Mental health system crisis deepens as Govt dithers

The mental health system is descending deeper into crisis and instability as the Federal Government delays its response to the National Mental Commission’s report, a Senate inquiry has said.

The Senate Select Committee on Health has warned that while Health Minster Sussan Ley ponders expert recommendations on how to reform mental health care, the prolonged policy and funding limbo is taking a heavy toll of the system.

“Mental health policy and funding in Australia is in a state of suspended animation while the Government re-reviews, re-consults on, and re-considers the findings of the National Mental Health Commission’s review,” the Committee said in its fourth interim report. “The uncertainty caused by the government’s constantly delayed decision making has caused workforce instability and increasing uncertainty for mental health consumers and carers. This is an unacceptable situation.”

Its call was backed by Mental Health Australia, which said the current mental health system was “fragmented and difficult to navigate”, and urged the Government to take a bold approach to reform.

“The mental health sector is ready to embrace reform, and to assist the Government in a carefully staged reform process,” Chief Executive Officer Frank Quinlan said. “We need to build a system around the individual, and ensure care is provided in the community, preventing illness where possible and providing early assistance when illness does occur.”

Ms Ley is examining the recommendations of the Expert Reference Group she appointed to advise on the implementation of the Commission’s reforms, and has said the Government will announce its plans by the end of the year.

But the seven-member Senate Committee, which chaired by Labor Senator Deborah O’Neill and includes three Coalition MPs, has called on Ms Ley to immediately release the Reference Group’s report and guarantee funding for mental health groups and providers for 12 months after the Government announces its reforms.

“Mental health policy has been on hold since the beginning of the Commission’s review in February 2014. In October 2015, ten months after the completion of the Commission’s thorough review, the government has still not responded to the Commission’s recommendations.

“As a result, the mental health sector struggles with ongoing funding uncertainty and indecision about the future direction of mental health policy in Australia,” the Committee report said. “The Committee considers that the Government’s lack of response to the Commission’s findings has caused significant harm.”

The National Mental Health Commission’s report, released in April, identified “fundamental structural shortcomings” in the nation’s health system, and urged a shift in emphasis away from acute care and more on to prevention and early intervention.

It argued this would reduce the severity and duration of mental health issues, ultimately slowing demand for expensive acute hospital care and lowering the incidence of long-term disability.

Ms Ley rejected the Commission’s suggestion that $1 billion be re-directed from hospitals to primary care, but endorsed the need to close service gaps and improve coordination between services.

“We needed to re-think our approach…and change the focus from a service-centred approach to one where services are organised around the needs of the person,” the Minister said.

The Senate Committee said the Government’s reforms should include recognition of the links between housing, employment and mental health, support models of care that promote early intervention, and articulate a clear and comprehensive mental health workforce strategy.

It said the Government needed to provide its response “as a matter of urgency”.

The Senate Committee’s report can be viewed at: http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Health/He…

Adrian Rollins

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Sharing the experience of grief from a doctor’s perspective

The blog docgrief.wordpress.com has recently been started by Dr Alison Edwards as a resource for reflection and sharing of stories about health professionals’ experience of grief and bereavement from a personal perspective. Follow her on twitter.

I am a GP in South Australia having lived and worked in my small rural community now for over 20 years. Twelve years ago I hooked up with my soul mate after spending most of my 38 years to that point mostly on my own. Ten years ago in the lounge room at home he had an unexpected, inexplicable, random cardiac arrest. He died. I know he had good CPR because I did it, but out-of-hospital cardiac arrests, particularly in small rural communities, do not have much of a survival rate. It is not an experience I would recommend to anyone.

Grief is a lonely space, and one we discuss little as a community generally. As a result there are few pointers about how people have faced it well or otherwise. There is little in the way of narrative about what are normal healthy thoughts and emotions and as a result, little to reassure the griever that they are doing it OK. Everything about grief feels wrong, particularly sudden loss. In all honesty there are no rules about how to grieve – what feels right and works for the individual is their right way to do it. Unfortunately this doesn’t stop others from opining that it should somehow be done differently.

When in the depths of my grieving, I yearned for a story with similar threads to my own to somehow reassure me I wasn’t all alone in my thinking. The themes I sought were loss after a short time together; dying young; sudden death; grieving as a somewhat public figure in a small town; supporting kids as a bereaved pseudo-step-parent; how doctors engage with death. This last point turned up very few links in 2005.

Doctors learn early on how to sanitise their emotional engagement with dying. From Pauline Chen’s 2007 “Final Exam- A Surgeon’s Reflections on Mortality” … “I learned from many of my teachers and colleagues to suspend or suppress any shared human feelings for my dying patients, as if doing so would make me a better doctor. These lessons in denial and depersonalization began as early as my first encounter with death in the gross anatomy dissection lab and were reinforced during the chaos of residency training and practice.”

While I think there is a need for distance in our clinical practice, I think this has the potential to leave us more vulnerable when grieving personally. We think we know death, but the dispassionate professional connection is not a useful introduction to it as a personal acquaintance.

I recognise that doctors understand death better than the average punter. We know the limits of modern medicine and harbour fewer illusions about its capacity to fix everything. We know that the inexplicable does happen without thinking everything is explainable or even understandable. I guess in a way this is helpful in the grieving process in that there may be less questioning of how, but doesn’t lessen the greater existential cry of why!

How about loss of control as an aspect of grieving? Doctors love control. Like many “high achievers” we have had to keep control in various stressful environments, we try to control our consults to not run too far overtime, we try to control our patients’ BGL/BP/Chol/BMI, we keep our professional distance and control our emotional response to others’ tragedies. Personal grieving turns all this on its head and I think presents an extra challenge to doctors in their grieving.

Small town issues are another aspect in losing a partner as a rural GP. My mate was the local footy legend, and had been the butcher with cheeky twinkle in his eye and a friendly word for everyone. Small communities are very connected and have a strong sense of ownership of “their” doctor and “their” footy legend/butcher. Strict “professional boundaries” are a very nuanced thing in country towns. I drop into the pub on a Friday night, I played netball in my day, I have friends who are patients and patients who are friends. There is no capacity for anonymity and sharing a grief with an entire town was both supportive and challenging. Returning to work and having most patients unable to hold back their desire to acknowledge my loss was a challenge. Grief counselling takes on a whole new depth when the recipient knows the lived experience of the counsellor. Choosing whether or not to reveal this is generally not an available option in a small town, but is also a powerful giver of credentials that has become easier to bear as the years have gone by.

Learning how to manage flashbacks and avoiding triggers when possible, like choosing not to be involved in the annual CPR update for the hospital, are other rarely discussed facets of doctor grief. Halting the video rerun of the resus attempt took about a year to control- most of the time -with some earlier helpful chats from our visiting psychologist about previous patients and finding the power to switch thinking to pleasant memories.

All these themes and more will eventually find their way onto my blog by way of my own personal reflections as well as links to others’ writing, submitted stories or interviews, book reviews and other useful articles. I welcome input from others reflecting on personal loss with similar or completely different themes as the more stories collected will increase the capacity to offer someone else one day seeking reassurance they are not alone.

Dr Alison Edwards is a rural GP from South Australia and set up docgrief.wordpress.com. If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

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Codeine-related deaths double in 10 years

Research has found that the number of codeine-related deaths has doubled between 2000 and 2009.

Ms Amanda Roxburgh and colleagues from the National Drug and Alcohol Research Centre at the University of New South Wales used National Coronial Information System data and found that codeine-related deaths increased from 3.5 to 8.7 per million population.

Their results were published in the Medical Journal of Australia.

“More than half (53.6%) of the cases of codeine-related death included a history of mental health problems, 36.1% a history of substance use problems (including misuse and dependence), 35.8% a history of chronic pain, 16.3% a history of injecting drug use, and 2.7% a history of cancer”, the researchers wrote.

Just under half (48.8%) were attributed to accidental overdose, and a third (34.7%) to intentional self-harm. Accidental overdoses increased significantly, with a 9.3% rise each year.

Codeine is the most consumed opioid Australia and is also the most accessible, available without a prescription however the TGA announced on Thursday that they would be reviewing this, with the opportunity for submissions until 15 October 2015.

The researchers said most codeine-related deaths (83.7%) were attributed to multiple drug toxicity.

“A small proportion (7.8%) were specifically attributed to codeine toxicity,” they wrote.

“Those who had intentionally overdosed were more likely to be older, female and have a history of mental health problems; those who had accidentally overdosed were more likely to have a history of substance use problems, chronic pain and injecting drug use”, the researchers found.

The pattern suggested that in accidental death, there may be evidence of:

codeine being used to top up prescribed pain medication;
dose escalation of codeine; and
the development of codeine dependence.

The researchers believe that there needs to be different public health and clinical strategies to prevent codeine overdoses.

“It is clearly necessary to increase the capacity to identify high-risk patients in primary care and to respond more effectively to their needs. Increasing the capacity of specialist pain, addiction and mental health treatment services in Australia should also be a priority,” they wrote.

Read the full article in the Medical Journal of Australia.

Providing a lifeline for rural doctors

Telemedicine programs are often designed to meet the needs of specialists rather than rural doctors

Australia has almost twice as many small rural hospital-based emergency facilities as designated emergency departments.1 They see 16% of Australia’s emergency patient presentations, or almost 1.3 million presentations each year.1 Although small rural facilities are tasked with managing mainly minor injury and illness, they also treat patients with complex and time critical problems.2 These facilities are staffed by nurses alone, or by junior doctors, general practitioners or rural generalists. Rural doctors often have specific training for rural emergency medicine, and they usually have more years of experience than junior doctors who treat most patients in urban emergency departments. What they lack is immediate access to onsite specialist advice.

Tertiary specialty units that receive patients from rural areas are often aware of this deficit. Concerned about the poor outcomes for their rural patients (although rural–urban outcome research is often confounded by hard-to-control-for factors3), some have created systems to provide a lifeline for early advice and support. A recent systematic review4 described tele-emergency programs that provide support for stroke thrombolysis, trauma management, burns care, eye conditions and several other specific problems.

Direct access to specialists with a passion to help rural doctors is incredibly valuable. Rural doctors feel more supported, and may be more likely to stay in rural practice.5 It is easier, and likely to be safer, than the usual process of speaking to a registrar at a suitable hospital, although robust evidence is lacking.4

However, telemedicine projects that are driven by specialty units create problems. When each program chooses a separate technology that is ideal for their condition of interest, rural doctors can struggle to maintain familiarity with each system. Of more concern is that advice can only be obtained if the patient is critically ill or has a condition that interests one of the specialty telemedicine programs. Advice is difficult to obtain if the patient presents with an undifferentiated illness that is probably self-limiting but in which life-threatening conditions have not been excluded. Telemedicine advice providers with limited resources have complained they are there to “consult with sick patients … Not [to deal with] every other thing”.6

But undifferentiated problems, such as dyspnoea, chest pain, abdominal pain, collapse and headache, are among the most common emergency presentations at both large and small facilities.2 No rural ambulance service has the capacity to transfer all such patients to a larger centre just to make sure that the small number of serious diagnoses are detected. These decisions can be difficult. An expert opinion in borderline cases can make a difference, sometimes avoiding unnecessary and expensive transport and keeping patients where they would rather be. It can also save lives. The South Australian Integrated Cardiology Clinical Network provides advice to rural clinicians for any patient with chest pain. As a result, within a decade, they have removed the gap between rural and urban mortality from myocardial infarction.7

The alternative approach is to create a centralised telemedicine system staffed by emergency medicine specialists.8 This replicates the practice in many regions where emergency physicians provide telephone support to surrounding small hospitals. This system has several advantages. Emergency specialists become more familiar with the small hospital environment by seeing it regularly during consultations. It provides a single access point for rural clinicians. No type of presentation should be out of their scope of practice, even if the patient has vague symptoms or is drug affected.

There is a disadvantage too. In emergency departments, emergency specialists rely on inpatient unit specialists directly reviewing some cases. Unless this is explicitly built into a centralised telemedicine system, emergency specialists must use an ad-hoc system of calling specialists or their registrars at surrounding hospitals who may have no access to the video-links and may feel that offering such advice is not part of their employment.

How do we combine a centralised system with a system of specialty units on call? A centralised telemedicine system may have to be located at an actual hospital with a full complement of speciality units resourced to help rural doctors. There is a system like this in Australia, or actually over Australia. For more than a decade, the Good Samaritan Hospital in Phoenix, Arizona, in the United States, has been providing advice for medical situations on Qantas, and many other airlines’, flights. A doctor on shift in the emergency department is called to provide advice, with all the specialist and subspecialist resources of a large tertiary hospital available for backup.9 Can we provide the same service, or something similar, for rural hospitals on the ground?

Government policies driving health divide

More than a fifth of patients in some areas have avoided seeing a doctor or filling a prescription even though they need care, with many saying they are put off by the cost.

Although a majority Australians report little difficulty in seeing their GP, the latest snapshot of patient experience from the National Health Performance Authority shows that in parts of rural New South Wales, Queensland, Western Australia and Tasmania, many people are avoiding or delaying treatment because of cost, running the risk of developing more serious and expensive-to-treat health problems.

Just as worrying, in some areas up to one in 10 say they cannot afford to fill their prescriptions, raising concerns around the management of serious chronic diseases such as diabetes and the treatment of infections.

The results underline the city-country divide in access to affordable care. While Australia-wide it was common for between 15 and 25 per cent of patients to complain of how long they have to wait to get an appointment with their GP, only around 2 to 4 per cent of those in major metropolitan areas said they could not afford to see their doctor, while in rural and regional Australia the rate was two to four times as high.

Chair of the AMA Council of General Practice Dr Brian Morton said strong competition between medical practices in urban areas drove high rates of bulk billing and helped contain patient out-of-pocket charges.

But the relative scarcity of doctors in country areas, and the need for adequate remuneration to recruit and retain them, encouraged lower rates of bulk billing and higher patient charges.

Dr Morton said this was not the fault of individual practitioners, and was instead the result of Federal Government policies including to screw down the value of Medicare rebates and hold back investment in training and support for rural GPs.

Dr Morton said of even greater concern when it came to preventive care was the relatively high instance of patients delaying or forgoing medicine because of expense.

He said patients, particularly those with a number of co-morbidities that had to be managed simultaneously, often faced a hefty monthly pharmacist bill.

For instance, he said, a patient with high blood pressure might be on three different medications which would cost more than $100 a month. If two or more people in a household have on-going courses of drugs, the costs can quickly mount up.

The consequences of foregoing treatment can be severe, Dr Morton said. Patients identified as at risk of heart disease who decide not to take prescribed statins can suffer a build-up of plaque in their blood vessels that can lead to blocked arteries, blood clots and other serious circulatory problems.

Protecting affordable access to care was at the centre of the AMA’s campaign late last year and early this year against the Abbott Government’s plans for a GP co-payment.

The AMA warned that charging a co-payment would deter many of the sickest and most vulnerable in the community from seeking care, creating the likelihood that their health would deteriorate and need more significant and expensive treatment later on.

And the latest official figures on national health spending suggest the pressure on patients to contribute to the cost of there is increasing.

The Australian Institute of Health and Welfare reported in September that the Commonwealth’s share of total health spending has plunged from almost 44 per cent to 41.2 per cent in just five years.

At the same time, individuals and families are shouldering more of the burden. In the past decade, the contribution of patients to the cost of health care has grown by an average of 6.2 per cent a year in real terms.

Adrian Rollins

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Effect of nasal balloon autoinflation in children with otitis media with effusion in primary care: an open randomized controlled trial [Research]

Background:

Otitis media with effusion is a common problem that lacks an evidence-based nonsurgical treatment option. We assessed the clinical effectiveness of treatment with a nasal balloon device in a primary care setting.

Methods:

We conducted an open, pragmatic randomized controlled trial set in 43 family practices in the United Kingdom. Children aged 4–11 years with a recent history of ear symptoms and otitis media with effusion in 1 or both ears, confirmed by tympanometry, were allocated to receive either autoinflation 3 times daily for 1–3 months plus usual care or usual care alone. Clearance of middle-ear fluid at 1 and 3 months was assessed by experts masked to allocation.

Results:

Of 320 children enrolled, those receiving autoinflation were more likely than controls to have normal tympanograms at 1 month (47.3% [62/131] v. 35.6% [47/132]; adjusted relative risk [RR] 1.36, 95% confidence interval [CI] 0.99 to 1.88) and at 3 months (49.6% [62/125] v. 38.3% [46/120]; adjusted RR 1.37, 95% CI 1.03 to 1.83; number needed to treat = 9). Autoinflation produced greater improvements in ear-related quality of life (adjusted between-group difference in change from baseline in OMQ-14 [an ear-related measure of quality of life] score –0.42, 95% CI –0.63 to –0.22). Compliance was 89% at 1 month and 80% at 3 months. Adverse events were mild, infrequent and comparable between groups.

Interpretation:

Autoinflation in children aged 4–11 years with otitis media with effusion is feasible in primary care and effective both in clearing effusions and improving symptoms and ear-related child and parent quality of life. Trial registration: ISRCTN, No. 55208702.

An easy introduction to Twitter (part 1)

Edwin Kruys is a Sunshine Coast GP who blogs about healthcare, social media and eHealth. If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

“It’s like being delivered a newspaper whose headlines you’ll always find interesting.” ~ Twitter

I was recently at a conference in Brisbane, organised by the Australasian Medical Writers Association. I met some interesting people and learned a lot about writing from speakers like Dr Justin Coleman and Ben Harris-Roxas.

Interestingly, many speakers mentioned Twitter. Social media are essential if you want to bring a health message across. Twitter is also a great tool to connect and collaborate with others and learn new things. It’s my favourite social media platform.

Twitter seems a bit daunting in the beginning, but it’s really easy to use. After reading both parts of this post, which should take you no more than five minutes, you will be ready to take the plunge.

Getting started

Because of the limited character count of 140, Twitter is called a microblogging platform. The social media giant describes itself as an information network made up of 140-character messages called tweets. A tweet is the expression of a thought or idea. It can contain text, links, photos and videos. Millions of tweets are shared in real-time, every day, all over the world.

You can read the tweets of people or organisations you follow in your timeline, and your followers can read your tweets, click on any links or hashtags you have included in your messages, or they can retweet your tweets, which means that they share your messages with their followers. I’ll explain it in more detail below. You can use twitter from your phone, computer or tablet.

To get started, first sign up at twitter.com or directly from the app on your phone or tablet, and choose a public Twitter username (also called a Twitter ‘handle’). The user name is always preceded by the @ symbol. I recommend to use your own name or business/practice name, but any available name is fine.

I picked @EdwinKruys, and Twitter has assigned this Twitter URL (or web address) to me: https://twitter.com/EdwinKruys. Twitter users will see your preferred name next to your Twitter username. This is how my names appear: ‘Dr Edwin Kruys (@EdwinKruys)’. It doesn’t matter if you use capitals or not.

You may want to register a few variants of your name or business name. I have also registered @DrKruys and @DrEdwinKruys.

Here are a few examples of Twitter user names:

Medical Journal of Australia: @the MJA
Royal Australian College of General Practitioners: @RACGP
RACGP President: @RACGPPresident
Australian Medical Association: @ama_media
AMA President: @amapresident
Australian College of Rural and Remote Medicine: @ACRRM

Next, you will have to set up your profile. Make sure you add a profile photo or Twitter will give you an egg-head (see above). For professional accounts I recommend a 400×400 pixels close-up photo of your face – not the dog, cat, flowers or a stethoscope. Fill out a short description of yourself and a link to your website or blog.

If you like you can add a background header photo (recommended dimensions are 1500×500 pixels). Once you’ve done all this, start following people. See who others follow and follow the interesting people, organisations and businesses.

Click here for my list of Australian GPs on Twitter.

Twitter lingo

There is a bit of Twitter lingo you need to learn, but it’s easy. Let’s start with hashtags. A hashtag is any word or phrase preceded by the # symbol. Conferences and television shows often use a hashtag, e.g. #GP15Melb. Hashtags are also used for advocacy campaigns, like #AHPRAaction, #ScrapTheCap and #CopayNoWay.

A hashtag is like a label added to your tweets to better file and retrieve messages with a certain topic or theme. It doesn’t matter where you place it. And you can add a few hashtags if you like, although two is probably ideal. When you click on a hashtag in someone’s tweet, you will see all other tweets containing the same word or topic.

Here are some other Twitter buzzwords:

Tweet: A Twitter message
Tweeting: the act of sending tweets
Tweeps: Twitter users
Favouriting a tweet: this indicates that you liked a specific tweet
A follow: someone following your Twitter account. You can see how many follows (or followers) you have from your Twitter profile
Home: your real-time stream of tweets from those you follow, also called a timeline.

Want to learn more? Click here for part 2 of Edwin Kruys’ An easy introduction to Twitter.

This blog was previously published on doctorsbag and has been republished with permission.

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Main image: PiXXart / Shutterstock.com

An easy introduction to Twitter (part 2)

This is the second part of Edwin Kruys’ Easy Introduction to Twitter. Click here to read part 1.

Your first tweet

When you compose your first tweet, you could write something like:

“Hi there, I’m new on Twitter. Still figuring out how this works.”

But if you haven’t got many followers, few people will read it. So you could tell someone that you have joined Twitter by adding their username to your tweet. I’ll use my username as an example, but of course anyone’s username can be inserted instead:

“Hi there, I’m new on Twitter. Still figuring out how this works. @edwinkruys”

Now I will receive a notification that you have mentioned me, and I may respond, retweet your message or suggest a few people to follow.

If you would put my username at the beginning of your tweet, your message is still public but only those who follow you and me will see the message:

“@edwinkruys. Hi there, I’m new on Twitter. Still figuring out how this works.”

If you put something in front of my name, all your followers will see your message (instead of only those who follow you and me):

“Hi @edwinkruys, I’m new on Twitter. Still figuring out how this works.”

Try adding a hashtag and a link:

“Hi @edwinkruys, I’m new on Twitter. Still figuring out how this works. #newontwitter. Read my profile here http://www.mywebsite.com”

You can link to websites, pdf-files, videos etc. The hashtag increases the chance that others with similar interests will read your tweet.

Retweets and replies

A great way to get started is to retweet someone’s message. Ask questions or make some friendly comments to get a conversation going.

A tweet from someone else, forwarded by you to your followers, is known as a retweet or RT. Often used to pass along interesting messages on Twitter, retweets always retain original attribution. Respect the original message and make sure you don’t change the original tweet when you retweet. If you do change it, for example when you delete a few words to save characters, it will become a modified tweet or MT instead of a retweet.

Here is one example of a retweet. Imagine I have just tweeted this message:

“Have a look at this great resource to get started on #Twitter: http://www.linktoresource.com”

You could retweet this – assuming you wanted to share it with your followers:

“RT: @edwinkruys: Have a look at this great resource to get started on #Twitter:http://www.linktoresource.com”

You could also add a brief comment to tell your followers what you think of it or to start a conversation:

“Excellent resource, thanks for sharing! RT: @edwinkruys: Have a look at this great resource to get started on #Twitter: http://www.linktoresource.com”

There are other ways to retweet, for example by retweeting the complete original message without adding your own text, or by retweeting the original message in a box and adding your own 140 character message. Press the retweet button under a message (the two arrows going up and down) to discover the various options.

You can send the same message by replying. Note that, by putting my username at the beginning of your tweet, your message is still public but only those who follow you and me will see the message:

“@edwinkruys Excellent resource, thanks for sharing!”

Again, if you want others to see your reply so they can follow our conversation, you need to add something in front of my name, even a full stop will do:

“.@edwinkruys Excellent resource, thanks for sharing!”

Or:

“Excellent resource @edwinkruys, thanks for sharing!”

When you share a resource you have found via someone else, it’s always nice to mention that person:

“Here’s and excellent resource to get started on Twitter: http://www.linktoresource.com – via@edwinkruys”

Direct messages, lists and login verification

Use Twitter direct messages to start a private or group conversation with your followers. It is possible to enable a setting to receive direct messages from anyone, not just followers, which may be useful for businesses. Direct messages have no character-limit so you can type as much as you want.

You can add images to your Tweets and even a link plus an image. Although you’re limited to 140 characters, it is easy to get around this by taking a screenshot from a large amount of text and attaching it as an image to your tweet.

Twitter lists are often used to create a group of other Twitter users by topic or interest. Lists contain a timeline of tweets from the users that were added, offering a way to follow individual accounts as a group on Twitter.

There are many third-party apps available to manage your Twitter account(s). I often use buffer to schedule tweets. To avoid getting hacked I recommend using two-step login verification as explained in this video. Have fun!

This blog was previously published on doctorsbag 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.

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Main image: Denys Prykhodov / Shutterstock.com

RACGP unveils new GP funding model vision

The Royal Australian College of General Practitioners has launched a new GP funding model vision on the first day of its annual conference.

RACGP President Dr Frank R Jones unveiled the vision this morning, saying it was developed in consultation with over 1000 GPs, stakeholders and community groups.

Titled Vision for general practice and a sustainable health system, the document introduces the concept of the ‘medical home’ for patients.

It would require a patient to register with a GP so their medical management can be tailored for them.

Related: Empowering General Practice

The intention of the model is to improve integration of care for patients and reduce the use of inappropriate services including emergency department use and avoidable admissions.

“There has been a lack of support for chronic disease management, integration of care, prevention, continuity of care, and population health,” Dr Jones said.

“This has led to fragmentation of care, which results in the duplication of patient services and testing, unnecessary care, loss of a coordination, and poorer health outcomes for patients. The consequences are unnecessary hospital presentations and admissions, costing our health system more than $3 billion per year.”

The vision includes a comprehensiveness payment to GPs and general practice teams and coordination support payments to help bridge the gap between hospitals and primary healthcare.

Read the full vision on the RACGP website.

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Success in Closing the Gap: favourable neonatal outcomes in a metropolitan Aboriginal Maternity Group Practice Program

Australian Aboriginal women are at greater risk of complications during pregnancy and labour than non-Indigenous Australian women. There are for many reasons for this, including a higher prevalence of medical, lifestyle and socioeconomic risk factors, and lower antenatal care participation rates. Providing culturally competent services improves antenatal care uptake, but historically there has been a lack of such services in Western Australia.1 Element Two of the National Partnership Agreement on Indigenous Early Childhood Development (IECD2), part of the Closing the Gap suite of health care reforms initiated in late 2008, aimed to improve the access of Aboriginal women (particularly teenagers) to antenatal care and other women’s health care services.2

The Aboriginal Maternity Group Practice Program (AMGPP) was funded under this element, and commenced operating at various locations in the area of Perth served by the South Metropolitan Health Service (SMHS) in early to mid 2011. The SMHS spans the entire metropolitan area south of the Swan River (estimated population in 2012: 893 379, of whom 1.8% are Aboriginal residents)3; the remainder of metropolitan Perth is served by the North Metropolitan Health Service (NMHS). There are five health districts in the SMHS, each with its own hospital (four hospitals are public and one is private). The district hospitals provide antenatal care to local women, except for those at the greatest risk, who are referred to the sole public tertiary maternity hospital in Perth (King Edward Memorial Hospital [KEMH]; located in the NMHS). The criteria for referral differ between hospitals, but generally include type 1 diabetes, illicit substance use, and being younger than 16 years of age. During 2011, 369 children were born to local Aboriginal women in this area, equating to 3.1% of all births to SMHS residents and 21.4% of all births to Aboriginal women in WA.4

Before the AMGPP was introduced, local Aboriginal community members were concerned that some women were presenting late in pregnancy or giving birth at KEMH irrespective of their risk status. The AMGPP aimed to improve timely access to existing antenatal and maternity services in south metropolitan Perth, and to thereby increase the number of women giving birth safely in a local hospital. The program employed Aboriginal Health Officers (AHOs), Aboriginal grandmothers and midwives in each district to work with the existing services. The program model was culturally secure, with a focus on early access to antenatal care, employment of Aboriginal staff, and holistic care, including awareness of the social determinants of health (Box 1). Clients with low-risk pregnancies gave birth at the local district hospital, and higher-risk pregnancies were referred to KEMH, as per the standard SMHS policy.

Our study aimed to explore any differences in neonatal health outcomes that were associated with AMGPP participation.

Methods

Study design

The study was a non-randomised intervention, with the intervention defined as participation in the AMGPP. The intervention group consisted of all Aboriginal women who gave birth while participating in the AMGPP between 1 July 2011 and 31 December 2012. These women received standard antenatal care and the additional services provided by the AMGPP (Box 1). The intervention group was compared with two control groups that were frequency matched on the basis of maternal age at the time of delivery (younger than 20 years or at least 20 years old) and gravidity (primigravida or multigravida). The historical control group consisted of Aboriginal women who resided in the SMHS and had given birth between 1 January 2009 and 30 June 2011; the contemporary control group consisted of Aboriginal women who resided in the NMHS and had given birth between 1 June 2011 and 31 December 2012. Women in the control groups were eligible to receive standard antenatal care. The outcome measures of the study were preterm delivery, low birthweight, neonatal resuscitation at birth, and the baby’s hospital length of stay (LOS).

Data sources

Data from the WA Midwives Notification System (MNS) was analysed. The MNS is a statutory database that records all births in WA occurring at a gestational age of at least 20 weeks, or where the birthweight is at least 400 g. The available data included maternal demographics, pre-existing medical conditions, smoking status, pregnancy complications and neonatal characteristics. Pregnancy complications included threatened miscarriage before 20 weeks, threatened preterm labour, urinary tract infection, pre-eclampsia, antepartum haemorrhage (placenta praevia, placental abruption, and other), pre-labour rupture of membranes, gestational diabetes, and “other”. Pre-existing medical conditions included asthma, diabetes, genital herpes, chronic hypertension, and “other”. Gestational age at the first antenatal visit was the only antenatal care variable recorded by the MNS, and this information was recorded only from January 2010. As the MNS does not identify AMGPP clients, midwives from each of the districts provided client lists directly to the Data Linkage Branch of the WA Department of Health for linkage to the relevant MNS record; in this manner, all but one AMGPP client could be identified.

Index of Relative Socioeconomic Disadvantage (IRSD) scores, one of the Australian Bureau of Statistics’ Socio-Economic Indexes for Areas (SEIFA), are routinely linked with MNS records using geocodes based on the latitude and longitude of the client’s address. In our study, population-level socioeconomic status was determined by the IRSD reported in the 2006 census at the collection district level (about 225 households), the smallest geographic unit of analysis available for the 2006 census.5 The IRSD was reported in quintiles that compared the raw score with other IRSD scores in WA, with the first quintile including the most disadvantaged 20% of collection districts in WA.

Services provided by AMGPP staff were reported biannually as part of Closing the Gap IECD2 funding requirements. However, reporting practices varied across the five program districts and during the course of the study, so that program service data must be interpreted with caution.

Data analysis

Baseline demographic, pre-existing medical and pregnancy characteristics for the intervention group were compared with those for each of the control groups. Health outcomes for the intervention group were compared with each control group, and reported as proportions and adjusted odds ratios (aORs). aORs with 95% confidence intervals were calculated using binomial logistic regression for the four dependent binary variables: birth before 37 weeks (preterm delivery, yes/no), birthweight under 2500 g (yes/no), neonatal resuscitation (yes/no), and baby LOS (>5 days or ≥5 days). Covariates included in the regression models were: the continuous variable, maternal age; the two categorical variables, IRSD quintile and parity (nulliparous, 1–4, or more than 4 previous pregnancies of at least 20 weeks’ gestation); and the five binary variables, previous caesarean delivery, caesarean delivery this pregnancy, one or more pregnancy complications, one or more pre-existing medical conditions and smoking during pregnancy. Covariates were retained in the final models only if they were independently associated with the neonatal outcome of interest.

Comparisons were made using Pearson or linear-by-linear χ² analyses (categorical variables) or Mann–Whitney U tests (continuous variables), with P < 0.05 defined as statistically significant.

Ethics approvals

Ethics approvals were obtained from the WA Aboriginal Health Ethics Committee (reference 493) and the SMHS Human Research Ethics Committee (reference 13/53). The WA Department of Health Human Research Ethics Committee provided approval for linkage to and analysis of statutory data (reference 2013/76).

Results

During the study period, there were 350 pregnancies and 353 babies born to 343 women in the AMGPP participant group, representing 58.2% of all pregnancies (350 of 601) and 66.0% of teenage pregnancies (99 of 150) in locally resident Aboriginal women. There were 350 pregnancies and 353 babies born in each of the two control groups.

Program participants

The mean age of AMGPP participants was 23.8 years, and 52.5% of the women resided in areas included in the most disadvantaged IRSD quintile (Box 2). Almost half of the women (44.6%) smoked during pregnancy. The most commonly recorded pre-existing medical conditions were “other” and asthma, occurring in 51.4% (180 of 350) and 13.1% (46 of 350) of pregnancies, respectively. The most common pregnancy complications were “other” and urinary tract infection, occurring in 14.9% (52 of 350) and 8.3% (29 of 350) of pregnancies, respectively.

Baseline characteristics

There were no significant differences between the AMGPP participant group and the control groups with respect to age, smoking status, parity or gravidity, body mass index (where data available), or multiple pregnancy (Box 2; multiple pregnancy data are not reported here because of MNS data-sharing agreement restrictions on the disclosure of data related to small numbers of individuals). Women in the contemporary control group were significantly less likely to reside in areas in the most disadvantaged IRSD quintile (χ² = 6.31, P = 0.01). Women in the historical control group were significantly less likely to have a pre-existing medical condition (χ² = 10.57, P = 0.001), although no significant differences were evident if the “other” diagnosis category was excluded from the analysis (AMGPP group, 50 of 350 (14.3%) v historical controls, 50 of 350 (14.3%): χ² = 0, P = 1.00; v contemporary controls, 58 of 350 (16.6%): χ² = 0.70, P = 0.40). The AMGPP participants were significantly less likely to have had a previous caesarean delivery (v historical controls, χ² = 6.29, P = 0.01; v contemporary controls, χ² = 9.76, P = 0.002).

Antenatal care and other services

Without adjusting for missing data, there were no significant differences in the proportions of women for whom an antenatal visit in the first trimester was recorded (AMGPP group, 102 of 337 (30.3%) v historical controls, 50 of 161 (31.1%): χ² = 0.03, P = 0.86; v contemporary controls, 84 of 341 (24.6%): χ² = 2.71, P = 0.10). For the AMGPP group, in addition to clinic-based antenatal visits, there were 294 outreach services by the AHO or an Aboriginal grandmother, with or without the midwife, during the study period. Individual brief smoking and alcohol interventions were delivered on 484 and 463 occasions, respectively. Program staff delivered a total of 62 antenatal education workshops, 1191 individual antenatal education services and 1155 individual sexual health education services.

Neonatal outcomes

The proportion of preterm births to AMGPP participants was significantly lower than in the two control groups (Box 3), and the program was associated with a significantly lower aOR for preterm birth (Box 4). Birthweight was correlated with gestational age (r_s = 0.53, P < 0.001), but significant differences between the groups in the proportions of low-birthweight babies were not found. The likelihood of neonatal resuscitation at birth or of having a hospital LOS of more than 5 days were significantly lower for babies of AMGPP participants (Box 4). There were significant differences between groups in the distribution of baby LOS (for the AMGPP, historical control and contemporary control groups, the respective means were 2.37 days, 3.01 days and 4.17 days; AMGPP v historical controls P = 0.002; v contemporary controls P < 0.001). The majority of AMGPP babies requiring a LOS of more than 5 days were born preterm (11 of 14 = 79%).

Discussion

Our study identified more favourable health outcomes for the babies of AMGPP participants than for babies of mothers in matched control groups, including significant reductions in the likelihood of preterm birth, neonatal resuscitation and a hospital LOS of more than 5 days. Notably, the proportion of preterm births to women in the program (9.1%) was similar to that reported for all births in WA during 2011 (8.6%, 2755 preterm births),4 and lower than that for all births to Aboriginal women in the SMHS area (15.6%, 56 preterm births)6 and in all of WA (14.4%, 251 preterm births).4

During 2008–2010, spontaneous preterm delivery was the most frequent contributor to Aboriginal neonatal mortality in WA (14 deaths in the first 28 days of life, 37.8% of neonatal deaths) and the second most frequent contributor to Aboriginal infant mortality (17 deaths during the first year of life, 27.9% of infant deaths).7 Premature birth, regardless of birthweight, has been associated with hypertension and insulin resistance in Aboriginal children.8 Reducing the likelihood of preterm birth is therefore likely to have long-term health benefits. Antenatal programs similar to the AMGPP in other states have found statistically significant reductions in the proportions of preterm births, but not of low-birthweight babies.9,10 In our study, having one or more pregnancy complications (both control groups) and smoking during pregnancy (comparison with contemporary control group only) were also independent predictors of a preterm birth.

Extended LOS can reflect complications for the mother, the baby or for both.11 WA data show that gestational age is a better predictor of neonatal LOS than birthweight.4 The LOS for AMGPP participants was significantly lower than in either control group, with potential impacts on hospital costs. The majority of AMGPP participants with a LOS greater than 5 days had delivered preterm babies (79%).

A significant proportion (58.2%) of locally resident Aboriginal women and an even greater proportion of Aboriginal teenagers (66.0%) who gave birth during the study period participated in the AMGPP. In 2008, 53.1% of locally residing Aboriginal women (179 women) gave birth at KEMH, compared with 36.8% (148 women) in 2013, with a commensurate increase in the proportion of pregnant Aboriginal women giving birth locally.6 Moreover, the proportion of local women participating in the AMGPP continued to grow in 2014–2015 (data not shown).

In 2011, birth rates were six times higher for WA Aboriginal teenagers than for non-Aboriginal teenagers.4 Compared with adult women, teenagers are more likely to experience complications during pregnancy, such as urinary tract infections and hypertension, and their babies are more likely to be of low birthweight or stillborn.12 Improving antenatal care uptake in this demographic was a major objective of the IECD2 program, and the AMGPP appeared to reach this risk group.

There were limited data in the MNS on the provision of antenatal care during the study period.13 However, separate qualitative data collected as part of an evaluation of the program have shown the positive impact of the Aboriginal staff on ensuring early and continued engagement of pregnant women with the AMGPP.13 Further, the 6-monthly district reports provided data about the outreach services, brief interventions and antenatal education delivered by the program staff.

Selection bias was potentially a limitation of the study design,14 as women presenting for care possibly had different risk profiles to those who did not. In this study, the risk of selection bias was reduced (although not eliminated) by the involvement of the Aboriginal grandmothers, who brought women into the program through their community networks.13 Almost two-thirds of teenage pregnancies were managed by the AMGPP, suggesting that high-risk females were making use of antenatal health care. In addition, no significant differences between AMGPP participants and controls were detected with respect to maternal age, body mass index (when data were available), smoking status, parity or multiple pregnancy. In fact, some baseline characteristics of the contemporary control group suggested that it was a lower-risk group than the AMGPP participants; a greater proportion of the contemporary control group lived in socioeconomically less disadvantaged areas and this group included a lower proportion of grand multiparas. However, it is possible that the groups differed in ways that could not be quantified with the MNS data, such as the frequency of substance misuse. Further, the nature of the program, with AMGPP staff working alongside various hospital- and community-based antenatal services, meant that complete data on antenatal care provision were not always available, and this limits the conclusions that can be made about the direct effect of AMGPP participation on neonatal outcomes.

The AMGPP endeavoured to deliver culturally competent and holistic antenatal care services for Aboriginal women in the south metropolitan region of Perth, and babies born to participants were at lower risk for several adverse health outcomes, including preterm birth. Given the association between preterm birth and infant mortality, as well as the impact of prematurity on chronic disease throughout life, programs providing access to culturally secure antenatal care for Aboriginal women may have long-term benefits for their children. The AMGPP enhanced existing maternal health services and enabled more Aboriginal women to give birth locally and safely. This model of care could be adapted for use in similar settings with the support of local Aboriginal communities.

1
Features of the Aboriginal Maternity Group Practice Program (AMGPP) in the South Metropolitan Health Service (SMHS), Perth, Western Australia

All aspects of program planning, implementation and progression were guided by Aboriginal community members through district steering group meetings. These meetings were held quarterly, and were also attended by AMGPP staff, South Metropolitan Population Health Unit (SMPHU) contract management staff, maternity ward staff from each local district hospital and antenatal care providers.
The Aboriginal Health Officer (AHO) was required to have the Certificate IV in Primary Health Care (or equivalent) as a condition of employment, and provided care coordination, including referrals to other health and social services providers.
The Aboriginal grandmothers were respected women in the local community with good community networks. They identified pregnant women, assisted with access to services (including transport), provided support (including being present at appointments, if requested), and advised on cultural and health promotion matters.
The AMGPP midwife delivered antenatal care in partnership with local antenatal care providers. Clinical staff provided clinical governance, working within existing hospital guidelines.
Women were referred to the program by AMGPP staff, community members, general practitioners, hospital antenatal clinics, Medicare Locals and social services providers.
A home-visiting service was available. Outreach clinics were provided in various locations, including women’s refuges, Aboriginal community centres and mobile GP services.
Aboriginal staff were trained to deliver culturally appropriate, brief interventions to assist with stopping smoking and alcohol use. Training was provided by the Drug and Alcohol Office (Strong Spirit, Strong Future), the Cancer Council WA (Fresh Start) and the SMPHU (Yarning It Up).
The AMGPP staff delivered antenatal and sexual health education on an individual basis. Antenatal education included information about the stages of pregnancy, managing problems occurring during pregnancy, healthy lifestyle behaviours (nutrition; stopping smoking and alcohol use), mental health, available services, birth registration, breastfeeding, baby care, and the prevention of sudden infant death syndrome. Sexual health education included information about the symptoms of sexually transmitted infections, the importance of Pap smears, and contraception. Aboriginal staff received training in health promotion from the Aboriginal Maternal Services Support Unit (WA Department of Health).

2
Characteristics of Aboriginal Maternity Group Practice Program (AMGPP) participants and mothers in the two control groups

Characteristic

AMGPP participant group (350 pregnancies)

Historical control group (350 pregnancies)

Contemporary control group (350 pregnancies)

Maternal age, years (mean, range)

23.8 (15–44)

23.5 (14–42)

24.2 (13–44)

Gravidity (primigravida)

99 (28.3%)

Parity

0 (nulliparous)

132 (37.7%)

127 (36.3%)

125 (35.7%)

1–4 births (multiparous)

188 (53.7%)

192 (54.9%)

209 (59.7%)

5 or more births (grand multiparous)

30 (8.6%)

31 (8.9%)

16 (4.6%)

Index of Relative Socioeconomic Disadvantage (IRSD) quintile

1st (most disadvantaged 20%)

179/341 (52.5%)

174/330 (52.7%)

150/339 (44.2%)^*

2nd

85/341 (24.9%)

94/330 (28.5%)

87/339 (25.7%)^*

3rd

43/341 (12.6%)

33/330 (10.0%)

49/339 (14.5%)^*

4th

21/341 (6.2%)

18/330 (5.5%)

37/339 (10.9%)^*

5th (least disadvantaged 20%)

13/341 (3.8%)

11/330 (3.3%)

16/339 (4.7%)^*

Body mass index

Underweight (< 18.5 kg/m²)

15/298 (5.0%)

4/136 (2.9%)

Normal weight (18.5–24.9 kg/m²)

122/298 (40.9%)

64/136 (47.1%)

Overweight (25–29.9 kg/m²)

72/298 (24.2%)

26/136 (19.1%)

Obese (= 30 kg/m²)

89/298 (29.9%)

42/136 (30.9%)

Smoking status

156 (44.6%)

163/349 (46.7%)

160 (45.7%)

One or more pre-existing medical conditions

201 (57.4%)

158 (45.1%)^*

185 (52.9%)

One or more complications during pregnancy

105 (30.0%)

127 (36.3%)

119 (34.0%)

Labour onset

Spontaneous

248 (70.9%)

246 (70.3%)

212 (60.6%)^†

Induced

77 (22.0%)

69 (19.7%)

90 (25.7%)^†

No labour

25 (7.1%)

35 (10.0%)

48 (13.7%)^†

Previous caesarean delivery

29 (8.3%)

50 (14.3%)^*

56 (16.0%)^*

Caesarean delivery this pregnancy

Elective caesarean delivery

20 (5.7%)

27 (7.7%)

40 (11.4%)^*

Non-elective caesarean delivery

46 (13.1%)

61 (17.4%)

na = not available. The denominator for the calculations is included where data for a variable were incomplete. *P < 0.05, †P < 0.001, each compared with AMGPP group.

3
Health outcomes for the babies of Aboriginal Maternity Group Practice Program (AMGPP) participants and of mothers in the two control groups

Health outcome

AMGPP participants (353 babies)

Historical control group (353 babies)

Contemporary control group (353 babies)

Preterm birth (< 37 weeks)

32 (9.1%)

56 (15.9%)^*

54 (15.3%)^*

Low birthweight (< 2500 g)

38 (10.8%)

51 (14.4%)

56 (15.9%)

Requiring resuscitation at birth

63 (17.8%)

86 (24.4%)^*

110 (31.2%)^†

Baby length of stay > 5 days

14 (4.0%)

40 (11.3%)^†

41 (11.6%)^†

*P < 0.05, †P < 0.001, each compared with the AMGPP group.

4
Multivariate models of neonatal health outcomes for Aboriginal Maternity Group Practice Program (AMGPP) participants compared with mothers in the two control groups

Health outcome

Historical control group

Contemporary control group

Predictive factor

aOR (95% CI)

Preterm birth

AMGPP

0.56 (0.35–0.92)

0.02

0.75 (0.58–0.95)

0.02

Pregnancy complications

6.24 (3.79–10.25)

< 0.001

3.69 (2.29–5.93)

< 0.001

Smoking

2.95 (1.79–4.84)

< 0.001

Low birthweight

AMGPP

0.79 (0.49–1.30)

0.36

0.83 (0.66–1.07)

0.14

Pregnancy complications

8.41 (4.95–14.27)

< 0.001

5.70 (3.52–9.23)

< 0.001

Smoking

2.94 (1.77–4.87)

< 0.001

3.33 (2.03–5.47)

< 0.001

Previous caesarean delivery

2.05 (1.10–3.81)

0.02

Requiring resuscitation at birth

AMGPP

0.68 (0.47–0.98)

0.04

0.71 (0.60-0.85)

< 0.001

Caesarean delivery this pregnancy

2.06 (1.36–3.12)

< 0.001

2.12 (1.45-3.10)

< 0.001

Baby length of stay > 5 days

AMGPP

0.34 (0.18–0.64)

0.001

0.56 (0.41–0.77)

< 0.001

Pregnancy complications

2.53 (1.44–4.47)

0.001

2.79 (1.58–4.93)

< 0.001

Smoking

2.38 (1.32–4.30)

0.004

aOR = adjusted odds ratio. *Not significant, and therefore not included in the final models for the comparison with the historical control group.