Better broadband needed for rural, regional health

Limitations in the roll out of satellite technology are impeding the take-up of the National Broadband Network (NBN) in regional, rural, and remote areas, the AMA has told a Senate committee.

In a written submission to the Joint Standing Committee on the NBN, AMA President Dr Michael Gannon said that all Australians, regardless of where they live or work, should have equitable access to high-speed and reliable internet services.

“Country Australians must have access to NBN services that enable them to conduct the same level of business via the internet as their city counterparts,” Dr Gannon said.

“These NBN services must also have the capacity to meet their future internet needs.

“This is particularly important for providers of vital health services. Data allowances and speeds must be sufficient to enable two-way applications for e-health and telehealth, including the transfer of high-resolution medical images, medical education, videoconferencing, Voice over Internet Protocol (VoIP), and other applications.

“However, it is widely acknowledged that there are significant cost, data allowance, and speed differences between fixed and satellite broadband services, putting some regional and remote areas at a significant disadvantage.

“While NBNCo (nbn) has advised the AMA that it is looking at how some of these issues can be addressed for critical services like health care, changes are yet to be detailed at this time.”

Dr Gannon said that nbn had advised the AMA that it was working to identify medical facilities and general practices within the satellite footprint in rural and remote areas that would qualify as Public Interest Premises (PIPs), and therefore be granted access to higher data allowances.

“This is a small step in the right direction, but the AMA remains concerned that, even as PIPs, these medical facilities will still not have sufficient data allowance to be able to fully utilise the e-health and telehealth opportunities that are taken for granted in metropolitan areas,” he said.

Last month, Minister for Regional Development and Regional Communications Fiona Nash announced that Medicare rebates will be paid for rural and remote Australians to access psychological counselling through teleconferencing.

Senator Nash said that mental health was a significant issue in rural and remote areas, but lack of easy access to a nearby psychologist often meant mental health issues went untreated.

“It’s difficult and sometimes impossible for rural and remote Australians to attend face-to-face counselling,” Senator Nash told the National Press Club.

“Today, I announce rural and remote Australians will, for the first time, have access to psychology through teleconferencing paid for by Medicare.

“This will mean rural and remote Australians can use Skype, FaceTime or video calling to access psychologists and psychiatrists all over Australia from their home or a local medical centre.”

Many Australians who were going without mental health treatment will now receive it, Senator Nash said, praising Health Minister Greg Hunt for delivering the first outcome from the Regional Australia Ministerial Taskforce.

Despite criticism of the speed of the nbn’s SkyMuster satellite service, Senator Nash said it was fast enough to deliver the service, and said people in the bush understood that they were not going to have the same internet speeds as their city counterparts.

“For those wondering, high definition video conferencing requires internet speed of just 1.5 megabits a second. A typical Sky Muster plan delivers enough data for 66 hours a month of high definition video conferencing,” she said.

“Regional people are very pragmatic. They know they are not going to get the same equivalence across a whole range of areas their city cousins do, but they want access to services so they can get on their lives.

“The (internet) speed you are going to get in the western parts of Queensland is not going to be the same that you get in the CBD in Brisbane.

“They (rural Australians) get that … as I am travelling around and talking to people in the regions, I’m not talking about the speed, I’m talking, ‘Can you do what you want to do in the regions through your internet connection?’

“By and large, most of them are happy with the service they’ve got.”

Maria Hawthorne

Has general practice lost its appeal?

Medical graduates are increasingly shunning general practice for specialist disciplines, according to a new report from the Melbourne Institute.

Looking at data from Medicare along with a ten-year study of 10,000 doctors, the report found the number of young doctors taking up general practice has declined in real terms over the past few years.

At the same time, for every junior doctor going into general practice, close to ten are opting for a specialist discipline.

“Money does matter,” says Professor Anthony Scott, who heads up the Health Economics Research Program at the Melbourne Institute lead author of the report.

“Specialists are paid two to three times what most GPs are, and that’s the route junior doctors want to take. Often it is those who can’t become specialists that move into general practice.”

The report also finds GPs are increasingly dissatisfied with their work and job-life balance in their profession.

Job satisfaction fell by 1.5% between 2013 and 2015, reversing a previous upward trend. Coincidentally or not, 2013 is the year the federal government instigated the Medicare rebate freeze.

That freeze also led to a decline in real terms of Medicare revenue per full-time equivalent GP.

However, total GP hourly earnings have increased at double the rate of real wage growth in the economy. The report authors say it’s not clear why, considering the decline in Medicare revenue, but it may be down to practice efficiencies or income from other sources.

And despite the Medicare rebate freeze, the proportion of services that are bulk-billed has continued to climb, with 86% of services in the last quarter of 2016.

The shape of general practice is changing, too, with a decline in the number of GPs owning their own practice. Correspondingly, practice sizes are increasing, with a wider range of services provided by a range of health professionals.

Almost half of GPs worked in a practice with six or more GPs in 2008, climbing to 61% by 2015.

Another striking change in general practice, and indeed in medicine generally, is the rise of the female doctor. In ten years, from 2005 to 2015, the proportion of doctors who were women went up from 33% to 40%. Over 60% of GPs under 35 are now women, which is 11% higher than for specialists.

And yet female GPs earn around 25% less than their male colleagues, even after accounting for the fact that they tend to work fewer hours. Being a mother further penalises women, who earn $30,000 a year less if they have children. By contrast, men with children earn $45,000 more than their childless male peers.

You can read the full report here.

Professor Scott’s views on junior doctors’ motivations for opting for general practice are not necessarily those of doctorportal.

Reducing the burden of neurological disease and mental illness

The key to finding solutions for brain disorders is cooperation and collaboration, from the laboratory to the clinic

Australia is challenged by the rising economic and social costs of neurological disease and mental illness, which together account for one-third of the total disease burden in Australia.1 The financial cost of these disorders — about $45.5 billion annually1–4 — does not take into account the emotional impact and social isolation they cause. Many are chronic conditions with limited options for even ameliorative treatment, so that research into finding new approaches to their management is urgently needed. Translation of research into improved clinical practice, however, requires a continuum of process, including basic research, application of research findings, clinical trials, and implementation. Involving both basic researchers and clinicians in this process is crucial to its success. The Australasian Neuroscience Society (ANS; www.ans.org.au) recognises this need both by representing neuroscientists and clinicians in Australia and New Zealand active in neuroscience and mental health research, and by acting as a conduit for clinicians to interact more closely with researchers to achieve their shared goals.

This issue of the MJA highlights examples of current progress in the neuroscience of neurological disease and mental health conditions. As discussed by Koblar and colleagues,5 restoring brain function in people who have had a stroke or incurred other damage to the central nervous system remains an area of unmet need. Australian researchers play significant roles in international efforts to develop regenerative neurology; for example, the 2017 Australian of the Year, Professor Alan Mackay-Sim, was recognised for his work in developing stem cell therapies for people with spinal cord injuries. Australians have long played an important role in developing devices for restoring central nervous system function. For instance, the cochlear implant, invented by Professor Graeme Clark and colleagues at the University of Melbourne in 1978, has restored hearing to nearly 350 000 individuals across the world with sensorineural hearing dysfunction. Australians continue to operate at the cutting edge of the development of devices at the brain–computer interface, such as those described in this issue by Rosenfeld and colleagues.6

The burden of neurodegenerative disorders is rising as the Australian population ages. Dharmadasa and her co-authors7 review advances in the treatment of motor neurone disease, including three ongoing Australian clinical trials of potentially neuroprotective therapies; that is, of interventions that aim to slow the progress of the disease, not just provide symptomatic relief.

2017 promises to be an exciting year for accelerating progress in understanding the human brain. Major research projects seeking to deepen our understanding of its function and to translate this understanding into practical therapies are underway in the United States, Europe, Japan, and China, and the number of participating countries is rapidly expanding.8 Australia itself has a national brain project; developed by the Australian Brain Alliance and coordinated by the Australian Academy of Science, it is a collaboration of 28 organisations (including ANS) involved in brain research.9 The Australian Brain Project aims to understand how the brain encodes, stores and retrieves information, and its goals will be the focus of a proposal to be presented to the federal government in 2018. The Australian Brain Alliance also participated in an historic meeting at Rockefeller University (New York) in September 2016 with the goal of promoting collaboration and cooperation between large scale brain research projects around the world.10

The fundamental brain functions investigated by the members of ANS and the Australian Brain Project are intrinsic to our humanity, and they are often compromised by neurological disease and mental illness. Comprehensive understanding of these processes, and of precisely how and why they are disrupted in disease states, will provide us with new opportunities for improving diagnostics and developing more effective therapies that enhance the lives of the many Australians burdened by these disorders.

[Correspondence] Obesity management in primary care

Obesity is a growing public health concern that might be neglected by primary care providers. In one study, 59% of patients with morbid obesity had no record of weight management advice in their primary care records over 7 years.1 The study in The Lancet by Paul Aveyard and colleagues2 that explores the role of brief interventions for obesity in primary care is welcome. Net weight loss following their intervention was 1·4 kg at 12 months. Systematic reviews of randomised trials conducted in primary care, which were not discussed by Aveyard and colleagues, reveal very similar findings.

[Correspondence] Obesity management in primary care

In a study published in The Lancet (Nov 19, 2016, p 2492)1, Paul Aveyard and colleagues’ successful application of a brief intervention for obesity in general practice is yet another example of the important role that GPs play in the health-care system.1

Indexation freeze hits veterans’ health care

A recent survey of some AMA members has highlighted the impact of the Government’s ongoing indexation freeze on access to Department of Veterans’ Affairs (DVA) funded specialist services for veterans.

The DVA Repatriation Medical Fee Schedule (RMFS) has been frozen since 2012.

The AMA conducted the survey following anecdotal feedback from GP and other specialist members that veterans were facing increasing barriers to accessing specialist medical care.

Running between March 3 and 10, the survey was sent to AMA specialist members (excluding general practice) across the country.

It attracted interest from most specialties, although surgery, medicine, anaesthesia, psychiatry and ophthalmology dominated the responses.

More than 98 per cent of the 557 participants said they treat or have treated veterans under DVA funded health care arrangements.

For the small number of members who said they did not, inadequate fees under the RMFS was nominated as the primary reason for refusing to accept DVA cards.

When asked, 79 per cent of respondents said they considered veteran patients generally had a higher level of co-morbidity or, for other reasons, required more time, attention and effort than other private patients.

According to the survey results, the indexation freeze is clearly having an impact on access to care for veterans and this will only get worse over time.

Table 1 highlights that only 71.3 per cent of specialists are currently continuing to treat all veterans under the DVA RMFS, with the remainder adopting a range of approaches including closing their books to new DVA funded patients or treating some as fully private or public patients.

If the indexation freeze continues, the survey confirmed that the access to care for veterans with a DVA card will become even more difficult.

Table 2 shows that less than 45 per cent of specialists will continue to treat all veterans under the DVA RMFS while the remainder will reconsider their participation, either dropping out altogether or limiting the services provided to veterans under the RMFS.

In 2006, a similar AMA survey found that 59 per cent of specialists would continue to treat all veteran patients under the RMFS.

There was significant pressure on DVA funded health care at the time, with many examples of veterans being forced interstate to seek treatment or being put on to public hospital waiting lists.

The Government was forced to respond in late 2006 with a $600m funding package to increase fees paid under the RMFS and, while the AMA welcomed the package at the time, it warned that inadequate fee indexation would quickly erode its value and undermine access to care.

In this latest survey, this figure appears likely to fall to 43.8 per cent – underlining the AMA’s earlier warnings. The continuation of the indexation freeze puts a significant question mark over the future viability of the DVA funding arrangements and the continued access to quality specialist care for veterans.

The AMA continues to lobby strongly for the lifting of the indexation freeze across the Medicare Benefits Schedule and the RMFS, with these survey results provided to both DVA and the Health Minister’s offices. The Government promotes the DVA health care arrangements as providing eligible veterans with access to free high quality health care and, if it is to keep this promise to the veterans’ community, the AMA’s latest survey shows that it clearly needs to address this issue with some urgency.

Chris Johnson

Table 1

Which of the following statements best describes your response to the Government’s freeze on fees for specialists providing medical services to veterans under the Repatriation Medical Fee Schedule (RMFS):
Answer Options	Response Percent
I am continuing to treat all veterans under the RMFS	71.3%
I am continuing to treat existing patients under the RMFS, but refuse to accept any more patients under the RMFS	9.9%
I am treating some veterans under the RMFS and the remainder either as fully private patients or public patients depending on an assessment of their circumstances	10.8%
I am providing some services to veterans under the RMFS (e.g. consultations) but not others (e.g. procedures)	5.6%
I no longer treat any veterans under the RMFS	2.4%

Table 2

Which of the following statements best describes your likely response if the Government continues its freeze on fees for specialists providing medical services to veterans under the RMFS:
Answer Options	Response Percent
I will continue to treat all veterans under the RMFS	43.8%
I will continue to treat existing patients under the RMFS, but refuse to accept any more patients under the RMFS	15.5%
I will treat some veterans under the RMFS and the remainder either as fully private patients or public patients depending on an assessment of their circumstances	21.1%
I will provide some services to veterans under the RMFS (e.g. consultations) but not others (e.g. procedures)	8.4%
I will no longer treat any veterans under the RMFS	11.2%

The Australasian Society for Infectious Diseases and Refugee Health Network of Australia recommendations for health assessment for people from refugee-like backgrounds: an abridged outline

There are currently more than 65 million people who have been forcibly displaced worldwide, including 21.3 million people with formal refugee status, over half of whom are aged under 18 years.1 More than 15 000 refugees have resettled in Australia in the 2015–16 financial year, which includes a proportion of the 12 000 refugees from Syria and Iraq recently added to Australia’s humanitarian intake.2 In addition, around 30 000 asylum seekers who arrived by plane or boat are currently in Australia awaiting visa outcomes.3

People from refugee-like backgrounds are likely to have experienced disruption of basic services, poverty, food insecurity, poor living conditions and prolonged uncertainty; they may have experienced significant human rights violations, trauma or torture. These circumstances place them at increased risk of complex physical and mental health conditions. They face numerous barriers to accessing health care after arrival in Australia, such as language, financial stress, competing priorities in the settlement period, and difficulties understanding and navigating the health care system.4–6 Most people require the assistance of an interpreter for clinical consultations.7 Offering a full health assessment to newly arrived refugees and asylum seekers is a positive step towards healthy settlement, and helps manage health inequity through the provision of catch-up immunisation and the identification and management of infectious and other health conditions.

These guidelines update the Australasian Society of Infectious Diseases (ASID) guidelines for the diagnosis, management and prevention of infectious diseases in recently arrived refugees8 published in 2009 and previously summarised in the MJA.9 When these recommendations were first published, more than 60% of humanitarian entrants arriving in Australia were from sub-Saharan Africa10 and had a high prevalence of malaria, schistosomiasis and hepatitis B virus (HBV) infection.11–15 The initial guidelines were primarily intended to help specialists and general practitioners to diagnose, manage and prevent infectious diseases. Since then, there have been changes in refugee-source countries — with more arrivals from the Middle East and Asia and fewer from sub-Saharan Africa16,17 — and an increased number of asylum seekers arriving by boat,18 alongside complex and changing asylum seeker policies and changes in health service provision for these populations. In this context, we reviewed the 2009 recommendations to ensure relevance for a broad range of health professionals and to include advice on equitable access to health care, regardless of Medicare or visa status. The revised guidelines are intended for health care providers caring for people from refugee-like backgrounds, including GPs, refugee health nurses, refugee health specialists, infectious diseases physicians and other medical specialists.

This article summarises the full guidelines, which contain detailed literature reviews, recommendations on diagnosis and management along with explanations, supporting evidence and links to other resources. The full version is available at http://www.asid.net.au/documents/item/1225.

Methods

The guideline development process is summarised in Box 1. The two key organisations developing these guidelines are ASID and the Refugee Health Network of Australia. ASID is Australia’s peak body representing infectious diseases physicians, medical microbiologists and other experts in the fields of the prevention, diagnosis and treatment of human and animal infections. The Refugee Health Network is a multidisciplinary network of health professionals across Australia with expertise in refugee health.20

We defined clinical questions using the PIPOH framework (population, intervention, professionals, outcomes and health care setting).21 The chapter authors and the Expert Advisory Group developed recommendations based on reviews of available evidence, using systematic reviews where possible. Australian prevalence data also informed screening recommendations; for example, the low reported prevalence of chlamydia (0.8–2.0%) infections and absence of gonorrhoea infections in refugee cohorts in Australia13,22–24 (and in other developed countries25–27) informed the new recommendation for risk-based sexually transmitted infection (STI) screening.

Despite the intention to assign levels of evidence to each recommendation, there was limited published high level evidence in most areas, and virtually all recommendations are based on expert consensus. Consensus was not reached regarding the recommendations relating to human immunodeficiency virus (HIV) and STIs.

The term “refugee-like” is used to describe people who are refugees under the United Nations Refugee Convention,28 those who hold a humanitarian visa, people from refugee-like backgrounds who have entered under other migration streams, and people seeking asylum in Australia. “Refugee-like” acknowledges that people may have had refugee experience in their countries of origin or transit, but do not have formal refugee status.

Current pre-departure screening

All permanent migrants to Australia have a pre-migration immigration medical examination 3–12 months before departure,29 which includes a full medical history and examination. Investigations depend on age, risk factors and visa type,30 and include:

a chest x-ray for current or previous tuberculosis ([TB]; age ≥ 11 years);
screening for latent TB infection with an interferon-γ release assay or tuberculin skin test (for children aged 2–10 years, if they hold humanitarian visas, come from high prevalence countries or have had prior household contact);
HIV serology (age ≥ 15 years, unaccompanied minors);
hepatitis B surface antigen (HBsAg) testing (pregnant women, unaccompanied minors, onshore protection visas, health care workers);
hepatitis C virus (HCV) antibody testing (onshore protection visas, health care workers); and
syphilis serology (age ≥ 15 years, humanitarian visas, onshore protection visas).

Humanitarian entrants are also offered a voluntary pre-departure health check depending on departure location and visa subtype.31 The pre-departure health check includes a rapid diagnostic test and treatment for malaria in endemic areas; empirical treatment for helminth infections with a single dose of albendazole; measles, mumps and rubella vaccination; and yellow fever and polio vaccination where relevant. The current cohort of refugees arriving from Syria will have extended screening incorporating the immigration medical examination and pre-departure health check, with additional mental health review and immunisations.

People seeking asylum who arrived by boat have generally had a health assessment on arrival in immigration detention — although clinical experience suggests that investigations and detention health care varies, especially for children. However, asylum seekers who arrived by plane will not have had a pre-departure immigration medical examination.

General recommendations

Our overarching recommendation is to offer all people from refugee-like backgrounds, including children, a comprehensive health assessment and management plan, ideally within 1 month of arrival in Australia. This assessment can be offered at any time after arrival if the initial contact with a GP or clinic is delayed, and should also be offered to asylum seekers after release from detention. Humanitarian entrants who have been in Australia for less than 12 months are eligible for a GP Medicare-rebatable health assessment. Such assessments may take place in a primary care setting or in a multidisciplinary refugee health clinic. Documented overseas screening and immunisations, and clinical assessment should also guide diagnostic testing.

Health care providers should adhere to the principles of person-centred care when completing post-arrival assessments.32,33 These include: respect for the patient’s values, preferences and needs; coordination and integration of care with the patient’s family and other health care providers; optimising communication and education, provision of interpreters where required (the Doctors Priority Line for the federal government-funded Translating and Interpreting Service is 1300 131 450) and use of visual and written aids and teach-back techniques to support health literacy.34 It is important to explain that a health assessment is voluntary and results will not affect visa status or asylum claims.

Specific recommendations

Recommendations are divided into two sections: infectious and non-infectious conditions. Box 2 provides a checklist of all recommended tests, and Box 3 sets out details of country-specific recommendations. A brief overview is provided below. For more detailed recommendations regarding management, follow-up and considerations for children and in pregnancy, see the full guidelines.

Infectious conditions

TB:

Offer latent TB infection testing with the intention to offer preventive treatment and follow-up.
Offer screening for latent TB infection to all people aged ≤ 35 years.
Children aged 2–10 years may have been screened for latent TB infection as part of their pre-departure screening.
Screening and preventive treatment for latent TB infection in people > 35 years will depend on individual risk factors and jurisdictional requirements in the particular state or territory.
Use either a tuberculin skin test or interferon-γ release assay (blood) to screen for latent TB infection.
A tuberculin skin test is preferred over interferon-γ release assay for children < 5 years of age.
Refer patients with positive tuberculin skin test or interferon-γ release assay results to specialist tuberculosis services for assessment and exclusion of active TB and consideration of treatment for latent TB infection.
Refer any individuals with suspected active TB to specialist services, regardless of screening test results.

Malaria:

Investigations for malaria should be performed for anyone who has travelled from or through an endemic malaria area (Box 3), within 3 months of arrival if asymptomatic, or any time in the first 12 months if there is fever (regardless of pre-departure malaria testing or treatment).
Test with both thick and thin blood films and an antigen-based rapid diagnostic test.
All people with malaria should be treated by, or in consultation with, a specialist infectious diseases service.

HIV:

Offer HIV testing to all people aged ≥ 15 years and all unaccompanied or separated minors, as prior negative tests do not exclude the possibility of subsequent acquisition of HIV (note that consensus was not reached regarding this recommendation).

HBV:

Offer testing for HBV infection to all, unless it has been completed as part of the immigration medical examination.
A complete HBV assessment includes HBsAg, HB surface antibody and HB core antibody testing.
If the HBsAg test result is positive, further assessment and follow-up with clinical assessment, abdominal ultrasound and blood tests are required.

HCV:

Offer testing for HCV to people if they have:
- risk factors for HCV;
- lived in a country with a high prevalence (> 3%) of HCV (Box 3); or
- an uncertain history of travel or risk factors.
Initial testing is with an HCV antibody test. If the result is positive, request an HCV RNA test.
If the HCV RNA test result is positive, refer to a doctor accredited to treat HCV for further assessment.

Schistosomiasis:

Offer blood testing for Schistosoma serology if people have lived in or travelled through endemic countries (Box 3).
If serology is negative, no follow-up is required.
If serology is positive or equivocal:
- treat with praziquantel in two doses of 20 mg/kg, 4 hours apart, orally; and
- perform stool microscopy for ova, urine dipstick for haematuria, and end-urine microscopy for ova if there is haematuria.
If ova are seen in urine or stool, evaluate further for end-organ disease.

Strongyloidiasis:

Offer blood testing for Strongyloides stercoralis serology to all.
If serology is positive or equivocal:
- check for eosinophilia and perform stool microscopy for ova, cysts and parasites; and
- treat with ivermectin 200 μg/kg (weight ≥ 15 kg), on days 1 and 14 and repeat eosinophil count and stool sample if abnormal.
Refer pregnant women or children < 15 kg for specialist management.

Intestinal parasites:

Check full blood examination for eosinophilia.
If pre-departure albendazole therapy is documented:
- if there are no eosinophilia and no symptoms, no investigation or treatment is required; and
- if there is eosinophilia, perform stool microscopy for ova, cysts and parasites, followed by directed treatment.
If no documented pre-departure albendazole therapy, depending on local resources and practices, there are two acceptable options:
- empirical single dose albendazole therapy (age > 6 months, weight < 10 kg, dose 200 mg; weight ≥ 10 kg, dose 400 mg; avoid in pregnancy, class D drug); or
- perform stool microscopy for ova, cysts and parasites, followed by directed treatment.

Helicobacter pylori:

Routine screening for H. pylori infection is not recommended.
Screen with either stool antigen or breath test in adults from high risk groups (family history of gastric cancer, symptoms and signs of peptic ulcer disease, or dyspepsia).
Children with chronic abdominal pain or anorexia should have other common causes of their symptoms considered in addition to H. pylori infection.
Treat all those with a positive test (see the full guidelines for details, tables 1.5 and 9.1).

STIs:

Offer an STI screen to people with a risk factor for acquiring an STI or on request. Universal post-arrival screening for STIs for people from refugee-like backgrounds is not supported by current evidence.
A complete STI screen includes a self-collected vaginal swab or first pass urine nucleic acid amplification test and consideration of throat and rectal swabs for chlamydia and gonorrhoea, and serology for syphilis, HIV and HBV.
Syphilis serology should be offered to unaccompanied and separated children < 15 years.

Skin conditions:

The skin should be examined as part of the initial physical examination.
Differential diagnoses will depend on the area of origin (see table 11.1 in full guidelines for details).

Immunisation:

Provide catch-up immunisation so that people of refugee background are immunised equivalent to an Australian-born person of the same age.
In the absence of written immunisation documentation, full catch-up immunisation is recommended.
Varicella serology is recommended for people aged ≥ 14 years if there is no history of natural infection.
Rubella serology should be completed in women of childbearing age.

Non-infectious conditions

Anaemia and other nutritional problems:

Offer full blood examination screening for anaemia and other blood conditions to all.
Offer screening for iron deficiency with serum ferritin to children, women of childbearing age, and men who have risk factors.
Check vitamin D status as part of initial health screening in people with one or more risk factors for low vitamin D.
People with low vitamin D should be treated to restore their levels to the normal range with either daily dosing or high dose therapy, paired with advice about sun exposure.
Consider screening for vitamin B₁₂ deficiency in people with history of restricted food access, especially those from Bhutan, Afghanistan, Iran and the Horn of Africa.

Chronic non-communicable diseases in adults:

Offer screening for non-communicable diseases in line with the Royal Australian College of General Practitioners Red Book35 recommendations, including assessment for:
- smoking, nutrition, alcohol and physical activity;
- obesity, diabetes, hypertension, cardiovascular disease, chronic obstructive pulmonary disease and lipid disorders; and
- breast, bowel and cervical cancer.
Assess diabetes and cardiovascular disease risk earlier for those from regions with a higher prevalence of non-communicable diseases, or those with an increased body mass index or waist circumference.

Mental health:

A trauma informed assessment of emotional wellbeing and mental health is part of post-arrival screening. Being aware of the potential for past trauma and impact on wellbeing is essential, although it is generally not advisable to ask specifically about details in the first visits.
Consider functional impairment, behavioural difficulties and developmental progress as well as mental health symptoms when assessing children.

Hearing, vision and oral health:

A clinical assessment of hearing, visual acuity and dental health should be part of primary care health screening.

Women’s health:

Offer women standard preventive screening, taking into account individual risk factors for chronic diseases and bowel, breast and cervical cancer.
Consider pregnancy and breastfeeding and offer appropriate life stage advice and education, such as contraceptive advice where needed, to all women, including adolescents.
Practitioners should be aware of clinical problems, terminology and legislation related to female genital mutilation or cutting and forced marriage.

Box 1 –
Guideline development process

An EAG, consisting of refugee health professionals, was formed and it included two ID physicians, an ID and general physician, two GPs, a public health physician, a general paediatrician and a refugee health nurse. An editorial subgroup was also formed.
The EAG determined the list of priority conditions in consultation with refugee health specialists and RACGP Refugee Health Special Interest Group clinicians, incorporating information from consultations with refugee background communities19 and previous ASID refugee health guidelines.
Each condition was assigned to a primary specialist author with paediatrician and primary care or specialist co-authors. Twenty-eight authors from six states and territories were involved in writing the first draft.
The EAG reviewed the first draft to ensure consistency with the framework and the rest of the guidelines. They were then revised by the primary authors.
External expert review authors reviewed the second draft and they were then revised by the primary authors.
The EAG and the refugee health nurse subcommittee reviewed the third draft.
The stakeholders reviewed the fourth draft: ASID, NTAC, RHeaNA, RACGP Refugee Health Special Interest Group, RACP, RACP AChSHM, the Victorian Foundation for the Survivors of Torture, the Multicultural Centre for Women’s Health, the Asylum Seeker Resource Centre, the Ethnic Communities Council of Victoria and community members.
The comments from the stakeholders were returned to the authors for review and the EAG compiled the final version.
ASID, RACP, NTAC and AChSHM endorsed the final version.

AChSHM = Australasian Chapter of Sexual Health Medicine. ASID = Australasian Society for Infectious Diseases. EAG = Expert Advisory Group. GP = general practitioner. ID = infectious diseases. NTAC = National Tuberculosis Advisory Council. RACGP = Royal Australian College of General Practitioners. RACP = Royal Australasian College of Physicians. RHeaNA = Refugee Health Network of Australia. Adapted from the ASID and RHeaNA Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds (2016; https://www.asid.net.au/documents/item/1225) with permission from ASID.

Box 2 –
Short checklist of recommendations for post-arrival health assessment of people from refugee-like backgrounds

Offer test to

Test

Comments and target condition

All

Full blood examination

Anaemia, iron deficiency, eosinophilia

Hepatitis B serology (HBsAg, HBsAb, HBcAb)

HBsAg testing introduced overseas in 2016 for Syrian and Iraqi refugee cohort and may have been completed in other groups

Strongyloides stercoralis serology

Strongyloidiasis

HIV serology*

≥ 15 years or unaccompanied or separated minor
Also part of IME for age ≥ 15 years

TST or IGRA

Offer test if intention to treat. All ≤ 35years; if≥ 35 years, depends on risk factors and local jurisdiction. TST preferred for children < 5 yearsTST or IGRA testing introduced in 2016 as part of IME for children 2–10 years (humanitarian entrants, high prevalence countries, prior household contact)
LTBI

Varicella serology

≥ 14 years if no known history of disease
Determine immunisation status

Visual acuity

Vision status, other eye disease

Glaucoma assessment

Africans > 40 years and others > 50 years

Dental review

Caries, periodontal disease, other oral health issues

Hearing review

Hearing impairment

Social and emotional wellbeing and mental health

Mental illness, trauma exposure, protective factors

Developmental delay or learning concerns

Children and adolescents
Developmental issues, disability, trauma exposure

Preventive health as per RACGP35

Non-communicable diseases, consider screening earlier than usual age

Catch-up vaccinations

Vaccine preventable diseases, including hepatitis B

Risk-based

Rubella IgG

Women of childbearing age
Determines immunisation status

Ferritin

Men who have risk factors, women and childrenIron deficiency anaemia

Vitamin D, also check calcium, phosphate, and alkaline phosphatase in children

Risk factors if dark skin or lack of sun exposure
Low vitamin D, rickets

Vitamin B₁₂

Arrival < 6 months, food insecurity, vegan diet or from Bhutan, Afghanistan, Iran or Horn of Africa
Nutritional deficiency, risk for developmental disability in infants

First pass urine or self-obtained vaginal swabs for gonorrhoea and chlamydia PCR

Risk factors for STI or on request*

Syphilis serology

Risk factors for STIs, unaccompanied or separated minors. Part of IME in humanitarian entrants aged ≥ 15 years

Helicobacter pylori stool antigen or breath test

Gastritis, peptic ulcer disease, family history of gastric cancer, dyspepsia

Stool microscopy (ova, cysts and parasites)

If no documented pre-departure albendazole or persisting eosinophilia despite albendazoleIntestinal parasites

Country-based (Box 3)

Schistosoma serology

Schistosomiasis

Malaria thick and thin films and rapid diagnostic test

Malaria

HCV Ab, and HCV RNA if HCV Ab positive

HCV, also test if risk factors, regardless of country of origin

HBcAb = hepatitis B core antibody. HBsAb = hepatitis B surface antibody. HBsAg = hepatitis B surface antigen. HCV = hepatitis C virus. HCV Ab = hepatitis C antibody. HIV = human immunodeficiency virus. IGRA = interferon-γ release assay. IME = immigration medical examination. LBTI = latent tuberculosis infection. PCR = polymerase chain reaction. TST = tuberculin skin test. * The panel did not reach consensus on these recommendations. See full guideline at http://www.asid.net.au/documents/item/1225 for details.

Box 3 –
Top 20 countries of origin for refugees and asylum seekers2,3,16 and country-specific recommendations for malaria, schistosomiasis and hepatitis C screening*

Country of birth

Malaria36

Schistosomiasis37

Hepatitis C^†38

Afghanistan

Bangladesh

Yes

Bhutan

Yes

Burma

Yes

China

Congo

Yes

Egypt

Yes

Eritrea

Yes

India

Yes

Iran

Iraq

Yes

Lebanon

Pakistan

Yes

Somalia

Yes

Sri Lanka

Yes

Stateless^‡

Yes

Sudan

Yes

Syria

Yes

Consider

Vietnam

* There are regional variations in the prevalence of these conditions within some countries. We have taken the conservative approach of recommending screening for all people from an endemic country rather than basing the recommendation on exact place of residence. Note that some refugees and asylum seekers may have been exposed during transit through countries not listed here. See full guideline for further details. † People with risk factors for hepatitis C should be tested regardless of country of origin. ‡ “Stateless” in this table refers to people of Rohingyan origin. Adapted from the ASID and RHeaNA Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds (2016; https://www.asid.net.au/documents/item/1225) with permission from ASID.

Clinical experience of patients with hepatitis C virus infection among Australian GP trainees

Since March 2016, new direct-acting antiviral agents (DAAs) for treating infection with hepatitis C virus (HCV) have been available in Australia under the Pharmaceutical Benefits Scheme (PBS). This represents a revolution in the treatment of hepatitis C, as DAA regimens have cure rates of more than 90%, minimal adverse effects, and low treatment complexity. In contrast to previous HCV treatments, general practitioners are authorised to prescribe HCV DAAs. The Fourth National HCV Strategy emphasises that, to maximise the impact of HCV DAAs, most HCV treatment will need to move from hospital-based clinics to the primary care setting.1

An estimated 230 000 Australians live with chronic HCV infection,2 with annual notification rates about twice as high among males as among females, and highest for people aged 30–50 years.3 Eliminating hepatitis C as a public health problem by using highly efficacious, well tolerated DAAs is possible, but would require a major increase in the number of people treated.4

Registrar Clinical Encounters in Training (ReCEnT) is a prospective cohort study that collected detailed data on more than 150 000 consultations by GP trainees in five Australian GP training programs during 2010–2015. ReCEnT documents the content of trainees’ consultations, and both informs and evaluates training program changes. Our methodology, described in detail elsewhere,5 and statistical analysis are summarised in the online Appendix. As most learning by GP trainees is acquired in an apprenticeship model in the workplace (supplemented by away-from-practice educational sessions),6 we aimed to determine prevalence of management of and testing for HCV in the consultations of trainee GPs.

Although at least 1.2% of the Australian population are infected with HCV,7 hepatitis C was managed as a problem (eg, discussed, investigated, referral of the patient) in only 0.08% of consultations (online Appendix, Table). This indicates that the current exposure of registrars to the diagnosis and management of HCV infections during training is very limited. Patients for whom HCV was managed were older than other patients, and more likely to be male or Indigenous Australian. HCV testing was performed in 0.7% of consultations, and the patients tested were significantly younger (mean age, 32 v 40 years; P < 0.001), and more likely to be female, Indigenous Australian, or from a non-English speaking background than those who were not (online Appendix, Table). Doctors who tested for HCV were younger, and were more likely to be female, graduates of Australian universities, and practising in a city (online Appendix, Table).

Our data indicate that the clinical exposure of GP trainees to patients infected with HCV is limited, and that their experiential training in this condition may be inadequate. Further, HCV testing was only infrequently ordered, and the wrong groups were targeted; we found that males and older patients were less likely to be tested, despite higher HCV seroprevalence in these groups. If hepatitis C is to be eradicated as a public health problem in Australia, it is important that diagnosing and treating HCV infections are prominent in the GP training curriculum.

End the loss on consumables

DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

Readers will need to pardon the pun, but the ban on charging for consumables like dressings when bulk billing a patient is an open wound that GPs and general practices have been struggling with for over a decade. It is estimated that more than 400,000 patients at any one time are suffering from hard-to-heal wounds. Venous leg ulcers, which are prevalent in the older population, for example, affect around 43,000 people. KPMG, as far back as 2003, estimated that $166 million a year could be saved by treating these patients with compression bandages and stockings.

The high incidence of chronic wounds produces a heavy burden on the Australian health care system. And a study on wound care costs in general practice conducted in 2011 showed that, in most cases, general practices are not recouping the costs of wound care. In providing this critical service for patients, GPs and practices typically incur a loss.

Before the introduction of the Practice Nurse Incentive Scheme, the practice nurse item for wound management helped offset the cost of wound care. Bandages and dressings generally cost anywhere from between $4 and $21 with the median just under $10. However some, such as a four-layer compression bandage, can be around $50.

As you know, many of the patients who need wound care are vulnerable. They are often aged and suffering from multiple conditions. GPs are faced with a difficult choice and tend to bulk bill them out of compassion. The GP/practice then is left with carrying the cost of the dressings, which in the context of an inadequate Medicare rebate is not a trivial sum.

Of course GPs could raise a charge for the bandage and just bill the patient the MBS fee for the attendance, which they can then claim on Medicare, but in doing this lose access to any bulk billing incentive. For GPs it is a lose-lose.

The Government’s freeze on Medicare rebates has made this situation even more intolerable.

As is so often the case when it comes to supporting best practice, the Department of Veterans’ Affairs is at the forefront, providing veterans with access to subsidised dressings for treating a range of wounds. While the Government may not want to pursue this model for non-DVA funded patients, it is time for a conversation about the potential for cost recovery on consumables like dressings, while still being able to bulk bill a patient. This is a conversation the AMA is now starting with the Government.

Ideally, the same arrangements that apply to vaccines should apply to consumables. Proper wound care is essential to managing patients in the community and keeping them out of hospital. It’s a classic situation where prevention is better than the cure and, from a patient’s perspective, a much better alternative than asking them to pop down to the pharmacy to purchase dressings (with a retail mark-up) and then having to return to the practice to have the dressing applied.

Pain for Your Thoughts

ROB THOMAS, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

One of the more difficult issues dealt with on a daily basis in medicine is patients with pain – not to mention the chronic pain patient. Pain is difficult to describe, complex in nature and specific to the individual. Unlike many other symptoms, chronic pain is largely invisible, hard to prove and even harder to disprove. It comes with a range of comorbidities, such as unintended weight gain, social isolation, and an increased rate of mental health conditions. Depending on one’s age, cultural background and personal experience, the experience of pain may vary widely.

Doctors, particularly junior doctors, find it especially hard to acknowledge chronic pain, probably because it is so difficult to treat. Our “fix it” mentality means that we find it testing when there is no simple solution. An opioid will dull it for now, but what does that do for the patient long term? Pain requires more than just a prescription. It requires scans, blood tests, referral to allied health and management plans. From this we ask ourselves, as young medical students or doctors, is there an acceptable level of pain that one should expect to live with? And who would determine that acceptable level? The medical staff? The patient?

We are taught to ask patients to scale pain on an arbitrary 0-10 scale. This scale may in fact be telling us more about a patient’s tolerance for pain than their symptom, and indeed may confuse the treating doctor who may suspect a high subjective score to be driven by a desire for strong pain medication. This may be an alert to staff to acknowledge and validate their pain, as well as to provide a plan of care in the treatment of it. The truth is the patient wants to lower their pain, they are not just “drug seeking”. The patient wishes to have their pain at a level under where it currently is. This would enable them to do activities of daily living, self-care and to get back to their everyday routine, where possible. Our journey with the patient is to navigate that pain with them, manage it and ensure a plan is put in place.

The next patient into your general practice is John, a 26-year-old man with a complaint of chronic back pain. You take a full history and find no red flags – in fact, his pain has already been investigated previously and found to be non-specific “musculoskeletal”. He has no significant past medical history and is otherwise well. His pain is currently 7/10 and constant for the past two weeks. He’s obviously in distress – what do you do?

Of course, there is no easy answer in a case like this, and that’s something that students need to be aware of. In particular, the use of non-evidence-based treatments must be acknowledged as “potentially helpful” – if nothing else, it can give patients hope. Adjuncts to the chronic health management plan could be physiotherapy, chiropractics, Pilates and other allied health referrals. The patient journey up until walking through your door will affect how they respond to your suggestions, and it’s important that we become comfortable with the uncertainty that is chronic pain.

Pain is an exceedingly difficult topic to cover in such a short passage. Junior doctors and medical students need to acknowledge the complexity of the nature of pain, then assess, treat and come up with a management plan. The patient journey starts with validating the patient’s pain and them trusting you enough to come back to develop a plan.

Email: rob.thomas@amsa.org.au

Twitter @robmtom