Indigenous constitutional recognition – more than symbolism

The AMA takes its commitment to closing the gap in Indigenous health outcomes seriously, and this involves engaging regularly with Indigenous leaders and communities, and with others committed to addressing social disadvantage.

The Garma Festival, which is held in Arnhem Land each year, brings together a diverse group of people to discuss Indigenous rights and culture, including health, education, and other social issues. I was fortunate to attend this year.

Garma is an opportunity to engage with Australia’s Indigenous leaders and to hear from Indigenous peoples, in their own words, what is needed to improve the health and lives of Australia’s First people.

One of the most important features of the program is the key forum. Sitting in the traditional meeting place of the Yolngu clan, high on an escarpment looking out to the Arafura Sea, it seems a long way from Canberra or the SCG. However, topics of constitutional recognition and racism towards Indigenous people in our society, including footballers, were among those most discussed.

The Aboriginal concept of ‘health’ centres on social and emotion wellbeing – a concept that applies to anyone. Indigenous people face racism on a daily basis. The treatment of Adam Goodes raises an important questions for the nation, for non-Indigenous people, and our commitment to issues such as raising the standards of health, education, and economic outcomes of Indigenous people.

There was clearly anger, which was well articulated by Noel Pearson’s speech on the topic, in which he asked “how well do we know our fellow Australians”? He called on the better parts of ourselves and this nation to triumph over racism.

The AMA is a supporter of Recognise – the campaign for constitutional recognition of Australia’s First Peoples. This is more than about symbolism. It is an important part of reconciliation and about the value that this nation places on Indigenous members of the Australian community. While there is bipartisan support for this process, the next step is for Indigenous people to agree on what form the change should take, and subsequently the specific wording of the question that should be taken to any referendum.

There was palpable disappointment at Garma at the response from the Prime Minister in rejecting a proposal for a series of Indigenous meetings to come to an agreement before wider discussion. It was pointed out that Indigenous people are often asked to take responsibility. There was a significant consensus around the need for Indigenous people to take this role.

Perhaps there is concern about the results of that process, and the model that is offered. Whatever the reason, unless there is unity behind the proposal, the referendum risks failing – and that would be a grim day for all Australians.

Many of the most important legal battles for Aboriginal land rights involve Arnhem Land and the While at Garma, there was also time to discuss some of the more concrete health issues. I sat with Professor Alan Cass, Dr Paul Laughton, and Senator Nova Peris discussing the high rates of renal failure in the Northern Territory, the role of prevention in addressing chronic kidney disease, the impacts of dialysis on patients and their families, along with the need to increase the rate of kidney transplantation.

As most chronic kidney disease is preventable, our discussion again highlighted the need for good primary care, particularly in Indigenous health. The Aboriginal community controlled health system is so important, particularly in the Northern Territory. It is one of the reasons why the AMA campaigned so strongly on the Government proposals that threatened funding for primary health care, such as the co-payment proposals and the freeze on Medicare indexation. These proposals all effectively defund primary health care.

While there was time for discussing health, in line with the Government’s Indigenous Advancement Strategy, there was a lot of discussion around education and employment. There is good work being done but, as was highlighted in some of the conversations on the sidelines with people working in schools and communities, health has to underpin these strategies. There cannot be any relaxing of our commitment to Close the Gap.

GP Alert – Scam letter regarding 80/20 rule

The Department of Human Services (DHS) advised the AMA this week that there are scam letters being sent to GPs in Sydney and Wollongong warning them that they are approaching the 80/20 rule. The letters have the DHS and the Australian Health Practitioner Regulation Agency (AHPRA) logos on them, and use the standard form of words that DHS uses in letters to GPs.

If GPs receive this letter they should disregard it. If they have any concerns, or indeed any information about the source of a letter they have received, they should contact the DHS Health Practitioner Area on 02 6143 6040.

Plan for future, no more piecemeal cuts: Owler

The foundations of the nation’s health system are being undermined by a dangerous period of policy drift characterised by piecemeal approaches to major challenges, AMA President Professor Brian Owler has warned.

In a major televised speech, Professor Owler bemoaned a lack of vision and resolve among the nation’s political leaders on health, and called for the formulation of an overarching National Health Strategy.

He said that too often, the slogan that health care should be about the ‘right care, right place, by the right person’, had become little more than code for cost shifting and responsibility ducking.

“A long-term, bipartisan National Health Strategy may be difficult to achieve, but allowing our health care system to meander risks its future, and allows its foundations to be undermined piece by piece,” the AMA President said. “A National Health Strategy should guide our health policy, our decisions, and any future reform of the health care system.”

Professor Owler’s call received strong backing from the Australian Health Care Reform Alliance, a coalition of peak health groups, which said the AMA President’s speech was “a wake-up call” on the need for national health strategy and greater focus on preventive and primary care.

“Apart from a focus on funding cuts with little evidence of their value and long-term impacts, the Government has not articulated its values and intentions to tackle the variety of urgent issues reducing the effectiveness and fairness of our health systems,” AHCRA Chair Tony McBride said. “Saving money by randomly cutting services, such as funds for…public hospitals and…for NGOs appears to be the extent of the Government’s vision for health.”

The outlook for health has for years been clouded by unresolved Commonwealth-State tensions and disagreements over funding and lines of responsibility.

Professor Owler said a national leaders’ retreat held last month to consider the division of health responsibilities and funding as part of reform of the Federation was a welcome first step, but talks limited to rearranging tasks or raising a little more revenue by themselves were not enough.

He called for a thoroughgoing reassessment and change in the way health is considered by governments.

“Health should not be an annoyance – a concerning budget line to be dealt with,” he said. “Health is an essential ingredient to any economy.

“We need to see health care expenditure not as a waste, but as an investment.”

The AMA President held up the Federal Government’s approach to Indigenous wellbeing as an example of the muddled and ineffective policymaking that can arise in the absence of an overarching strategy.

The Commonwealth has instituted a crackdown on truancy among Aboriginal children and carrot-and-stick measures to boost Indigenous employment.

But Professor Owler said that, by neglecting health, the Government’s strategy would achieve only limited success in closing the gap.

“The lack of focus on health is one of the reasons why I struggle to understand the Government’s Indigenous advancement strategy,” he said. “Making kids go to school, encouraging young people to get a job, and making a safer society are all noble objectives. But health must underpin these strategies, particularly when it comes to Closing the Gap.”

The AMA President said a more honest and incisive assessment of the health system was needed to identify and take advantage of opportunities to achieve better and more cost-efficient care.

He said that, contrary to the claim of politicians, health spending was not out of control, though he acknowledged that scarce health dollars could be used to greater effect.

Rather than trying to hold down health spending by rationing access to care and other punitive measures, Professor Owler said a smarter approach was to drive dollars further by improving health system integration, particularly through the use of information technologies.

In addition, he said, governments should invest in general practice to help care for patients with complex and chronic conditions and to upgrade preventive health initiatives.

“Investment in general practice is essential if we are going to keep people well and in the community,” the AMA President said.

“Seven per cent of hospital admissions may be avoidable with timely and effective provision of non-hospital or primary health care.

“Our family doctors are the cornerstone of chronic disease management. They need to be supported to do this work with investment, funding, and resources.”

Mr McBride said that the Government should search for efficiencies before resorting to rhetoric and fearmongering about “unsustainable” health expenditure: “This means being smarter about what services we fund, not just cutting them.”

Adrian Rollins

AMA in the News – 4 August 2015

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

Print/Online

Patients set to pay in Medicare impasse, Courier Mail, 21 July 2015
AMA President Professor Brian Owler warned there would be a sharp rise in the number of visits in which patients would be hit with out-of-pocket fees unless the Government lifted its freeze on Medicare rebates.

AMA calls for no GST on GP visit, Courier Mail, 22 July 2015
Patients face paying GST on doctors’ visits if the tax is broadened. AMA President Professor Brian Owler called on the Government and the states to rule out broadening the GST to include health care.

Medibank blasted for cost-cutting, The Age, 23 July 2015
AMA President Professor Brian Owler warned Australia was heading toward a US-style health care system, saying the cost-cutting behaviour of private insurance giant Medibank was offensive.

Medibank’s offensive stand lacks insight: AMA head, Australian Financial Review, 23 July 2015
AMA President Professor Brian Owler said Medibank Private’s hardball negotiating demands are offensive and misunderstand the motivations of health professionals. Professor Owler said one of the highly preventable adverse events that Medibank has said it would not pay for was maternal death associated with childbirth.

GPs could have seen to hospital visits: survey, The Australian, 24 July 2015
Almost a fifth of emergency department visits by the elderly are for problems that could have been managed by their GPs. AMA Vice President Dr Stephen Parnis said it was hard to differentiate when the best care should be provided by a primary care physician or an emergency department.

AMA President’s wrong diagnosis on budgets, The Australian, 28 July 2015
AMA President Professor Brian Owler is calling for an urgent recognition of the costs of providing high quality care. Professor Owler told the National Press Club it was not the AMA’s job to say where the funding should come from.

Medibank Private ready for scrap with hospitals, Weekend Australian, 25 July 2015
Medibank Private is ready for a long battle with private hospitals. AMA President Professor Brian Owler said negotiations between hospitals and private insurers had become increasingly aggressive and he warned that Medibank’s patients would no longer be fully covered for treatment in a Calvary hospital.

Radio

Professor Brian Owler, 2UE Sydney, 21 July 2015
AMA President Professor Brian Owler talked about health funding. Professor Owler said that, when it comes to public hospital funding, the states and territories are the ones that have the responsibility to get the job done, but they rely on Commonwealth funding.

Professor Brian Owler, 2GB Sydney, 22 July 2014
AMA President Professor Brian Owler talked about the dispute between the AMA and Medibank Private. Professor Owler said that Medibank Privates decision to list 165 conditions for it will not provide insurance cover was not common practice.

Professor Brian Owler, 2UE Sydney, 23 July 2014
AMA President Professor Brian Owler discussed Medibank wanting to change its maternity coverage so that if the mother dies during child birth they don’t have to pay. Professor Owler said it was “offensive” that anyone could think that a financial penalty was needed to motivate hospital staff to prevent deaths during child birth.

Dr Stephen Parnis, 5AA Adelaide, 27 July 2015
AMA Vice President Dr Stephen Parnis discussed alcohol advertisements. Dr Parnis said foetal alcohol syndrome was a serious problem in Australia and that sometimes warning labels on packaging were used as an excuse for not taking more significant action.

Television

Professor Brian Owler, ABC, 22 July 2015
Acknowledging the political and economic realities that confront governments, AMA President Professor Brian Owler outlined the practical, affordable, and achievable policies and actions that the AMA believes will best serve the health needs of the Australian population.

We’re overdosing on medicine – it’s time to embrace life’s uncertainty

The more we learn about the problem of too much medicine and what’s driving it, the harder it seems to imagine effective solutions. Winding back unnecessary tests and treatments will require a raft of reforms across medical research, education and regulation.

But to enable those reforms to take root, we may need to cultivate a fundamental shift in our thinking about the limits of medicine. It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death.

We’re all ill now

A growing body of evidence shows that when it comes to health care, we may simply be getting too much of a good thing. In the United States, it’s estimated that more than US$200 billion a year is squandered on unnecessary tests and treatments. In the United Kingdom, senior medical groups are calling on doctors to reduce all the wasteful things they do. And in Australia, the Choosing Wisely campaign recently kicked off with lists of unnecessary and harmful health care.

Not only are we overusing pills and procedures, we’re creating even more problems with “overdiagnosis” by labelling more and more healthy people with diseases that will never harm them.

Screening programs targeting the healthy can detect potentially deadly cancers and extend lives. But they can also find many early abnormalities that are then treated as cancers, even though they would never have caused anyone any symptoms if left undetected.

The common ups and downs of our sex lives are often re-labelled as medical dysfunctions. Older people who are simply at risk of future illness – those with high cholesterol, for instance, or reduced kidney function, or low bone mineral density – are portrayed as if they were diseased.

The doctors expanding disease definitions and lowering the thresholds at which diagnoses are made are often being paid directly by the companies that stand to benefit from turning millions more people into patients.

What’s driving all this excess is a toxic combination of good intentions, wishful thinking and vested interests – fuelled by sophisticated diagnostic technology that often offers the illusion of more certainty about the causes of our suffering. It’s as if we’re seeking technical fixes for the fundamental reality of human existence – uncertainty, ageing and death.

Fundamental shifts in thinking

Indeed, intolerance of uncertainty has been suggested as among the most important drivers of medical excess. Doctors order ever more tests to try, often in vain, to be sure about what they’re seeing – to be more certain. But disease and the benefits and harms of treating it are inevitably fraught with uncertainty because we’re trying to apply knowledge derived from populations to unique individuals.

More broadly, uncertainty is the basis of all scientific creativity, intellectual freedom and political resistance. We should nurture uncertainty, treasure it and teach its value, rather than be afraid of it.

No matter how much the marketers of medicines try to make us feel broken by the mere passing of time, ageing is not a disease. Disease definitions that equate “normal” with being young are fundamentally flawed and require urgent review.

The doctors who defined osteoporosis, for instance, arbitrarily decided the bones of a young woman were normal, automatically classifying millions of older women as “diseased”. Similarly, those who defined “chronic kidney disease” have classified the normal changes in kidney function that happen as many of us age as somehow abnormal. Brace yourself for the impending arrival of pre-dementia, the latest attempt to medicalise the ageing process.

In all cases, the people who wrote these definitions included those with ties to pharmaceutical companies – reinforcing the need for much greater independence between doctors and the industries that benefit from expanding medical empires.

Rays of hope

Everyone must die and everyone, patients and doctors alike, is more or less fearful of dying. So, it’s perhaps not surprising that we so often turn to biotechnical approaches rather than paying real attention to the care of the dying – a core purpose of medicine.

We're overdosing on medicine – it's time to embrace life's uncertainty - Featured Image

What we tend to forget is that medicine cannot save lives – it can only postpone death. Yet we persuade ourselves it might somehow keep extending our lives, and we come to view almost every death as a failure of medicine.

Doctors persist with treatments for the dying well after these have become obviously futile, often with the support of patients or their families. Deep, difficult and necessary conversations about death and dying are only possible in a context of trust, which becomes increasingly difficult as health-care systems are ever more fragmented.

But, there are many positive signs of change within medicine. The Choosing Wisely campaign mentioned above is a partnership between doctors and wider civil society. And it’s now an international movement to wind back excess medicine.

A new approach called shared decision making is promoting much more honest conversations between doctors and the people they care for, embracing uncertainty about benefits and harms, rather than peddling false hopes. Another new approach among GPs called quaternary prevention is urging doctors to protect people from unnecessary medical labels and unwarranted tests and treatments.

Perhaps all these new movements will re-establish doctor-patient trust, helping us reduce fear and embrace uncertainty, and end the pretence that medicine can cure ageing and even death. Biomedical science has made our lives immeasurably better, but it’s time to accept that too much medicine can be as harmful as too little.

Former president of the UK Royal College of General Practitioners, Dr Iona Heath, co-authored this article. Dr Heath will deliver a free public lecture on the problem of “Too Much Medicine” at the University of Sydney this Wednesday night, August 5.

Ray Moynihan is Senior Research Fellow at Bond University.

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

Some truths about the “low” childhood vaccination coverage in Sydney’s eastern suburbs

Among the hype and controversy prompted by the Australian Government’s recent announcement that conscientious objectors to childhood vaccination would lose childcare subsidies and part of the family tax benefit,1 including the accompanying media rancour,2 it is worth noting that published vaccination coverage figures based on the Australian Childhood Immunisation Register (the Register) are only an estimate of the extent of coverage. In the case of the eastern suburbs of Sydney, they significantly underestimate the true coverage.

In January 2002, we studied a cohort of children aged between 12 and less than 15 months residing in south-eastern Sydney; according to the Register, 81% had received all vaccination doses scheduled for the first year of life. Systematic follow-up — by contacting providers and/or parents — of one-third of the children recorded by the Register as being overdue for one or more do ses established that the overall proportion of children who were up-to-date with their vaccinations was, in fact, at least 91%.3

In March 2013, we undertook a similar follow-up survey, on this occasion focusing on children aged between 12 and less than 15 months who resided in the Waverley and Sydney City local government areas, where the Register-based coverage level was reported as being 87%. These areas were targeted because this figure was significantly lower than the overall south-eastern Sydney figure of 91%. Of 112 children recorded as being overdue for one or more vaccinations and whose records were checked with providers and parents, 37 (33%) were actually up-to-date, leading to an increase of 4% in the estimated total coverage, to at least 91%.

Although there is evidence of underreporting of childhood vaccinations in urban areas,4 the purportedly low childhood vaccination coverage in parts of Sydney has been cited critically on a number of occasions, including in the New South Wales parliament.5 On the basis of our follow-up surveys, which we have continued since 2013 in collaboration with Medicare Locals, we have established that published coverage rates based on Register data are significantly underestimated.

Discussions with medical practice staff and support officers suggest that in many instances where children have been incorrectly recorded in the Register as being overdue for vaccinations, it is because general practitioners do not understand the reporting process, data have been entered incorrectly, or there are technical problems in the practice software that transmits encounter data to the Register.

In some localities, including ours, the true level of coverage is higher than that reflected in the Register. It then becomes a public health priority to identify those populations where coverage is genuinely low, so that education and other appropriate efforts can be properly focused. To obtain a more accurate picture of variations in coverage, investment is required to provide ongoing support to general practice staff and to ensure that practice software interfaces seamlessly with the Register.

General practitioner understanding of abbreviations used in hospital discharge letters

The transition from hospital to the community is a potentially dangerous time for patients.1 It often involves a change in medical management, with potential for error. Hospital discharge letters aim to facilitate safe transition of patients into the community. To be effective, discharge letters must reach the general practitioner in a timely manner and contain easily understandable information. These are essential ingredients in effective continuity of care.

Deficits in discharge letters can contribute to a failure of information transfer. Studies have found high rates of omissions and errors in such letters.2–4 This contributes to errors in care after discharge. One study found that 49.5% of patients discharged from a large academic medical centre experienced at least one medical error relating to change of care on discharge.2

In this article, we focus on the potential danger of using abbreviations (shortened forms of words or phrases5) in medical communication. Abbreviations used in medical communications are either acronyms or initialisms. Acronyms use the initial letters of words and are pronounced as words (eg, ASCII, NASA); initialisms use initial letters pronounced separately (eg, BBC).5 Abbreviations are commonly used in medical specialties, but may not be understood by the broader profession. Doctors are under pressure to complete discharge letters in a timely fashion, and abbreviations may be used to facilitate this process.

We identified few published studies of the frequency of abbreviations in discharge letters.6,7,8 Some reported that abbreviation use is increasing and identified this as a concern. A recent audit at Royal Melbourne Hospital reported that 20.1% of all words in discharge letters were abbreviations.8 Another study audited abbreviation use in inpatient medical records and surveyed members of an inpatient multidisciplinary team for their understanding of abbreviations.9 The mean correct response rate was 43%, with Postgraduate Year 1 doctors posting the best scores (57%) and dietitians posting the worst (20%).

However, we identified no published studies determining whether the abbreviations used in hospital discharge letters are understood by GPs, who are usually the recipients of discharge letters.

Methods

We retrospectively analysed 200 electronic hospital discharge letters (eDLs) of patients discharged from Nepean Hospital, Sydney, a tertiary referral centre, from 31 December 2012, working backwards to 18 December 2012. We stopped at this point because few new abbreviations were being identified. To be included in the audit, an eDL had to be addressed to a GP.

We chose 31 December to begin the analysis to provide a representative sample of junior doctors who had a minimum of almost a year of hospital experience.

The meaning of each abbreviation was inferred from the surrounding text, and abbreviations were categorised as shown in Box 1.

Survey of GPs

From the audit, we developed a survey using the 15 most commonly used abbreviations plus five less frequently used but clinically important abbreviations. We determined that abbreviations of investigations, management or services were likely to be most clinically significant, based on our clinical experience and the potential consequences of misinterpretation. We defined commonly used abbreviations as those that were used at least 20 times in the audit. In the resulting survey of GPs, each abbreviation was provided in the context of a phrase in which it had been used in a discharge letter (Appendix).

To provide adequate precision, we aimed for 100 GP responses. The survey was mailed to all 240 GPs listed in the 2014 edition of the Medical Practitioners’ Directory for the Nepean, Blue Mountains and Hawkesbury areas. This was the most extensive directory of GPs in this area available to us. Responses were returned in a coded envelope inside a postage-paid envelope. GPs who did not respond were resent surveys on up to two additional occasions.

Outcome measures

Survey responses were analysed to determine what proportion of GPs understood each abbreviation.

Ethics approval

The study was approved by the Nepean Blue Mountains Local Health District Human Research Ethics Committee.

Results

Electronic discharge letter audit

We found 321 different abbreviations in the 200 eDLs audited (a rate of 1.6 new abbreviations per eDL and 7.1 total abbreviations per eDL); most were initialisms. The frequency of abbreviations in eDLs is shown in Box 2.

Hospital coding-approved abbreviations accounted for 62.6% of all abbreviations identified. Seven unapproved abbreviations (2.2%) were in common use (ie, found more than 20 times in the audit).

GP survey

The response rate was 55% (132 of 240 GPs). No abbreviation was correctly interpreted by all GPs, but 10 abbreviations (50%) were interpreted correctly by 97.0% of GPs (128).

The frequency of incorrect interpretation of all abbreviations in the survey is shown in Box 3. Box 4 shows the range and frequency of individual GP scores.

Discussion

The results of our survey show that there is poor understanding among GPs of abbreviations used in hospital discharge letters. The response rate to our survey was fair, so our results are likely to be representative of GPs in the area.

Worryingly, more than half of the abbreviations we found related to investigations, management or services that we considered to be the most clinically significant categories. Misinterpretation of abbreviations by GPs can adversely affect patient care through duplication of investigations, failing to institute treatment based on investigation results or failing to follow up with recommended management. We could find no studies that identified which types of abbreviations confer the worst outcomes if misinterpreted. Also of concern is that almost half of the abbreviations we identified were used only once in the 200 eDLs.

The difference identified in the use of abbreviations by junior doctors and understanding of abbreviations by GPs suggests a lack of consistency between the language commonly used in hospitals and that used by GPs. It is uncertain how well understood these same abbreviations are by hospital doctors in different specialty areas. The language of abbreviations may also vary between hospitals. Common abbreviations found previously in Royal Melbourne Hospital discharge letters8 were different from those we found. The five most common inappropriate ambiguous or unknown abbreviations in the Royal Melbourne Hospital audit were not found in any eDL in our audit. Their abbreviation rate was higher, with a mean of 10.5 new abbreviations per discharge letter compared with our rate of 1.6. Widespread use of abbreviations in paediatric medical notes with no standardisation and difficulty in interpretation by health care professionals has also been previously reported.11

Our study has some limitations. Non-responding GPs might have scored differently on the survey compared with those who responded. Also, we did not ascertain GP demographic characteristics such as length of career outside the hospital setting. GPs with more recent hospital practice may better understand these abbreviations. In addition, we could not assess GPs’ understanding of most abbreviations we identified in the eDL audit because of the large number identified. However, we expect that understanding of these less frequently used abbreviations would be poorer than for the 20 we included in our survey. Also, this study was conducted in a single centre, so the results may not be generalisable to other centres. However, junior doctors are drawn from many universities and it is likely that discharge practices are similar in other hospitals.

Conclusion

Discharge letters are an essential means of communication between hospitals and GPs to facilitate optimal care of patients when they return to the community. All abbreviations used should be understood by all GPs. Strategies to improve communication by means of discharge letters are urgently needed. Potential solutions include banning the use of abbreviations in eDLs or using only a limited number of hospital-approved abbreviations and providing GPs with an approved abbreviation list. Another option would be use of computer software to auto-complete mutually exclusive abbreviations (ie, allowing only one possible meaning for each).

1
Categorisation of the 321 abbreviations used in 200 sequential electronic hospital discharge letters

Type of abbreviation	Number	% of total	Representation of the types of abbreviation in the survey

Investigations	102	31.8%	30%
Physical examination finding	56	17.5%	30%
Management	56	17.5%	5%
Service*	22	6.9%	5%
Patient history	20	6.2%	30%
Other	65	20.1%	0
Total	321	100.0%	100%

*A hospital outpatient service such as outreach or outpatient clinics.

2
Frequency with which the 321 abbreviations were used in 200 sequential electronic hospital discharge letters

Frequency	Number (%)

> 20 times	17 (5.3%)
15–19 times	5 (1.6%)
10–14 times	14 (4.4%)
5–9 times	32 (10.0%)
0–4 times	253 (78.8%)

3
Frequency of incorrect interpretation by general practitioners of 20 common or clinically significant abbreviations

Abbreviations

GPs misinterpreting abbreviation

Number

Percentage (95% CI)10

SNT

47.0% (38.5%–55.5%)

TTE*

33.3% (25.3%–41.3%)

EST*

33.3% (25.3%–41.3%)

NKDA

32.6% (24.6%–40.6%)

CTPA*

31.1% (23.2%–39.0%)

ORIF*

28.0% (20.4%–35.7%)

HSDNM

23.5% (16.3%–30.7%)

B/G

23.5% (16.3%–30.7%)

GCS*

18.2% (11.6%–24.8%)

ADLs

13.6% (7.8%–19.5%)

PMHx

3.0% (0.1%–6.0%)

ECG

3.0% (0.1%–6.0%)

CXR

3.0% (0.1%–6.0%)

O/E

3.0% (0.1%–6.0%)

2.3% (0–4.8%)

GORD

2.3% (0–4.8%)

1.5% (0–3.6%)

1.5% (0.–3.6%)

ADLs = activities of daily living. B/G = background. BP = blood pressure. CT = computed tomography. CTPA = computed tomographic pulmonary angiography. CXR = chest x-ray. ECG = electrocardiogram. ED = emergency department. EST = exercise stress testing. GCS = Glasgow coma scale. GORD = gastro-oesophageal reflux disease. HR = heart rate. HSDNM = heart sounds dual and no murmur. NKDA = no known drug allergies. O/E = on examination. ORIF = open reduction and internal fixation. PMHx = past medical history. RR = respiratory rate. SNT = soft, non-tender. TTE = transthoracic echocardiogram.
*Less common but clinically significant abbreviations.

4
Proportion of general practitioners receiving particular survey scores for correct interpretation of abbreviations

Actual availability of general practice appointments for mildly ill children

There are concerns that there may be shortages in the Australian primary care workforce, especially in rural and regional areas. However, some have suggested that a shortage of general practitioners is also a problem in metropolitan areas.1 In some outer suburbs of Melbourne, residents have reported significant difficulty in acquiring a medical certificate for sick leave in a timely manner, and that waiting 2 weeks for a doctor’s appointment is common.2 Similarly, some GPs in Melbourne have reported having to close their books due to excessive demand, with one doctor stating he had to turn patients away for 2 years3. Even in some inner-city Melbourne practices, doctors have reported having to close their books, and hearing from patients that they have had to telephone four or five clinics just to obtain an appointment.4

An actual or perceived lack of availability of primary care appointments may contribute to the increased rates of attendances at hospital emergency departments (EDs), as patients seek alternative ways to reach health care providers. Attendances at EDs are increasing at a rate exceeding population growth, and there is a perception among hospital staff that a significant portion of attendances are for conditions that do not require the urgent or specialised services that such departments provide.5,6 While some ED visits are for serious acute conditions some of which result in hospitalisation, a large number could be treated in a primary care setting.6–8

Many hospital EDs are experiencing a severe strain on their limited resources, as evidenced by chronic overcrowding and long waiting periods.9,10 Thus, ensuring that primary care practitioners are sufficiently available and accessible in the community is essential for both individuals and the health system as a whole. This would help patients with urgent conditions receive more timely treatment in hospitals by reducing demand for ED services, while those who do not require emergency treatment would benefit from the continuity of care and preventive services available in the community.11

Understanding the true availability of the primary care workforce for the population is necessary to determine whether a shortage actually exists. Projected models of supply and demand for the primary care workforce do indicate a possible shortage of practitioners.12 However, beyond head counts of providers, there are few data that provide more than anecdotal reporting of primary care workforce supply and demand in Australia. For example, in 2009 the Australian Bureau of Statistics found that, in 1 year, about 937 800 people reported they had been unable to access health services when they needed them. Of the 82% who were attempting to access general practice services, 47% cited long waiting periods or a lack of available appointments as the main reason for lack of access.13 A study of an outer metropolitan region in Western Australia found that 59% of people had reported difficulty in obtaining GP appointments, citing lack of appointments, long waiting periods and inconvenient hours.14 Although indicative, such data are of limited use in assessing the actual availability and accessibility of services, given their focus on modelled data or on patient recall of health service access. No previous studies have provided a real-time assessment of GP availability or appointment charges from the patient’s perspective.

The lack of such data hinders adequate policy responses to ensure that the needs of the population are met. We undertook this study specifically to help fill this gap. We focused particularly on children because previous studies have shown a decrease in the proportion of GP visits specifically provided to children over the past 2 decades.15

Methods

We used “secret shopper” techniques, a well known and often-used method to determine the actual versus reported availability of physician appointments.16 This involved having research assistants pose as parents and telephoning general practice clinics seeking treatment for children with non-urgent, low-acuity conditions. The study was conducted between 1 August and 30 September 2014.

Sample

The sampling frame included all GPs working within the catchment areas of three Medicare Locals in the greater Melbourne metropolitan area. The Medicare Local catchments included urban, suburban and regional areas. Each Medicare Local provided contact details of all GPs within their catchment areas. A random sample of 225 practices were contacted, 75 from each Medicare Local list.

Data collection and analysis

Same-day appointments were sought for paediatric patients based on one of two clinical scenarios, each of which was designed to present non-urgent, low-severity conditions appropriate for general practice. The scenarios were developed with the help of two clerical staff from two general practice clinics and two GPs from other practices. The scenarios were:

a 3-year-old child with an earache and a mild fever; and
an 8-month-old with a slight cough, runny nose and mild fever.

Research assistants telephoned clinics between 9:00 am and 12:00 pm on weekdays to maximise the likelihood of same-day appointment availability.

Attempts were made to make an appointment with a specific, randomly selected GP in the practice. If a same-day appointment with that GP was not available, a request was made for a same-day appointment with any GP in the clinic. Same-day appointments offered with other GPs within the clinic were classified as an available appointment. Data were recorded on whether an appointment was unavailable, available with the requested practitioner, or available with another practitioner within the clinic. Where same-day appointments were available, the time between making the call and the next available appointment was recorded. Bulk-billing status of the clinic was a binary variable (yes/no). Where clinics did not bulk bill, both the upfront cost of an appointment and the final out-of-pocket cost (upfront cost minus the Medicare rebate amount) was recorded. Where the receptionist stated the cost of an appointment was likely to vary on length of appointment, a minimum and maximum cost provided by the practice were recorded.

Where an appointment was offered, the appointment itself was not accepted. Receptionists were told by the research assistant that they would call back if an appointment was actually needed and if the time offered was acceptable. No appointments were actually booked in any practice. The call process was developed and pilot-tested with medical reception staff from GP clinics to ensure that it did not have a significant impact on the administration of the clinics.

The study received ethics clearance from the University of Melbourne Human Research Ethics Committee. This committee required that, after the data were collected, letters be sent to clinics that had been selected within the catchment areas alerting them to the possibility of having been contacted by the research team and describing the nature of the study.

Statistical analysis

All data were analysed using Stata, version 13 (StataCorp). Analyses primarily involved the use of descriptive statistics, with the ?2 test used to investigate potential associations between appointment availability and the availability of bulk-billing in clinics.

Results

Appointment availability

Overall, same-day appointments to see any doctor were offered by 78% of clinics (175/225). Appointment availability between the three Medicare Local catchment areas varied only slightly, from 72% to 81%. However, availability to see a specific doctor in the practice was more limited (Box 1).

Time until available appointments ranged from less than 1 hour in 15% of practices to over 8 hours in a single practice (Box 2). About half of the clinics contacted (111; 49%) were able to offer an appointment within 4 hours. A further 9% offered walk-in appointments, for which a waiting time could not accurately be determined (Box 2).

Appointment cost

About three-quarters of the clinics contacted (168; 75%) offered bulk-billing for paediatric patients. Actual proportions varied between 72% and 80% in the three Medicare Local catchment areas (Box 3).

Box 4 provides a comparison of appointment availability by clinic billing practices. Appointments were more likely to be available in clinics that provided bulk-billing for paediatric appointments, with 82% of those able to offer an appointment compared with 67% of private-billing clinics (P = 0.01). Mean out-of-pocket costs were lower at clinics in which appointments were available than at those in which no appointment was offered. In clinics that did not bulk bill, the minimum out-of-pocket costs cited by reception staff ranged from $2 to $75.65, with a mean of $32.18. Maximum out-of-pocket costs ranged from $12 to $94.30, with a mean of $34.67.

Discussion

Among the most important findings from this study is that there is significant same-day GP appointment availability for children with low urgency, low-acuity conditions in the areas we studied. Further, about three-quarters of clinics with same-day appointment availability offered bulk-billing for paediatric patients, suggesting that financial constraints are unlikely to be a significant barrier to accessibility of primary care appointments. With 78% of clinics able to offer a same-day appointment and with there being multiple GPs practising within the postcodes of our catchment areas, it seems likely that most people attempting to procure such an appointment would be able to do so, and with no out-of-pocket cost. In addition, a high proportion (almost 60%) of appointments were offered either within 4 hours of contacting the clinic or on a same-day walk-in basis.

Our results indicate that increasing attendances for children at EDs are unlikely to be driven primarily by a lack of availability of appointments in general practice. It is possible that a perceived lack of primary care appointment availability may be a contributing factor in some ED presentations. Parents and guardians may simply be assuming a lack of availability of GP appointments, and believe they are more likely to be provided with timely care in an ED. If this is the case, public information campaigns based on our findings may help to change the behaviour of patients in seeking acute care for low urgency conditions at their general practice clinic. Although not all GPs had same-day appointments available, there were multiple GPs able to see patients for non-urgent conditions in a timely manner. This is in contrast to the picture presented in some media reports.2–4

Our findings on the high proportion of clinics that bulk bill for paediatric care (75%), and the higher availability of appointments in these clinics compared with private-billing clinics is important. The perceived cost of appointments may be influencing the behaviour of parents seeking care for children with non-urgent conditions.17 A study of patients 15 years and older found that over a million Australians reported that they had not seen, or had delayed seeing, a doctor due to cost in a given year; another study found that 24.5% of those living in an outer metropolitan suburb cited financial matters as a barrier to visiting a GP.13,14 Publicising the availability and accessibility of same-day appointments for children in bulk-billing clinics may allay concerns over the cost of appointments.

A previous study has shown that if parents are unable to obtain appointments with a practitioner that they know and trust, they may instead seek treatment in an ED.18 Although parents may wish to see the same GP for all of their child’s health care needs, that appears to be an increasingly unrealistic goal. Trends in GP practices indicate that the number of GPs working in larger practices (of four or more partners) is increasing, while only about 11% work in solo practices.19–21 Frequently, patients are seen by several members of a practice.

A limitation of our study is that that the distribution of GPs may differ between metropolitan, regional and rural areas across the country, so our findings may not be generalisable to other parts of Australia. Further research would be required to assess the availability of same-day GP appointments in other areas. Further, we collected our data on weekday mornings — a time likely to maximise appointment availability. A similar audit conducted nearer closing time may produce different results.

This study provides an accurate and current real-time assessment of availability and accessibility of general practice appointments for children with non-urgent conditions from the patient’s perspective. We found high availability of appointments in GP practices, although not necessarily with a specific doctor in the practice. Additionally, the high availability of appointments in bulk-billing clinics indicates a lack of economic barriers to available care. We believe this information can aid in developing data-driven policy approaches for ensuring the availability of the primary care workforce and the use of paediatric ED services for non-urgent conditions. Further, the public should be made aware of the ready availability of GP appointments.

1
Availability of same-day appointments for a mildly ill child in 225 general practices within three Medicare Local catchment areas

Medicare Local	Total phone calls	Appointments available
Medicare Local	Total phone calls	With requested general practitioner	With another general practitioner	Total

NMML	75	25 (33%)	36 (48%)	61 (81%)
MRNWMML	75	17 (23%)	43 (57%)	60 (80%)
INWMML	75	30 (40%)	24 (32%)	54 (72%)

NMML = Northern Melbourne Medicare Local (outer urban); MRNWMML = Macedon Ranges and North Western Melbourne Medicare Local (outer urban and regional); INWMML = Inner North West Melbourne Medicare Local (inner urban).

2
Availability of appointments and time until appointment in 225 general practices

Time to appointment (hours)	Appointments
Time to appointment (hours)	No.	Proportion	Cumulative proportion

Within 1	34	15%	15%
Within 2	38	17%	32%
Within 3	26	12%	44%
Within 4	13	6%	49%
Within 5	20	9%	58%
Within 6	13	6%	64%
Within 7	6	3%	67%
Within 8	4	2%	68%
8 or more	1	0%	69%
Walk-in (time unknown)	20	9%	78%
No appointments available	50	22%	100%

3
Availability of bulk-billing for paediatric appointments in 225 general practices within three Medicare Local catchment areas

Medicare Local	No. of practices	Bulk-billing practices

Within 2	38	17%
Within 3	26	12%
Within 4	13	6%
Within 5	20	9%
Within 6	13	6%
Within 7	6	3%
Within 8	4	2%
8 or more	1	0%
Walk-in (time unknown)	20	9%
No appointments available	50	22%

NMML = Northern Melbourne Medicare Local (outer urban); MRNWMML = Macedon Ranges and North Western Melbourne Medicare Local (outer urban and regional); INWML = Inner North West Melbourne Medicare Local (inner urban).

4
Availability of and billing practices for paediatric appointments in 225 general practices

Appointment available	No. of practices	Bulk-billing	Private-billing

No	50	31 (62%)	19 (38%)
Yes	175	137 (78%)	38 (22%)
All practices	225	168	57

GPs failing to help patients lose weight

A study has found Australian general practitioners are confusing lack of motivation with low health literacy resulting in a failure to help those who are overweight and obese lose weight.

It’s believed one in five Australians have low health literacy, meaning they don’t have a good understanding of their own health, the measures they can take to improve it and how the healthcare system can help them.

The UNSW study examined how GPs and practice nurses managed overweight and obese patients in 20 practices in disadvantaged areas of Sydney and Adelaide.

It found few of the 61 health staff surveyed assessed a patient’s health literacy, which Professor Mark Harris, Executive Director of UNSW’s Centre for Primary Health Care and Equity, said was important as health professionals often confuse low health literacy with poor motivation.

“Many medical professionals wrongly assume the growing ranks of overweight and obese Australians are not sufficiently motivated to lose weight. Instead, existing research suggests low health literacy may be the culprit,” Professor Harris said.

There are National Health and Medical Research Council (NHMRC) obesity management guidelines to assess health literacy in patients.

Professor Harris and his team are assessing how the NHMRC guidelines can best be incorporated into GP practices.

“In this age when we are drowning in information about lifestyle and weight management, it is important that people with low health literacy are not left behind,” Professor Harris said.

“Tailoring our approach to the needs of those with low health literacy is part of the solution to reversing this trend.”

The results of the study are being presented at the Primary Health Care Research Conference in Adelaide.

New GP guide for prescribing benzodiazepines to help prevent ‘doctor shopping’

The Royal Australian College of General Practitioners (RACGP) has launched a new guide for GPs to follow when prescribing benzodiazepines.

Nearly 7 million prescriptions for these drugs are issued every year in Australia, mostly to treat anxiety and insomnia.

The most common varieties are Valium and temazepam.

RACGP President Dr Frank R Jones says their use has led to concerns about the harms associated with both authorised and unauthorised use of the drugs.

“There is significant debate in the medical community about the appropriate role and use of these drugs and this has been exacerbated by a lack of clinical guidelines in the area. The RACGP’s new guide, Prescribing drugs of dependence in general practice, Part B: Benzodiazepines is the first in Australia to comprehensively address these issues,” Dr Jones said.

The guide explains that prescribing benzodiazepines shouldn’t be the first treatment option and should be regarded as a short-term therapeutic option.

Problems associated with the use of these drugs in the short term are rare, however some patients are more vulnerable to harm than others.

“As GPs we need to be vigilant in identifying patients who may be misusing or abusing benzodiazepines because this can become a long-term and distressing problem.”

Use of these types of drugs beyond four weeks should be uncommon and should be made with a full risk-benefit analysis. There should also be careful monitoring.

The RACGP hopes the guide will help reduce patient harm associated with benzodiazepine misuse.

“Patients who have a substance use disorder may ‘doctor shop’ to gain prescriptions and increase their use and dosage. When taken in combination with other substances such as opioid medications, illicit drugs and alcohol, this can result in death,” Dr Jones warned.