The quick fix that dramatically cuts antibiotic use

Simply asking patients to wait a couple of days to see if their symptoms resolve before filling their script substantially cuts antibiotic use, an Australian meta-analysis has found.

The Cochrane review, led by the University of Queensland’s Primary Care Clinical Unit, looked at 11 studies involving 3,500 patients with suspected common respiratory tract infections. It essentially found no significant clinical difference in outcomes between patients randomised to immediate prescription of antibiotics, delayed prescription, or no prescription.

There were also very low rates of complications or missed treatment of serious complications in those randomised to the ‘wait-and-see’ prescriptions.

But delaying prescription led to a massive drop in antibiotic use. Over 90% of patients with an immediate prescription filled it, compared with around 30% of those with a delayed prescription.

Patients were more satisfied with being given a delayed prescription compared with being given no prescription at all – a significant finding since it’s well recognised that some of the pressure to prescribe antibiotics comes from the patients themselves.

The studies reviewed involved acute respiratory tract infections, including cough, sore throat, colds and otitis media.

Lead author Dr Geoffrey Spurling said the review showed delayed prescribing could be an acceptable compromise if a doctor didn’t believe antibiotics were needed at the time of the consult, but was uneasy about adopting a ‘no-antibiotics’ approach.

“The evidence indicates that delayed prescribing is an effective strategy for reducing antibiotic use and now we need to get this message out the medical community,” he said. “Individual GPs can feel confident implementing this strategy for reducing antibiotic use as a way of treating infections if they are uncomfortable with not prescribing antibiotics.”

As outlined in research recently published in the MJA, Australia has a very high rate of prescribing antibiotics for respiratory tract infections, with antibiotics prescribed at 4-9 times more often than is recommended by therapeutic guidelines.

Australia’s Chief Medical Officer recently sent written warnings to the top 30% of antibiotic prescribers, asking them to think about what they can do to reduce their prescribing.

You can access the Cochrane Review here.

[Editorial] An annual spotlight on Australian general practice

On Sept 13, the Royal Australian College of General Practitioners (RACGP) published an inaugural Gene-ral Practice: Health of the Nation report. Their analysis will become an annual review of Australian general practice: to plan for a future workforce, to track conditions most commonly presented by patients, and to gauge general practitioner (GP) job satisfaction and discontent. The RACGP represents 35 000 members and 17 000 Fellows, treating Australia’s population of 24 million.

No place for photo ID checks in General Practice

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

Universal access to health care is highly valued by Australians. The furore caused when a badly designed co-payment model was proposed provided strong evidence that Australians will not tolerate any threat to their right to access medical care when needed. The AMA strongly advocated to protect vulnerable patients’ access to care at the time.

Following the sale of a small number of Medicare numbers on the dark web, AMA advocacy is needed to ensure the Government’s response is proportionate and that attempts to improve the security of Medicare numbers do not diminish patient access to care.

To the Government’s credit, it was quick to react to security concerns raised by the alleged breach, commissioning an independent review of the accessibility by health providers of Medicare card numbers. The Review is being led by Professor Peter Shergold, with the AMA represented on the review panel. The panel recently released a discussion paper, giving stakeholders the opportunity to provide submissions, with a final report due by the end of this month.

The AMA President has met with both the Ministers for Health and Human Services on this issue and the AMA has also provided a submission in response to the discussion paper.

This is a good opportunity for the Government to assess the risks to its systems. However, the AMA has made it very clear that an excessive response could impact adversely on patients and practitioners.

The Department of Human Services’ Health Professional Online Services (HPOS) is a valued service for health care providers and their delegates, enabling streamlined and secure access to Medicare Australia and Department of Human Services programs, services, tools and resources. Every day there are around 45,000 interactions with HPOS.

HPOS has continuously evolved since its introduction to ensure it increasingly enables secure and streamlined transfer of data between providers and Government entities and timely access to information. Nevertheless, there are still some clunky aspects to using HPOS, particularly when it comes to the use of PKI certificates.

The introduction of PRODA has made it much simpler for individual health care providers or delegates to securely access HPOS. However, PRODA is yet to provide the same secure business to business functionality of the PKI site certificate.

The AMA believes that introducing this functionality in PRODA as soon as possible would make it easier for providers to interact with HPOS. It would ensure provider systems flexibility by removing the need for a physical certificate tied to a physical machine, retain secure capability, and streamline provider access. We need to keep up with technological developments in an increasingly mobile, digital, online and cloud based world.

What we don’t want to see as an outcome of this Review is over-the-top security measures that go well beyond the problem that has been identified. Ideas like requiring photo ID to see a GP are heavy handed and simply add to a practice’s administrative burden. It could also see patients unable to access care and place reception staff in a very difficult environment, facing sick and often distressed people who will not be able to understand why their Medicare card is no longer sufficient enough evidence to access a basic right – health care.

My gender and my degree

BY DR DANIKA THIEMT

The ﬁrst documented English-speaking female doctor was Dr James Miranda Barry, a medical ofﬁcer of the British Army between 1813 and 1865. Dr Barry devoted her life to the British Army, earning the highest medical rank available: Inspector General of military hospitals. In an era when academic professions were the sole privilege of male members of society, it was necessary for Dr Barry to conceal her gender, living and practising medicine as a man. Her sad reality was exposed only posthumously where examination revealed her secret. Even in death, she was denied her right to her true identity; her gender kept secret for a further 100 years.

In Australia, medical training was opened to women in the late 1800s, and our ﬁrst female graduate was registered to practice in 1891. Female medical trainees are now thriving, with female medical graduates in Australia outnumbering men since the mid-1990s. Women currently make up more than two-ﬁfths of vocational trainees, focused largely in obstetrics and gynaecology (74.5 per cent), paediatrics (72.8 per cent) and general practice (63.1 per cent). Contrast this to the ﬁgures from oral and maxillofacial surgery, intensive care and surgery and female trainees make up less than a third of trainees. How, when we see women making up half or more of medical graduates and provisional trainees, are we still seeing unequally representation in the ongoing workforce? What is happening along the way? How and why does a speciality that starts out gender-neutral result in a specialist workforce that is predominantly male?

Fixing gender inequity in medicine requires supporting women in leadership. Diversity in the boardroom enhances corporate performance and, to advance as a profession, we need to attract and retain female leaders. Female specialists, on average, earn 16.6 per cent less than their male counterparts. Although differences in average hours worked account for some discrepancies, other contributory factors include a lack of women in senior positions and a lack of part-time or ﬂexible senior roles. There are already inspiring and engaged female leaders within our profession, leading the world in clinical practice, medical research and education. We should be harnessing their talent to inspire the next generation.

The changing demographic of our workforce could, in part, be to blame. Trainees are graduating from medical school later and spending more time in vocational training. This leads to greater family and social pressures on trainees and possibly an increase in the need for breaks or ﬂexible training options. Evidence shows that access to ﬂexible training helps to retain female trainees and is desired by both female and male trainees regardless of parental status. We need to dispel the belief that trainees must choose between career and family and instead focus on how we enable trainees to have both.

Gender inequity extends beyond medical workforce.Many of my female colleagues report being mistaken for nursing or allied health staff, a rare occurrence among my male colleagues. Similarly, senior female doctors are often overlooked by patients who prefer to talk to the male junior by her side. How do women thrive in medicine and become leaders when public perception seems to favour male doctors? I watch senior medical staff respond to “Miss” in conversation rather than the respectful “Dr”. Although this seems petty in the scheme of everyday practice, it is easy for female doctors to believe that our degrees come second to our gender. Although the actions of some do not make a rule, it is time that we stand together as a profession to advance women in medicine. It is time to advocate for female leadership not only in the eyes of the profession but also in the eyes of the public.

Equity isn’t about creating a false forced equality. We aren’t all equal and that should be celebrated. It certainly shouldn’t hold us back. Opportunities to become leaders won’t be taken by all of our trainees, but they should be provided to all, regardless of gender.

(A version of this article first appeared in Emergency Medicine Australasia in 2016.)

Supervisors – powerhouses of the medical workforce

By AMA VICE PRESIDENT DR TONY BARTONE

I recently had the opportunity to reflect momentarily on how our well-oiled training allows us to so confidently and expeditiously care for our patients in a vast array of situations. One of my colleagues in the clinic had to attend to a patient with chest pain in the treatment room, something most of us have had to deal with. Making sure he did not need extra assistance, I observed the calm yet confident manner with how he dealt with the critical situation.

We can do all of those things because of our medical training and education, the clinical and professional skills we learned from working with dedicated supervisors, who in many cases become our mentors and friends.

The standard of medicine practised in Australia is consistently ranked among the best in the developed world. This is because we have a highly trained medical workforce based on the established apprenticeship model, with our Colleges maintaining education and independently determined training standards.

However, this model which has served us so well in the past is now at risk. Insufficient postgraduate positions and increasing numbers of graduates and aspiring trainees are stretching the system.

Continual advocacy by the AMA has ensured that there is a growing awareness that we do not have enough prevocational and specialist training places for the increasing number of new doctors. Whether governments and health policymakers are fully awake to the urgency of these worsening shortages is a topic for another time.

Unfortunately, I think it’s forgotten sometimes that clinical supervisors are the powerhouses of our apprenticeship model of training doctors. For the AMA, it is clear that to meet the challenge of training the expanding medical workforce, more clinical supervisors need to be found, supported and properly recognised and rewarded.

Boosting supervision capacity is a pivotal issue for our doctors in training, and the AMA has developed a significant suite of policy proposals and ideas in recent years.

To assist our ongoing advocacy, the AMA, led by the Medical Workforce Committee, has prepared a position statement that brings together these policies into a stand-alone document.

Building Capacity for Clinical Supervision in the Medical Workforce 2017 affirms our view that training and supervising new doctors is just as important as delivering services in the health system.

The document emphasises that the apprenticeship model of medical training is as relevant as it was as five decades ago, and shows that building supervision capacity across the spectrum of public, private, general practice and rural settings has common and unique sets of challenges and solutions.

Any discussion on this issue should not neglect the importance of ensuring that clinical supervisors have the support they need to train the next generation of doctors, as well as fostering a culture within medicine that encourages teaching and training.

From a personal perspective, many of my colleagues and I have found supervising junior colleagues to be a demanding yet thoroughly rewarding experience, with much gained in return.

Regrettably, I hear from different sources that protected time is not always available for teaching and training and simply added onto other responsibilities. Worse still, I hear many stories of those who have ended their roles because of a lack of support time or resources. I also know of VMOs and staff specialists who are actively discouraged from setting aside time for these activities. This makes no sense at all. Surely, now is the time to be boosting, not diminishing support for our supervisors.

Building Capacity for Clinical Supervision in the Medical Workforce 2017 outlines what the AMA believes has to be done from the industrial, financial, regulatory and cultural perspectives. I encourage you to take a look.

advocacy/position-statements

Press Club address covers wide range of topics

AMA President Dr Michael Gannon’s Address to the National Press Club of Australia was both well delivered and well received – covering a wide range of topics of importance to health practitioners and their patients.

It was the second time Dr Gannon had addressed the Press Club, a Canberra-based national institution and forum for policy debate, and will likely be the last as President of the AMA.

During the nationally televised event on August 23, Dr Gannon laid out the AMA’s priorities for the future and highlighted its recent achievements in influencing policy outcomes.

He also fielded a range of questions from the Canberra Press Gallery.

Titled Beyond the Freeze – Time for Heavy Lifting in Heath, Dr Gannon noted there had been numerous changes in the realm of health policy since he last spoke at the Press Club 12 months ago.

“There is no more talk of co-payments,” he said.

“The cuts to pathology and diagnostic imaging bulk billing incentives have been reversed.

“The general practice pathology rents issue has, for the most part, been resolved.

“The Medicare freeze has a ‘use by date’. It can’t come soon enough.”

Dr Gannon said while the AMA wanted an immediate end to the freeze right across the Medicare Benefits Schedule, it didn’t quite get it.

The hour-long address, which involved both a speech and a question and answer session, was moderated by National Press Club President Chris Uhlmann.

Mr Uhlmann at the time was also the ABC News Political Editor, but has since resigned to join the Nine Network as Laurie Oakes’s replacement as Political Editor.

Not one to be passive while in the moderator’s chair, Mr Uhlmann joined in with his Press Gallery colleagues to grill Dr Gannon on a few policy areas.

One insightful exchange was over the emotive issue of euthanasia and the role doctors have in end-of-life care.

“Could you speak just a little bit more on the principle of double effect?” Mr Uhlmann asked.

“I don’t think that most people actually understand that it’s available and actually exists in Catholic canon law, that if someone dies as effect of their pain management being turned up to a point where that’s the secondary effect, that’s something you can even request in a Catholic hospital.”

Dr Gannon’s response was both revealing and informative.

“One of the things you have to be very careful doing when you’re talking on ethical matters is to invoke Catholic canon law, because there are some people who would have great concerns about that,” he said.

“But, Chris, who I know is a scholar in this area, will be able to tell you that this all goes back to St Thomas Aquinas. This is well established in Catholic ethics. And it’s a well-established ethical principle which is very much secular as well.

“But in very simple terms it means that if your primary intention is to relieve suffering, and by secondary effect it has the effect of hastening someone’s life, that is ethically, completely distinct from the intention of ending someone’s life.

“So, if we look at proposed assisted dying laws, the intention is to end the patient’s life. If you look at palliative care, the intention is to relieve pain and suffering. The intention is important.

“I can promise you that palliative care physicians, the nurses who work with them, the teams they work in, they’re a great example of multidisciplinary care for all of us, but they work very carefully and compassionately to provide a level of care which is seven levels above the morphine drip that you’ve all heard of.”

CHRIS JOHNSON

Seven keys to treating hypertension in primary care

Blood pressure is one of the most important modifiable risk factors for cardiovascular disease. Hypertension significantly raises the risk of stroke, heart failure, coronary heart disease and chronic kidney disease, and is in fact regarded as a cardiovascular disease in its own right.

Managing hypertension has been a subject of considerable controversy over the past few years, with the debate revolving around how aggressively it should be treated, so-called white-coat hypertension, and the importance of home blood pressure monitoring.

Current Australian recommendations were updated in 2016 and include a number of changes from previous guidelines, including a new recommendation for ambulatory or home monitoring in patients with clinic BP of ≥ 140/90 mmHg.

Here are seven key recommendations from the guidelines:

Patients with suspected hypertension should have their absolute cardiovascular disease risk calculated using the Australian absolute cardiovascular disease risk calculator;
Recommend an antihypertensive for patients with a low cardiovascular risk (under 10%) and blood pressure that is persistently 160/100mmHg or higher;
Recommend an antihypertensive for patients with a medium cardiovascular risk (10-15%) and blood pressure that is persistently 140/90mmHg or higher.
Recommend an antihypertensive for patients with normal blood pressure but high cardiovascular disease risk (greater than 15%).
Use home or ambulatory blood pressure monitoring to confirm blood pressure if the clinic blood pressure is 140/90mmHg or higher.
ACE inhibitors, angiotensin II receptor blockers (ARBs), calcium-channel blockers and thiazide-like diuretics are the first-line antihypertensives of choice;
Any of these first-line antihypertensives can be recommended for patients with hypertension and diabetes, chronic kidney disease or a history of stroke.

Source: Guideline for the diagnosis and management of hypertension in adults; MJA, 2016

Click here for more information on doctorportal’s CPD module for managing hypertension.

AMA letting legislators know its views on pharmacy review

Below is an edited version of the AMA’s submission to the Pharmacy Remuneration and Regulation Review Interim Report.

Overall, the AMA considers the recommendations, if implemented, will benefit consumers by improving access to affordable medicines and enhancing the quality of medicines related care provided by pharmacists.

The AMA’s submission focuses on the recommendations and options described in the interim report which impact patient care.

The recommendations and options relating to patient access to medicines and their experiences within pharmacies appear sensible and well considered.

In particular, the AMA supports:

improvements to the PBS Safety Net which would enhance patients’ understanding and access, for example, the introduction of a central electronic system that automatically tracks individual patient PBS expenditure;
audits of pharmacy compliance with medicines dispensing requirements, such as correct medicines labelling and the provision of Consumer Medicines Information leaflets, in line with State/Territory legislation and Pharmacy Board of Australia and Pharmaceutical Society of Australia guidelines; and
improvements to electronic prescription systems and medication records to enhance continuity of care and reduce medication errors. However, the AMA notes that prescribing software would require updating to enable full electronic prescribing and that a small, but still significant, proportion of medical practitioners do not use these systems, especially in rural/remote locations with poor internet connections.

The AMA supports the Review recommendation that homeopathic products should not be sold in PBS-approved pharmacies. Selling these products in pharmacies encourages consumers to believe they are efficacious when they are not.

The AMA notes the interim report proposal that if pharmacists provide a service that is also offered by alternative primary healthcare professionals, the same Government payment should be applied to that service. While a service may superficially appear the same, it is important to recognise that the delivery, quality and comprehensiveness of that service may differ between health professionals and the context within which it is provided.

For example, a patient administered a flu vaccine in a pharmacy just receives a flu vaccine. A patient receiving a flu vaccine administered by a General Practitioner also receives a preceding consultation which includes a health assessment specific to that patient, based on a sound understanding of the patient’s past history and health needs.

This might include a check whether the patient’s other recommended vaccinations are up-to-date, whether a cervical screening test is due, a blood pressure check if appropriate, a check of the patient’s adherence and tolerance of any prescription medicines, and any other appropriate and (evidence-based) opportunistic preventative health care.

Even if the General Practice employs nurse practitioners to deliver the vaccine itself, a patient has first been assessed by a General Practitioner who continues to be close at hand if needed.

If the Commonwealth Government were to consider paying pharmacists to administer flu vaccines to high risk populations, the services provided by a pharmacist and a medical practitioner in this context would not be equivalent.

Clearly there would also need to be research on whether flu vaccinations in pharmacies are cost-effective in comparison to a flu vaccination in a General Practice clinic given the value-add provided in the latter service.

Any cost-benefit analysis would also need to take into account the indirect costs of delayed or missed diagnoses leading to higher cost care, that are more likely when care is fragmented by patients relying on health care provided by a pharmacist.

The AMA agrees with the recommendations in the interim report that government-funded services should be evidence-based and cost-effective. Pharmacy-based services that do not meet these criteria, such as the Amcal’s Pathology Health Screening Service targeting “relatively young and fit customers … for general health purposes … as opposed to risk assessment or diagnosis” should not be eligible for government funding.

The AMA’s earlier submission to this review expanded in some detail regarding the push by the Pharmacy Guild, motivated by revenue generation, to expand the scope of practice of pharmacists into the provision of medical services.

The AMA has already stated its views on the barriers imposed by current pharmacy location rules in its previous submission to the Review, and in numerous earlier submissions to Government. The AMA supports changes to pharmacy regulation which would allow more pharmacies and medical practices to be co-located. The current restrictions are inflexible and are difficult to justify in terms of public benefit.

AMA understands that the Australian Government has entered into an agreement with the Pharmacy Guild of Australia to continue indefinitely the current protections the rules provide to Guild members. However, the AMA is disappointed that the Government has made this decision despite the obvious benefits that would accrue by allowing access to high quality primary health care services in a way that is convenient to patients, enhances patient access and improves collaboration between healthcare professionals.

Facilitating collaboration between medical practitioners and pharmacists will only improve patient outcomes through less medication mismanagement and better medication compliance.

The AMA agrees there are benefits in future community pharmacy agreements being limited to remuneration for the dispensing of PBS medicines and associated regulation. This would allow pharmacy programs, such as medication adherence and management services currently funded under the Agreement, to be funded in ways that are more consistent with how other primary care health services are funded.

Given these programs are about providing health services, rather than medicines dispensing per se, it makes sense for them to be assessed, monitored, evaluated and audited in a similar way to medical services under the MBS.

Approximately $1.2 billion has been provided to pharmacies under the current community pharmacy agreement without this level of transparency and accountability. No evaluations of pharmacy programs under the Sixth Community Pharmacy Agreement have been made public.

Moving pharmacist health services outside of the Agreement would also open the way for more flexible models of funding, for example, support for pharmacists working within a General Practice team and other innovative, patient-focused models of care.

The AMA would also welcome inclusion in future consultations undertaken prior to the finalisation of the next community pharmacy agreement, as proposed in the Review interim report. The AMA recognises the valuable contribution pharmacists make in improving the quality use of medicines.

Pharmacists working with doctors and patients can help ensure medication adherence, improve medication management, and provide education about medication safety. The AMA fully supports ongoing and adequate funding of evidence-based pharmacist services such as home medicine reviews and the provision of dose administration aids.

It is important that Government-funded pharmacy programs are monitored and evaluated for effectiveness and cost effectiveness to ensure the expenditure provides tax payers with value for money. The findings from these evaluations will help improve and strengthen the programs.

The AMA fully supports the recommendations made to enhance access to medicines programs for Indigenous Australians and to support Aboriginal Health Service pharmacy ownership and operations.

The full submission can be found at:

system/tdf/documents/AMA%20Submission%20-%20Interim%20report%20-%20Pharmacy%20remuneration%20and%20regulation%20review%20Jul17.pdf?file=1&type=node&id=46835

Perinatal suicide in Ontario, Canada: a 15-year population-based study [Research]

BACKGROUND:

Death by suicide during the perinatal period has been understudied in Canada. We examined the epidemiology of and health service use related to suicides during pregnancy and the first postpartum year.

METHODS:

In this retrospective, population-based cohort study, we linked health administrative databases with coroner death records (1994–2008) for Ontario, Canada. We compared sociodemographic characteristics, clinical features and health service use in the 30 days and 1 year before death between women who died by suicide perinatally, women who died by suicide outside of the perinatal period and living perinatal women.

RESULTS:

The perinatal suicide rate was 2.58 per 100 000 live births, with suicide accounting for 51 (5.3%) of 966 perinatal deaths. Most suicides occurred during the final quarter of the first postpartum year, with highest rates in rural and remote regions. Perinatal women were more likely to die from hanging (33.3% [17/51]) or jumping or falling (19.6% [10/51]) than women who died by suicide non-perinatally (p = 0.04). Only 39.2% (20/51) had mental health contact within the 30 days before death, similar to the rate among those who died by suicide non-perinatally (47.7% [762/1597]; odds ratio [OR] 0.71, 95% confidence interval [CI] 0.40–1.25). Compared with living perinatal women matched by pregnancy or postpartum status at date of suicide, perinatal women who died by suicide had similar likelihood of non–mental health primary care and obstetric care before the index date but had a lower likelihood of pediatric contact (64.5% [20/31] v. 88.4% [137/155] at 30 days; OR 0.24, 95% CI 0.10–0.58).

INTERPRETATION:

The perinatal suicide rate for Ontario during the period 1994–2008 was comparable to international estimates and represents a substantial component of Canadian perinatal mortality. Given that deaths by suicide occur throughout the perinatal period, all health care providers must be collectively vigilant in assessing risk.

[Correspondence] China, Africa, and US academia join hands to advance global health

In 2016, Chinese President Xi Jinping announced the Healthy China 2030 plan—an ambitious agenda to promote health across China and to strengthen South–South cooperation, including the China–Africa Public Health cooperation plan.1 In 2005, African heads of state championed the Agenda Africa 2063, which had a similar emphasis on population health.2 Ongoing health reforms across both Africa and China offer immense potential for mutual learning.3,4 China’s success in the provision of preventive and primary care has the potential to inform health care in Africa, which faces similar challenges today as China did more than three decades ago; however, Chinese academic health experts have been unable to translate Chinese experiences to the African context, and suggest academic institutions in both countries need more capacity building to foster sustainable changes to the local health systems.