Effectiveness of steam inhalation and nasal irrigation for chronic or recurrent sinus symptoms in primary care: a pragmatic randomized controlled trial [Research]

Background:

Systematic reviews support nasal saline irrigation for chronic or recurrent sinus symptoms, but trials have been small and few in primary care settings. Steam inhalation has also been proposed, but supporting evidence is lacking. We investigated whether brief pragmatic interventions to encourage use of nasal irrigation or steam inhalation would be effective in relieving sinus symptoms.

Methods:

We conducted a pragmatic randomized controlled trial involving adults (age 18–65 yr) from 72 primary care practices in the United Kingdom who had a history of chronic or recurrent sinusitis and reported a “moderate to severe” impact of sinus symptoms on their quality of life. Participants were recruited between Feb. 11, 2009, and June 30, 2014, and randomly assigned to 1 of 4 advice strategies: usual care, daily nasal saline irrigation supported by a demonstration video, daily steam inhalation, or combined treatment with both interventions. The primary outcome measure was the Rhinosinusitis Disability Index (RSDI). Patients were followed up at 3 and 6 months. We imputed missing data using multiple imputation methods.

Results:

Of the 961 patients who consented, 871 returned baseline questionnaires (210 usual care, 219 nasal irrigation, 232 steam inhalation and 210 combined treatment). A total of 671 (77.0%) of the 871 participants reported RSDI scores at 3 months. Patients’ RSDI scores improved more with nasal irrigation than without nasal irrigation by 3 months (crude change –7.42 v. –5.23; estimated adjusted mean difference between groups –2.51, 95% confidence interval –4.65 to –0.37). By 6 months, significantly more patients maintained a 10-point clinically important improvement in the RSDI score with nasal irrigation (44.1% v. 36.6%); fewer used over-the-counter medications (59.4% v. 68.0%) or intended to consult a doctor in future episodes. Steam inhalation reduced headache but had no significant effect on other outcomes. The proportion of participants who had adverse effects was the same in both intervention groups.

Interpretation:

Advice to use steam inhalation for chronic or recurrent sinus symptoms in primary care was not effective. A similar strategy to use nasal irrigation was less effective than prior evidence suggested, but it provided some symptomatic benefit. Trial registration: ISRCTN, no. 88204146.

Primary amoebic meningoencephalitis in North Queensland: the paediatric experience

Primary amoebic meningoencephalitis (PAM) is a rare but fulminant disease leading to diffuse haemorrhagic necrotising meningoencephalitis, and has a very poor prognosis.1 Naegleria fowleri is the causative agent. At Townsville Hospital, our first confirmed case of PAM was an 18-month-old girl from a rural location in North Queensland who presented with fever, seizures and an altered level of consciousness.2 Organisms resembling Naegleria spp. were seen on microscopy of cerebrospinal fluid (CSF). Despite aggressive therapy with multiple antimicrobial agents, the patient died within 72 hours of presentation. An older sibling of the patient had presented with a similar syndrome several years earlier and had died of an undifferentiated meningitic illness. The sibling was retrospectively suspected to also have had PAM.2

Our second confirmed patient presented in early 2015. A previously well 12-month-old boy from a nearby West Queensland cattle-farming area had had a 36-hour history of fevers, rhinorrhoea and frequent emesis, which progressed to lethargy and irritability. Before arrival at the local rural hospital, he had a tonic–clonic seizure lasting 3–5 minutes. On arrival he appeared drowsy, had mottled skin, a blanching maculopapular rash, which may not necessarily have been related to PAM, and a central capillary refill of 3–4 seconds. He was treated with intravenous antibiotics for presumed bacterial meningitis. Given the remote location and clinical suspicion of elevated intracranial pressure, lumbar puncture was not performed. On arrival at Townsville Hospital, his Glasgow Coma Scale score was 8/15, he was increasingly febrile, and had an evolving maculopapular rash. Broad spectrum antimicrobial therapy was subsequently started for presumed meningoencephalitis. Within 18 hours of leaving home, he had no spontaneous respiratory effort, reduced tone, up-going plantar reflexes and fixed pupils.

Neuroimaging showed diffuse cerebral oedema with progressive dilation of the ventricular system on sequential studies. An external ventricular drain was placed because of clinical instability, and CSF microscopy showed motile trophozoites on a wet preparation and Giemsa stain, consistent with N. fowleri. The patient was commenced on intrathecal amphotericin, with no improvement in his clinical state. The organism seen in the CSF was confirmed after the patient’s death by polymerase chain reaction (PCR) analysis as being N. fowleri. When reviewing the patient’s history, it was noted that, as in previous cases, he lived on a property that used untreated and unfiltered bore water domestically, to which he had multiple potential exposures, including via water play with hoses and bathing.

Literature review

We searched the PubMed database using the terms “Naegleri”, “fowleri” and “meningitis”. No time period was specified. The James Cook University eJournal database was searched for historical information.

We also searched the Queensland Health Communicable Diseases Branch and the Communicable Diseases Network Australia databases for Australian cases, but, as N. fowleri infection is not a notifiable disease, this returned a low yield.

History of Naegleria fowleri

In 1899, the Austrian scientist Franz Schardinger published the first description of an amoeba that transforms into a flagellate, with drawings of the amoeba, cysts and flagellates. In 1912, Alexeieff coined the name Naegleria, but physicians at the time thought that the genus did not cause disease in humans.3 It was not until the late 1960s that Naegleria was implicated as the cause of PAM by the work of Adelaide pathologists Malcolm Fowler and Rodney Carter, and of South Australian rural general practitioner Robert Cooter. In 1965, it was first proposed that the organism entered the CSF through the cribriform plate after Fowler isolated the organism in autopsy specimens. Following communication of his findings, Cooter and colleagues were able to directly observe the live amoeba in a CSF sample from a 10-year-old boy who presented with meningoencephalitis.4,5

Pathophysiology

N. fowleri lives and multiplies in warm freshwater areas, and acquisition is often associated with water-based recreational activities.6 Infection may occur when contaminated water is flushed into the nasal cavity. After penetrating the nasal mucosa and passing through the cribriform plate, trophozoites migrate along the olfactory nerve directly into brain tissue. Cases are almost universally fatal, although survival has been reported in the literature following early diagnosis and management.7,8

Epidemiology

The worldwide incidence of PAM is not accurately known,9 and the disease is likely to be under-diagnosed and under-reported. In the developing world, numerous factors affect accurate identification, including a lack of resources or expertise in microbiological diagnosis; prioritising management of other infections that are more common; and cultural beliefs that prevent autopsies.9 Higher water temperatures, inadequate sanitation, unsafe water sources, and religious ablution practices, such as the use of Neti pots for nasal cleansing, could potentially increase the risk for acquiring PAM.10,11 N. fowleri is a thermophilic organism and would therefore be expected to occur more frequently in tropical areas; however, the majority of cases are reported from subtropical or temperate regions.12 In a study in Karachi, Pakistan, N. fowleri was recovered from 8% of 52 domestic water taps that were sampled.13

An epidemiological review of PAM cases in the United States showed that N. fowleri infections are rare and primarily affect younger males exposed to warm recreational freshwater in the southern states.14–16 There are two case reports of patients who acquired N. fowleri from using treated municipal water for nasal irrigation,17 and another patient who contracted the disease from inadequately treated municipal water.18

In Australia, Dorsch and colleagues reported 20 cases of PAM, 13 of which occurred between 1955 and 1972 in South Australia. These cases were attributed to household water that was piped overland for long distances,19 allowing it to be heated to temperatures that promoted growth of the amoeba.5 After the introduction of continuous water chlorination in 1972, only one further case was reported in South Australia in 1981.19 In Queensland, only three previous patients have been described in the literature: one from Mount Morgan who survived, one from Charters Towers,19 and one referred from North West Queensland to Townsville Hospital.2

Clinical challenges

Patients with PAM present with the same symptoms as those with bacterial meningitis, and clinical differentiation between the two conditions is impossible. Patients often have a history of recent exposure to warm fresh water, although the definite exposure event is not always identified.9 The incubation period ranges from 2 to 15 days, and presenting symptoms may include meningism, fever, confusion and signs of elevated CSF pressure, such as seizures or coma.14

Diagnosis is made more difficult in North Queensland by the vast distances between remote towns in the western part of the state. Townsville Hospital services an area of nearly 150 000 km² and has the only dedicated paediatric intensive care unit north of Brisbane. Patients with PAM inevitably require intensive care unit management and tertiary level investigations. Obtaining CSF samples for formal microscopic diagnosis is often impossible in small clinics with limited medical imaging or local laboratory services, and where performing a lumbar puncture is contraindicated by symptoms of raised intracranial pressure. Because of the rarity of the infection, greater awareness of PAM among primary health care professionals is required in order to increase suspicion in a clinically compatible case. Most importantly, education about prevention is essential for the continued health of rural communities, of which local medical professionals are a vital part. To this end, recent guidelines for the management of encephalitis20 include assessing risk factors for this condition and performing appropriate testing, as described below.

Diagnostic challenges

Diagnosis requires identification of motile trophozoites in CSF or characteristic morphology in stained specimens by a trained microbiologist (Box 1), with confirmation using molecular methods (PCR) or culture (Escherichia coli lawn culture). The trophozoites are visible in a wet unstained preparation of CSF (magnification, × 400), exhibiting sinusoidal movement by means of lobopodia; however, specimens need to be examined very soon after collection, as the amoebae degenerate rapidly in vitro and can be easily mistaken for leucocytes.

CSF chemistry is not diagnostic and will usually reveal a similar pattern to that of bacterial meningitis (Box 2). PCR analysis is performed using in-house methods at reference laboratories, and confirmation is often posthumous due to the rapid decline experienced by most patients. The US Centers for Disease Control and Prevention has developed a multiplex real-time TaqMan PCR assay to simultaneously identify three free-living amoebae (N. fowleri, Acanthamoeba spp. and Balamuthia mandrillaris) in clinical specimens.21 In Queensland, the pathology laboratory which performs all N. fowleri molecular testing uses primers and probes in line with the method of Qvarnstrom and colleagues.21 Culture may take several weeks and is difficult to perform.

Treatment

Given the limited data available, there are no set guidelines for antimicrobial therapy; however, it can be extrapolated from cases of patients who have survived that combination therapy with multiple anti-parasitic agents is required.

In 1969, Carter was able to demonstrate the sensitivity of the organism to amphotericin B (AMB) and it has remained the mainstay for treatment of PAM to this day.22 AMB has been used in all patients who have survived the illness.23 N. fowleri is highly sensitive to AMB in vitro with a minimum amoebicidal concentration of 0.01 μg/mL,24 and no resistance has been reported. Conventional AMB is preferred to liposomal forms as it can be given intrathecally as well as intravenously. Despite this, only a few patients have survived.25

Other antifungal drugs, such as miltefosine and the azoles, have all shown in vitro activity against N. fowleri.22–24 Miconazole has synergistic activity when combined with AMB, and fluconazole is used as first line in combination therapy.

Miltefosine is a protein kinase B inhibitor that was originally developed as an antineoplastic agent. It also has anti-parasitic activity and is used for the treatment of leishmaniasis. Schuster and colleagues26 reported that miltefosine showed in vitro activity against free-living amoebae, including N. fowleri, Acanthamoeba spp. and B. mandrillaris. Recently, miltefosine has been used in the treatment of Acanthamoeba granulomatous amoebic encephalitis and PAM. Linam and colleagues27 described the case of a child treated for PAM with combination therapy including amphotericin, miltefosine, fluconazole and rifampicin, who survived with no significant neurological sequelae.

Rifampicin is commonly used in the treatment of PAM; however, it has variable central nervous system penetration and poor efficacy in vitro.24 It may also reduce the efficacy of the azole drugs due to cytochrome P450 interactions. Although azithromycin has shown some in vitro and in vivo activity against N. fowleri, the other macrolides are less effective.9 Atypical agents such as the diamidines and chlorpromazine have been studied in animal models but have yet to be utilised clinically.24,28

Public health

As described, our patient was probably the third child to die with PAM in 14 years in a small area with a tiny population on remote Queensland cattle stations. As a response to the third death, a public health investigation found large numbers of N. fowleri at the patient’s homestead. In this district, water was sourced from deep artesian bores at about 60°C (Box 3) and cooled in open surface dams before being piped hundreds of metres on the surface to households, keeping water temperatures high. It was noted that the cases described in North Queensland were of children too young to be swimming in surface waters, the assumption being that they contracted the disease in the home environment. There had never been water treatment or filtration in the homesteads for generations; the clarity and taste of the bore water had often been a source of pride for owners. The difference in the present era of rural life was the advent of modern facilities, allowing the heated bore water to be pressurised via taps, hoses, toys and showerheads and delivered directly into the homestead.

The public health hypothesis was that:

Hot artesian bore water and long surface pipelines promote large concentrations of N. fowleri, which can be sucked into water pipes from sediments, particularly in drought years.
There had been no form of treatment for apparently clean water.
In recent years, among young families with modern water facilities, there were many more opportunities for water to be forced into a vulnerable (non-immune) child’s nose at pressure.
Simple filtration and disinfection of all water for washing and playing would prevent child deaths on these properties.

The public health dilemma was whether health promotion for a single, rare disease could be cost-effective or gain traction among rural people possibly reluctant to accept an expensive treatment of their water. Untreated surface water can also lead to a whole spectrum of gastrointestinal diseases, even if these were not familiar to the remote communities. It was decided that a health promotion campaign about domestic water filtration and treatment could protect not only from PAM but also from a range of other diseases.

The family of our second confirmed patient embarked on a rural education campaign of their own to prevent any further deaths from PAM or other waterborne diseases, culminating in an episode of the television series Australian Story in November 2015.29 To coincide with this story, public health physicians gave a series of talks to communities and health staff across a wide area of outback Queensland. To follow up the face-to-face campaign, Queensland Health released a safe water booklet with advice on cost-effective filtration and disinfection.30 As a result, many rural properties and some small towns are installing water treatment equipment for the first time. The South Australian and Western Australian governments have online education resources specifically targeting rural communities at risk of amoeba acquisition,31,32 with the primary focus on prevention. The aim of the Queensland public health booklet was to provide a more comprehensive education document for water treatment in rural communities.30

Conclusion

We hope an increased awareness of N. fowleri and its association with warm, non-chlorinated water provides an opportunity for counselling families about safe water use: avoiding diving or jumping into or squirting untreated water, and disinfecting or filtering water used for washing and playing, as well as for drinking. In particular, bore water at warm or hot temperatures and other warm water sources should be considered ideal reservoirs for this organism. In the clinical setting, difficulties with analysing CSF make it unlikely that an accurate diagnosis could be provided in a remote environment. The presentation of an acutely unwell child with a history of bore water exposure and signs of meningitis or encephalitis should, however, prompt consideration of PAM as a potentially life-threatening diagnosis. Our experience with this disease clearly demonstrates the crucial role of medical professionals working in rural and remote Australia in primary prevention of this almost universally fatal condition.

Box 1 –
Microscopy of cerebrospinal fluid of Patient 2,showing trophozoites (Giemsa stain, black arrows) and mononuclear leucocytes (white arrows)

Box 2 –
Analysis of cerebrospinal fluid (CSF) in patients with primary amoebic meningoencephalitis at Townsville Hospital

Microscopy

White cell count (10⁶/L)

Polymorphonuclear leucocytes

Protein (mg/L)

CSF:blood glucose

Normal

No organisms

< 1

< 0.4

> 0.6

Patient 1

Motile trophozoites

7200

91%

3900

0.17

Patient 2

Motile trophozoites

240

54%

2700

0.12

Box 3 –
Great Artesian Basin

The Great Artesian Basin, from which bore water comes, covers a vast area of rural Australia. Western Queensland has a particularly wide coverage, and rural properties use bore water extensively.

Source: Australian Government Department of Sustainability, Environment, Water, Population and Communities, 2011. Available at http://www.agriculture.gov.au/water/national/great-artesian-basin (accessed Aug 2016).

Superbugs could be ‘worse than global financial crisis’: World Bank

The rise of drug-resistant superbugs could cost more than US$1 trillion a year in extra health costs, plunge millions into extreme poverty and inflict greater economic damage than the global financial crisis if left unchecked, the World Bank has warned.

As world leaders prepare to discuss the threat of antimicrobial resistance (AMR) at the UN General Assembly in New York, the World Bank has released projections showing that the current widespread and often indiscriminate use of antibiotics will have severe health and economic consequences unless urgent action is taken.

“The scale and nature of this economic threat could wipe out hard-fought development gains and take us away from our goals of ending extreme poverty and boosting shared prosperity,” World Bank Group President Jim Yong Kim said.

Modelling by the global development agency indicates that without more careful use of antibiotics, AMR will have an increasing effect. Growing numbers of people, particularly in poorer countries, will succumb to infectious diseases; people will get sick more often; health costs will soar; livestock production will tumble and global trade will shrink.

Even in the best case scenario, the World Bank warns that without urgent action to curb AMR, by 2050 global economic growth would be 1.1 per cent lower, health costs will be up by US$300 million a year, global trade would be down by 1.1 per cent and an extra eight million people would be thrown into extreme poverty.

But the consequences could be much worse.

In its more pessimistic high-AMR scenario, the agency estimates that by 2050 global growth could be cut by 3.8 per cent, the number in extreme poverty would soar by an extra 28.3 million and countries would have to spend an extra US$1.3 trillion a year on health care.

“Drug-resistant infections, in both humans and animals, are on the rise globally,” the World Bank said.

“If AMR spreads unchecked, many infectious diseases will again be untreatable. Without AMR containment, humanity may face a reversal of the massive public health gains of the past century, and the economic growth, development, and poverty reduction that they enabled.

“The annual costs could be as large as those of the global financial crisis that started in 2008.”

The World Bank said these “immiserating” effects would fall hardest on low-income countries and would derail current progress toward the goal of eliminating extreme poverty by 2030.

The AMA has been at the forefront of efforts to curb the use of antibiotics, supporting campaigns such as the Choosing Wisely initiative to educate doctors and, more importantly, patients, about the appropriate application of such medications.

One of the biggest targets of these campaigns has been to educate patients, particularly parents, about the inappropriateness of prescribing antibiotics for the treatment of colds and other viral infections.

Sydney GP and former Chair of the AMA Council of General Practice Dr Brian Morton advised in 2014 that, “prudent use of antibiotics…includes not using them when their benefit is minimal. Patients…need to understand that the symptoms they are experiencing is their own immune system working to resolve the infection. They also need to understand that using antibiotics in such cases may actually do more harm than good. Not only can it contribute to the development and transfer of resistant bacteria but patients risk possible side effects, such as upsetting the balance of gut bacteria and rashes”.

The World Bank has urged a holistic approach to tackling AMR, warning it cannot be treated as a discrete health problem.

“Drug-resistant diseases are very much like infectious diseases with pandemic potential: because there is “no cure,” their spread can be hard to control. The surveillance, diagnostic, and control capacity to deal with the first group of diseases is the same capacity that is required to control of diseases in the second group,” it said.

The World Bank said investing in core human and veterinary public health systems in low- and middle-income countries was fundamental to establishing the surveillance needed to identify and control AMR.

“Increased global cooperation is essential as AMR containment is a global public good. It will require coordinated efforts to monitor, regulate, and reduce the use of antibiotics and other antimicrobials,” the agency said.

The World Bank report can be viewed at: http://pubdocs.worldbank.org/en/527731474225046104/AMR-Discussion-Draft-…

Adrian Rollins

Rebate freeze threatening quality GP care

The nation’s GP leaders have warned the Federal Government’s Medicare rebate freeze is undermining the quality of care and will have “serious repercussions” for patients.

The nation’s peak general practice representative group United General Practice Australia (UGPA), which includes the AMA, the Royal Australian College of General Practitioners, the Rural Doctors’ Association of Australia and several other doctor organisations, has told the Government that financial pressure caused by the Medicare rebate freeze was threatening the kind of services general practices could provide.

“Modern general practice relies on sophisticated infrastructure to support quality care. The Government’s policies are eroding this infrastructure,” UGPA said in a statement. “It is challenging for practices to even maintain the status quo as the impact of the Medicare freeze compounds year on year.”

The peak group said GPs were being caught in a financial squeeze between increasing patient demands and rising running costs on one side, and stagnant income from Medicare on the other.

“Like all small businesses, general practices must cover many costs, including for staff, equipment, technology, building, insurance, and medical indemnity,”. “Many general practices are reviewing their practice costs and business operations in order to remain viable. The ongoing freeze is eroding the ability of practices to continue to meet demand and maintain the highest possible levels of primary care.”

The warning follows the release of data showing that patient out-of-pocket costs have surged as struggling practices have moved to offset the relative loss of income caused by the rebate freeze.

Medicare figures show that GP patient fees jumped 6.5 per cent last financial year, the biggest rise in four years, to reach an average $34.25, underlining AMA warnings that Government policies were pushing many general practices to the financial breaking point, with serious consequences for patients and access to quality care.

“GPs are caught in a diabolical squeeze,” AMA President Dr Michael Gannon said recently. “They are caring for increasingly sick patients while the Government tightens the financial screws in the name of budget repair. GPs are now at breaking point. Many patients who are currently bulk billed will face out-of-pocket costs well over $20.”

Health Minister Sussan Ley has claimed the record high bulk billing rate of 85.1 per cent showed that patients continued to get ready access to care.

But UGPA said this ignored the enormous pressure being placed on GPs and the increased costs imposed on patients.

“With an ageing population and a dramatic increase in the number of patients with complex and chronic conditions, the demand on quality health care from GPs is growing significantly and quickly,” the peak general practice coalition said. “The Medicare rebate freeze is squeezing general practice. It will have serious repercussions for our patients, especially the most vulnerable, and the health of the economy.

The group has added its voice to AMA calls for the Government to immediately scrap the rebate freeze.

Adrian Rollins

Recruit local to relieve rural doctor shortage

The AMA has intensified its calls for the Federal Government to boost its investment in rural GP education amid mounting evidence that doctors who grow up and train in the bush are far more likely to practice there.

A study published in the latest edition of the Medical Journal of Australia found there is up to a 90 per cent chance that doctors who have a rural background and train in a rural area will still be practising in the bush five years later.

The result lends weight to AMA proposals for increased training opportunities for aspiring GPs and other specialists interested in practising in the country.

AMA President Dr Michael Gannon said the findings showed that the right investments by Government could make a real difference to access to care for rural communities.

“This study provides some important lessons for policy makers looking at how we can ensure that Australians living in rural areas have access to medical care,” Dr Gannon said.

While there has been an explosion in the number of medical school graduates in the past decade, relatively few are opting to train and practice in the bush, which remains chronically under-served.

Governments continue to recruit doctors from overseas to help fill the gap – the Herald Sun has revealed they sponsored 2268 health professionals to enter the country on 457 visas last year, including 1692 GPs and registered medical officers, 228 registered nurses, 35 specialists, 38 psychiatrists,28 surgeons and 19 anaesthetists.

Dr Gannon said proposals to build more medical schools were misguided.

“The problem isn’t a shortage of medical graduates. With medical school intakes now at record levels, we don’t need more medical students or any new medical schools.

“What we need are more and better opportunities for doctors, particularly those who come from the bush, to live and train in rural areas. The evidence shows that they are the most likely to stay on and serve their rural community once that qualify.”

The MJA study, Vocational training of general practitioners in rural locations is critical for the Australian rural medical workforce, found “a strong association between rural training pathways and subsequent rural practice”.

“[The] findings suggest that the periods leading up to and immediately following the vocational training are critically important windows of opportunity for ensuring that appropriate policies optimise recruitment of GPs for rural practice and their subsequent retention,” the study’s authors said.

Dr Gannon said these conclusions backed a number of policy proposals developed by the AMA to boost access to care in rural areas, including:

• for the targeted intake of medical students from rural areas to be increased from a quarter to a third of all new enrolments;

• the establishment of a Community Residency Program to give prevocational doctors, particularly those in rural areas, with access to three-month general practice placements;

• an increase in the GP training program intake to 1700 places by 2018;

• an expansion of the Specialist Training Program to 1400 places by 2018, with priority given to rural settings, under-supplied specialties and generalist roles; and

• access to regional training networks to support doctors to train and remain in rural areas.

“The Federal Government has a wonderful opportunity to make a real and lasting difference by adopting these sensible, effective, evidence-based measures,” Dr Gannon said.

The Government has promised to appoint a Rural Health Commissioner to champion rural health issues, including developing a National Rural Generalist Pathway to help address the shortage of rural medical practitioners.

Adrian Rollins

AMA in the News

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Lift freeze on Medicare rebate, AMA tells Libs, The Australian, 18 August 2016

Australian Medical Association President Dr Michael Gannon has called on Malcolm Turnbull and Health Minister Sussan Ley to “stare down” their cabinet colleagues and restore funding to the sector.

Health funds put profits first, Australian Financial Review, 18 August 2016

Dr Gannon wants the Federal Government and regulators to check private health insurers’ increasingly aggressive behaviour that he says puts profits above patients.

Show us the money, Adelaide Advertiser, 18 August 2016

Doctors will boycott the Federal Government’s Health Care Homes program unless it is better funded, the Australian Medical Association warns. Dr Gannon, in his first address to the National Press Club, listed primary prevention as one of the key priorities of the doctors’ group.

Health insurance fee crisis put down to prostheses costs, The Australian, 22 August 2016

Dr Gannon talked about claims by health insurers that the price of pacemakers and replacement hips and knees is the cause of Australia’s rising health insurance premiums. Dr Gannon said that he did not believe that Australia’s healthcare costs were out of control.

Australia produces more specialists, not enough GPs, The Age, 25 August 2016

The Australian Institute of Health and Welfare reported that while the number of registered medical practitioners overall has increased by 3.4 per cent a year, the ratio of general practitioners has remained steady. AMA Vice President Dr Tony Bartone, said the increase in specialists was needed, but the number of GPs remained too low, especially in rural and remote areas.

Doc drug spruiking revealed, Adelaide Advertiser, 1 September 2016

Drug companies have revealed they are paying Australian doctors up to $19,000 for overseas trips, and more than $18,000 in speaking and consultancy fees to spruik and critique their medicines. Dr Gannon said some of the payments helped doctors attend medical conferences to keep up to date with developments in their field.

Radio

Dr Michael Gannon, ABC 666 Canberra, 17 August 2016

Dr Gannon speaks about his upcoming National Press Club Address. He says health is not the problem in the Federal Budget and there will be inevitable increases in health spending due to the aging population.

Dr Michael Gannon, 2CC Breakfast, 17 August 2016

Dr Gannon talks about his upcoming address to the National press Club. He says the AMA is a voice independent from Government.

Dr Michael Gannon, ABC North West, 22 August 2016

Dr Gannon talks about a body representing private health insurance called “For Government Reforms” which they say will make private health insurance cheaper.

Dr Michael Gannon, 702 ABC Perth, 24 August 2016

Dr Gannon talks about a GP who has admitted assisting in hastening the death of a patient. Dr Gannon says that doctors have to act within the limits of the law and ethical code.

Dr Michael Gannon, 6PR Perth, 6 September 2016

Dr Gannon says the Federal Government is looking to drop the requirement for a doctor to issue medical certificates for sickness, dismissing Medicare costs and reducing the cost of the country’s medical services. Dr Gannon says doctors would miss out on health promotion opportunities.

Dr Michael Gannon, ABC 666 Canberra, 6 September 2016

Dr Gannon accused the Federal Government of unfairly blaming GPs for ballooning health costs after an interim report for the MBS Review was released.

Dr Michael Gannon, 2UE, 12 September 2016

Dr Gannon talks about a review into the Medicare Benefits Schedule. Dr Gannon said primary care lacks funding, which creates problems.

Dr Michael Gannon, Radio National, 13 September 2016

Dr Gannon talks about the warning signs of stillbirths, saying decreased foetal movement is not normal. Dr Gannon says decreased foetal movement is a sign that the baby is at risk due to placental deficiency and pregnant women who think that their babies are being quiet should take the time to rest and assess the foetal movement.

Dr Tony Bartone, Radio National, 13 September 2016
AMA Vice President Dr Tony Bartone commented about the latest report on Australian health which found alarming rates of chronic disease caused by lifestyle choices. Dr Tony Bartone said good preventive care is worth much more than the cost of consultation as many cases of chronic disease could have been avoided by preventive measures such as quitting smoking or reducing alcohol consumption.

Television

Dr Michael Gannon, ABC News 24, 17 August 2016
Address to the National Press Club by AMA President Dr Michael Gannon.

Dr Michael Gannon, Sky News, 2 September 2016

Dr Gannon discusses ethical implications from a court ruling that a child with brain cancer does not have to undergo treatment. Dr Gannon also discusses same sex marriage and foetal alcohol syndrome.

Dr Michael Gannon, Channel 7 Perth, 3 September 2016

Dr Gannon comments on swabs taken on hand rails, doors and ticket machines that revealed the presence of a range of germs responsible for many common respiratory and stomach infections.

Dr Michael Gannon, ABC News 24, 5 September 2016

Dr Gannon comments on the interim report of the Medical Benefits Schedule Review, which found patients visiting doctors for sick certificates, repeat scripts and routine test results cause costs to surge. He said patients who present for repeat prescriptions provided doctors with a health promotion opportunity. He says bashing GP as inefficient or expensive is not right.

Dr Michael Gannon, Channel 9 The Today Show, 10 September 2016

Dr Gannon talks about the MBS Review interim report, saying the current situation, with doctors prescribing medicines and pharmacists dispensing them, is working well and avoids ethical conundrums.

Updated medical standards to help doctors assess driver fitness

Doctors and other health professionals can now have access to best practice information to help them assess a patient’s ability to drive.

The updated medical guidelines will be contained in the new edition of Assessing Fitness to Drive for commercial and private vehicle drivers, a joint publication by the National Transport Commission (NTC) and Austroads to come into effect from October 1, 2016.

NTC Chief Executive Paul Retter said the edition included new features to guide the assessment of conditions such as epilepsy and dementia, and further information to determine and support functional driver capacity.

“We have worked closely with health professionals, driver licensing authorities and consumer health groups to update the guidelines, which has resulted in some changes to the licensing criteria to account for developments in medical understanding and practice,” Mr Retter said.

“The updates also include clearer guidance for health professionals to support consistent assessment and decision making.”

Austroads Chief Executive Nick Koukoulas said doctors would also be given information to assist them in having important conversations with their patients about driving.

Late last year Dr Genevieve Yates shared her story on doctorportal with the aim of raising awareness of the importance of thorough driver assessments.

Austroads is responsible for publication and distribution of Assessing Fitness to Drive, and will host the electronic version on their website.

A summary of the changes in the new edition and other support materials are also available on the Austroads website.

Three changes to medical criteria in the updated guidelines:

Aneurysms – The aneurysm diameter at which a conditional licence may be considered has been amended based on risk stratification for different aneurysm types and current management guidelines.
Epilepsy and seizures – For drivers with epilepsy under treatment who have been seizure-free for an extended period (10 years for private drivers), the driver licensing authority may consider a longer review period on the advice of an independent specialist.
Stroke – For private drivers, the requirement for a conditional licence and periodic review has been removed if the driver has recovered adequate neurological function. This reflects the non-progressive nature of stroke. The standard cross refers to management of treatable causes of stroke.

Latest news

Government taskforce doesn’t back sick certificate scare

The MBS Review Taskforce has sounded a warning on assertions that doctors are blowing out health costs by issuing sick certificates, ordering prescription repeats and writing specialist referrals.

Two-thirds of health professionals responding to an online survey run by the Taskforce called for MBS rules to be reviewed, particularly regarding the use of referrals and restrictions on eligible providers, seemingly lending weight to claims that GPs were wasting much of their time on ‘routine’ tasks like filling out medical certificates and writing referrals.

Health Minister Sussan Ley seized on the claims, telling ABC radio that “if the Government is paying effectively too much for small appointments that aren’t necessarily adding to a person’s overall health, particularly if they have chronic conditions, then that money does need to be reinvested”.

Extending her attack on primary health care, Ms Ley said a quarter of patients believed they had been recommended tests or treatments that were unnecessary.

The suggestion has fuelled calls, including from the Pharmacy Guild of Australia, for pharmacists, nurses and other allied health professionals to be granted an increased scope of practice to ease the burden on family doctors.

But the Taskforce itself has cast doubt on the extent of the problem, and has instead inferred that its prominence was being driven by health groups like pharmacists and nurses keen to expand their scope of practice.

“Many health professional respondents argued that referrals through GPs were unnecessary, particularly when accessing allied health services,” the Taskforce said in an interim report on its consultation. “It should be noted that the prevalence of this issue may reflect the skew towards allied health providers in the respondent group”.

AMA President Dr Michael Gannon dismissed the claim that valuable health dollars and GP time was being wasted on writing out certificates and referrals.

Dr Gannon said that not only was general practice very cost effective – accounting for just 6 per cent of total health spending – but performing such services was often a valuable opportunity to undertake preventive health care such as performing blood tests and assessing for diabetes and heart disease risk.

Related: Patient charges rising fast

In its discussion of the results of the online survey and stakeholder consultations, the Taskforce notably avoided the issue and turned its focus elsewhere.

It backed proposals for greater transparency on Medicare fees, and endorsed the idea of giving practitioners data on their own Medicare item usage, benchmarked against their peers.

But it flagged a cautious approach to changes to Medicare pay arrangements and MBS items.

In consultations there were calls for the fee-for-service model to be scrapped and replaced with an outcomes-based payment system.

But although expressing interest in pay for performance as a complement to fee-for-service in supporting multidisciplinary care, it was lukewarm on a wholesale change.

“The evidence suggests that clinically-based outcomes linked to payment have mixed success and may not be superior to activity-based payments in driving high-value care,” the Taskforce said. “Indeed, the MBS itself has many examples where incentive payments directed to addressing service deficits have had undesirable outcomes.”

And, while the Government has emphasised the scope for the MBS Review to axe Medicare items, the Taskforce indicated it would be moving with careful deliberation.

It noted that its terms of reference “do not preclude” recommending new items, and was considering “the addition of temporary item numbers to be used specifically for the acquisition of evidence to support the long-term retention or removal of items from the MBS”.

The case to remove items will depend on more than simply how often it is used.

“The Taskforce recognises that low usage of an item is not in itself conclusive evidence of obsolescence,” the Taskforce said.

View the Taskforce interim report here.

Latest news

Poor GP relations put ‘essential’ reform at risk

One of the boldest reforms to Medicare in decades could collapse if the Federal Government persists with the Medicare rebate freeze, AMA President Dr Michael Gannon has said.

Dr Gannon praised the Commonwealth’s plan to establish a Health Care Home model of care for patients with chronic illness, but warned that its chances of success were being hobbled by inadequate investment and relentless Government attacks on general practice, particularly the rebate freeze.

“Unless the Government restores some goodwill by unravelling the freeze and invests the extra funding that is required for enhanced patient services, GPs will not engage with the trial, and will walk away from this essential reform,” he said.

Under the model, also known as the Medical Home, patients suffering from complex and chronic health problems will be able to voluntarily enrol with a preferred general practice, with a particular GP to coordinate all care delivered.

Dr Gannon told the National Press Club the Health Care Home, if properly implemented, could deliver big improvements in quality of care, reduced hospital admissions and fewer emergency department visits.

“This is potentially one of the biggest reforms to Medicare in decades”, the AMA President said, and the AMA was keen for it to succeed.

But he warned that it faced major obstacles without a change in approach by Government.

The Government has initiated a two-year trial of the Health Care Home model, involving 65,000 patients and 200 practices across 10 Primary Health Networks.

It has committed $21 million to pay for test infrastructure, training and evaluation, and has allocated more than $90 million in payments for patient services.

But the Dr Gannon said these funds were simply being shifting from other areas of health, and the Government must invest if the reform was to be a success.

“There is no new funding for the Health Care Homes trial,” he said. “GPs are being asked to deliver enhanced care to patients with no extra support. This simply does not stack up.

Dr Gannon warned that “if the funding model is not right, GPs will not engage with the trial, and the model will struggle to succeed”.

Adding to the Government’s challenge, it is trying to recruit GP support for the policy while at the same time freezing the Medicare rebate and threatening to axe incentive payments to practices that do not upload enough health records to its My Health Record e-health system.

All this in addition to two aborted attempts to introduce a GP co-payment.

Dr Gannon said that these polices had damaged the relationship between the Government and GPs, and it would need to be repaired if Health Care Homes was to realise its potential.

“For the Health Care Home model to succeed, the Government needs to engage with and win the support of general practice. To do this, it must first overcome the significant trust and goodwill deficit attached to the co-payment saga and the Medicare freeze,” he said.

Adrian Rollins

Vocational training of general practitioners in rural locations is critical for the Australian rural medical workforce

The known In efforts to reduce the longstanding geographically inequitable distribution of Australian GPs, current policy requires that 50% of GP vocational training (registrar) positions are located in rural or remote areas.

The new We identified a strong association between rural training pathways and subsequent rural practice, and it is intensified by a rural origin effect. Despite some attenuation over time, these associations remained strong up to 5 years after vocational registration.

The implications Ongoing support for rural GP vocational training opportunities and the selection of rural origin medical students are critical components of GP workforce policy.

The geographically inequitable distribution of the Australian medical workforce continues, and rural and remote general practitioner positions are largely filled by international medical graduates (IMGs).1 This dependency persists despite substantial government efforts to stimulate recruitment and retention of Australian-trained GPs in rural areas. Recent government initiatives have included a large increase in the number of federally supported medical school places for students, and supporting medical education and training in rural communities through the Rural Clinical Training and Support (RCTS) program.1,2 A quota for the proportion of domestic students with a rural background selected by medical schools (at least 25%) has also been introduced, and rural clinical exposure during undergraduate and pre-vocational medical training programs has increased. In addition, Australian policy now requires that 50% of GP vocational (registrar) training occurs outside metropolitan areas.1 This policy is based chiefly on research that has indicated that a positive educational experience in rural settings, targeted training of GP registrars for rural practice, and clear pathways to rural practice are the most effective incentives for interesting a GP in a rural career.3,4 Doctors accepted into GP training are selected into either the Rural Pathway or the General (mostly metropolitan) Pathway, with about 50% of candidates allocated to each.5

Evidence for the effectiveness of these interventions for increasing rural recruitment and retaining Australian medical graduates in rural areas has accumulated. Ranmuthugala and colleagues6 reported that evidence for the effectiveness of increased rural exposure during undergraduate medical training on the uptake of rural practice was inconclusive, but Wilkinson and colleagues7 found that postgraduate rural GP training had a stronger association with rural practice uptake than rural exposure during undergraduate training (although the availability of rural GP postgraduate training was low at the time of this study because the number of rural training positions was limited). More recent empirical data8–10 and data on intentions collected at training completion11,12 suggest moderate improvement in the uptake of rural practice by students who have participated in RCTS programs. However, as reported in three literature reviews on the recruitment and retention of medical practitioners in rural areas3,13,14 and as lamented in a recent letter to the Medical Journal of Australia,15 there remains a large evidence gap as to the effectiveness of rural exposure during vocational training programs. A review of the outcomes of the regionalised Australian General Practice Training Program16 found that only 27% of former Rural Pathway registrars remained in rural practice after 7 years. In addition, several North American studies have produced limited quantitative evidence of associations between vocational training in a rural primary care setting and subsequent rural practice.17–20

The geographic origin of doctors also has an impact on their commencing rural practice, with convincing evidence about a strong link between an individual’s rural upbringing and their subsequent decisions about a rural career.21,22 The consistency of the reported association between GPs having a rural background and their choosing a rural career suggests that their origin is a critical factor in making this decision, regardless of vocational training location. Our study therefore aimed to investigate the association between vocational training location and the subsequent choice of practice location for newly registered GPs, including the effect of a rural background.

Methods

This study was based on data from the Medicine in Australia: Balancing Employment and Life (MABEL) study, conducted by the Centre for Research Excellence in Medical Workforce Dynamics (https://mabel.org.au/). MABEL is a national longitudinal survey that collects annual data from a panel of doctors, with a regular small participation top-up. The first wave of the MABEL study (2008) invited the entire medical workforce to participate, and 10 498 doctors (19.4% of the medical population) completed the initial survey, including 17.7% of GPs. There has subsequently been an annual 70–80% study retention rate. Further participants (generally recently graduated, non-specialist hospital doctors or IMGs newly registered in Australia) are added to the MABEL pool each year.

Our study analysed data from MABEL waves 1 to 7 (2008–2014), and was restricted to respondents who had completed their GP vocational training and were transitioning to independent practice. The transition year for a GP was identified from MABEL data on the basis of their participation in GP registrar training and details of newly completed medical qualifications. Data for IMG GPs — defined as those who had completed their initial medical training outside Australia and New Zealand — were analysed separately.

Rural origin and work location

Rural origin was defined for doctors trained in Australia or New Zealand as their having resided for at least 6 years in a rural area before the age of 18 years. Each doctor’s work location was geocoded in each MABEL wave to a specific town or suburb, then classified as metropolitan or rural. Rural location was defined as including Australian Standard Geographic Classification Remoteness Areas (ASGC-RA) 2 to 5;23 it was self-defined for New Zealand-trained doctors. Vocational training location was defined in two ways: as rural or metropolitan by work location in the year the doctor completed their training (final training location), and as an aggregate of work locations in the 2 to 3 years preceding their completion of training.

Statistical analysis

Four cohorts were defined by a combination of origin type and final training location: rural origin/rural training, metropolitan origin/rural training, rural origin/metropolitan training, and metropolitan origin/metropolitan training. For comparison purposes, IMGs were separately divided into two cohorts: rural training and metropolitan training.

A secondary (sensitivity) analysis defined four cohorts by multiple training locations: rural training only; completed training in a rural area, but also had some metropolitan training; completed training in a metropolitan area, but also had some rural training; metropolitan training only.

For each cohort, the proportions of GPs working in rural and metropolitan locations were calculated for each of the first 5 years after they had completed their vocational training. Rurally trained GPs were further classified according to whether they were working in the same or a different rural community from that in which they completed their vocational training; a buffer of 20 kilometres was allowed.

Separate generalised estimating equation (GEE) models with a logit link function and exchangeable correlation structure were used to test associations between vocational training pathways and subsequent work location for the four primary cohorts (non-IMGs only) for each of the 5 years after completing vocational training. Adjustments were made for four additional demographic variables during each particular year: sex, age, living with a partner, and having dependent children. A further variable — whether the GP was rurally bonded (contracted to work for part of their early career in rural locations) in a particular year — was included in each regression model. These models were repeated for the four secondary cohorts, with rural origin as an additional covariate; its multi-year cohort definitions limited analysis to 4 outcome years. All calculations were performed in StataSE 12 (StataCorp).

Ethics approval

The MABEL study was approved by the University of Melbourne Faculty of Business and Economics Human Ethics Advisory Group (reference, 0709559) and the Monash University Standing Committee on Ethics in Research Involving Humans (reference, CF07/1102 – 2007000291).

Results

During the 7-year study period, 610 doctors completed their GP vocational training and commenced in at least one subsequent work location. The demographic characteristics of these GPs are summarised in Box 1. Just under half of the local graduates (ie, those who graduated in Australia) trained in the Rural Pathway, and about one quarter were of rural origin (consistent with current policy requirements for GP training posts and medical student intakes); fewer than 10% were rurally bonded. Most local medical graduates were women, most lived with a partner, and almost 40% had dependent children. The proportions of IMGs who trained in the Rural Pathway, were men, were aged 35 years or more, lived with a partner, or had dependent children were higher than for local medical graduates (Box 1).

Box 2 summarises the practice location as an independent GP for the four primary cohorts of local medical graduates for each of the 5 years following their completion of vocational training. There were very strong and sustained associations between final vocational training location type and subsequent practice location for the rural origin/rural training and metropolitan origin/metropolitan training cohorts; 74–91% and 87–95% respectively remained in their origin/training type during their first 5 post-training years. Moreover, 61–70% of the rural origin/rural training cohort practised in the same rural community in which they trained during the first 4 years after completing their vocational training. Outcomes for GPs from cohorts 2 and 3 also showed a clear pattern: initially, these GPs generally remained in their final vocational training location type, but there was subsequently a gradual move in work location toward their origin type. The career patterns of rurally trained IMGs was similar to those of metropolitan origin/rural trained local graduate GPs, with a gradual move in work location toward metropolitan areas during the 5 years after vocational registration (Box 3).

The rural training pathway, regardless of childhood location, was highly significantly associated with subsequent rural practice. The odds of rural practice for each of the rural training cohorts of GPs decreased with time, but a strong and highly significant association was nevertheless retained across the 5 years. Unsurprisingly, rural bonding and rural origin were positively associated with rural practice. Higher age was also associated with rural practice, while there were no consistent statistically significant associations between practising in a rural location and sex, or with having a partner or dependent children (Box 4).

Secondary analysis, using the multiple year training location definition, confirmed the importance of rural training, particularly that of the final GP training year (Box 5).

Discussion

We have provided empirical evidence for the contribution of rural vocational training, in combination with the selection of rural origin students, to the Australian rural GP workforce. This is highly significant for rural workforce policy, as the Australian government requires that more than half of Australian GP vocational training positions be located in rural areas; our study allows an opportunity to assess the effect on the workforce of these policies.1

We found that training in the rural training pathway and the trainee having a rural background were each strongly associated with early career rural practice. The strength of the association between vocational training location and choosing rural practice remained strong and statistically significant up to 5 years after completing GP training for doctors of either rural or metropolitan origin (primary cohorts 1 and 2). Sustained rural practice was very strongly linked with the combination of a rural origin and rural training, but this cohort alone is unlikely to provide a sustainable rural GP workforce while only 25% of Australian-trained doctors are of rural origin, as about 30% of the Australian population live in rural or remote areas.

Most mixed rural/metropolitan origin/training GPs (cohorts 2 and 3) subsequently practised in a same location type as that in which they trained, although some gradually returned to their origin type. Diminution of the pathway effect over time is perhaps expected, as 50% of GP registrar training positions are in rural areas but about 75% of young doctors are of metropolitan origin. Other research has found that work location changes are most likely during early career stages,24 when personal circumstances, including relationships with spouses and dependents, are more fluid. The secondary analysis confirmed the strong influence of rural training on subsequent rural practice, especially location during the final year of vocational training. Together, these findings suggest that the periods leading up to and immediately following vocational training are critically important windows of opportunity for ensuring that appropriate policies optimise recruitment of GPs for rural practice and their subsequent retention.25,26

The largest cohort, metropolitan origin doctors undertaking GP training in metropolitan areas (cohort 4) largely remained in metropolitan practice. Further, there was no evidence that rural origin Australian doctors were more likely than metropolitan origin doctors to choose general practice as their specialty (unpublished MABEL data). Consequently, metropolitan origin doctors continue to remain the major source of non-IMG rural GPs, making cohort 2 (metropolitan origin/rural training) critical for the rural GP workforce. This cohort is nearly twice the size of cohort 1, and the association with rural practice was much stronger than for those in the metropolitan pathway (cohort 4). However, more than 50% of cohort 2 had moved to metropolitan practice after 5 years, further highlighting the importance of targeted retention initiatives focused on this cohort.

The odds of members of the smallest cohort (cohort 3: local medical graduates with a rural background who undertook their training in metropolitan areas) practising in rural areas was three times that for metropolitan origin/metropolitan training GPs, although the association was statistically significant only from 3 years after completing vocational training. However, the odds were much lower than for the rural origin/rural training cohort 1, highlighting the importance of the rural training pathway.

A key limitation of this study is that it cannot establish cause and effect. There is probably a strong self-selection bias, in that the rural training pathway attracts those who are interested in a rural career. Further limitations include the use of a self-selected cohort, the participants of the MABEL survey, who represent 15–18% of all Australian GPs. While the panel design of our study enabled individual tracking of doctors over a 7-year period and application of GEE (logit) modelling, the observed patterns, particularly in the mixed origin/training cohorts, suggest that these doctors have not yet decided on their long term preferred work location, and it is therefore difficult to accurately predict outcomes at, for example, 10 or 20 years. Additionally, vocational training location was primarily defined for the purposes of this study as the location of the trainee in the year they completed their training, as this was considered to be the most influential year for subsequent practice location. Our secondary analysis partially examined this aspect by separately analysing GPs who had undertaken vocational training in a mix of rural and metropolitan locations. Further, our key focus was on the joint effects of rural origin with rural/metropolitan training pathways. This necessitated a focus on GPs who had completed their medical degrees in Australia or New Zealand, despite IMGs comprising a considerable proportion of the rural GP workforce in Australia (more than 50% in some regions). Finally, this study used a binary measure of rurality (metropolitan v non-metropolitan) that may not adequately adjust for the substantial heterogeneity in the attractiveness to GPs of different rural and remote Australian locations. It is possible that more nuanced measures of rurality, including multiple levels of remoteness and population size, might have identified different associations for the four cohorts.27

Conclusion

Our study analysed the best available Australian longitudinal data about individual GPs to provide new quantitative evidence of a strongly positive association between rural GP vocational training location and subsequent rural practice, even after adjusting for the influence of rural origin. This evidence supports the objectives of existing policies that require at least 50% of GP training to occur in rural locations, and that at least 25% of medical students should be of rural origin. While Australia strives to reduce its reliance on IMG GPs for the rural workforce, this aim requires long term improvements in the rural recruitment and retention of Australian-trained GPs. Ongoing support for rural GP vocational training opportunities is a critical component of rural GP workforce policy in Australia.

Box 1 –
Demographic characteristics of participating doctors at the time they completed general practitioner vocational training

	Local medical graduates	International medical graduates

Number	467	143
Rural Pathway (year of training completion)	221 (47.3%)	101 (70.6%)
Rural origin	118 (25.3%)	NA
Sex (women)	322 (69.0%)	74 (51.8%)
Age, median	32 years	41 years
Age, ≥ 35 years	153 (32.9%)	125 (89.9%)
Living with a partner	335 (72.7%)	119 (83.2%)
Has dependent children	179 (39.4%)	119 (83.8%)
Rurally bonded	35 (7.5%)	NA

NA = not applicable. Percentages exclude missing data for local medical graduates (age, 2; living with partner, 6; dependent children, 13) and international medical graduates (age, 4; dependent children, 1).

Box 2 –
Final vocational training location and general practice location for local medical graduates during the first 5 years after completing general practitioner vocational training

Time since completion of training	Location of practice	(1) Rural origin/rural training	(2) Metropolitan origin/rural training	(3) Rural origin/metropolitan training	(4) Metropolitan origin/metropolitan training

	Number of GPs	78 (17%)	143 (31%)	42 (9%)	204 (44%)
1 year	Same rural	70%	54%	—	—
	Other rural	20%	22%	18%	5%
	Metropolitan	10%	25%	82%	95%
2 years	Same rural	62%	42%	—	—
	Other rural	24%	31%	30%	13%
	Metropolitan	14%	27%	70%	87%
3 years	Same rural	68%	24%	—	—
	Other rural	15%	42%	35%*	11%
	Metropolitan	18%	34%	65%*	89%
4 years	Same rural	61%	25%	—	—
	Other rural	30%	29%	46%*	9%
	Metropolitan	9%	45%	54%*	91%
5 years	Same rural	42%*	15%	—	—
	Other rural	32%*	33%	33%*	9%
	Metropolitan	26%*	52%	67%*	91%

* Groups with fewer than 20 participants.

Box 3 –
Final vocational training location and general practice location for international medical graduates during the first 5 years after completing general practitioner vocational training

Time since completion of training

Location of practice

Rural training

Metropolitan training

Number of GPs

101 (71%)

42 (29%)

1 year

Same rural

81%

—

Other rural

Metropolitan

13%

96%

2 years

Same rural

57%

—

Other rural

17%

Metropolitan

26%

92%

3 years

Same rural

49%

—

Other rural

10%

Metropolitan

41%

100%*

4 years

Same rural

45%

—

Other rural

21%

18%*

Metropolitan

34%

82%*

5 years

Same rural

53%*

—

Other rural

7%*

20%*

Metropolitan

40%*

80%*

* Groups with fewer than 20 participants.

Box 4 –
Odds of local medical graduates practising in a rural location during the first 5 years after completing general practitioner vocational training

Odds ratio (95% confidence interval)

1 year post-GP training

2 years post-GP training

3 years post-GP training

4 years post-GP training

5 years post-GP training

Primary cohorts

(1) Rural origin/rural training

159 (45–558)^†

65 (27–158)^†

48 (22–102)^†

50 (24–106)^†

52 (24–111)^†

(2) Metropolitan origin/rural training

68 (26–175)^†

32 (16–60)^†

28 (16–51)^†

23 (13–41)^†

24 (13–43)^†

(3) Rural origin/metropolitan training

2.8 (0.7–11)

2.4 (0.9–6.2)

2.9 (1.2–6.7)*

3.3 (1.5–7.4)^†

3.5 (1.5–7.9)^†

(4) Metropolitan origin/metropolitan training

1.00

Age (for each 1-year increase in age)

1.06 (1.00–1.13)*

1.04 (0.99–1.08)

1.04 (1.00–1.08)*

1.05 (1.01–1.08)*

1.04 (1.01–1.08)*

Sex (reference: men)

1.00 (0.48–2.1)

0.9 (0.5–1.6)

1.03 (0.6–1.7)

0.8 (0.5–1.4)

Living with a partner

0.8 (0.3–1.9)

0.9 (0.5–1.7)

0.98 (0.6–1.7)

0.9 (0.6–1.5)

Has dependent children

1.8 (0.8–4.1)

1.9 (1.06–3.3)*

1.4 (0.9–2.3)

1.3 (0.9–2.0)

1.3 (0.9–1.9)

Rurally bonded

5.1 (1.2–22)*

3.5 (1.1–11)*

3.8 (1.4–11)*

3.7 (1.4–10)*

3.6 (1.3–10)*

Odds ratios from generalised estimating equation (logit) model: * P < 0.05; † P < 0.01.

Box 5 –
Odds of practising in a rural location for each of the 4 years after completing general practitioner training for local medical graduates

Odds ratio (95% confidence interval)

1 year post-GP training

2 years post-GP training

3 years post-GP training

4 years post-GP training

Secondary cohorts

(1) Rural training only

92 (27–312)^†

49 (21–115)^†

41 (19–88)^†

29 (14–59)^†

(2) End training rural, with some metropolitan training

17 (5–58)^†

11.6 (4.6–29)^†

11.5 (4.9–26)^†

9.9 (4.3–23)^†

(3) End training metropolitan, with some rural training

0.94 (0.09–9.4)

2.8 (0.8–9.4)

2.9 (1.00–81)

2.7 (0.96–7.9)

(4) Metropolitan training only

1.00

Rural origin

4.1 (1.3–13)*

2.0 (0.9–4.3)

2.1 (1.02–4.1)*

2.5 (1.3–4.9)^†

Age (for each 1-year increase in age)

1.2 (1.04–1.3)^†

1.08 (1.01–1.16)*

1.07 (1.01–1.14)*

1.05 (1.00–1.12)

Sex (reference: men)

0.9 (0.3–2.4)

0.8 (0.4–1.7)

0.9 (0.5–1.9)

0.8 (0.4–1.5)

Living with a partner

0.6 (0.2–2.1)

1.1 (0.5–2.6)

1.1 (0.5–2.4)

1.07 (0.5–2.1)

Has dependent children

0.6 (0.2–2.0)

1.3 (0.6–2.7)

1.09 (0.6–2.1)

1.02 (0.6–1.8)

Rurally bonded

2.0 (0.4–10)

2.21 (0.6–7.8)

3.8 (1.2–13)*

3.6 (1.1–11)*

Odds ratios from generalised estimating equation (logit) model: * P < 0.05, † P < 0.01.