Not alarmist, just the boring truth

DR JOHN ZORBAS, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING

The truth is often incredibly boring. It doesn’t sell papers. It doesn’t get people tuning in. It doesn’t win votes. And thus it follows that when things don’t make sense, one should assume incompetence before malice. But I’m finding it incredibly hard to suspend my disbelief when I stand back and take a look at the medical training system that we have in front of us today.

I’m not trying to be alarmist. I’m not here to tell you all that medical training is broken, and we should burn the books, burn the witches and behead Ned Stark. But I hope that I can convince you at the very least that the current progression to Fellowship is entirely unnatural and is fertile ground for unhealthy professional culture. To really understand this progression, I want you to pair up with each other, junior and senior doctors alike, and I want you to compare your respective paths through your medical journey. I find that often people have no idea what is or was on the other side of the fence. Let’s begin.

We finish medical school as the ultimate in medical pluripotency: the intern. We complete a year of heavily regulated and supervised training where we meander through medicine, surgery, emergency and whatever else might lie in our path that year. We then transition to residency, where without the pressure of training progression, we expand our medical buffet of specialisation and become more attuned to our final path in the journey. Armed with the knowledge of our experiences in areas such as general practice, ICU and plastics, and well rested from the safe hours worked, we apply for a training college. We get onto a program and begin to complete the pathway to specialty. Along the way, we have kids, and we do this by working part time at points along the way to balance the load. We complete our final exams and we become a Fellow of our chosen College, and apply for jobs in what is a reasonably well-balanced workplace. Right? Wrong. The truth is boring, but the truth is the truth, and this picture definitely isn’t the truth.

We finish medical school as the ultimate in medical pluripotency: the intern. We apply for internships, and a number of us will fail to get them as State governments are defaulting on their COAG agreement to provide medical graduates with internships. Without an internship, a number of doctors are unable to progress to general registration and are out before they begin. Those who remain become residents. With no national body to oversee PGY2+ terms, and with health services hungry to provide services to increasing populations with shrinking budgets, these residents work terms that don’t provide any meaningful experience. This veritable army of night cover and discharge summary monkeys are forced to scrounge around for the breadcrumbs falling off the training table. The smart ones quit, locum and complete further study, but not without further financial and temporal penalty. We’ve built a system in which the best way to advance your career is to quit the system for a while; a perverse incentive. This of course leaves behind fewer residents to fill the gaps in the roster, who are already at breaking point due to being denied leave for three years.

Nevertheless, you move towards a College. You identify the entry requirements and you undertake the extra mile to become a candidate with a chance. In some instances, that means completing a $5000 exam before you’re even a trainee. Once in, you work full-time and then the rest of it. You complete graduate diplomas, Masters and PhDs to progress. You fill your CV with publications and courses that cost thousands of dollars to progress. But you do it anyway. Because at this point you’re the blackjack player with a hard twelve. You’ve sunk enough cost into this game that you can’t quit, and there’s a glimmer of a nine sitting on top of that deck. But there are many more face cards, and maybe it’s just me, but I swear I’m seeing more and more doctors folding and busting around me.

So, you make it through. With everyone else. You’ve completed a number of extra qualifications and courses. With everyone else. You’ve participated in the medical arms race, and you’re surrounded by tens of thousands of other nuclear nations who’ll do anything for that job. The fat has been trimmed and now we’ve hit muscle. Welcome to exit block; a nation of Australian Fellows who can’t move on to consultant positions because we’re doing more with less, in every sense of the phrase. Competition is one thing, but when you’ve got multiples of trainees to every consultant position, you don’t have a competition. You’ve got a war.

I told you I wasn’t going to be alarmist and I stand by that. My examples above are all based on real life cases. I believe firmly in having a competitive workplace. I believe that smart hard work should be rewarded in the workplace. But this is not the system we currently have. We have a system that rewards the single-minded.

This is nobody’s fault. But it’s definitely our problem. It’s up to us as a profession to recognise that this isn’t about doctors eschewing hard work. It isn’t about people wanting an easy life. This is about a culture that has not kept up with the times and it’s important for those working in well-run institutions to recognise that this is not the norm anymore.

AMA contributes to new guidelines

Two members of the AMA policy team have been thanked for their contributions to the first edition of the Guidelines for on-screen presentation of discharge summaries, developed by the Australian Commission on Safety and Quality Health Care.

Chair of the AMA Council of General Practice, Dr Richard Kidd, and Chair of the AMA Ethics and Medico Legal Committee Dr Chris Moy both took part in developing the guidelines.

Chief Executive Officer of the Commission, Adjunct Professor Debora Picone, expressed her gratitude to the doctors in a recent letter to AMA President Dr Michael Gannon.

“Development of the guidelines was supported by a clinical expert group that included and informed through an extensive national consultation,” Professor Picone wrote.

“I would like to take this opportunity to thank Dr Richard Kidd and Dr Chris Moy from the Australian Medical Association who contributed to this important work.”

The Guidelines for on-screen presentation of discharge summaries are available on the Commission’s website at: https://www.safetyandquality.gov.au/publications/national-guidelines-for…

According to the site, the guidelines specify the sequence, layout and format of the core elements of hospital discharge summaries, as displayed in clinical information systems.

They were developed through extensive research, consultation and iterative testing with more than 70 clinicians.

The guidelines are intended to be adopted by vendors of medical software, and health services that procure and implement systems which generate and present discharge summaries.

“The clinical handover of a patient on discharge from hospital generally occurs using an electronic discharge summary (eDS),” the guidelines say.

“A discharge summary is a collection of information about events during care of a patient by a provider or organisation, in a document produced during a patient’s stay in hospital, as either an admitted or non-admitted patient, and issued when or after the patient leaves the care of the hospital.

“Clinical handover is a known area of potential risk for patient harm, particularly in the transition from acute care to the community setting. Discharge summaries are critical for providing well-coordinated and effective clinical handover because they are the primary communication mechanism between hospitals and primary health care providers.”

In July 2012, the Commission was appointed to develop and manage a clinical safety program for the My Health Record system, which is a secure online summary of health information, personally controlled by individuals.

Patients’ discharge summaries can be added to their My Health Record. As part of the Commission’s clinical safety program, eight clinical safety reviews of the My Health Record system were completed.

The fourth clinical safety review, conducted in 2014, included an end-to-end investigation of the accuracy and data quality of eDS.

The guidelines were endorsed by the National Health Chief Information Officer Forum in August 2016 and presented at the Commission’s Inter-Jurisdictional Committee in October the same year, and are now freely available on the Commission’s website.

Other safety in e-health findings can also be found on the Commission’s website at: https://www.safetyandquality.gov.au/our-work/safety-in-e-health/

Chris Johnson

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

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

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

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

Diagnostic triage for primary care management of low back pain

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

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

Specific spinal pathology

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

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

Radicular syndrome

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

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

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

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

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

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

Non-specific low back pain

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

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

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

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

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

Conclusion

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

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

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

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

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

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

Box 2 –
Specific spinal pathologies presenting in primary care

Prevalence in primary care

Alerting features

Diagnostic workup

Tertiary referral

Vertebral fracture

1.8–4.3%6

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

Imaging:

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

Spine surgeon

Malignancy

0.2%8

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

Imaging:

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

Oncologist

Spinal infection

0.01%9

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

Imaging:

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

Infectious diseases specialist

Axial spondyloarthritis11

0.1–1.4%12,13

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

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

Refer to rheumatologist if strong suspicion of axial spondyloarthritis

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

Cauda equina syndrome

0.04%9

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

Imaging: immediate MRI

Spine surgeon

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

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

Condition

History

Physical examination

Radicular pain^†

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

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

Radiculopathy^‡

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

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

Lumbar spinal stenosis^§

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

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

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

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

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

Using aggregated general practice data to evaluate primary care interventions

Aggregated data extracted from computerised general practice records should be used to improve outcomes at patient, health system and population levels

A report released in 2016 by the Primary Health Care Advisory Group (PHCAG), Better outcomes for people with chronic and complex health conditions, highlights the need to use aggregated general practice data to target health resources and interventions.1 The aim of any health program should be to improve outcomes at patient, health system and population levels. These outcomes should be measurable and part of a feedback loop to improve patient care.

To date, much of the data on general practitioner clinical activity has come from surveys such as the Bettering the Evaluation and Care of Health (BEACH) program.2 Following the cessation of data collection by this program in April 2016, there is a need to strategically invest in future data collection systems.3 With the vast majority of Australia’s 32 000 GPs using computers, electronic medical records held in general practice provide a potentially rich data source on the 85% of the Australian population who visit a GP at least once per year. The recommendation to establish a national minimum dataset by the PHCAG supported by a data collection model using a national data warehouse would be a major step toward addressing current data gaps. Drawing on existing resources such as the relational database developed by the BEACH program could expedite this process.2

Need for a coordinated approach to electronic data held in primary care

Key to the success of a sustainable ongoing data collection is the ability to extract information from existing primary care medical record systems, rather than requiring busy practitioners to collect additional data. The United Kingdom research system QResearch (http://www.qresearch.org) is an example of how this can be done by using a centralised data extraction system to collect information. The system contains data from about 1000 general practices with historical records extending back to the early 1990s. There are examples of some similar smaller scale Australian initiatives4,5 supported by academic general practice units that could guide in the development of larger systems.

The use of routinely collected general practice data is problematic in Australia because of the large variation in recording practices among GPs. There are more than ten general practice medical record software packages in use across Australia, although two dominate the market.6 The drivers for GPs to record electronic data for chronic disease management of patients are complex. They include criteria to meet funding arrangements for care,7 doctor computer skills, fitness for purpose of data (particularly around diagnostic data), coding issues, consent, confidentiality, and the relationship of data with decision support and guidelines.8 The completeness of clinical records appears to have improved since the early 2000s,9 although some concerns remain regarding the quality of data extracted.5 Consequently, there is a need to implement strategies to ensure data quality if the full potential of clinical data extraction is to be realised. Fundamental to the process of data collection is GP engagement and, as such, ongoing practical support of general practices is essential.10

The 2016 MJA Supplement “Value co-creation: a methodology to drive primary health care reform” (https://www.mja.com.au/journal/2016/204/7/supplement) discusses a value co-creation approach to deliver health care reform in Australia. Coming out of this debate has been the increasing recognition that the better use of existing health data is an area that must be addressed to fully realise the potential of such an approach.11 Chronic and complex care management is a good example of where better data management that crosses all health levels of patient care from the individual patient through to the development of government policy and funding is critical. Primary care data are key in this process, with potential users including not only general practices but also Primary Health Networks, allied health professionals, specialist practitioners, the hospital sector, all levels of government, researchers and the private sector.

Potential for better evaluation

To date, the evaluation of some primary care programs in Australia has focused on process rather than outcomes. An example is the Practice Incentives Program, whose evaluation was the subject of an Australian National Audit Office audit in 2010.12 The audit noted that the key performance indicators used to monitor the program primarily measured take-up or participation rates rather than assessing effectiveness. To measure effectiveness, there is a need for evaluators to have ready access to data on clinically important outcomes and, at present, this is an information gap in Australian general practice.1

Even when outcome measures are used to evaluate chronic care programs, there is a temptation to use short term measures (eg, changes in clinical parameters) simply because outcomes such as complications and death have a long lead time. This can be seen clearly in the evaluation of many diabetes programs where changes in glycated haemoglobin, blood pressure and lipids are often used in isolation to measure effectiveness. These measures may be appropriate for assessing quality assurance programs for the implementation of established interventions but are likely to be inadequate for clinical trials where interventions are being tested.

But how can long term impacts be measured or at least estimated in a time frame that is useful for decision makers? In the field of diabetes, there is now a well established body of work that uses computer modelling to predict long term outcomes based on changes in clinical factors such as glycated haemoglobin, blood pressure, serum lipids and smoking status.13 The models developed use risk equations derived from cohort studies but unfortunately none are based upon Australian data. This raises the concern about the applicability of current models to assist in the evaluation of chronic care programs in Australia. Consequently, it has been argued that we need to develop country-specific models.13 Data collected by Australian GPs could be used for this task, provided high quality data management systems are established and maintained. The need for a “fresh approach” to research and data alluded to by the federal government14 provides an opportunity to invest in general practice data systems that allow better targeting of health resources and interventions. To do so requires the impact of initiatives to be measured in terms of patient-focused outcomes, including long term clinical sequelae.

Conclusion

There is little doubt that routinely collected data stored in Australian general practices provides an opportunity not only to assist practitioners to review their practice but also to facilitate research initiatives, evaluate the effectiveness of interventions and better target health resources. The questions that need urgent answers are how best to implement this vision and how to put in place the necessary infrastructure. Building a consensus around data sharing in this space is fundamental to any co-creation approach aimed at delivering health care reform in Australia.

Financing patient-centred health care homes through value capture

An innovative approach to funding primary health care involving collaboration between different levels of government and other stakeholders

The Commonwealth Government initiative to establish patient-centred health care homes (PCHCHs), announced in late 2015 following the recommendations of the Primary Health Care Advisory Group,1 represents an ambitious reform to better deliver and coordinate primary care to individuals with chronic conditions.2 PCHCHs, developed originally in the United States,3 involve patients voluntarily enrolling with a primary care provider (a home base such as a general practice or Aboriginal medical service) to receive tailored treatment based on individualised chronic disease management plans. Providers are remunerated through a bundled quarterly payment for each patient enrolled — the aim being to eliminate the fragmented care and duplication that is often associated with the current fee-for-service system.4

At present, $21 million has been set aside over 3 years to fund the first phase of this scheme. Phase one is expected to enrol 200 medical practices and 65 000 patients,2 which works out to be around $100 per annum per patient. Although this sum seems modest, given that about half of all Australians have a chronic disease and that one in five have multiple chronic conditions,5 the investment required for the subsequent rollout of PCHCHs is likely to be substantial. With a limited appetite among the public and governments to tap into existing sources of revenue to meet our ever-growing funding needs, it remains to be seen where this money will come from.

One option that has previously been applied to the funding of public investment in infrastructure projects is that of value capture. In this article, we explore the potential for the use of this framework in funding PCHCHs, and how this principle might be applied more broadly to facilitate the funding of new health care programs.

Value capture is a form of public financing that involves redistributing to government some of the windfall gains that private property owners receive as a result of government investment in infrastructure projects. As an example, it has been proposed as a means of funding the building of railway lines in Sydney and capitalising on the increase in the value of adjacent land this generates. Like many cities, Sydney faces major funding challenges in the coming years to meet the infrastructure needs of a rapidly growing population. In this case, value capture involves the New South Wales government imposing a levy on private developers via a land tax to claw back some of the private value created.6,7 Such innovative contracting arrangements and financial instruments, by adjusting the share of costs and benefits between different stakeholders, can turn conventional investment proposals into win–win scenarios. Applied more broadly, it potentially addresses areas of underinvestment by enabling governments to find additional funds from non-government sources.

Another form of value capture currently underway is the social impact bond (SIB; also known as social benefit bond) program being rolled out across a number of states and territories in Australia. SIBs are a method of financing health and social programs that are delivered by non-government organisations but expected to achieve cost savings to government through improved health and social outcomes and ultimately reduced service use (eg, hospitalisations). The bonds that finance these programs are purchased by private investors and the returns paid by government are subject to the program achieving future cost savings, as determined by a third party evaluation. In principle, SIBs enable governments to access private capital and offset the risk associated with public investment.

The NSW government, the earliest adopter of SIBs in Australia,8 recently completed a pilot of Newpin — a parenting program delivered by UnitingCare to support families to avoid children being put into out-of-home care. In successfully restoring 130 children to their families and preventing another 47 children from entering out-of-home care (restoration rate of 61% over 3 years versus a baseline of 21%), Newpin achieved a return of 12.2%, paid by NSW Treasury to bondholders.9 In 2016, the NSW SIB program was extended to health with the announcement of two new bonds: Managing mental health hospitalisations (Richmond PRA and Social Ventures Australia) and Managing chronic health conditions (Silver Chain Group). The expectation is that these programs will deliver cost savings through reduced hospitalisations, although specific details are not yet available.10

Through this lens, PCHCHs can be seen as another value capture opportunity in the health sector, albeit on a much larger scale involving a potential arrangement between Commonwealth and state and territory governments. The opportunity arises because the upfront funding for PCHCHs will occur through the Commonwealth Government via Medicare, while much of the potential value will be generated in terms of reduced hospitalisations that benefit state and territory governments. As indicated in the media release accompanying the PCHCH announcement: “Investing in prevention and management of chronic disease keeps people healthier and out of hospital, easing the strain on the hospital system, and increasing efficiency across the wider health system.”2

Underlying the value capture proposal set out here is the critical role of primary health care in disease prevention, and explicit recognition that Medicare expenditure is to a large extent investment in such prevention. The substantial value capture envelope that is ready to be realised is reflected in the over 600 000 hospitalisations per year that would be preventable through effective or timely provision of primary care in Australia.11

There are two general options for how a value capture arrangement could be developed for PCHCHs. The first could be an arrangement in which states and territories would contribute toward the costs of implementing the program; akin to the conventional value capture model in which property developers are charged a fixed levy. The second option, more like the SIB model, would entail gain sharing, where investment in PCHCHs is packaged as a bond underwritten by state and territory governments and held by the Commonwealth, with returns payable based on demonstrable reductions in preventable hospitalisations. This approach would involve:

State and territory governments underwriting bonds in which they pay a dividend contingent on financial savings from reduced hospitalisations after, say, 3 years. As with SIBs, the share of savings retained by states and territories compared with that which is factored into the dividend would be based on a predetermined scale linking performance levels with rates of return. See, for example, the arrangement involving the Benevolent Society.12
Funding for PCHCHs coming from the Commonwealth acting as a bondholder, although the option exists to part or fully fund the program through the sale of bonds to private investors.
PCHCHs being delivered by the Commonwealth — as currently envisaged — alongside an evaluation conducted by a third party to assess whether the PCHCHs achieve their expected cost savings.
State and territory governments paying out a dividend to the Commonwealth as bondholders, pending achievement of performance targets.

There are a number of clear advantages with this gain-sharing approach:

It requires no financial burden on state and territory governments until cost savings are realised.
It strengthens the Commonwealth case for investing in the rollout of PCHCHs. Existing arrangements will require costs to be borne by the Commonwealth (via Medicare); the proposed approach provides the Commonwealth with an offsetting stake in the expected savings in hospitalisation costs.
It makes explicit the stake that state and territory governments have in the success of PCHCHs. Despite being major stakeholders, at present there do not appear to be clear plans for how they will be engaged in this initiative. By aligning interests so that savings realised in terms of reduced hospitalisations are shared between levels of government, value capture arrangements reduce incentives to cost shift and may be a catalyst for the intergovernmental collaboration needed to ensure the success of PCHCHs. Therefore, while cost-saving programs in health tend to be rare and the recent experiences with coordinated care programs have generally been disappointing,13–15 a unique feature of this proposal is the alignment of the financial incentives of key players toward a common goal.

Within this value capture arrangement, evaluation is no longer an optional extra. It is reliant on the collection of data, ongoing evaluation and the use of data in determining the returns achieved by such programs. While decisions to invest in health programs are often predicated on claims regarding future cost savings and outcomes, there is nothing in the current system that compels such claims to be subsequently tested. Value capture creates feedback loops and institutionalises evidence-based investment decision making. It therefore vests in health service funders a strong interest to use evidence effectively and, ultimately, to become better at picking winners.

The template for this value capture arrangement has already been established through the SIB programs being implemented across Australia. These are based on gain-sharing deals contingent on savings in future health care costs. As such, the arrangement proposed here involves no additional cost or risk to the states and territories over the status quo, as any payout by an individual state or territory to bondholders would only be apportioned from the money that it has already saved.

The fiscal pressures caused by chronic illness, an ageing population, technological innovation and consumer expectations have created an urgent need to find new ways of encouraging investment in the health sector. By realising the potential for investment in primary health care to prevent future health care costs, value capture represents an innovative means by which different levels of government and other stakeholders can work together to address health sector funding needs.

AMA backs call for inquiry into institutionalised racism

The gap between health outcomes for Indigenous and non-Indigenous Australians will not be closed until systemic racism is rooted out of the health system, the Close the Gap Campaign says.

Releasing its 2017 Progress and Priorities Report on National Close the Gap Day on 16 March, the Campaign Steering Committee called for a national inquiry into institutionalised racism in hospitals and other healthcare settings.

“The reality for Aboriginal and Torres Strait Islander peoples is that we have a life expectancy at least 10 years shorter than non-Indigenous Australians. We need urgent action,” Close the Gap Campaign co-chair Jackie Huggins said.

The report found that four interacting factors within Australia’s health system continue to be ‘potentially lethal’ for many Indigenous people:

limited Indigenous-specific primary health care services;
Indigenous peoples’ under-utilisation of many mainstream health services and limited access to government health subsidies;
Increasing price signals in the public health system and low Indigenous private health insurance rates; and
Failure to maintain real expenditure levels over time.

“The persistence of these factors reflects systemic racism; that is, racism that is ‘encoded in the policies and funding regimes, healthcare practices and prejudices that affect Aboriginal and Torres Strait Islander people’s access to good care differentially,” the report said.

“Failure to engage effectively with Aboriginal and Torres Strait Islander people through their elected peak organisations allows such racism to continue.

“The progress of the headline targets in the Closing the Gap strategy will continue to be disappointing until these issues are properly addressed.”

The AMA supported the call for the inquiry, and for knowledge of Indigenous culture to be built into medical school curricula.

AMA President Dr Michael Gannon, AMA Vice President Dr Tony Bartone, and all eight State and Territory AMA Presidents toured the Winnunga Nimmitjah Aboriginal Health Service in Canberra on Close the Gap Day.

Dr Gannon said that while Aboriginal community-controlled health centres like Winnunga Nimmitjah were vital for primary care, it was not realistic to have hospitals dedicated to treating Indigenous patients only.

“It’s so important that patients feel safe in the hospital setting, whether that’s the tertiary hospital setting or in secondary hospitals,” Dr Gannon told reporters.

“If patients don’t feel safe, if they don’t feel secure, if they’re exposed to racism, well that’s simply not good enough.

“So we support that call for the inquiry. It’s so important that primary health care services are very much driven and delivered by Indigenous communities, but we need to do better when, inevitably, like all other Australians, Aborigines and Torres Strait Islanders end up in hospital.”

Keeping medical curricula up to date with community needs was a constant challenge, but more needed to be done to teach medical students about Indigenous culture, he said.

“We talk a lot about the importance of positive experiences at medical student level, at junior doctor level, into specialist training level in rural areas, and the same should apply when it comes to Aboriginal and Torres Strait Islander health,” Dr Gannon said.

“If I reflect on my training as a medical student in Perth, seeing Aboriginal patients was in many ways sadly commonplace.

“But it’s so important that we give medical students across Australia, whether that’s in the rural clinical schools or in the middle of our big cities, exposure to Aboriginal and Torres Strait Islander patients and their wants and needs.”

Dr Gannon said that days like Close the Gap Day were a good opportunity to recognise the advances that have been made, but to realise that there is still so much work to do.

“It’s going to take time, when we look at the metrics, whether they’re in the area of health, whether they’re in the area of employment or education, it is going to take time,” he said.

“But I think that it’s important that at least once a year on National Close the Gap Day, that we reflect on how far we’ve come, and hopefully as every year goes by, we talk about the gap shrinking in whichever target we’re talking about.”

Maria Hawthorne

Doctor as patient

DR RICHRAD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

In the week that the AMA released its 2017 Public Hospital Report Card, a dose of salmonella saw me experience first-hand the pressures that public hospitals are under, and appreciate the value of a GP home visit for urgent care in circumstances when you can’t access your usual GP.

I had flown into Canberra for a weekend meeting of the AMA Council of General Practice, already feeling unwell with established symptoms of food poisoning. I was becoming sicker and more dehydrated. With abdominal pain and rebound tenderness, I found myself at the local emergency department at 10pm on the night of my arrival.

During the next eight hours I got to see my hospital colleagues dealing with the pressures of managing multiple patients in varying states of illness and distress, with limited resources and a bed capacity unable to keep up with demand.

Here it seems the world revolves around assessing and prioritising the steady stream through the door, although things can quickly change when a major incident happens. While I was there, the deluge of more than 80 patients affected by a local bushfire appeared to almost overwhelm available resources. The doctors, nurses and other staff worked diligently to ensure that patients were seen as soon as possible but, on a night like this, benchmark targets seemed to have very little relevance.

Sometime around 5am, with blood cultures taken and intravenous rehydration commenced, a long awaited physical examination revealed that my earlier rebound tenderness had resolved although there was still significant point tenderness. With no acute abdomen I was discharged around 6am Saturday.

During the morning I deteriorated, with worsening diarrhoea, vomiting and abdominal pain. I desperately needed a doctor and did not want a return visit to the ED. It was time to call one of the after-hours GP services, which sent a GP to see me in my hotel room. Following a comprehensive examination, which revealed marked lower abdominal tenderness and a positive Murphy’s sign, I had a script for ciprofloxacin. Armed with this, some ondansetron and gastro-stop I tried to make my flight home only to be bumped because I was too sick. Following a visit to the after-hours chemist and after commencing my ciprofloxacin I finally turned the corner, improving enough to fly home Monday morning.

I understand the health system better than most and know how daunting it can be to navigate – particularly at times when your usual GP is not there to guide. This experience was a timely reminder of the challenges our patients experience when seeking care, and why the AMA’s advocacy for our profession and our patients is so important.

Besides getting a taste of what my patients experience when seeking care outside of surgery hours, this episode has also highlighted the importance of looking after our own health. I did try and soldier on for too long, not wanting to let my colleagues down.

We are not super human and we do get sick. When we are, perhaps we should consider what advice we would give a patient in the same situation. We need to be kind to ourselves and recognise when we need another’s medical expertise.

Nurses should have greater role in diabetes management – study

A study has found a new program where primary care nurses led insulin treatment for Type 2 diabetics can dramatically improve longer term health outcomes of patients.

Published in the BMJ, it looked into 74 primary health clinics across Australia and compared a nurse led insulin treatment initiation with a traditional approach to diabetes management.

70% of patients in the ‘Stepping Up’ program began treatment when compared to just 22% at clinics taking a traditional approach to diabetes management.

According to Associate Professor John Furler from the University of Melbourne: “By focusing on an enhanced role for the practice nurse, who is trained and mentored by a registered nurse with diabetes educator credentials, the model uses existing resources within the practice to improve outcomes.”

Early adoption of insulin can improve health outcomes and reduce the chance of damage to the eyes, kidney and nerves.

However according to the study: “Insulin initiation is often delayed, however, particularly in primary care, where implementation is not widespread despite being recommended as part of routine clinical management of type 2 diabetes.”

“After 12 months, we found that patients had significantly better HbA1c levels (an important measure of glucose in the blood), which is associated with better long term outcomes, such as reduced rates of kidney and eye disease, compared to the control group,” Associate Professor Furler said.

Thanks to these results, a further implementation study of the ‘Stepping Up’ model of care will be widened to include diabetes therapy generally and will be carried out in the North-West Melbourne Primary Health Network.

Latest news

Flu vaccine not available until April 2017

The Federal Government has announced that the quadrivalent influenza vaccine stocks won’t hit GPs until mid-April this year.

According to a Health department spokeswoman, “The vaccine companies are finding it harder each year, with some many strain changes, to produce enough vaccine for mass distribution before April.“

Although flu vaccines are being administered in some chemists from mid March, there is an advantage to a slightly later vaccination date.

According to Australian Technical Advisory Group on Immunisation (ATAGI) advice, “Recent evidence suggests protection against influenza may start to decrease from 3 to 4 months following vaccination and early vaccination needs to be balanced with this.”

The peak month for influenza in Australia is August and it’s estimated to be responsible for more than 5000 hospitalisations and almost 170 deaths each year.

The strains covered in this year’s vaccination are:

A (H1N1): an A/Michigan/45/2015 (H1N1)pdm09* like virus
A (H3N2): an A/Hong Kong/4801/2014 (H3N2) like virus
B: a B/Brisbane/60/2008 like virus
B: a B/Phuket/3073/2013 like virus

Typically, people most commonly affected are young children and older adults with pregnant women particularly high risk of becoming seriously ill.

The immunisation vaccine is funded under the National Immunisation Program for certain at risk groups. They are:

Aboriginal and/or Torres Strait Islander children between 6 months and 5 years and 15 years and over,
Anyone 65 years and over,
Anyone 6 months and over who have certain medical conditions including severe asthma, lung or heart disease, low immunity or diabetes,
Pregnant women.

For more information, visit the: Australian Technical Advisory Group on Immunisation (ATAGI) advice for immunisation providers regarding the administration of seasonal influenza vaccines in 2017 and the updated Australian Immunisation Handbook 10th edition.

Latest news

The role of pharmacists should be overhauled, taking the heat off GPs

A Grattan Institute report released earlier this week, Cutting a better drug deal, calls for a major shake-up of pharmacies and pharmaceutical pricing.

The market for retail pharmacies is highly regulated. States regulate who can own pharmacies – essentially prohibiting anyone other than pharmacists owning them – and how many pharmacies one person can own. The Commonwealth regulates where pharmacies can be located, and have used that regulation to slow the growth of big discount pharmacies.

The current rules prevent competition in a way that benefits pharmacy owners more than consumers. International evidence suggests deregulation, allowing more pharmacies in urban market areas, actually improves access. The regulations in Australia restricting the number of pharmacies need to be changed.

The role of pharmacists

Pharmacists could also do more than they currently do. If there are more pharmacies in competition with each other, the hope is they would compete on prices and the services they provide. Pharmacists could take some of the load off doctors, allowing GPs to concentrate on more difficult diagnostic problems.

The role of pharmacists should be expanded so they become part of a coordinated team providing health care to their local community. In particular, local pharmacies, as part of a team with GPs, should be empowered to:

administer vaccinations
give drug information to patients, review their medication and adjust doses when required
prescribe repeat medications for patients with simple and stable medical conditions such as some cases of asthma, or straightforward drug requirements such as the contraceptive pill
work with GPs to manage treatment for patients with chronic diseases.

Pharmacists are highly skilled health care professionals. With appropriate further training, they could safely perform these additional tasks. And giving pharmacists wider roles such as the authority to administer vaccinations and provide repeat prescriptions has been found to improve patient outcomes.

Better pricing of PBS-listed medications

The Grattan report also shows Australian taxpayers could save half a billion dollars a year from better pricing of medications listed on the Pharmaceutical Benefits Scheme (PBS). Most of these savings come from strengthening and extending an existing policy known as Therapeutic Group Premiums.

This policy applies to seven “therapeutic groups” – groups of similar drugs such as angiotensin II receptor antagonists used for the treatment of high blood pressure – and dictates that if a drug has a similar effect, the PBS should pay a similar price for it. The devil is in the detail, of course, and the implementation rules for this policy mean it is full of loopholes.

The current rules set generous standards about how different prices are allowed to be from the benchmark medication. Tightening these rules, by revising how to calculate if the price of a drug is different from another, could ensure many more drugs were scoped into the policy. Our report shows that just this one change – which may not even need any legislative approval – would save taxpayers A$240 million each year.

Other countries apply their equivalent policy much more broadly. Germany, for example, has more than 30 therapeutic groups to Australia’s seven. If Australia extended its existing seven groups to 18, adding new groups such as one for insulin, more drugs would come within the scope of the therapeutic group premium policy. With additional medications in scope, taxpayers could save a further A$205 million each year from these 11 new groups.

Benchmarking drug prices

Still more savings could be made if Australia benchmarked the prices it pays for drugs against prices paid overseas. This would cut prices in Australia by more than the current policy of “price disclosure”.

Under price disclosure, drug companies are forced to disclose to the PBS the prices they actually charge pharmacies for their products. Where that price is less than the price the PBS currently pays, the PBS drops its price accordingly. This policy has been quite successful; the prices paid by the PBS for many drugs have now dropped, in some cases quite substantially (as in the graph below).

In 2013, for example, the PBS paid almost 30 times the world best practice benchmark price for the anti-psychotic medication, Olanzapine. It is now six times the international benchmark. Similar improvements have occurred across almost all generic drugs.

In a 2013 report, Grattan estimated benchmarking could save Australian taxpayers more than A$600 million dollars a year. Since then there have been several rounds of price disclosure, each bringing the prices of drugs covered by the policy closer to international benchmarks. So in our new report, we estimate savings from benchmarking at A$93 million a year. That $93 million is worth saving. The PBS should benchmark its prices regularly, and publish the results.

The savings identified in this new Grattan report could be used to meet the costs of new drugs with proven benefit, or to kill off one of the zombie measures sitting outside the Senate door such as the one designed to increase PBS co-payments.

Improved pricing for the PBS is a much more equitable policy. Relaxing location rules for pharmacies in metropolitan areas and enhancing the role of pharmacists will also benefit consumers through lower prices and better access to vaccinations and medication management.

Stephen Duckett, Director, Health Program, Grattan Institute

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