%.12

At the time of diagnosis of dementia, and at regular intervals subsequently, assessment should be made for medical comorbidities and key psychiatric features associated with dementia, including depression, to ensure optimal management of coexisting conditions.

The guidelines recommend comprehensive role-appropriate dementia-specific training for health and aged care professionals. Such training can improve the quality of life for the person with dementia13 and reduce restraint use14,15 by teaching staff how to understand a person with dementia and to read body language and behaviour as signs of communication and respond appropriately. The evidence supports training models that focus on understanding symptoms and behaviours and providing person-centred care.16

The guidelines recommend a greater emphasis on promoting and maintaining independence through activities of daily living, continuing exercise and supporting the person to pursue activities that are meaningful and of interest to them. Adequate nourishment and hydration through maintaining a healthy, balanced diet should be encouraged and supported. People with dementia should have their weight monitored and nutritional status assessed regularly. Oral health is important17 and, on diagnosis, the medical practitioner should recommend that the person with dementia (or their carer[s] or family) make an appointment to see a dentist to conduct an assessment and formulate a long-term treatment plan.

Acetylcholinesterase inhibitors and memantine are routinely prescribed for people with mild to moderate Alzheimer disease in order to delay functional decline, and the guidelines support their use.18 Based on recent evidence, the guidelines also state that any one of the three acetylcholinesterase inhibitors (donepezil, galantamine or rivastigmine) could also be considered for people with dementia with Lewy bodies, Parkinson disease dementia, vascular dementia or mixed dementia.19–22 The combination of an acetylcholinesterase inhibitor and memantine could be considered for managing the symptoms of functional decline for people with moderate to severe Alzheimer disease.23 Clinicians should be aware that not all of these indications are reimbursed under the Pharmaceutical Benefits Scheme and that acetylcholinesterase inhibitors are associated with a number of side effects including (but not limited to) nausea, vomiting, diarrhoea, dizziness, increased urinary frequency, falls, muscle cramps, weight loss, anorexia, headache and insomnia.24 Acetylcholinesterase inhibitors should not be prescribed for people with mild cognitive impairment.25

If people with dementia cannot express their needs through communication, they may communicate through their actions and behaviour. The guidelines recommend the need to understand the person and symptoms via a comprehensive assessment and analysis of the behaviour (eg, antecedent [triggers], behaviour description and consequence [ABC approach]). The objective measurement of behavioural and psychological symptoms of dementia should be undertaken using tools to monitor the type and patterns of behaviours. The provision of care that is consistent with the ten principles of dignity in care26 and non-pharmacological interventions should be implemented before considering use of medications. Non-pharmacological interventions should ideally involve engagement in activities that are enjoyable for the person with dementia and individualised support. Working with the carer and family to build skills in managing symptoms, communicating effectively and problem solving have been shown to be effective in reducing symptoms.27,28

A number of pharmacological treatments are recommended to complement non-pharmacological approaches when the person with dementia is severely distressed or there is an immediate risk of harm. Analgesics are recommended when pain is suspected.29 A trial of selective serotonin reuptake inhibitors is recommended for agitation; the strongest evidence is for citalopram.30 The role of antidepressants in the treatment of depression in people with dementia is uncertain. Larger trials conducted in people with dementia have not shown benefit (in group data) for antidepressants for treatment of depression per se.31 Nevertheless, the committee considered that those with a pre-existing history of major depression (before developing dementia) who develop a comorbid major depression should be treated in the usual way.

People with Alzheimer disease, vascular dementia or mixed dementias with mild to moderate behavioural and psychological symptoms of dementia should not usually be prescribed antipsychotic medications, owing to the increased risk of cerebrovascular adverse events and death.32 For people with severe symptoms who are distressed or causing distress to others, treatment with an antipsychotic may be offered following a full discussion with the person with dementia and/or their carer(s) or family about the possible benefits and harms. Treatment should be reviewed every 4–12 weeks, considering the need for antipsychotics and possible cessation of medication.

Care for people with advanced dementia should be based on a palliative approach and involve a palliative care service if indicated. Treatment and care should be provided as per the person’s advance care plan.

Carers and families should be included in the planning, decision making and care and management of people with dementia. Carers are often not provided with enough support or adequate training to effectively provide care.33 There is evidence that tailored multifaceted programs involving both the carer and the person with dementia can improve quality of life for both.34 Carers should have access to programs that include education regarding dementia; information regarding relevant services such as respite; information about support organisations such as Alzheimer’s Australia; individualised care management strategies to overcome specific problems; training in providing care and communicating most effectively with the person with dementia; and support regarding coping strategies to maintain their own wellbeing, including stress management.

Box –
Key recommendations identified by the committee as priorities for implementation*

  • Health and aged care professionals should provide person-centred care, by identifying and responding to the individual needs and preferences of the person with dementia, their carer(s) and family. The 10 principles of dignity in care (http://www.dignityincare.org.uk) should be used as the standard by which care is delivered and evaluated.
  • People with a possible diagnosis of dementia should be offered referral to memory assessment specialists or services for a comprehensive assessment.
  • The medical practitioner should be honest and respectful and use a gradual and individualised approach when communicating the diagnosis to the person with dementia and their carer(s) and family.
  • Health system planners should ensure that people with dementia have access to a care coordinator who can work with them and their carers and families from the time of diagnosis.*
  • Health and aged care organisations should ensure that all staff working with people with dementia receive dementia-care training (attitude, knowledge and skill development) that is consistent with their roles and responsibilities. Training should reflect programs that have been shown to optimise care for people with dementia.*
  • Training programs should be comprehensive and have a strong focus on communicating effectively with the person with dementia and his or her carer(s) and family and recognising, preventing and managing behavioural and psychological symptoms of dementia. Staff should be trained in the principles of person-centred care and how these principles are applied in practice.
  • People with dementia living in the community should be offered occupational therapy interventions which should include: environmental assessment and modification to aid independent functioning; prescription of assistive technology; and tailored intervention to promote independence in activities of daily living.*
  • People with dementia who develop behavioural and psychological symptoms should be offered a comprehensive assessment at an early opportunity by a professional skilled in symptom assessment and management. This should involve their carer(s) and families as appropriate and include; analysis of the behaviours, assessment of physical and mental health, pain or discomfort, side effects of medication, the influence of religious and spiritual beliefs and cultural norms, physical environmental and interpersonal factors, an assessment of carer(s) health and communication style, understanding the behaviour as a form of communication.*
  • People with Alzheimer’s disease, vascular dementia or mixed dementias with mild-to-moderate behavioural and psychological symptoms of dementia should not usually be prescribed antipsychotic medications because of the increased risk of cerebrovascular adverse events and death.
  • The person with dementia, their carer(s) and family should be offered respite appropriate to their needs.
  • Carers and families should have access to programs designed to provide support and optimise their ability to provide care for the person with dementia. Programs should be individualised, multifaceted and delivered over multiple sessions.*

* Note that some recommendations have been shortened in this publication.