Exploring the value of interprofessional student-led clinics for chronic disease patients

Interprofessional student-led clinics have recently been established to extend educational capacity beyond traditional single-discipline placements in the acute sector and to facilitate the development of a collaborative approach to health care.1 Although student satisfaction with interprofessional education (IPE) is common,2 it is unclear whether IPE improves chronic disease management, a global priority of health care practice.3 This study explored the impact of interprofessional student-led clinics on chronic disease management in the primary care setting.

Patients (n = 44) with chronic disease at a primary care practice in Melbourne were invited to attend a student-led interprofessional clinic made up of senior university student volunteers from medicine, nursing, occupational therapy, pharmacy and physiotherapy. In a one-hour consultation between May and September 2014, mixed-discipline student teams interviewed patients to explore their perceived health issues, review medications and make recommendations to the treating general practitioner. Postconsultation, health issues identified by students were analysed to determine if any new health concerns had been identified. At 6-week follow-up, patient files were audited and GPs consulted to determine whether the students’ recommendations had been implemented.

New health issues were identified in five patients. Medication modifications were suggested for 17 patients, of which action was undertaken for 12 patients at follow-up. Referrals for additional services or support were recommended for 29 patients, of which action was undertaken for nine patients at follow-up. Referral recommendations included physiotherapy, podiatry and diabetes education, and new preventive health approaches were commonly adopted.

The ability of student teams to identify previously unknown health issues and propose useful health management changes highlights the potential of IPE to improve the management of patients with chronic disease. Findings from this study resonate with previous literature which suggests IPE can lead to improved patient health management.4 Over time, GPs acquire a breadth of knowledge about their patients’ health, but student teams in this study only had a single consultation with each patient. Longitudinal exposure to interprofessional consultations may facilitate students to evaluate and further refine their health management recommendations.

This study builds upon the literature examining chronic disease management by interprofessional student teams in primary care. The use of outcome measures such as health issues, medication and referral recommendations facilitated an objective assessment of health management changes. Limitations of this study are that all participants were volunteers and a comparison group was not employed. There is also the potential for experimenter bias, as one of the authors (M D) was a treating GP for some of the patients in the study. Employing a random sample of patients in future studies is recommended.

Positive early findings suggest further investigation of the potential of interprofessional student-led clinics to improve health care management for patients with chronic disease is warranted.

The challenges of early diagnosis of cancer in general practice

Managing missed opportunities when most cancer symptoms are only weakly predictive

The incidence of cancer in Australia is rising due to an ageing population and increased detection of certain cancers through screening. In 2012, an estimated 120 000 Australians were diagnosed with cancer, not counting basal and squamous cell skin cancers.1 Most cancers present symptomatically, even those for which there are national screening programs. In Australia, and other countries with strong primary health care systems, 75%–85% of cancers first present in general practice as a result of symptoms. General practitioners therefore play a key role in the early detection of cancer.2

Delayed diagnoses

Intuitively, diagnosing cancer early should be beneficial. Indeed, perception of a missed diagnosis of cancer is a leading cause of medicolegal complaints in primary and ambulatory care, on the assumption that harm occurred as a result of diagnostic delay.3 There is ongoing debate about the value of early cancer detection in asymptomatic populations through screening tests. At the same time, proving that earlier detection of symptomatic cancer “matters” is also epidemiologically challenging. The waiting time paradox describes the phenomenon in which patients with late-stage cancers present with severe symptoms and are therefore diagnosed promptly but have poorer outcomes.4 This is an important source of bias in studies examining the effect of time to diagnosis on outcomes in symptomatic cancer populations. However, a recent systematic review has found that shorter time to diagnosis was associated with better outcomes in symptomatic populations; the strongest evidence was for melanoma, breast, colorectal, head and neck, and testicular cancer.4

So-called delays in cancer diagnosis can occur due to patient, health care provider and health system factors.5 Research from the United Kingdom and Australia shows that major contributors to the overall time to diagnosis occur both before a patient presents with symptoms to a doctor and their subsequent management in general practice. For most cancers, the patient interval (time from developing a symptom to seeing a doctor) is longer than the primary care interval (time from presentation to the GP to referral for specialist management).6 This is the rationale behind cancer symptom awareness campaigns aimed at promoting earlier presentation to health care. Nonetheless, many patients with cancer will have multiple visits to their GP before a diagnosis is made; this is particularly so for certain cancers such as myeloma, pancreatic, gastric and lung, suggesting that some cancers are harder to diagnose in primary care than others.7 This may also reflect a degree of therapeutic nihilism, in which doctors assume there is little to be gained from early diagnosis of some cancers and so may not refer as promptly.

Missed opportunities

A potentially useful approach to this issue is to consider if there have been missed opportunities for earlier diagnosis when a patient presented with symptoms in general practice.8 Of course, the concept of a “missed opportunity” can only ever be part of a post-hoc analysis of whether some alternative action might plausibly have led to an earlier cancer diagnosis, but it is worth reflecting on the possible reasons for such missed opportunities in general practice.

One of the most significant reasons is that doctors may simply not consider cancer in their differential diagnoses. A full-time GP will only see five to 10 new cases of non-cutaneous cancer among several thousand consultations per year. This low prevalence of cancer in primary care means that even red-flag cancer symptoms have low positive predictive values. Only a few symptoms, such as haemoptysis, breast lump and haematuria, have > 5% chance of being due to cancer in primary care.9 Most symptoms of cancer have more common benign causes in general practice. Further, cancers in general practice often present initially with more subtle non-specific symptoms. In a large prospective cohort study, only 22% of patients with lung cancer first presented with haemoptysis, but this was the only symptom significantly associated with a final diagnosis of lung cancer.10 Doctors also experience a range of cognitive biases which affect their decision making. For example, over-relying on a single element of the history (anchoring bias), only seeking evidence from the history that agrees with the initial impression (confirmation bias) and overweighting elements of the history based on recent similar cases (availability bias).

From a systems perspective, missed opportunities can occur for a variety of reasons. For example, excessive workloads can lead to shorter consultation times and potentially incomplete clinical assessment or failure to follow-up abnormal test results. Safety netting is increasingly recognised as an important aspect of quality care in reducing potential diagnostic delay. This means that GPs should explain to patients when to return if their symptoms persist or if they develop new symptoms.

Later cancer diagnosis can also occur as a result of limited access to diagnostic tests or the use of the wrong test. In Australian general practice, there is relatively good access to a wide range of pathological and radiological investigations, but access to other key tests, such as gastrointestinal endoscopy, is more problematic, especially in public hospitals. This imbalance risks GPs ordering tests that are most accessible rather than most appropriate. The recently launched Choosing Wisely initiative specifically recommended against the use of serum tumour markers as a diagnostic test in people with suspected cancer, because of their low sensitivity and specificity (http://www.choosingwisely.org.au/recommendations/rcpa). In the UK, new guidance from the National Institute for Health and Care Excellence recommends use of faecal occult blood testing in people with low-risk bowel cancer symptoms as a cost-effective alternative to either colonoscopy or computed tomography colonography (https://www.nice.org.uk/guidance/ng12).

Improving cancer diagnosis in general practice

Research using routine general practice data has helped to inform our understanding of the epidemiology of cancer symptoms in primary care. As a result, we can now estimate the likelihood of cancer based on a patient’s combinations of symptoms, signs and baseline risk factors.2 This is more sophisticated than the traditional red-flag single-symptom approach to prompt consideration of a cancer diagnosis. Arising from this research are risk assessment tools (RATs) such as the charts developed by Hamilton and colleagues11 (Box 1) and the QCancer model of Hippisley-Cox and Coupland.12 These tools could support GPs to assess patients’ symptoms more accurately and identify those who require more urgent investigation or referral. They should also inform Australian guidelines on early cancer diagnosis and could potentially support triage of referrals. In the UK, these tools have been integrated into GP computing systems and are currently being widely disseminated. But there is limited evidence on how GPs will use such tools or what impact they will have on diagnostic decision making.

A study exploring Australian GPs’ use of a QCancer tool (Box 2) in simulated consultations found several challenges. GPs found the tool difficult to introduce into the workflow of the consultation, were distrustful of the risk output compared with their own clinical judgement, and varied symptom interpretation meant that there was significant variation in risk assessment, even with standardised consultations.13 A cluster randomised controlled trial of implementing the Hamilton RATs in rural Western Australia is due to report later this year and will provide further evidence on the utility of such tools.14

The complex nature of the Australian health care system means that diagnostic pathways for patients with suspected cancer are not always clear. Several states have developed recommended cancer diagnostic and treatment pathways in recognition of this problem, some with maximum recommended intervals along the pathway. Cancer Australia has produced national guidelines aimed at general practice for the assessment of patients with suspected breast, ovarian and lung cancer.15 However, as with all practice guidelines, they need a significant and sustained effort to ensure that they are used in general practice. A report for the Sax Institute recommended establishing fast-track referral pathways, initially for colorectal and lung cancer.16 This was based on evidence from the 2-week wait referral initiatives in the UK, in which patients meeting symptom-based criteria were fast-tracked for an outpatient assessment for suspected cancer; an approach that was associated with significant reductions in diagnostic intervals for several cancers.17 Piloting of fast-track pathways for specific cancers is occurring in Victoria and New South Wales.18

Summary

General practice can make important contributions to improving cancer outcomes through early recognition and investigation of patients most likely to have the disease. As gatekeepers, GPs must balance the risk of later diagnosis against overinvestigation of patients who are unlikely to have cancer, with resultant costs to the patient and to the health care system, and potential harms from invasive tests including overdiagnosis of incidental low-risk cancers. Over-referral of low-risk patients can extend waiting times for diagnostic tests (eg, gastrointestinal endoscopy in public hospitals) and potentially delay diagnosis in those who do have cancer.

Further research is required on how best to apply the epidemiological evidence about the predictive value of symptom clusters in general practice, through the implementation of risk tools or fast-track referral pathways. General practices should consider conducting significant event audits of new cancer diagnoses to reflect on potential missed opportunities for earlier diagnosis. Such audits could inform practice system improvements in ensuring adequate follow-up of abnormal tests and safety-netting patients with persistent symptoms, both of which could contribute to earlier cancer diagnosis in general practice.

Box 1 –
Reported positive predictive values for colorectal cancer for individual features, repeat presentations and for pairs of features (in the context of a background risk of 0.25%)^∗

The top row shows the positive predictive value (PPV) for an individual feature. The cells along the diagonal relate to the PPV when the same feature has been reported twice. Thus, the constipation/constipation intersect is the PPV for colorectal cancer when a patient has attended twice (or more often) with constipation. Other cells show the PPV when a patient has two different features. The top figure in each cell is the PPV. It has only been calculated when a minimum of 10 cases had the feature or combination of features. The two smaller figures are the 95% confidence intervals for the PPV. These have not been calculated when any cell in the 2 × 2 table was below 10. For haemoglobin levels < 10 g/dL with abdominal tenderness, no controls had this pair. It was scored as a PPV of > 10%. The yellow shading is when the PPV is > 1%. The amber shading is when the PPV is > 2.5%, which approximates to a risk of colorectal cancer of 10 times normal. The red shading is for PPVs > 5.0%, approximating to a risk of 20 times normal.

^∗Reprinted by permission from Macmillan Publishers Ltd on behalf of Cancer Research UK: Hamilton et al.11

Box 2 –
Illustrative screenshots of the QCancer tool^∗,†

^∗Reprinted by permission from Macmillan Publishers Ltd on behalf of Cancer Research UK: Chiang et al.13 †Information in these screenshots should not be used as diagnostic advice.

General practitioners’ prescribing of lipid-lowering medications for Indigenous and non-Indigenous Australians, 2001–2013

Aboriginal and Torres Strait Islander Australians (Indigenous Australians) bear a disproportionate burden of disease in Australia and have a life expectancy 13 years shorter than that of other Australians.1,2 Heart disease is the leading cause of death among both Indigenous and non-Indigenous Australians, and it is also the single largest contributor to the gap in life expectancy between the two populations.3,4 The mortality rate associated with cardiovascular disease is 60% higher in Indigenous than in non-Indigenous populations; the prevalence of cardiovascular disease is 30% higher and that of its risk equivalent, diabetes, is three times greater among Indigenous Australians.3–6

Promoting access to prescription drugs and improving the management of chronic disease are key components of the national strategy for reducing health disparities in Australia. In 1999, the Australian Government eliminated out-of-pocket drug costs for Indigenous patients attending remote Aboriginal community-controlled health clinics.7 Two subsequent initiatives, in 2008 and 2010, reduced medication co-payments for Indigenous patients who attended non-remote Aboriginal community-controlled clinics or mainstream general practices.8,9 Further, the Pharmaceutical Benefits Scheme modified its criteria for subsidised lipid-lowering medications to include all Indigenous Australians with diabetes or a blood total cholesterol level above 6.5 mmol/L.10 The Indigenous Practice Incentives Program of the federal Department of Health provides bonus payments to general practitioners who enrol chronically ill Indigenous patients and prepare chronic disease management plans for them.11

Whether these efforts have translated into increased prescribing of cardiovascular medications to Indigenous Australians or better control of cardiovascular risk factors is unknown. We therefore evaluated trends in the prescribing of lipid-lowering medications for Indigenous and non-Indigenous Australians seen in general practice. We focused on therapies that reduce blood lipid levels because treating this modifiable risk factor can reduce coronary events and mortality in selected patients.12,13

Methods

Study design, source of data and population

We conducted an observational time trend study, from April 2001 to March 2013, that determined the proportion of patient encounters in which GPs prescribed lipid-lowering medications. We analysed data from the Bettering the Evaluation and Care of Health (BEACH) survey, which randomly samples 1000 GPs each year.14 The source population included all registered GPs and GP registrars who had claimed at least 375 Medicare service items in the past 3 months.

Each participating GP provided information about 100 consecutive patient encounters. The BEACH survey collects reasons for the encounter, problems addressed during the encounter, and clinical actions undertaken to manage each problem. GPs record up to four medications for each problem managed, and link each medication with a single managed problem. The final study sample encompassed 759 673 GP encounters with patients aged 30 years or over: 9594 with Indigenous and 750 079 with non-Indigenous patients.

Outcome measures

The primary outcome was the report that at least one lipid-lowering medication had been prescribed during an encounter. Lipid-lowering medications included five classes: statins, bile acid sequestrants, fibrates, niacin, and cholesterol absorption inhibitors. The primary independent variable was Indigenous status (dichotomous: yes v no), based on the GP’s record of the patient’s self-report during the encounter.

Statistical analyses

We calculated the unadjusted rate of prescribing lipid-lowering medications (ie, the proportion of encounters at which at least one such medication was prescribed) for Indigenous and for non-Indigenous patients. These data were further stratified by time period (1 April 2001 – 31 March 2005, 1 April 2005 – 31 March 2009, 1 April 2009 – 31 March 2013) and by the clinical condition that was addressed during an encounter (non-gestational diabetes mellitus, hypertension, ischaemic heart disease, lipid disorder). We also calculated the age–sex standardised rate of prescription of lipid-lowering medications for Indigenous patients, using 14 discrete age–sex subgroups (men and women in seven age groups spanning 10 years each). Age–sex standardisation yields an estimate of the lipid-lowering prescribing rate for encounters with Indigenous patients, assuming an age–sex structure identical to that of the non-Indigenous population.

A further subgroup analysis calculated the proportions of all lipid-lowering medications prescribed for each specified clinical condition. To assess whether there were statistically significant increases over time in the age–sex standardised rate of prescribing of lipid-lowering medications, we constructed logistic regression models, with the time period (the three 4-year time periods) as the independent variable.

All analyses were adjusted for clustering by GP using SAS 9.3 survey procedures (SAS Institute). Differences were considered statistically significant at P < 0.05. For routine analyses of BEACH data, we report a significant difference only if there was no overlap of the 95% confidence intervals of the two comparison groups. This is a stricter threshold than the usual P < 0.05 criterion, equivalent to P < 0.006, and reduces the risk of Type 1 errors when making multiple comparisons.

The University of Sydney Human Research Ethics Committee approved the study (reference 2012/130).

Results

Rate of prescription of lipid-lowering medications for Indigenous and non-Indigenous patient encounters

During the study period, lipid-lowering medications were prescribed during 4.9% (95% CI, 4.2%–5.6%) of encounters with Indigenous patients, and at 4.6% (95% CI, 4.5%–4.7%) of encounters with non-Indigenous patients. After age–sex standardisation (which adjusts the Indigenous but not the non-Indigenous rate), the rate of prescription during Indigenous patient encounters was 5.5% (95% CI, 4.7%–6.3%), significantly greater than that for non-Indigenous patient encounters.

For Indigenous patient encounters, the age–sex standardised rate of prescription of lipid-lowering medications increased from 4.1% during 2001–2005 to 6.4% during 2009–2013 (P = 0.013 for trend). For non-Indigenous encounters, the rate of prescription increased from 3.8% to 5.2% over the same period (P < 0.01) (Box 1). The point estimates for these proportions were higher for Indigenous patient encounters for each of the three time periods, but these individual differences were not statistically significant.

Specified clinical conditions addressed during Indigenous and non-Indigenous patient encounters

Diabetes and ischaemic heart disease were significantly more commonly managed at encounters with Indigenous patients than at those with non-Indigenous patients: in age-standardised analyses, diabetes was managed at 13.8% (95% CI, 12.6%–15.1%) of encounters with Indigenous patients and at 4.7% (95% CI, 4.6%–4.7%) of encounters with non-Indigenous patients. Ischaemic heart disease was managed at 3.2% (95% CI, 2.6%–3.8%) of encounters with Indigenous patients and at 1.7% (95% CI, 1.7%–1.8%) of those with non-Indigenous patients. Lipid disorders were managed significantly less frequently during Indigenous encounters (3.8%; 95% CI, 3.1%–4.5%) than during non-Indigenous encounters (4.6%; 95% CI, 4.5%–4.7%). There was no significant difference between the proportions of encounters at which hypertension was managed (12.6% for each group).

Rate of prescription of lipid-lowering medications, according to clinical condition

The proportion of Indigenous patient encounters involving diabetes, hypertension or ischaemic heart disease at which lipid-lowering medication was prescribed was similar to that for non-Indigenous patient encounters. However, for encounters at which GPs managed a lipid disorder, the age–sex standardised proportion at which lipid-lowering medication was prescribed was 78.4% (95% CI, 72.6%–84.2%) for Indigenous patient encounters, significantly greater than that for non-Indigenous patient encounters (65.2%; 95% CI, 64.5%–65.8%) (Box 2).

Proportion of lipid-lowering prescriptions linked with specific clinical conditions

Box 3 depicts the proportions of all 35 798 prescriptions for lipid-lowering medication according to the specified clinical conditions managed, and stratified by Indigenous status. Only the proportions linked with diabetes (Indigenous: 13.1% [95% CI, 9.1%–17.3%] v non-Indigenous: 4.2% [CI, 4.0–4.5]) and lipid disorders (Indigenous: 53.3% [95% CI, 46.1%–60.4%], v non-Indigenous 64.3% [95% CI, 63.5%–65.1%]) were significantly different between the two groups.

Discussion

There were three major findings from this nationally representative study of the prescribing of lipid-lowering medications for Indigenous and non-Indigenous adults managed in Australian general practice. First, the rates of prescription of lipid-lowering medication by GPs for both Indigenous and non-Indigenous Australians increased substantially from 2001–2005 to 2009–2013, with relative increases of 37% for non-Indigenous and 56% for Indigenous patients. Second, lipid-lowering medication was more likely to be prescribed at encounters with Indigenous patients than at those with non-Indigenous patients, including encounters at which lipid disorders were managed. Third, diabetes was about three times as likely to be managed at encounters with Indigenous patients.

We found that the rates of prescription of lipid-lowering medication were higher for all Indigenous patient encounters, and for encounters at which a lipid disorder was managed; the prescription rates at encounters during which diabetes, heart disease or hypertension were managed were similar for Indigenous and non-Indigenous patients. These findings may reflect extensive efforts by the Australian Government, clinicians and other stakeholders to identify and reduce cardiovascular risk among Indigenous people, to increase their access to medications, and to revise clinical and benefit guidelines for lipid-lowering prescriptions so that they include all Indigenous patients with diabetes or blood total lipid levels greater than 6.5 mmol/L.7–11 Our study cannot establish a causal link between these policies and increased prescribing of lipid-lowering agents. However, it is reassuring that, as lipid-lowering therapies have continued to diffuse into clinical practice over the past 15 years, we found no evidence that GPs were less likely to prescribe these agents to Indigenous patients.

As noted by other authors, screening for and managing cardiovascular risk in Australian general practice is suboptimal.15,16 It is therefore also possible that the equivalent prescribing rates may reflect underuse of these medications in both Indigenous and non-Indigenous patients who might benefit from these therapies. Future studies should characterise disparities in the proportion of clinically appropriate treatment candidates who are prescribed effective cardiovascular medications.

Our study has some limitations. First, the BEACH data do not include information on whether patients filled or adhered to lipid-lowering prescriptions. Second, data concerning managed conditions, medications prescribed, and the patient’s self-identified ethnicity may include errors, although we have no reason to believe that rates of misclassification changed over time. Third, the sample in our study included only patients seen in primary care. Fourth, the sample sizes for some subgroup analyses were small. Fifth, the data were collected at the encounter level, precluding calculation of the overall prevalence of lipid-lowering therapy in Indigenous and non-Indigenous populations. Finally, we lacked laboratory values and comprehensive data on comorbid conditions to determine the clinical appropriateness of prescribing decisions or to adjust for casemix.

In conclusion, we detected substantial increases in the rate of prescribing of lipid-lowering medication at encounters with both Indigenous and non-Indigenous patients in Australian general practice between 2001 and 2013, and found no evidence that Indigenous patients were less likely to be prescribed these agents. Indigenous patients were more likely than non-Indigenous patients to be prescribed lipid-lowering therapy during encounters at which a lipid disorder was managed. Our findings suggest some measure of success in expanding access to medications and reducing cardiovascular risk in Indigenous populations. Further efforts are needed to promote long-term adherence to effective medications and to improve cardiovascular health for Indigenous people in Australia.

Box 1 –
Age–sex standardised proportions of patient encounters (with 95% CI) at which lipid-lowering medication was prescribed, by time period and Indigenous status

Box 2 –
Age–sex standardised proportions of patient encounters (with 95% CI) at which lipid-lowering medication was prescribed, by specified clinical condition and Indigenous status

* Significant difference: no overlap of 95% confidence intervals.

Box 3 –
Age–sex standardised proportion of lipid-lowering medication (with 95% CI) prescribed for each specified clinical condition, by Indigenous status

* Significant difference: no overlap of 95% confidence intervals.

Super made easy – SuperStream

The ATO will be assisting general practice, dental and specialist business industry over the coming weeks to transition over to SuperStream.

Small business owners with 19 or fewer employees need to start paying super contributions and sending member information electronically through SuperStream.

The process which came into effect 1 July provides a consistent and simplified way for employees to make super contributions on behalf of their employees.

Under the system – those responsible for paying super guarantee for general practice, dental and specialist business will be able to pay super to multiple super funds through one channel.

The ATO is holding a webinar to help practice managers, employers, accountants, BAS agents, bookkeepers and anyone responsible for paying superannuation for general practice, dental and specialist businesses on Tuesday 20 October.

The ATO has an employer checklist can help employers prepare visit www.ato.gov.au/SuperStreamChecklist

Kirsty Waterford

5 questions to ask if prescribing to family and friends

Prescribing for family and friends is a difficult topic that has been raised again in a recent article in Australian Prescriber.

Manager of the Medico-Legal and Advisory Service at MDA National, Sara Bird writes that it’s not prohibited by law, however isn’t recommended by the Medical Board of Australia.

“It is only considered ethically and professionally appropriate to prescribe in exceptional circumstances, and there are potential risks to you and your family member or friend if you do,” she writes. She advises to think carefully before prescribing to family and friends.

According to Section 3.14 of the Medical Board of Australia’s ‘Good medical practice: a code of conduct for doctors in Australia’:

Whenever possible, avoid providing medical care to anyone with whom you have a close personal relationship. In most cases, providing care to close friends, those you work with and family members is inappropriate because of the lack of objectivity, possible discontinuity of care, and risks to the doctor and patient. In some cases, providing care to those close to you is unavoidable. Whenever this is the case, good medical practice requires recognition and careful management of these issues.

The Board highlights a recent example of a decision by a medical practitioner ‘to not call an ambulance for their unconscious friend and to monitor them instead, resulted in that friend’s death from a medication overdose. The doctor was inappropriately influenced by the friend’s family’s potential embarrassment.’

They say the standard of care for family and friends can be compromised because the relationship can cloud professional objectivity. It also makes it difficult for the doctor to obtain a complete medical history and perform a proper examination.

Legally, there are different restrictions depending on the state or territory however there are generally no legal restrictions on prescribing Schedule 4 or 8 drugs for family and friends, except in South Australia which says it must be a ‘verifiable emergency’.

Sara Bird writes that before you consider prescribing, you should ask yourself the following five questions:

Am I able to provide appropriate medical care to my family member or friend in this situation?
Am I following my usual practice in providing a prescription or repeat prescription in this situation?
Would my peers agree that prescribing in this situation was consistent with good medical practice?
If I prescribe, does this mean that my family member or friend is my patient?
Would our personal relationship survive an adverse outcome of treatment?

She concludes that the starting point for a request to prescribe for family or friends should always be no unless there are exceptional circumstances.

Latest news:

Nation’s cut-price health system ‘performs well’: OECD

Australia’s health system has been given a big tick by the Organisation for Economic Co-operation and Development for delivering world-class life expectancy and cancer survival rates despite below-average funding.

In its latest Health at a Glance report, the OECD reported that Australia’s average life expectancy of 82.2 years was the sixth highest among the world’s richest countries, and its record on breast and colorectal cancer survival was “among the best”.

Significantly, given the Federal Government’s claims of unsustainable growth in health spending, the Organisation reported that Australia’s expenditure was 8.8 per cent of gross domestic product, below the OECD average of 8.9 per cent.

“Australia performs well in terms of overall population health status,” the OECD said. “[It] achieves good outcomes relatively efficiently.”

But, echoing AMA arguments for increased investment in general practice, the Organisation said the country could cost-effectively achieve even better outcomes if it cut down on the number of patients with chronic health problems who end up in hospital.

It found that Australia had among the highest rates of avoidable hospitalisations for patients with asthma and chronic obstructive pulmonary disease among its member countries, and recommended a greater emphasis on treatment by family doctors.

“Effective treatment for these conditions can be delivered at a primary care level, negating the need for hospital admissions that are not in the best interests of patients, and are more costly for the health system,” the OECD said. “A well-organised primary health care system emphasises health promotion and prevention, and educating patients about self-management of chronic disease.”

Its comments are in line with AMA calls for greater support for GPs in managing patients with chronic conditions and providing health promotion and preventive care, and came a day after the release of a major report showing there has been a blow-out in the demands faced by GPs from an aging population with increasingly complex health needs.

The Bettering the Evaluation and Care of Health (BEACH) report from Sydney University’s Family Medicine Research Centre found that older patients were seeing their GP more often, and with a wider array of health problems.

Because of this, doctors are having to spend more time with each patient – on average, a little less than 15 minutes – heightening the financial strain caused by the increasingly inadequate Medicare rebate, which has been frozen by the Federal Government until mid-2018.

The BEACH researchers said GPs were playing a crucial ‘gatekeeper’ role in preventing duplication and ensuring the coordination and continuity of care patients receive from hospitals, specialists, allied health professionals and other providers, and recommended greater support for them in carrying out the role.

With the incidence of patients with multiple complex and chronic health complaints set to increase as the population ages, AMA President Professor Brian Olwer said the Government needed to lift its investment in general practice.

Out-of-pocket costs among highest

AMA concerns that the Government is increasingly abrogating its health responsibilities and dumping more of the cost of care on to patients, the OECD found that Australians face above average out-of-pocket costs.

It reported that 20 per cent of health spending comes directly from the pockets of patients – much more than is faced by patients in other countries with Government-funded health systems like the United Kingdom, Canada and New Zealand – and jumped by 1 percentage point between 2008 and 2012.

The OECD warned that in such an environment, there was a heightened risk that increasing the barriers to access to care could “unduly affect” the sickest and most vulnerable.

In conclusions that that endorse the AMA’s successful campaign last year and early this year against Coalition Government proposals for an up-front patient charge to see their GP, the OECD said that “co-payments remain a blunt policy instrument that can have many unintended consequences, particularly when the prevailing economic conditions are simultaneously reducing incomes for many citizens”.

“The risk remains that citizens forego needed care that can have long-term adverse health outcomes,” it said.

“Given the current level of out-of-pocket payments in Australia, there is a need to ensure that policy options aimed at improving the appropriate use of care do not unduly affect the most vulnerable, and the overall burden of out-of-pocket payment I the community more generally.”

The OECD report can be viewed at: http://www.oecd.org/health/health-at-a-glance-19991312.htm

An interactive chart comparing Australian and OECD helath spending can be viewed at the folling link:

Adrian Rollins

Social Media for Health Professionals – Benefits and Pitfalls

Welcome to our doctorportal blog section. If you have a blog topic you would like to write for doctorportal, please get in touch!

I am an avid user of social media – mostly Twitter, Facebook, and WordPress – predominantly for educational and professional purposes. As a health practitioner, I am well aware that there are concerns about the use of social media for professionals, and that many are still reluctant to engage with social media for fear of getting in trouble, or simply because they can’t understand why they should bother. This is actually a really good place to start; safety, confidentiality and professionalism are of the utmost importance when it comes to health professionals using social media.

I was first introduced to Twitter for professional purposes during General Practice Registrars Australia (GPRA)‘s “Breathing New Life into General Practice” conference (now the “Future of General Practice” conference) in early 2012, however I must admit that it took me a while to figure out the best way to use social media, rather than just for passing time with my short attention span! I have already recorded a 5-minute video podcast on this blog site regarding the how and why of social media for health professionals, so if this suits you better, you can find it here. Otherwise I am going to flesh out why I bother using social media as a rural GP in Australia in this post.

There are multiple reasons for engaging online with social media, including (but not limited to) medical teaching and learning, patient education and health promotion, advocacy, networking and staying up to date.

The most exciting aspect of using social media in my opinion is the expanding world of Free Open Access Medical Education (FOAM/FOAMed/FOAM4GP), especially for isolated rural clinicians. Believe it or not, there are hundreds of intelligent, highly skilled, altruistic health professionals out there who are willing to share their knowledge and skills with you. For free. No strings attached. Anytime, anywhere, via social media. The most enthusiastic and dedicated of these have been (and still are) those working in emergency, critical care and pre-hospital/retrieval medicine. Some of these greats include Dr. Mike Cadogan (@sandnsurf), Dr. Chris Nickson (@precordialthump) and the team at Life In The Fast Lane, Dr. Casey Parker (@broomedocs) of Broome Docs, Dr. Minh Le Cong (@ketaminh) of PHARM, and Dr. Tim Leeuwenburg (@KangarooBeach) of KI Doc. There is also an expanding group of enthusiastic GPs contributing to this space through the FOAM4GP blog or their own work, including Dr. Rob Park (@Robapark), Dr. Penny Wilson (@nomadicgp), Dr. Edwin Kruys (@EdwinKruys), Dr. Gerry Considine (@ruralflyingdoc) and Dr. Ewen McPhee (@Fly_texan) to name just a few! Some health professionals have concerns about the veracity and trustworthiness of information like this online. One could argue that peer review via social media is more rapid and critical than via any other means. Ultimately it is still up to the individual to critically appraise online information, just as they would with any other source of information.

Social Media for Health Professionals – Benefits and Pitfalls - Featured Image

Producing material for FOAMed is also a wonderful way to learn and stay up to date. In the lead up to the RACGP examinations in 2013, several GP registrars, including myself, shared information and ideas, as well as asking questions on Twitter, using the hashtag #GPexams13. I have since produced a blog post on my study tips for GP registrars as they prepare for their RACGP exams (I can’t comment on ACRRM examinations as I have not sat them).

Health promotion activities are so much easier these days with the rapid and broad dissemination of public health information via social media platforms. Advocacy campaigns are cheap, easy and extremely effective using social media. #scrapthecap, #interncrisis, #copaynoway are just a few of the more successful social media campaigns which have been responsible for positive changes in government policy. Grass-roots campaigns gain momentum quickly through social media. Two people taking advocacy to the next level on social media are Dave Townsend, medical student and aspiring GP (@futuregp) and Alison Fairleigh, passionate rural mental health advocate (@AlisonFairleigh). I encourage you to check out their extensive and powerful work online.

Professional isolation is a very real problem for rural practitioners, however social media has been a wonderful way to overcome this, through online networks of like-minded practitioners in similar situations, who can support one another and share ideas from afar. There are many different Tweet Chats, for example #hcsm (Health Care Social Media) and closed Facebook groups where health professionals can interact online to share ideas and support one another.

I mentioned earlier about my short attention span…sometimes it is nice to just be able to flick through the headlines on Twitter and pick and choose the articles that interest me to either read now or later. It is a quick and easy way to ensure that you stay up to date with medical news and politics as well as new research findings. The good thing about Twitter is that you can follow the people or companies that interest you, when you have time. One of the pitfalls of this, however, is social media addiction; we need to be wary of being antisocial whilst using so-called “social” media! Another pitfall is the ease and speed with which a person can send out a Tweet or a Facebook post. If you are going to post more than just an opinion or a quote, keep “The Credible Hulk” in the back of your mind, and make sure that you back up and reference your post with credible sources.

Finally, coming back to the safety concerns around professionals using social media. It comes down to common sense; if you wouldn’t say it in a crowded elevator, then don’t put it online. There are a multitude of social media policies and guidelines, indluding AHPRA guidelines. The social media guideline from the Canadian Medical Association is another useful document to have a look at.

In summary, social media use by health professionals has many benefits, including professional support and networking, education, public health promotion and advocacy. Use of social media requires a common sense approach, keeping basic guidelines for safety, confidentiality and professionalism in mind. It would be rather sad for people to decide not to use social media at all simply because of safety concerns. I encourage all health professionals to consider branching out into social media, as it is where a lot of our patients are. Have fun!

This blog was previously published on Dr Melanie Considine’s blog Green GP and has been republished with permission. If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

Cost-effective GPs a health saving

A major study has found that the nation’s GPs are playing a vital role in holding health costs down, calling into question the Federal Government’s push to gouge money out of primary care to boost the Budget bottom line.

Sydney University health researchers have found that GPs are playing a crucial role in caring for aging patients with multiple and complex health problems, helping them lead longer and healthier lives at a fraction of the cost of other health systems, particularly the United States.

The conclusion is politically awkward for the Federal Government, which has targeted the health budget for cuts, claiming that Medicare expenditure is out of control.

The Government has imposed a four-year freeze on Medicare rebates, and Health Minister Sussan Ley has directed a review of the Medicare Benefits Schedule to achieve savings that can be ploughed back into general revenue.

The Minister has sought to justify the cuts by accusing doctors of manipulating and exploiting the Medicare system for personal financial gain – a line of attack that AMA President Professor Brian Owler has condemned as deeply offensive.

The latest report from the long-running Bettering the Evaluation and Care of Health (BEACH) study being undertaken by the Family Medicine Research Centre backs AMA warnings that the Government’s attack on primary health care funding is misguided and will cost both patients and the country dearly.

The BEACH report found that the aging of the population is imposing an increasing burden on the health system.

While less than 15 per cent of all Australians are aged 65 years or older, they are twice as likely to see a GP, have a pathology test, see a specialist and be on medication as the rest of the population.

This is due, to a large extent, to the fact that they tend to have multiple chronic health complaints – the study found 60 per cent of them had three or more health problems, and a quarter had five or more.

And the health demands of older Australians are growing quickly – their use of GP time, diagnostic tests, medicines and referrals is expanding much more rapidly than their numbers would imply.

But, despite this, Australia’s total health spending as a proportion of GDP is on a par with countries such as Britain, Canada and New Zealand while achieving among the longest life expectancies in the world – and is far better than the United States, which spends double the amount but whose life expectancy is four years shorter.

The BEACH researchers attributed this world-class result to the work of the nation’s GPs and central role they play in the health system.

“One of the biggest differences between the health care systems in Australia and the United States is that primary care is the core of Australia’s system, with GPs acting as ‘gatekeepers’ to more expensive care,” they said. “If general practice wasn’t at the core of our health care system, it is likely the overall cost of health care would be far higher.”

The BEACH researchers said that the early diagnosis of health complaints and increasing life spans meant people were living longer with complex conditions, adding greatly to health costs: “This is the price Australia pays for good health, but we would argue this price is very reasonable”.

GPs are central to holding costs down, in large part because of the work they do in co-ordinating the care provided by hospitals, specialists, allied health professionals and community and aged care services.

The BEACH researchers said this coordinating role was crucial because it cut down on duplication of tests and helped ensure continuity of care – both considered vital in sustaining health and holding down costs.

They found that 98.6 of older patients had a general practice they usually attended – a de facto ‘medical home’.

“If our Government wants to make our health care system sustainable, it should invest in primary care to improve the integration of, and communication between, these different parts of the health system,” the researchers said.

“Further strengthening the role of general practitioners will reduce unnecessary interventions in the secondary and tertiary health sectors.”

Adrian Rollins

More patients, more complex problems, more often: the lot of GPs

Patients are seeing their GP more often, and taking up more of their doctor’s time seeking help with an increased array of health problems, adding weight to medical practitioner complaints about the inadequacy of the Medicare rebate.

A long-running study of general practice has found that the proportion of older patients being seen by GPs has increased as the nation’s population has aged, bringing with them multiple health problems that require more time-consuming and complex care.

The Bettering the Evaluation and Care of Health (BEACH) study, which involves a random sample of 1000 GPs each year, found that between 2005 and 2014 the proportion of patients 65 years or older seen by GPs increased from 27 to 31 per cent.

At the same time, the number of consultations claimed through Medicare climbed 36 per cent to more than 137 million and the number of problems managed per 100 encounters rose from 146 to 155.

Together, these results mean that 65 million more problems were managed by GPs in 2014-15 compared with 2005-06 – underlining concerns that doctor remuneration through Medicare has failed to keep pace with the volume and complexity of the work GPs undertake.

The AMA has condemned the Federal Government’s decision to freeze the Medicare rebate until mid-2018, warning the measure is likely to drive some GPs out of practice and cause many more to cease bulk-billing, potentially deterring the sickest and most vulnerable from seeking care.

While the rebate is stuck, the complexity and multiplicity of problems that GPs are treating has meant a blow-out in the time they spend with each patient. Consultation time has increased from a mean of less than 14 minutes a decade ago to 14.7 minutes last financial year – and the increase in time taken could be accelerating. The BEACH study found that in the last two years alone, the median consultation has increased from 12 to 13 minutes.

While hypertension, check-ups, coughs and colds remain the common reason to see a GP, in the past decade there has been a sharp increase in other types of complaints – particularly those chronic in nature.

Last financial year, GPs has 23 million more consultations for chronic complaints than in the mid-2000s, including many more for depressive disorders, oesophageal disease, heart problems, chronic back pain and other, unspecified, chronic pain.

Not only has the type of patients and the problems they have changed in the past decade, but so has the way GPs operate.

The BEACH study found that GPs now were less likely to prescribe medicine, particularly antibiotics and anti-inflammatories, than they were 10 years ago.

Instead, they were likely to order more pathology and imaging tests, and more readily referred their patients to a specialist.

Adrian Rollins

Latest news:

Fee-for-service should be part of new pay blend: doctors

Doctors and health organisations have demanded that fee-for-service must be retained as part of any overhaul of doctor payment arrangements amid concerns that other models of remuneration could create perverse incentives that would undermine patient health.

In a fillip for advocates who argue for a change in the way doctors are paid, a self-selected online survey of 995 individuals and organisations conducted by the Federal Government’s Primary Health Care Advisory Group found general support for a blended payment model that incorporated elements of fee-for-service, capitated payments and pay-for-performance.

But those surveyed cautioned that great care would need to be taken in designing a new payments system so as to avoid pitfalls and perverse incentives, such as the potential for doctors to focus only on activities that were rewarded, to cherry pick healthier patients rather than taking on those with chronic and complex conditions, to encounter greater red tape, and to subject practitioners to inappropriate criteria.

“There is support for a blended payment mechanism which recognises and caters for different complexities and levels of care needed,” the Group said in a communique reporting on the results of the survey.

“Within such an approach, there should be elements of care provision…where fee-for-service would remain an effective option. Payment mechanisms should also support ongoing engagement across the sector and disciplines to deliver better outcomes.

“Care should be taken as to not create perverse incentives, and concerns were raised about the risk of cherry-picking of patients in an enrolment model,” the communique said.

Earlier this year, the Advisory Group – chaired by immediate-past AMA President Dr Steve Hambleton – issued a discussion paper that canvassed a range of reforms to primary care, including methods of remuneration.

The Group said that while the fee-for-service model worked well in the majority of instances, it did not provide incentives for the efficient management of patients who required ongoing care.

Instead, it suggested alternatives included capitated payments, where GPs, health teams, practices or a Primary Health Network receive a set amount to provide specified services over a given period of time; or pay-for-performance, where remuneration is tied to the achievement of particular care outcomes; or some combination of all three.

The discussion paper also suggested changes to how care was organised and managed, including the creation of medical homes, GP-led team-based care, improved use of technology and upgraded techniques to monitor and evaluate care.

Not just fees

Regarding the creation of a health care home model of care, the survey showed strong support for the voluntary enrolment of patients with chronic and complex health conditions, though this was qualified subject to clarification of the mechanisms used to enrol patients, and the impact of enrolment, particularly on the patient’s ability to choose their doctor.

On the use of technology, the survey found there was, according to the Advisory Group, “general support” for the MyHealth Record system and the opt-out model of enrolment – something the Government is yet to settle upon.

The survey showed there was also general acceptance of reporting patient outcomes and general health status at the aggregate level, though any reporting system would need to take into account the different ‘starting points’ of patients, the effect of their own behaviour on treatment outcomes and the limits on improvement arising from social, economic and lifestyle factors.

The AMA has supported discussion about alternative remuneration models, including arrangements that would appropriately fund patient-centred and GP-led comprehensive, quality and coordinated care.

AMA Council of General Practice Chair Dr Brian Morton said recently that the Department of Veterans’ Affairs’ Coordinated Veterans’ Care program provided a one possible model.

“This program supports GPs and the general practice team to proactively manage and coordinate primary and community care for Gold Card holders most at risk of an avoidable hospitalisation,” Dr Morton said.

Last year Dr Hambleton, while still AMA President, said that although there were shortcomings with the fee-for-service system, the risks of performance payment arrangements could not be ignored.

Dr Hambleton said there was already an imbalance in the existing rebate system that rewarded high patient turnover rather than extended consultations and team-based care, and warned any pay-for-performance system would need safeguards to ensure the quality of care was enhanced rather than undermined.

At the time, he said it should be a supplement to fee-for-service payments, align with clinical practice, be indexed, encourage appropriate clinical and preventive health care services and minimise administrative burden.

Current AMA President Professor Brian Owler said any change to GP remuneration must include increased Government investment and resources.

Professor Owler said the ongoing freeze on Medicare rebates, in particular, was putting primary health providers under intense financial pressure.

The Primary Health Care Advisory Group is due to present its final report to the Government by the end of the year.

Adrian Rollins