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Preference: General Practice and Primary Care

333

Govt wants kids to have cut-price health checks

The Federal Government wants children to have cut-price health checks after confirming it would rip almost $145 million out of general practice by abolishing a Medicare program that last year provided comprehensive pre-school health assessments for 154,000 children.

But Health Minister Sussan Ley said parents would still be able to get their GP to conduct a similar Medicare-funded health check of their child, though at a fraction of the cost to the taxpayer.

The Minister was forced to make the clarification after an announcement in the Federal Budget that $144.6 million would be taken out of general practice over the next four years by “removing the current duplication” Medicare-funded health checks and child health assessments provided by the states and territories.

AMA President Associate Professor Brian Owler voiced concern about the cut, saying it was “very unclear” whether or not there was duplication occurring.

The measure was also heavily criticised by health groups angered by what appeared to be a decision to axe comprehensive health checks for children aged three to five years, introduced by the former Labor Government in 2008.

But Ms Ley rushed to assure parents that they could still get Medicare-funded health checks for their children.

“Parents needing to access the pre-school health check for their child in order to access income support will still be able to do so through a GP or the various state-based nurse infant and children checks, as is currently the case,” the Minister said. “The only change in the Budget is to the Medicare items GPs can bill taxpayers and patients for undertaking the check.”

The Government has moved to scrap Labor’s “Healthy Kids Check”, which costs Medicare $268.80 per visit, and instead allow GPs to bill for the check as a standard GP item costing $105.55 for an equivalent amount of time.

“Instead of GPs billing a special Medicare item worth hundreds of dollars per visit, they will instead be able to deliver the pre-school health check for three- and four-year-olds through a standard GP item worth about half that,” Ms Ley said.

The Government said an increase in the number of people using the Healthy Kids Check in recent years had sent the cost spiralling.

It reported that the number of assessments had jumped from 40,031 in 2008-09 to 153,725 last financial year, driving the annual cost from $1.8 million to $20 million.

While lamenting the cost of the program, Ms Ley simultaneously criticised it for not being comprehensive enough.

“Currently, only half of Australia’s 300,000-plus four-year-olds have accessed a pre-school health check at the more expensive billing rates,” the Minister said, adding there was no evidence show Labor’s program provided health checks superior to standard GP and state infant check services.

But a study published in the Medical Journal of Australia last year did not support this conclusion.

It found the program was effective in detecting problems with speech, toileting, hearing, vision and behaviour in about 20 per cent of children, and directly led to changes in the clinical management of between 3 and 11 per cent of such children.

The study’s authors said their results suggested “GPs are identifying important child health concerns during the Healthy Kids Checks, using appropriate clinical judgement for the management of some conditions, and referring when concerned”.

They added that GPs were also using the checks as an opportunity to identify other health problems.

The authors admitted to having no knowledge of the cost-effectiveness of the program, “although, given that its timing coincides with vaccination at four years of age, the incremental cost is likely small”. 

It followed a study published in the MJA in 2010 which found that although the evidence behind the Healthy Kids Check at that stage was “not compelling”, it had the potential to play an important role in monitoring child development by filling a gap between maternal and child health nurse screening and examinations of selected children by school nursing services.

Adrian Rollins

Talking About The Smokes: a large-scale, community-based participatory research project

Community-based “participatory research” (PR) is desirable because it fosters partnerships between a community and research agencies, enabling inclusivity, interdependence and democratic knowledge production to reduce health inequalities.1–4 Support for PR is particularly strong when research involves indigenous peoples5,6 as it promotes self-determination, creating more transparent and equitable conditions for knowledge creation and benefit sharing.3,7 PR as a methodology may range from being consultative5 through community-directed8 to community-controlled, where community groups exercise the highest expression of autonomy over research, assisted by research institutions.9

In Australia, one Aboriginal human research ethics committee (HREC) will only approve a research project when “there is Aboriginal community control over all aspects of the proposed research”, including design, data ownership, interpretation and publication.10 Other approval criteria include the betterment of Aboriginal peoples’ health, cultural sensitivity and a capacity to benefit. These are hallmarks of PR, and there are now World Health Organization guiding principles specific to indigenous peoples,7 along with guidelines,11,12 joint statements,13–15 and a systematic review,1 to influence PR design and complement guidelines for ethical research involving Indigenous Australians.16 The WHO principles for PR reflect experience in various countries and provide guidance on the joint management of research by research institutions and indigenous peoples. These principles are described as being “applicable everywhere and to all fields of research involving Indigenous Peoples”.7

In this supplement, we report on the Talking About The Smokes (TATS) project, a large-scale PR collaboration between Aboriginal and Torres Strait Islander peoples, their representative bodies, and researchers. This national research project was initiated in 2010 to examine pathways to quitting smoking and the impact of tobacco control policies in the Aboriginal and Torres Strait Islander population. The TATS project is one of many studies within the International Tobacco Control Policy Evaluation Project (ITC Project) to follow nationally representative cohorts of smokers, to measure psychosocial and behavioural impacts of tobacco control policies.17 However, it is the first to sample only a high-prevalence subpopulation within a country.18

In this article, we describe the TATS project PR methodology according to the WHO guiding principles, to assist others planning large-scale PR projects.

Background

In 2012–2013, 42% of the Aboriginal and Torres Strait Islander population aged 15 years or older were daily smokers — 2.6 times the age-standardised prevalence among other Australians.19 Australian governments aimed to halve the Indigenous Australian smoking rate by 2018 (from the 2009 baseline) through a range of Indigenous tobacco control initiatives.20 Funded by the Australian Government in support of these national initiatives, the TATS project was conducted mainly through Aboriginal community-controlled health services (ACCHSs).

ACCHSs provide comprehensive primary health care services to more than 310 000 people (2010–11), with nearly 80% identifying as Aboriginal and/or Torres Strait Islander. The 150 ACCHSs located across Australia are almost entirely Aboriginal-controlled, with a governance structure comprising elected members of the Aboriginal community.21 Although funded largely by the Australian Government,21 they are independent not-for-profit agencies, established by Aboriginal leaders from 1971 in response to significant unmet health needs.22 ACCHSs were involved in the TATS project partly because those most affected by the research outcomes were likely to be patients and staff of these services, but also because of the representativeness of ACCHSs at the local community level, which enabled community control over the research process at each site.

The TATS project was led by the Menzies School of Health Research (Menzies) in a formal partnership with the National Aboriginal Community Controlled Health Organisation (NACCHO). The research team included researchers from Menzies, the Centre for Excellence in Indigenous Tobacco Control, Cancer Council Victoria, two state affiliate organisations of NACCHO (Affiliates) — the Queensland Aboriginal and Islander Health Council (QAIHC) and the Aboriginal Health and Medical Research Council of New South Wales (AH&MRC) — and researchers representing NACCHO. The researcher from Cancer Council Victoria is an investigator on other ITC Project surveys. Project support staff were employed at Menzies and NACCHO, and at 34 local ACCHSs as research assistants (Box 1).

The project used two waves of survey data in 35 locations (the 34 ACCHSs and a community in the Torres Strait). In the first of these waves, 2522 community members and 645 ACCHS staff were surveyed from April 2012 to October 2013. The research methods and baseline sample are described elsewhere.18

Methods

The WHO guiding principles were adapted from their narrative form into a reporting framework in which the text (verbatim) was rearranged into seven themes with numbered subsections (Appendix 1). A condensed version of the framework is shown in Box 2. This framework was used to assess the PR process in the TATS project. Anticipated and unanticipated benefits of the project were sourced from the research protocol, ethics submissions and anecdotal reports from ACCHSs.

Throughout this report, links to the numbered subsections of the framework are shown in parentheses. The framework and the WHO principles refer to indigenous peoples as those “with clearly identifiable community and leadership structures … and a significant political voice”.7 Our references to Indigenous peoples include Aboriginal peoples and Torres Strait Islanders and their representative bodies, such as NACCHO, ACCHSs and Affiliates — all independent but related entities.

Permission to use the framework was provided by the lead author of the WHO principles (Harriet Kuhnlein, Founding Director, Centre for Indigenous Peoples’ Nutrition and Environment, Quebec, Canada, personal communication, February 2014).

Results

The PR approach adopted by the TATS project is described using the seven themes from the adapted framework (Box 2).

1. Consultation and approval

The TATS project was initiated as a result of conversations between three researchers (from Menzies, Cancer Council Victoria and the Centre for Excellence in Indigenous Tobacco Control), one of whom is Aboriginal, and was influenced by the usefulness of ITC Project surveys in other settings. A decision was made to invite Aboriginal organisations as partners. Initial contact with these organisations was made at a meeting of all Affiliates, after which two researchers (from QAIHC and AH&MRC) agreed to participate. In view of the national significance of the proposed research and synergies with national tobacco control policy and community priorities, NACCHO proposed a partnership with Menzies, which was accepted, and NACCHO representatives joined the research team (1.1–1.5).

2. Partnerships and research agreements

Several types of research agreements, some legally binding, were made between the partners (Box 3). The earliest agreement comprised a memorandum of understanding (MOU) initiated by NACCHO to guide the shared development of the research protocol and funding proposal with Menzies, and to ensure consistency with the research and policy priorities of both institutions (2.1). Other agreements comprised two funding contracts between Menzies and the Australian Government and a subcontract with NACCHO, the research protocol, site agreements and consent forms.

Other research team members chose not to make legal agreements between their employers and Menzies; their involvement was sustained by common interests and a history of existing relationships between individuals. Researchers from QAIHC and AH&MRC received endorsement from the Aboriginal leadership of these bodies to participate as individuals in the project.

The research team collaboratively developed the research protocol, with review by the Project Reference Group (PRG), and this was endorsed by the NACCHO Board 18 months after the MOU was signed. The protocol articulated the roles and responsibilities of all partners, the agreed conditions and all steps of the research process (2.2–2.6). Menzies was the administering agency and project manager, and NACCHO acted as advisor for responsible research conduct, communication and coordination involving ACCHSs, in collaboration with other research team members.

Local ACCHSs were informed about the TATS project and the NACCHO–Menzies research partnership and invited to express an interest in participation, pending funding. Although ACCHSs had minimal involvement in the development of the research protocol, it formed the basis of the individually negotiated site consent forms and site agreements (Box 3). All parties to these agreements committed to the successful completion of the research, but could withdraw at any time with notice (2.7–2.8).

3. Communication

Lines of authority within participating Aboriginal organisations were respected; the project staff communicated with managers, chief executive officers and boards where appropriate (Box 1). The key to coordination was the employment of project staff to facilitate engagement between the research team and sites using existing ACCHS sector networks, communication between Menzies and NACCHO, and reporting to the NACCHO Board (3.1).

The NACCHO Board approved the structure, role and membership of the research team and the PRG. Appointments to the PRG were facilitated by NACCHO and comprised Aboriginal peoples and Torres Strait Islanders from all Affiliates and a member of the NACCHO Board as Chair. This ensured the PRG could represent ACCHSs from all jurisdictions. The PRG provided advice, monitored the ethical conduct of research, and assisted in prioritising data analysis (3.2). Members of the PRG were also involved in the interpretation of results, increasing the involvement of Indigenous peoples in this part of the research process.

Communication responsibilities were articulated in the research protocol, funding agreements and site agreements, and included the release of progress reports and a national knowledge exchange forum involving all sites (3.3–3.4).

4. Funding

The initiating three researchers procured establishment funding to negotiate and make agreements with key stakeholders and develop the research protocol and instruments. Thereafter, all research team members had oversight of project fund seeking, as the establishment of partnerships preceded the acquisition of these funds (4.1).

To assure mutual interests, primary contract negotiations involving Menzies and the funder were synchronously aligned with the development of the subcontract with NACCHO. All site agreements were also contracted with Menzies, which funded ACCHSs to undertake local surveys by employing research assistants (4.2) (Box 3).

5. Ethics and consent

Approval from three Aboriginal HRECs and two other HRECs with Aboriginal subcommittees was secured across four jurisdictions before finalisation of the research protocol and signing of the funding contract with NACCHO (5.2–5.3). The MOU, ethics applications and research protocol committed the parties to adhere to ethics guidelines16 and conform to NACCHO data protocols.23 These protocols were developed and endorsed by the ACCHS sector to affirm the importance of Aboriginal peoples and their representative bodies acting as owners and custodians of their own data (5.1, 5.4, 5.7).

Three levels of consent were sought and obtained: Aboriginal collective consent at the national level through NACCHO;24 local community collective consent from each individual ACCHS and the Torres Shire Council (representing the Torres Strait community, as there is not a local ACCHS); and informed consent procured from individual survey participants by research assistants (5.5) (Box 2).

Research assistants had some control over how data would be collected in their community, thereby accommodating cultural and geographic diversity across sites. The consent of study participants was obtained in writing using consent forms approved by the research team as per ethics guidelines (5.6).16

6. Data

Primary contract negotiations stated that intellectual property rights to products arising from the project were vested in Menzies. Through subcontracting, NACCHO and individual ACCHSs were granted a perpetual licence to use, adapt and publish project outputs in accordance with the research protocol and, therefore, the NACCHO data protocols (6.1). The primary funding contract, NACCHO subcontract and research protocol stipulated that raw (unanalysed) data collected from ACCHSs remained the property of the specific ACCHSs “when considered both in isolation and at a national level”. Site agreements clarified that: the collected data were to be used by the research team only as outlined in the research protocol; release of information identifying ACCHSs required their review; and publication of aggregated national results required review by NACCHO (or Affiliates where jurisdictions were identified) (6.2).

Confidential information was protected using a password-protected database, with separate storage of a unique identifying code available only to approved staff and research team members (6.3). This code was necessary for the re-identification of participants in the follow-up survey a year after the baseline survey.

Research agreements ensured that data analyses and interpretations in publications and conference presentations were agreed on by the research team or through joint meetings with the PRG, and then reviewed by NACCHO before submission for publication (6.4). Authorship of manuscripts was negotiated based on international criteria,25 with capacity for Indigenous members of the research team, PRG or project staff, or Indigenous research assistants, to be authors (6.5). ACCHSs were also provided with summaries of their local data in clear language and in formats enabling their independent use (6.6).

ACCHSs’ ownership of their unanalysed data meant that new research requests unrelated to the original agreement would require endorsement from the relevant ACCHS or, on national matters, the NACCHO Board and the PRG (6.7).

7. Benefits of the research

Anticipated research benefits were identified in all research agreements and other information provided to ACCHSs and participants (7.1) (Box 4). No commercial benefits were considered likely (7.2). The recruitment of Aboriginal and Torres Strait Islander peoples to the PRG and the employment of three project staff at NACCHO and 101 local research assistants in ACCHSs helped build individual Indigenous and organisational capacity (7.3) (Box 4). All except seven of the research assistants were local Indigenous people. Funding was provided to ACCHSs for these appointments and to compensate survey participants (in the form of vouchers). Anecdotal benefits to survey participants and services were freely communicated (Box 5).

Discussion

The TATS project exemplifies community-directed research,8 where participation between partners is democratised. While the design of the TATS project was shaped by the institutional, policy and research experience of Aboriginal organisations, research agencies and individual researchers, it closely mirrored the WHO’s PR principles. The TATS project involved 34 ACCHSs conducting baseline and follow-up surveys, making it one of the largest PR projects in Australia. We can affirm that large-scale PR involving vulnerable populations is achievable.

When communities and researchers seek solutions to the same health problems, negotiating this interdependence into a research partnership can help community researchers feel like they are “doing meaningful public health work, not just conducting research”.26 Ultimately, PR relies on forming the right partnerships.27 The relational ethics of the TATS project were negotiated through pre-existing trust between individuals from partner organisations and the individual relationships that developed during the project. They were also negotiated formally through research agreements that embedded community “ways of knowing” and Indigenous ownership over products such as research data.5 This meant that ACCHSs retained autonomy over their collected local information, including into the future — an outcome normally considered challenging.6 Establishing partnerships can take months, particularly where legal agreements are negotiated. Securing an establishment grant for TATS project preparatory work, as well as being transparent about funding uncertainty and research time frames, allowed time for partnerships to develop.

Through NACCHO, the project received the approval and involvement of the Aboriginal health leadership of the ACCHS sector nationwide. Research assistants recruited by ACCHSs from the local population enhanced trust and increased participant recruitment, as did the provision of financial compensation. These strategies are known to increase research response rates in minority populations.26,28,29 Aboriginal peoples and Torres Strait Islanders were employed and involved in all aspects of the project, from conception and design to analysis and dissemination. While the WHO principles promote active Indigenous involvement, including self-determination over the degree of research involvement, advice on building Indigenous capacity through Indigenous employment and career development is more explicit in other guidelines.13,15

We did not attempt to quantify congruence of our project with PR principles,1,8 but the framework we adapted served to structure and focus our reporting “beyond the rhetoric”,5 illustrating applied PR principles in large-scale community-based research. Investment in a research process that is participatory, in both “methodology and method”, is rewarding and sometimes more important than the outcome.30 Participation can empower communities and is recognised as an outcome in itself.31 Community participation in research delivers social and cultural validity when inquiries are aligned with the needs and priorities of those being researched, and better external validity of findings for generalisability.3 Achieving this through PR may be more costly in the short term but in the long term builds health equity32 and facilitates translation of research into policy.3

PR is common but there is no single PR strategy, as self-determined community priorities are unique.4 Sharing our strategies may encourage others to adopt similar research models involving indigenous peoples for equitable knowledge creation, and to build stronger future partnerships.

1 Governance structure of the Talking About The Smokes project

NACCHO = National Aboriginal Community Controlled Health Organisation. ACCHS = Aboriginal community-controlled health service. CEO = chief executive officer. ITC Project = International Tobacco Control Policy Evaluation Project.

2 Condensed framework: guiding principles for participatory health research involving research institutions, Indigenous peoples and their representative bodies*

Theme

Subsection

The guiding principles refer to:

1. Consultation and approval

1.1–1.3

Initiation of research and making contact

1.4–1.5

Approval for the research to proceed

2. Partnerships and research agreements

2.1–2.4

Equality of research relationships, joint preparation of a research agreement and research proposal

2.5–2.6

Development of agreed research processes

2.7–2.8

Joint obligations towards the research

3. Communication

3.1

Clarification of, and respect for, the lines of authority of the partners

3.2

Committee selection by Indigenous peoples (for communication, facilitation and promotion); the committee should represent all relevant community-controlled organisations

3.3–3.4

Maintenance of communication, including progress reports, results and implications of the research

4. Funding

4.1–4.2

A joint commitment to fund seeking, and agreement of sources in advance

4.3

Research institutions’ obligation to ensure Indigenous peoples are involved where resources or capacity are lacking

5. Ethics and consent

5.1–5.2

Respect for ethical guidelines, approval from human research ethics committees and Indigenous-controlled ethics committees

5.3

Research commencing only after ethics approval is received and signed agreements are finalised

5.4

Research conforming to additional protocols of the Indigenous peoples involved

5.5

Consent for research at various levels: individual (study participants), representatives of Indigenous peoples, and the umbrella Indigenous organisation

5.6

A jointly agreed consent-seeking process

5.7

Umbrella Indigenous organisation demonstrating the collective consent of Indigenous peoples

6. Data

6.1–6.2

Intellectual property rights, benefit sharing and boundaries pertaining to information use

6.3

Confidentiality and limiting access to research data

6.4

Joint review and interpretation of data before publication

6.5

Authorship or acknowledgement of participants in joint research

6.6

Formatting data and reports for independent use by Indigenous peoples

6.7

Indigenous ownership of data and authorisation for further use

7. Benefits of the research

7.1

Obligation for research to provide short-term and long-term benefits for Indigenous peoples, including provision of health care where lacking

7.2

Disclosure of potential economic benefits of the research

7.3

Research benefits including training, employment, general capacity building and improved health status or services (or prospects for such improvement)

* Adapted from the World Health Organization, 2003.7 See Appendix 1 for the full framework.

3 Types of research agreements used in the Talking About The Smokes (TATS) project

Research agreement

Function

Signatories

Memorandum of understanding

Commit parties to developing a research partnership

Menzies, NACCHO

Funding contracts

Fund both the establishment phase and the full TATS project

Menzies, Australian Government Department of Health and Ageing

Subcontract

Fund NACCHO project staff to deliver TATS services

Menzies, NACCHO

Research protocol

Document the agreed research processes (goals, planning, design, methods, consent, data collection, analysis, interpretation, dissemination and reporting)

Research team members (and endorsed by NACCHO Board)

Site agreements

Articulate the terms of engagement including roles and responsibilities, and provide funding for employment of research assistants and purchase of consumables

Menzies, ACCHSs

Site consent forms

Document collective consent of the community served by the ACCHS

Menzies, ACCHSs

Survey consent forms

Document individual consent

Survey participants, research assistants

Menzies = Menzies School of Health Research. NACCHO = National Aboriginal Community Controlled Health Organisation. ACCHS = Aboriginal community-controlled health service.

4 Benefits of the Talking About The Smokes project

Benefits

Explanation

To study participants
  • Those identified as having an interest in quitting smoking were referred to health personnel in ACCHSs for quit support
  • Financial compensation for time spent doing surveys

To health services
  • Provision of local information about smoking and tobacco control encouraged ACCHSs to develop:
    • more effective local quit initiatives (eg, quit smoking programs were newly established in some ACCHSs; health promotion activities were improved)
    • workplace smoking policies
  • Funds were provided for the employment of local staff on the project

Towards employment
  • Employment of local Indigenous and non-Indigenous Australians:
    • 101 research assistants across 35 sites, with all but seven being Aboriginal or Torres Strait Islander; three NACCHO staff (one of whom was Aboriginal); two Menzies staff (one of whom was Torres Strait Islander)
  • Some research assistants were offered ongoing employment in ACCHSs

Enhancing research capacity

  • Onsite training of research assistants by regional coordinators, which was also sometimes attended by other ACCHS staff
  • ACCHSs’ ownership of their survey data, enabling further analyses at each service’s discretion

Towards partnerships
  • Collaborative relationships between partners in the research sector, the Aboriginal community and communities in the Torres Strait

Towards Indigenous participation

  • Involvement of Indigenous peoples in all aspects of the project

Towards improved knowledge exchange
  • Results from the project will inform improved tobacco control activities and policies to reduce the harm caused by smoking
  • This knowledge exchange will be enhanced by the involvement of the potential users of this research, especially ACCHSs, throughout the project

ACCHS = Aboriginal community-controlled health service. NACCHO = National Aboriginal Community Controlled Health Organisation.

5 Quote from a project site illustrating the benefits of the Talking About The Smokes project

“In our 2 years doing the Talking About The Smokes project, [our] Aboriginal Corporation has been able to engage with over 125 community members (smokers!!), allow a staff member to get paid, and allow a staff member to be in a leadership role in the community. These results from the 2 years will now feed into the Tobacco Action Group that is newly formed for [our] region. We supported World No Tobacco Day last year, with over 60 community members attending, and hope for a repeat this year.”

Matt Burke, OAM, Chief Executive Officer, Mungabareena Aboriginal Corporation, Wodonga, Victoria, March 2014 (with permission).

General practitioner management of notifiable diseases is central to communicable disease control

To the Editor: Public health units routinely carry out investigations into cases of notifiable diseases, specified by state and territory Public Health Acts, because of the potential impact on the health of the public. Investigations involve contacting individuals and their contacts, and providing advice for follow up and treatment. This may include seeing a general practitioner for further testing, treatment, or prophylaxis of contacts.1 To assess the extent of input from GPs in managing notifiable diseases we documented GP encounters related to public health unit communicable disease control activity in inner-western and south-western Sydney.

Data on routine communicable disease activity in Sydney and Sydney South West Local Health Districts were collected over 2 months from 1 June to 31 July 2014. For all investigations into suspected and confirmed cases of notifiable disease, data were collected on the type of condition, visits to GPs and tests specifically requested as part of routine public health follow-up. The study was approved by Sydney Local Health District Ethics Review Committee. There were 220 investigations associated with suspected or confirmed cases of 34 notifiable conditions during the study period, requiring 212 GP visits and 286 tests. The Box lists conditions according to their required level of GP input (those involving GP encounters more than 50% of the time were considered to require high-level GP input). Influenza and gastroenteritis outbreaks, typhoid, rubella, hepatitis E and measles were the conditions requiring the highest level of GP input per investigation. Measles, arbovirus, pertussis and gastroenteritis outbreaks were conditions with the highest frequency of suspected or confirmed cases that also required high-level GP input. Based on population size, we estimated that, if extrapolated to state level, communicable disease control activities would have resulted in about 1047 GP visits across New South Wales in the same time period.

Our findings indicate that GP encounters are central to communicable disease control and shed light on which conditions require the most input from GPs. Influenza outbreaks, measles and gastroenteritis outbreaks are of particular concern. Influenza outbreaks require particularly high-intensity input from GPs, while measles and gastroenteritis outbreaks are frequently investigated conditions that require high-level GP input. Influenza and measles are serious conditions, often involving vulnerable populations (nursing home residents and children).2,3 Our results indicate that primary care plays an important role in protecting the public from conditions with potentially serious consequences. This finding should be considered in policy discussions about access to primary care.

Visits to general practitioners and tests associated with communicable disease investigations

Condition or infection investigated
(suspected and confirmed cases)

No. of investigations

Average no.
of visits per investigation

Average no.
of tests per investigation

High-level GP input

      

Influenza outbreak*

5

14.8

20.2

Typhoid

1

9.0

17.0

Gastroenteritis outbreak†

17

2.1

3.7

Rubella

2

1.5

1.0

Hepatitis E

8

1.4

1.4

Measles

24

1.0

1.6

Varicella

1

1.0

1.0

Arbovirus

19

0.9

0.8

Pertussis

18

0.9

0.7

Legionella

9

0.8

0.9

Intermittent GP input

      

Hepatitis A

4

0.5

0.5

Q fever

2

0.5

1.0

MERS Co-V

2

0.5

1.0

Hepatitis B

7

0.4

0.4

Malaria

3

0.3

0.3

Shigella

11

0.2

0.3

< 16 Chlamydia‡

6

0.2

0.0

Salmonella

9

0.1

0.1

Cryptosporidiosis

11

0.1

0.0

No GP input

      

Rotavirus

5

0.0

0.0

Mumps

5

0.0

0.2

Meningococcal

7

0.0

0.0

Lymphogranuloma venereum

1

0.0

0.0

Invasive pneumoccocal disease

22

0.0

0.0

Hepatitis D

3

0.0

0.0

Hepatitis C

2

0.0

0.0

Haemophilis influenzae B

1

0.0

0.0

Diphtheria

4

0.0

0.5

Creutzfeldt–Jacob disease

1

0.0

0.0

Brucellosis

2

0.0

0.0

< 16 Gonorrhoea‡

1

0.0

0.0

MERS Co V =  Middle East Respiratory syndrome (MERS) coronavirus.
* Three or more epidemiologically linked cases of Influenza-like Illness in residents or staff of child care or aged care facilities within 72 hours PLUS at least one case with a positive laboratory test result OR at least two cases with a positive point-of-care test. † Two or more cases of vomiting or diarrhoea in an institution are followed up as a possible outbreak. ‡ Conditions followed up in children aged under 16 years only to ensure they are not at risk.

Use of nicotine replacement therapy and stop-smoking medicines in a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers

In 2012–2013, 44% of Aboriginal and Torres Strait Islander adults smoked, 2.5 times the age-standardised prevalence among other Australian adults, and 26% were ex-smokers.1 Although the proportion of those who had ever smoked and had successfully quit was only 37%, compared with 63% of other Australians, this had increased from 24% in 2002.1,2 Several types of nicotine replacement therapy (NRT; gum, patches, lozenges, sublingual tablets and inhalers) and two prescription-only stop-smoking medicines (SSMs; bupropion and varenicline) are available in Australia to assist cessation.3 All have been shown to increase the chance of successfully quitting, with varenicline and combinations of NRT being the most effective.4

Nicotine gum became available in Australia in the 1980s, followed by patches in the 1990s and other forms of NRT in the past decade.3 Over-the-counter availability of NRT occurred first in pharmacies, then supermarkets. Subsidised availability by prescription for patches followed listing with the Pharmaceutical Benefits Scheme (PBS) for veterans from 1994, Aboriginal and Torres Strait Islander people from 2009, and all others from 2011. Bupropion was listed on the PBS in 2001, and varenicline in 2008.3 Since 1999, Aboriginal health services in remote areas have been able to dispense these PBS items at no cost through Section 100 of the National Health Act 1953.5 In addition, since July 2010, many non-remote Aboriginal health services and general practices participating in the Indigenous Health Incentive of the Practice Incentives Program have been able to reduce or eliminate the copayment for all PBS medicines, including SSMs, for their Aboriginal and Torres Strait Islander patients.6

Clinical guidelines suggest that NRT, bupropion or varenicline be recommended to all dependent smokers who are interested in quitting.7–9 Here, we explore the use of these medicines and beliefs about them among a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers. We also explore variation in their use among dependent smokers in this population, and make comparisons with smokers in the general Australian population.

Methods

The Talking About The Smokes (TATS) project surveyed 1643 Aboriginal and Torres Strait Islander smokers and 78 recent ex-smokers (who had quit ≤ 12 months before), using a quota sampling design based on the communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait. It has been described in detail elsewhere.10,11 Briefly, the 35 sites were selected based on the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. In 30 sites, we aimed to interview 50 smokers or recent ex-smokers and 25 non-smokers, with equal numbers of women and men, and those aged 18–34 and ≥ 35 years. In four large city sites and the Torres Strait community, the sample sizes were doubled. People were excluded if they were aged under 18 years, not usual residents of the area, staff of the ACCHS or deemed unable to complete the survey. In each site, different locally determined methods were used to collect a representative, although not random, sample.

Baseline data were collected from April 2012 to October 2013. Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey was completed on a computer tablet and took 30–60 minutes. A single survey of health service activities was also completed at each site. The baseline sample closely matched the distribution of age, sex, jurisdiction, remoteness, quit attempts in the past year and number of daily cigarettes smoked reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.10

The TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project) collaboration. Interview questions were closely based on those in ITC Project surveys, especially the Australian surveys.12 We asked all smokers and recent ex-smokers whether they had ever used NRT or SSMs, and which they had used. For those who had used NRT, we asked if they were currently using it, when and for how long they last used it, where they got it and if it was free, and whether they would use it again in the future. We asked similar questions of those who had used SSMs. We asked all smokers and recent ex-smokers whether they thought NRT and SSMs help smokers to quit, and about their quit attempts and sociodemographic factors. The questions are described in detail in Appendix 1.

We used the Heaviness of Smoking Index (HSI) to assess dependence among daily smokers. The HSI was coded 0 to 6 based on the sum of the responses to two questions: cigarettes per day (CPD) and time to first cigarette (TTFC). These items were each coded as 0 (0–10 CPD; TTFC, ≥ 61 min), 1 (11–20 CPD; TTFC, 31–60 min), 2 (21–30 CPD; TTFC, 6–30 min) or 3 (≥ 31 CPD; TTFC, ≤ 5 min).13 We categorised HSI as low (0–1), moderate (2–3) or high (4–6).14,15 We also assessed the three criteria for dependence in the Royal Australian College of General Practitioners (RACGP) cessation guidelines: TTFC ≤ 30 min, > 10 CPD, and withdrawal symptoms on previous quit attempts (defined in our sample as strong cravings during the most recent quit attempt).7

TATS project results were compared with those of 1017 daily smokers surveyed in Wave 8 of the Australian ITC Project between July 2010 and May 2011. The ITC Project survey was completed by random digit telephone dialling or on the internet, and included smokers contacted for the first time and those who were recontacted after completing surveys in previous waves. For respondents who had completed surveys in previous waves, the ITC Project questions about use of NRT or SSMs were different to the TATS project questions, so for these comparisons we included only the 189 daily smokers who were newly recruited to the ITC Project.

The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees: Aboriginal Health & Medical Research Council Ethics Committee, Sydney; Aboriginal Health Research Ethics Committee, Adelaide; Central Australian HREC, Alice Springs; HREC for the Northern Territory Department of Health and Menzies School of Health Research, Darwin; and the Western Australian Aboriginal Health Ethics Committee, Perth.

Statistical analyses

We calculated the percentages and frequencies of responses to the TATS project questions, but did not include confidence intervals for these as it is not considered statistically acceptable to estimate sampling error in non-probabilistic samples. We compared results for daily smokers with those from the Australian ITC Project, which were directly standardised to the distribution of age and sex of Aboriginal and Torres Strait Islander smokers reported in the 2008 NATSISS.

Within the TATS project sample, we assessed the association between variables using logistic regression, with confidence intervals adjusted for the sampling design, using the 35 sites as clusters and the age–sex quotas as strata in Stata 13 (StataCorp) survey [SVY] commands).16 P values were calculated for each variable using adjusted Wald tests. However, we used χ2 tests to assess the association of variables with beliefs about whether NRT and SSMs help in quitting, and the association of past use with reasons for not intending to use them in the future. Median durations of NRT use are reported with interquartile ranges (IQRs) and were compared using the non-parametric equality of medians test.

Reported percentages and frequencies exclude those refusing to answer or answering “don’t know”, except for questions on future interest in NRT or SSM use and whether they help in quitting, which include those answering “don’t know”. Less than 2% of smokers and recent ex-smokers answered “don’t know” or refused to answer each of the questions analysed here.

Results

Compared with other daily Australian smokers in the ITC Project, lower proportions of Aboriginal and Torres Strait Islander daily smokers reported ever using any NRT or SSMs (37% [515/1379] v 58.5% [95% CI, 42.8%–72.6%]) and having used them in the past year (23% [318/1369] v 42.1% [95% CI, 29.4%–56.0%]).

Among all Aboriginal and Torres Strait Islander smokers and recent ex-smokers in the TATS project sample, 29% (501/1700) had ever used NRT and 11% (193/1700) had used SSMs. Nicotine patches were the most commonly used, by 24% (415/1699), followed by varenicline (11%; 183/1699), nicotine gum (10%; 174/1699), lozenges (3%; 50/1699), and inhalers (3%; 50/1699). Only 1% (17/1699) had used bupropion.

Of the Aboriginal and Torres Strait Islander smokers and recent ex-smokers who had used NRT within the past year, most had last got it from an Aboriginal medical service (46%; 99/216), pharmacy (31%; 66/216) or another local health service (15%; 32/216), with only 3% (6/216) getting it from an ordinary store. Three-quarters (74%; 161/217) got their NRT at no cost, including almost all who got it from an Aboriginal medical service (93%; 92/99) or another local health service (91%; 29/32).

Of the Aboriginal and Torres Strait Islander smokers and recent ex-smokers who had used NRT within the past year but were currently not using it, only 9% (16/174) had used it for the recommended period of more than 2 months;7–9 49% (85/174) used it for a week or less and 79% (138/174) for a month or less. The median duration of NRT use was 14 days (IQR, 3–30 days), with no significant differences by HSI score or whether it was free.

Aboriginal and Torres Strait Islander daily smokers who were more dependent, according to the HSI and RACGP criteria, were more likely to have ever used NRT or SSMs than those who were less dependent (Box 1). Fewer non-daily smokers than daily smokers or recent ex-smokers had ever used them. These associations were similar but less marked for use in the past year.

Among Aboriginal and Torres Strait Islander smokers who were at least moderately dependant (HSI score ≥ 2), the group for whom NRT and SSMs are recommended, those who were socioeconomically advantaged were more likely than the disadvantaged to have ever used NRT or SSMs and to have used them in the past year (Box 2). Use decreased with increasing remoteness and area-level disadvantage, increased with education, and was lower among those who reported being treated unfairly in the past year because they were Indigenous. Use also increased with age and was higher among smokers whose local health service had dedicated tobacco control resources. Those who were socioeconomically disadvantaged were even less likely to use SSMs than NRT (Appendix 2).

Most Aboriginal and Torres Strait Islander daily smokers said NRT and SSMs help smokers to quit: 70% said they help “very much” or “somewhat”, 16% said “not at all” and 14% did not know (Box 3). Similarly, the Australian ITC Project reported that 74.2% (95% CI, 68.9%–78.9%) of Australian daily smokers agreed that NRT and SSMs would make it easier to quit, 11.0% (95% CI, 8.7%–13.8%) disagreed, and 14.8% (95% CI, 10.8%–20.0%) neither agreed nor disagreed or did not know.

Having used NRT or SSMs was strongly associated with Aboriginal and Torres Strait Islander smokers believing that they help in quitting. Heavy smokers were more likely to believe that they would not help at all (Box 3).

Dependent Aboriginal and Torres Strait Islander smokers who believed NRT and SSMs would help in quitting and those who had used them (ever or in the past year) were more likely to be interested in using them in the future (Box 4). Frequency of strong urges to smoke and strong cravings on the most recent quit attempt were not associated with interest in future use of NRT and SSMs (data not shown).

The main reasons given by dependent smokers who were not interested in using NRT and SSMs in future were that they were not ready to quit (NRT, 36% [162/445]; SSMs, 29% [131/449]), because of side effects (19% [85/445]; 25% [114/449]), they did not think they would work (18% [81/445]; 16% [73/449]) and they preferred not to use them (16% [73/445]; 18% [82/449]). Cost was rarely mentioned as a reason (3% [15/445]; 2% [10/449]). There were significant differences between the reasons given by those who had and had not used NRT or SSMs in the past year (P < 0.001). Those who had used NRT were more likely than those who had not to say they would not use it in the future because of side effects (45% [26/58] v 15% [59/386]) and were less likely to report not being ready to quit (12% [7/58] v 40% [155/386]).

Discussion

We found lower use of NRT and SSMs among daily smokers in a large nationally representative Aboriginal and Torres Strait Islander sample than among those in the general Australian population. This is consistent with research in various countries that has found that smokers from more disadvantaged groups are less likely to use these medicines.17,18 We also found a social gradient of reducing use with increasing disadvantage (including perceived experiences of racism) within the Aboriginal and Torres Strait Islander community. Consistent with previous research, we found this gradient was steeper for the use of varenicline (bupropion accounted for very little of the SSM use) than for NRT.18,19

In recent years, many ACCHSs and their government funders have increased their focus on, and directed significant resources towards, tobacco control and cessation support. Our finding of greater use of SSMs by smokers whose local ACCHS had dedicated tobacco control resources provides some evidence for the effect of these policy decisions. We explore other non-pharmacological cessation support elsewhere in this supplement.20

Early research into Aboriginal and Torres Strait Islander smokers’ use of SSMs focused on the disincentive of the cost of NRT, and interventions to subsidise or provide free NRT.21–24 Covering the costs of treatment has been demonstrated to increase the use of NRT and bupropion in other contexts.25,26 Following policy changes, we found that nearly three-quarters of participants had got their most recent NRT at no cost, removing this financial impediment to its use. Unlike earlier research, cost was rarely given as a reason in our survey for not intending to use NRT or SSMs in the future.21,23 While some smokers are still paying a proportion of the cost, it is reassuring that policies to provide access to free NRT seem to be effectively reaching many Aboriginal and Torres Strait Islander smokers.

It is encouraging that a similar proportion of Aboriginal and Torres Strait Islander daily smokers as those in the broader Australian population think these medicines assist cessation. Further, Aboriginal and Torres Strait Islander smokers who were more dependent were more likely than the less dependent to have used them, in accordance with current clinical guidelines. However, there is still opportunity to improve their use. The clinical guidelines can be better promoted during the training and ongoing education of clinicians and tobacco control workers, to enable more frequent discussion about them with smokers. There remains a large proportion of Aboriginal and Torres Strait Islander smokers who have never used these medicines, are less likely to think they help and less likely to use them in the future, who could be informed about their effectiveness in assisting quitting.27

The frequent use of NRT for much less than the recommended 8 weeks is similar to earlier reports in this population; likewise, the median duration was similar to those found in other research in Australia and elsewhere, particularly the shorter durations reported when NRT is available over the counter rather than by prescription.22,28–31 Research into the common reasons for stopping NRT and SSMs (resuming smoking, side effects and the belief that it has already worked) suggests that these are generally legitimate and may not be cause for great concern. For example, data from other ITC Project surveys show that 66% of those who stopped early because they believed that they no longer needed the medication were still abstinent at 6 months.30

There has been a significant increase in the use of SSMs in Australia in recent years, especially associated with the release of varenicline in 2008.32 The release of new varieties of NRT and other SSMs has also been shown to be associated with this increase in the total use of SSMs, often with very little compensatory decline in the use of older medicines.19,26,32 We found that a variety of types of NRT were used (most commonly patches), as well as varenicline and a small amount of bupropion. The range of NRT formulations and other medicines is likely to increase in the future.3 The potential impact of e-cigarettes as an aid to cessation remains unclear and contested.33,34

Strengths and limitations

The main strength of our study is its large national sample of Aboriginal and Torres Strait Islander smokers, providing the first detailed national information about the use of NRT and SSMs in this population. However, it is a non-random, albeit broadly representative, sample, and caution is needed in interpreting the comparisons with the Australian ITC Project sample and in generalising the results to the whole Aboriginal and Torres Strait Islander population. The use of NRT or SSMs in our sample of Aboriginal and Torres Strait Islander people in communities served by ACCHSs may be different to that in communities without access to an ACCHS, who use private general practices. Our self-reported data are probably limited by incomplete recall of past use of NRT and SSMs and quit attempts. The effect of these biases will be to weaken reported associations, leading to greater confidence in the significant associations but requiring caution in the implications of findings of no association.

1 Aboriginal and Torres Strait Islander use of nicotine replacement therapy (NRT) or stop-smoking medicines (SSMs)

 

Ever used NRT or SSMs

Used NRT or SSMs in the past year

Smoking characteristic

% (frequency)*

Odds ratio (95% CI)†

P‡

% (frequency)*

Odds ratio (95% CI)†

P‡

Smokers and recent ex-smokers (n = 1721)

            

Smoking status

            

Daily smokers

37% (515)

1.0

< 0.001

23% (318)

1.0

0.001

Non-daily smokers

17% (43)

0.35 (0.24–0.51)

  

12% (30)

0.46 (0.29–0.73)

  

Recent ex-smokers§

36% (28)

0.94 (0.57–1.55)

32% (25)

1.59 (0.95–2.66)

  

Daily smokers only (n = 1369)

            

Heaviness of Smoking Index score

            

Low (0–1)

30% (69)

1.0

< 0.001

18% (42)

1.0

0.06

Moderate (2–3)

36% (284)

1.34 (1.00–1.81)

  

23% (184)

1.39 (0.92–2.08)

  

Heavy (4–6)

45% (148)

1.98 (1.42–2.76)

  

27% (86)

1.65 (1.08–2.51)

  

RACGP criteria for dependence

            

None

24% (38)

1.0

< 0.001

13% (20)

1.0

< 0.001

One

27% (91)

1.23 (0.78–1.92)

  

17% (55)

1.38 (0.84–2.28)

  

Two

35% (192)

1.71 (1.12–2.61)

  

21% (118)

1.89 (1.11–3.22)

  

All three

59% (193)

4.66 (2.99–7.27)

  

39% (125)

4.39 (2.56–7.51)

  

RACGP = Royal Australian College of General Practitioners. * Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † Odds ratios calculated using simple logistic regression adjusted for the sampling design. ‡ P values for the entire variable, using adjusted Wald tests. § Those who had quit ≤ 12 months before. ¶ Time to first cigarette ≤ 30 min, > 10 cigarettes per day, and withdrawal symptoms on previous quit attempts (strong cravings during most recent quit attempt).

 

2 Use of nicotine replacement therapy (NRT) or stop-smoking medicines (SSMs) by dependent Aboriginal and Torres Strait Islander smokers,* by sociodemographic factors (n = 1124)

 

Ever used NRT or SSMs

Used NRT or SSMs in the past year

Sociodemographic factor

% (frequency)†

Odds ratio (95% CI)‡

P§

% (frequency)†

Odds ratio (95% CI)‡

P§

All dependent smokers

39% (432)

    

24% (270)

    

Age (years)

   

0.002

    

0.08

18–24

28% (59)

1.0

  

18% (39)

1.0

  

25–34

35% (102)

1.43 (0.98–2.08)

  

23% (67)

1.35 (0.91–2.02)

  

35–44

40% (112)

1.78 (1.12–2.83)

  

24% (65)

1.37 (0.85–2.23)

  

45–54

44% (86)

2.07 (1.29–3.33)

  

29% (55)

1.78 (1.12–2.83)

  

≥ 55

53% (73)

3.00 (1.79–5.01)

  

32% (44)

2.13 (1.25–3.64)

  

Sex

    

0.18

    

0.11

Female

41% (233)

1.0

  

27% (150)

1.0

  

Male

36% (199)

0.80 (0.58–1.11)

  

22% (120)

0.77 (0.55–1.07)

  

Indigenous status

    

0.14

    

0.76

Aboriginal

40% (398)

1.0

  

25% (245)

1.0

  

Torres Strait Islander or both

31% (34)

0.70 (0.44–1.12)

  

23% (25)

0.93 (0.56–1.52)

  

Labour force status

    

< 0.001

    

0.02

Employed

45% (166)

1.0

  

29% (105)

1.0

  

Unemployed

30% (113)

0.51 (0.38–0.70)

  

20% (76)

0.62 (0.45–0.86)

  

Not in labour force

41% (151)

0.85 (0.64–1.14)

  

24% (88)

0.80 (0.56–1.14)

  

Highest education attained

    

0.001

    

0.03

Less than Year 12

35% (206)

1.0

  

21% (127)

1.0

  

Finished Year 12

38% (109)

1.18 (0.88–1.58)

  

26% (73)

1.28 (0.92–1.78)

  

Post-school qualification

50% (115)

1.90 (1.36–2.67)

  

30% (68)

1.58 (1.12–2.23)

  

Treated unfairly because Indigenous in past year

    

0.01

    

0.02

No

43% (207)

1.0

  

28% (135)

1.0

  

Yes

35% (214)

0.71 (0.54–0.92)

  

21% (129)

0.68 (0.50–0.93)

  

Remoteness

    

0.002

    

0.03

Major cities

43% (127)

1.0

  

29% (85)

1.0

  

Inner and outer regional

41% (239)

0.94 (0.60–1.47)

  

25% (141)

0.80 (0.53–1.20)

  

Remote and very remote

27% (66)

0.50 (0.31–0.80)

  

18% (44)

0.54 (0.34–0.86)

  

Area-level disadvantage

    

0.03

    

0.02

1st quintile (most disadvantaged)

33% (141)

1.0

  

19% (81)

1.0

  

2nd and 3rd quintiles

41% (189)

1.40 (1.01–1.94)

  

27% (122)

1.54 (1.09–2.17)

  

4th and 5th quintiles

45% (102)

1.64 (1.07–2.51)

  

30% (67)

1.78 (1.10–2.87)

  

Local health service has dedicated tobacco control resources

    

0.006

    

0.003

No

31% (97)

1.0

  

18% (57)

1.0

  

Yes

42% (335)

1.66 (1.16–2.37)

27% (213)

1.70 (1.20–2.39)

* Daily smokers with Heaviness of Smoking Index scores ≥ 2. † Percentages and frequencies exclude those answering “don’t know” or refusing to answer. ‡ Odds ratios calculated using simple logistic regression adjusted for the sampling design. § P values for the entire variable, using adjusted Wald tests.

3 Aboriginal and Torres Strait Islander smokers and recent ex-smokers’ beliefs about whether nicotine replacement therapy (NRT) and stop-smoking medicines (SSMs) help smokers to quit*

 

Do you think NRT and SSMs help smokers to quit?

Smoker characteristics

Very much

Somewhat

Not at all

Don’t know or haven’t heard of them

P†

Smokers and recent ex-smokers (n = 1721)

20% (337)

51% (867)

16% (274)

14% (234)‡

  

Ever used NRT or SSMs

        

< 0.001

Yes

31% (179)

55% (324)

9% (50)

5% (32)

  

No

14% (158)

48% (541)

20% (223)

18% (196)

  

Used NRT or SSMs in the past year

        

< 0.001

Yes

35% (132)

53% (197)

7% (27)

5% (17)

  

No

15% (203)

50% (659)

19% (245)

16% (211)

  

Smoking status

        

0.2

Daily smokers

19% (268)

51% (700)

16% (218)

14% (197)

  

Non-daily smokers

18% (45)

53% (132)

18% (44)

12% (30)

  

Recent ex-smokers§

31% (24)

45% (35)

15% (12)

9% (7)

Daily smokers only (n = 1383)

Heaviness of Smoking Index score

        

0.007

Low (0–1)

17% (39)

49% (115)

14% (33)

20% (46)

  

Moderate (2–3)

20% (161)

53% (416)

14% (112)

13% (103)

  

Heavy (4–6)

19% (61)

46% (149)

22% (70)

14% (45)

  

* Percentages and frequencies exclude those answering “don’t know” or refusing to answer, except for whether NRT and SSMs help, which do include those answering “don’t know”. † P values were calculated using the χ2 test adjusted for sampling design. ‡ Comprises 19 smokers and recent ex-smokers who had not heard of NRT and SSMs, and 215 who did not know if they helped smokers to quit. § Those who had quit ≤ 12 months before.

4 Interest in using nicotine replacement therapy (NRT) or stop-smoking medicines (SSMs) to help quit smoking in the future among dependent Aboriginal and Torres Strait Islander smokers* (n = 1124)

 

Interested in using NRT in the future

Interested in using SSMs in the future
 

% (frequency)†

Odds ratio (95% CI)‡

P§

% (frequency)†

Odds ratio (95% CI)‡

P§

Variable

Yes

No

Don’t know

Yes

No

Don’t know

All dependent smokers

54% (608)

41% (462)

4% (47)

    

51% (575)

42% (470)

7% (73)

    

Think NRT and SSMs help smokers to quit

        

< 0.001

        

< 0.001

Not at all

24% (43)

73% (132)

4% (7)

1.0

  

23% (42)

74% (134)

3% (6)

1.0

  

Somewhat

59% (335)

37% (211)

3% (19)

4.87
(3.19–7.45)

  

58% (325)

37% (209)

5% (31)

4.96
(3.18–7.73)

  

Very much

80% (177)

18% (40)

2% (4)

13.58
(8.29–22.26)

  

74% (164)

23% (51)

3% (7)

10.26
(6.3–16.7)

  

Don’t know or haven’t heard of them

36% (53)

53% (78)

11% (17)

    

30% (44)

51% (75)

20% (29)

    

Ever used NRT or SSMs

        

< 0.001

        

< 0.001

No

48% (352)

48% (354)

5% (34)

1.0

  

48% (461)

46% (438)

6% (62)

1.0

  

Yes

69% (255)

29% (106)

2% (8)

2.42
(1.82–3.22)

  

75% (112)

21% (31)

4% (6)

3.43
(2.22–5.31)

  

Used NRT or SSMs in the past year

        

< 0.001

        

< 0.001

No

49% (427)

46% (401)

5% (41)

1.0

  

49% (499)

45% (454)

6% (65)

1.0

  

Yes

74% (176)

25% (60)

1% (2)

2.75
(1.95–3.90)

  

78% (72)

17% (16)

4% (4)

4.09
(2.21–7.57)

  

Heaviness of Smoking Index score

        

0.05

        

< 0.001

Moderate (2–3)

56% (446)

39% (311)

4% (34)

1.0

  

53% (418)

41% (323)

6% (51)

1.0

  

Heavy (4–6)

50% (162)

46% (151)

4% (13)

0.75
(0.56–0.99)

  

48% (157)

45% (147)

7% (22)

0.83
(0.62–1.09)

  

* Daily smokers with Heaviness of Smoking Index scores ≥ 2. † Percentages and frequencies exclude those answering “don’t know” or refusing to answer, except for questions on future interest in NRT or SSM use and whether they help in quitting, which include those answering “don’t know”. ‡ Odds ratios calculated using simple logistic regression adjusted for the sampling design. § P values for the entire variable, using adjusted Wald tests.

Smoking cessation advice and non-pharmacological support in a national sample of Aboriginal and Torres Strait Islander smokers and ex-smokers

Quitting smoking reduces the risk of smoking-related death, with greater benefits from quitting at a younger age.1 Receiving brief advice to quit from health professionals and more intensive support from specialist clinics and courses, stop-smoking medicines, telephone quitlines, websites and printed materials have been shown to increase successful quitting.2–8 In Australia, just over half of smokers have been recently advised to quit, and a similar proportion of those who have tried to quit have used stop-smoking medicines.9,10 Fewer smokers are referred to or use other cessation support services.9–11

In 2012–2013, Aboriginal and Torres Strait Islander adults had 2.5 times the smoking prevalence of other Australian adults, and those who had ever smoked were less likely to have successfully quit (37% v 63%).12 There is a long history of widespread training in how to give brief advice for health professionals working with Aboriginal and Torres Strait Islander peoples.13 In recent years, the national Tackling Indigenous Smoking program has increased funding to support this training, enhancement of the telephone Quitline service to be more culturally appropriate, and other local cessation support activities.14

Here, we describe recall among a national sample of Aboriginal and Torres Strait Islander smokers and recent ex-smokers of having received advice to quit smoking and referral to non-pharmacological cessation support from health professionals, and examine the association of advice and referrals with making a quit attempt. We examine the use of stop-smoking medicines elsewhere in this supplement.15

Methods

The Talking About The Smokes (TATS) project surveyed 1643 Aboriginal and Torres Strait Islander smokers and 78 recent ex-smokers (who had quit ≤ 12 months before), using a quota sampling design based on the communities served by 34 Aboriginal community-controlled health services (ACCHSs) and one community in the Torres Strait. It has been described in detail elsewhere.16,17 Briefly, the 35 sites were selected based on the distribution of the Aboriginal and Torres Strait Islander population by state or territory and remoteness. In 30 sites, we aimed to interview 50 smokers or recent ex-smokers and 25 non-smokers, with equal numbers of women and men, and those aged 18–34 and ≥ 35 years. In four large city sites and the Torres Strait community, the sample sizes were doubled. People were excluded if they were aged under 18 years, not usual residents of the area, staff of the ACCHS or deemed unable to complete the survey. In each site, different locally determined methods were used to collect a representative, although not random, sample.

Baseline data were collected from April 2012 to October 2013. Interviews were conducted face to face by trained interviewers, almost all of whom were members of the local Aboriginal and Torres Strait Islander community. The survey was completed on a computer tablet and took 30–60 minutes. A single survey of health service activities was also completed at each site. The baseline sample closely matched the distribution of age, sex, jurisdiction, remoteness, quit attempts in the past year and number of daily cigarettes smoked reported in the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). However, there were inconsistent differences in some socioeconomic indicators: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas.16

We asked all smokers and recent ex-smokers whether they had seen a health professional in the past year and, if so, whether they had been asked if they smoke and, if so, whether they had been encouraged to quit. We asked those who had been encouraged to quit about pamphlets or referrals to the Quitline, quit-smoking websites, or quit courses or clinics they had received. We also asked all smokers and recent ex-smokers whether they had sought out these services themselves, and about quit attempts and sociodemographic factors. At each site, we asked questions about tobacco control funding and staff positions to determine if the health service had resources dedicated to tobacco control. The questions reported here are described in detail in Appendix 1.

The TATS project is part of the International Tobacco Control Policy Evaluation Project (ITC Project) collaboration. Interview questions were closely based on those in ITC Project surveys, especially the Australian surveys.18 TATS project results were compared with those of 1412 daily smokers newly recruited to Waves 5–8 (2006–2011) of the Australian ITC Project. The ITC Project survey was conducted by random digit telephone dialling. We only used data from the newly recruited participants as questions for recontacted participants referred to advice received since the previous survey rather than in the past year. Slightly different definitions of smokers between the TATS project and ITC Project surveys meant that only daily and weekly smoker categories were directly comparable. We concentrated our comparisons on daily smokers. We have also concentrated our other descriptions of recall of advice and associations between variables within the TATS sample on daily smokers.

The project was approved by three Aboriginal human research ethics committees (HRECs) and two HRECs with Aboriginal subcommittees: Aboriginal Health & Medical Research Council Ethics Committee, Sydney; Aboriginal Health Research Ethics Committee, Adelaide; Central Australian HREC, Alice Springs; HREC for the Northern Territory Department of Health and Menzies School of Health Research, Darwin; and the Western Australian Aboriginal Health Ethics Committee, Perth.

Statistical analyses

We calculated the percentages and frequencies of responses to the TATS project questions, but did not include confidence intervals for these as it is not considered statistically acceptable to estimate sampling error in non-probabilistic samples. We compared results for daily smokers with those in the Australian ITC Project surveys, which were directly standardised to the distribution of age and sex of Aboriginal and Torres Strait Islander smokers reported in the 2008 NATSISS.

Within the TATS project sample, we assessed the association between variables using simple logistic regression, with confidence intervals adjusted for the sampling design, using the 35 sites as clusters and the age–sex quotas as strata in Stata 13 (StataCorp) survey [SVY] commands.19 P values were calculated using adjusted Wald tests.

Reported percentages and frequencies exclude those refusing to answer or answering “don’t know”, leading to minor variations in denominators between questions. Less than 2% of daily smokers answered “don’t know” or refused to answer each of the questions analysed here.

Results

Three-quarters of Aboriginal and Torres Strait Islander daily smokers (76%) reported having seen a health professional in the past year (Box 1). Of these, 93% said they were asked if they smoked, and 75% also reported being advised to quit. These proportions are higher than those among Australian daily smokers in the ITC Project.

Within the TATS project sample, Aboriginal and Torres Strait Islander daily smokers who had been advised to quit by a health professional had twice the odds of having made a quit attempt in the past year, compared with those who did not recall being advised to quit (Box 2).

The proportion of Aboriginal and Torres Strait Islander daily smokers who had been advised to quit increased with age and was higher among women, those with post-school qualifications and those whose local health service had dedicated tobacco control resources; the proportion was lower among the unemployed (Box 3). There was more sociodemographic variation in having seen a health professional than in recalling being advised to quit (Appendix 2).

Among all Aboriginal and Torres Strait Islander smokers and ex-smokers who were advised to quit, 49% were given a pamphlet or brochure on how to quit, and lower proportions were referred to the telephone Quitline (28%), a quit-smoking website (27%) or a local quit course, group or clinic (16%) (Box 4). Most of those who received pamphlets said they read them (70%, 321/457), but lower proportions reported following up on other referrals. Daily smokers who were referred to each resource were non-significantly more likely to have made a quit attempt in the past year than those who had been advised to quit but not referred (Box 2). We also found that 13% of smokers and recent ex-smokers (215/1696) had sought out quit information or services themselves, and that 62% (1047/1692) had been encouraged by family or friends to quit or to maintain a quit attempt.

A higher proportion of the Aboriginal and Torres Strait Islander daily smokers who had been advised to quit by a health professional in the past year had been given a pamphlet, compared with other Australian daily smokers in the ITC Project (50% [390/778] v 29.6% [95% CI, 25.4%–34.3%]).

Discussion

Daily smokers in our Aboriginal and Torres Strait Islander sample were more likely than those in the broader Australian ITC Project sample to recall having been advised to quit by a health professional in the past year. This was in part due to being more likely to have been seen by a health professional, but mainly due to a greater proportion of those seen being advised to quit.

Strengths and limitations

The main strength of this study is its large, nationally representative sample of Aboriginal and Torres Strait Islander smokers and ex-smokers. However, the sample was not random and there were some sociodemographic differences compared with a random sample of the population.16

Our survey was conducted face to face, whereas the comparison Australian ITC Project surveys were conducted by telephone, potentially leading to differential social desirability bias. Further, some ITC Project surveys were conducted much earlier than the TATS project survey, and although many questions were identical on both surveys, the order and structure of the comparison ITC Project questionnaire was different. While we are confident that the large difference in recall of health professional advice between the TATS project and ITC Project samples is real, we have not described the differences in referral to cessation support as, except for the question about pamphlets, the questions were not directly comparable.

The main limitation of our study is that partnering with ACCHSs to recruit participants may have led to a selection bias towards people with closer connections to the health services, inflating the percentage who recalled being seen by a health professional. However, this percentage was similar to that reported in the 2004–2005 National Aboriginal and Torres Strait Islander Health Survey.16 We also report a higher prevalence of having received advice among only those who had seen a health professional, which would be less affected by this bias. Our results are also based on patient recall, not clinical records. Australian general practice research has found that clinical records poorly record health advice and poorly agree with patient recall of referrals to other cessation services.10 Some patients will have misremembered or forgotten advice and referrals they received, but we would expect that advice and referrals that were useful for quitting would be more likely to be remembered.

Comparisons with other studies

The proportion of smokers who had seen a health professional and recalled being asked if they smoke was similar to that among a sample of pregnant Aboriginal and Torres Strait Islander women who smoked, who were only slightly more likely to be advised to quit (81% of pregnant smokers v 75% of daily smokers in our sample).20

SmokeCheck, a commonly used training program to increase health professionals’ skills in giving brief quit-smoking advice to Aboriginal and Torres Strait Islander patients, has been shown to improve participants’ confidence in regularly providing brief advice.21,22 The long history of such training programs, along with support for and promotion of brief interventions in ACCHSs, may have contributed to advice being given more often to Aboriginal and Torres Strait Islander smokers than other smokers.

We found that the likelihood of receiving advice to quit from health professionals increased with participant age, as in earlier Australian ITC Project research.9 Most of the focus of chronic disease prevention is on older patients, but there is an opportunity to increase the provision of advice about smoking to younger patients.

Our finding that a high proportion of Aboriginal and Torres Strait Islander daily smokers recalled receiving this advice is encouraging, as even brief advice from a doctor increases cessation, with minimal additional benefit from more extensive advice or follow-up.2 Provision of brief advice is achievable even in very busy primary care settings and, as we found, can reach most of the population. In both urban and remote settings, Aboriginal and Torres Strait Islander interviewees in qualitative research have emphasised that advice and support from health professionals was a significant factor in their quit attempts.23–25 Consistent with this, we found that recalling advice from a health professional to quit was associated with making a quit attempt. While it is possible that making an attempt may increase the likelihood of advice being recalled, or may have led to making a visit to a health professional, it seems reasonable to conclude that advice from health professionals is contributing to Aboriginal and Torres Strait Islander smokers’ motivation to try to quit.

The frequent use of pamphlets by Aboriginal and Torres Strait Islander smokers is positive but not likely to have much impact on cessation, as the additional effect of such printed material is only modest.6 In contrast, Cochrane reviews show a greater effect on cessation of telephone quitlines, more intensive individual counselling outside primary care, and quit groups.4,7,8 Currently, evidence for internet-based quit support is inconsistent but promising.5

A meta-analysis of two randomised controlled trials showed intensive cessation counselling programs for Aboriginal and Torres Strait Islander smokers were effective in increasing cessation.26 We found that most people who attended special cessation programs said they were specifically designed for Aboriginal and Torres Strait Islander peoples.

Quitlines can be a cost-effective element in cessation support, but there has been a perception of distrust and low usage of quitlines by Aboriginal and Torres Strait Islander people.13 In 2010, Aboriginal and Torres Strait Islander callers to the Quitline in South Australia received fewer calls back and were less likely to have successfully quit than non-Indigenous callers.27 Since then, the Tackling Indigenous Smoking program has funded activity to improve the appropriateness and accessibility of the Quitline.

These non-pharmacological cessation support options benefit smokers who use them, but we found that most do not, as has been found in other contexts.9–11 Indigenous and non-Indigenous Australian research has shown that many smokers see using cessation support as a sign of weakness and lack of willpower, which is a challenge in promoting these evidence-based services.24,28

1 Daily smokers’ recall of receiving advice to quit when seeing a health professional in the past year*

 

Australian ITC Project, % (95% CI)†

TATS project, % (frequency)‡

Seen a health professional

68.1% (64.8%–71.1%)

76% (1047)

Of those seen

    

Asked if he/she smokes§

—

93% (968)

Advised to quit

56.2% (52.3%–59.9%)

75% (782)

ITC Project = International Tobacco Control Policy Evaluation Project. TATS = Talking About The Smokes. * Percentages and frequencies exclude refused responses and “don’t know” responses. † Results are for daily smokers (n = 1412) newly recruited to Waves 5–8 of the Australian ITC Project (2006–2011) and were age- and sex-standardised to smokers in the 2008 National Aboriginal and Torres Strait Islander Social Survey. ‡ Results are for Aboriginal and Torres Strait Islander daily smokers (n = 1377) in the baseline sample of the TATS project (April 2012 – October 2013). § Not asked in the Australian ITC Project.

2 Aboriginal and Torres Strait Islander daily smokers who made a quit attempt in the past year, by recall of being advised to quit and referred to cessation support

 

Attempted to quit in the past year
 

% (frequency)*

Odds ratio (95% CI)†

P‡

All daily smokers (n = 1354)

      

Advised to quit by a health professional in the past year

    

< 0.001

No

39% (223)

1.0

  

Yes

56% (433)

2.00 (1.58–2.52)

  

If advised to quit by a health professional in the past year (n = 777)§

      

Given a pamphlet

    

0.053

No

52% (203)

1.0

  

Yes

60% (230)

1.34 (1.00–1.79)

  

Referred to telephone Quitline

    

0.15

No

55% (306)

1.0

  

Yes

60% (125)

1.25 (0.92–1.68)

  

Referred to quit-smoking website

    

0.48

No

55% (305)

1.0

  

Yes

58% (121)

1.13 (0.80–1.6)

  

Referred to quit course, group or clinic

    

0.19

No

55% (357)

1.0

  

Yes

61% (73)

1.30 (0.88–1.92)

  

* Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † Odds ratios calculated using simple logistic regression adjusted for the sampling design. ‡ P values calculated using adjusted Wald tests. § Only participants who recalled being advised to quit by a health professional were asked about referral to cessation support resources.

3 Aboriginal and Torres Strait Islander daily smokers who recalled being advised to quit by a health professional in the past year, by sociodemographic factors (n = 1366)

 

Advised to quit by a health professional

Characteristic

% (frequency)*

Odds ratio (95% CI)†

P‡

Total

57% (782)

    

Age (years)

   

0.001

18–24

48% (136)

1.0

  

25–34

55% (203)

1.29 (0.93–1.79)

  

35–44

58% (188)

1.47 (1.01–2.16)

  

45–54

62% (145)

1.72 (1.15–2.57)

  

≥ 55

71% (110)

2.61 (1.67–4.06)

  

Sex

   

0.003

Male

52% (342)

1.0

  

Female

62% (440)

1.50 (1.15–1.95)

  

Indigenous status

   

0.74

Aboriginal

57% (694)

1.0

  

Torres Strait Islander or both

59% (88)

1.07 (0.73–1.56)

  

Labour force status

    

< 0.001

Unemployed

48% (226)

1.0

  

Not in labour force

65% (273)

2.00 (1.47–2.71)

  

Employed

59% (282)

1.57 (1.20–2.05)

  

Highest education attained

    

0.007

Less than Year 12

54% (380)

1.0

  

Finished Year 12

57% (206)

1.17 (0.91–1.51)

  

Post-school qualification

66% (194)

1.72 (1.23–2.41)

  

Treated unfairly because Indigenous in past year

    

0.72

No

58% (342)

1.0

  

Yes

57% (423)

0.96 (0.75–1.22)

  

Remoteness

   

0.33

Major cities

54% (194)

1.0

  

Inner and outer regional

60% (430)

1.25 (0.86–1.81)

  

Remote and very remote

54% (158)

0.98 (0.64–1.52)

  

Area-level disadvantage

    

0.18

1st quintile (most disadvantaged)

55% (285)

1.0

  

2nd and 3rd quintiles

61% (357)

1.28 (0.94–1.74)

  

4th and 5th quintiles

54% (140)

0.97 (0.68–1.38)

  

Local health service has dedicated tobacco control resources

    

0.05

No

52% (207)

1.0

  

Yes

60% (575)

1.38 (1.00–1.91)

  

* Percentages and frequencies exclude those answering “don’t know” or refusing to answer. † Odds ratios calculated using simple logistic regression adjusted for the sampling design. ‡ P values calculated for the entire variable, using adjusted Wald tests.

4 Aboriginal and Torres Strait Islander smokers and recent ex-smokers who recalled receiving or being referred to cessation support resources when advised to quit by a health professional (n = 960)*

 

Pamphlet

Quit-smoking website

Telephone Quitline

Quit course, group or clinic

Received information or a referral

49% (460)

27% (252)

28% (266)

16% (149)

If so, read, used or attended it

70% (321)

22% (54)

16% (43)

44% (65)

If so, it was specifically for Aboriginal and Torres Strait Islander peoples

52% (168)

48% (26)

44% (18)

88% (56)

* Data only include smokers and recent ex-smokers who recalled being advised by a health professional to quit. Percentages and frequencies exclude those answering “don’t know” or refusing to answer.

AMA proposes pharmacy and GP team to improve patient care

The AMA has provided the Federal Government with their proposal to integrate non—dispensing pharmacists as a key part of the general practice health care team.

According to AMA President, A/Prof Brian Owler, the ‘Pharmacist in General Practice Incentive Program (PGPIP)’ would create greater efficiencies for general practices, better care for patients, new career opportunities for pharmacists, and significant Budget savings across the whole health system.

“Under this program, pharmacists within general practice would assist with things such as medication management, providing patient education on their medications, and supporting GP prescribing with advice on medication interactions and newly available medications,” A/Prof Owler said.

“Evidence shows that the AMA plan would reduce fragmentation of patient care, improve prescribing and use of medicines, reduce hospital admissions from adverse drug events (ADE), and deliver better health outcomes for patients.”

The proposal is backed by an independent analysis from the highly respected Deloitte Access Economics, which shows that the AMA proposal delivers a benefit-cost ratio of 1.56, which means that every $1 invested in the program generates $1.56 in savings to the health system.

Deloitte Access Economics estimates that, if 3,100 general practices took up the PGPIP, it would cost the Federal Government $969.5 million over four years. However, this would be more than offset through broader savings to the health system in the following areas:

  • hospital savings of $1.266 billion – due to reduced number of hospital admissions following a severe ADE;
  • PBS savings of $180.6 million – due to the reduced number of prescriptions from better prescribing and medication compliance;
  • individual patient savings of $49.8 million – reduced co-payments for medical consultations and medicines; and.
  • MBS savings of $18.1 million – due to reduced number of GP attendances following a moderate or severe ADE.

The AMA has developed this model in consultation with the Pharmaceutical Society of Australia (PSA), and it has the full backing of the PSA.

The AMA proposal for the Pharmacist in General Practice Incentive Program (PGPIP), including the Deloitte Access Economics analysis, is at https://ama.com.au/article/general-practice-pharmacists-improving-patient-care

Rural and remote health: a progress report

Doing better, but we still need to sort out who is responsible for what and strengthen primary care

Following an active period of policy development and implementation in the 1990s,1 there have been two national great leaps forward that tackled geographical health inequalities in Australia in the new century. In 2000, in the context of growing disaffection in the rural electorate,2 the then health minister, Michael Wooldridge, was responsible for a federal Budget centrepiece of $562 million, the Regional Health Strategy: More Doctors, Better Services. The package included the establishment of university departments of rural health and rural clinical schools, as well as retention incentives for rural doctors. The second leap resulted from the balance of power held by the two rural independents in 2010. Their agreement with the minority Labor government for regional development included investment of some $2.33 billion in rural and remote health infrastructure, including regional cancer centres. As ever, the political imperative was key.

Where are we now?

As the fiscal belt tightens and we scan for a similar policy window of opportunity for rural health, it is timely to reflect on progress.

There is no doubt that there have been some very significant gains since 2000. We have moved beyond a deficit view of rural health and there is a stronger recognition that our tough context provides an “incubator for developing and testing new models of care and expanded scopes of practice”.3 Persistent advocacy from groups like the National Rural Health Alliance (NRHA) has resulted in increased public knowledge about the health inequalities between rural and metropolitan Australia. This health inequality has a complex aetiology that includes social determinants, disease risk factors and a proportionally larger Indigenous population. Nevertheless, access to health services is still critically important. There are examples of exemplary services that enhance access to primary health care.4 Some of the best examples of services that result in improved outcomes support the most remote Indigenous outstations.5

As highlighted above, rural and remote health infrastructure has improved access to primary and acute care, and there is emerging evidence of its impact.6

While medical workforce maldistribution and problems with training continuity (from student to prevocational to specialist training) persist, there are some promising trends resulting from the current suite of policies, including increasing numbers of medical students of rural origin and lengthening time of training in rural areas.7 This is a salutary example of the importance of long-term investment in infrastructure and workforce development. Proposed changes in the more equitable distribution of general practitioner incentives as the result of changes in the rural classification system to the Modified Monash Model should provide another medical workforce boost to small rural and remote communities.8

Despite these significant investments, the gap in health funding for rural and remote areas persists.9 The NRHA estimates a primary and aged care service deficit in the order of $3 billion.10 Less access to primary health care is reflected in lower Medicare expenditure, higher compensatory hospitalisation and more potentially preventable hospital admissions with increasing remoteness.9 Although activity-based hospital funding is adjusted for rurality and Indigenous population, there is no adequate formula to adjust primary health care funding appropriately for morbidity and the higher costs of providing services to a highly dispersed population. The Mason health workforce review saliently comments on the need to refocus on prevention and “to move beyond a focus on specialist medicine and acute care beds, to appropriate generalist skills, team based community care and the training and development of the nursing and allied health workforce”.8

Integration and optimal coordination of services are still hampered by divided federal and state responsibilities. There was a missed opportunity to “end the blame game” with national health care reform initiated by the Rudd government. At the same time, the health care reforms have resulted in increased community participation through local hospital networks, and some regionalised health service models that allow for a degree of improved coordination.

Where to next?

Many of our policy settings are right, and we need to hold the course for the long term. Australia has an effective rural and remote academic infrastructure that is the envy of the world. Service infrastructure, including telehealth capacity, continues to improve. The main outstanding challenges relate to macropolicy — who is responsible for what — and its impact on coordination and adequate funding of services, especially primary health care services.

The available evidence from Australia and abroad is that cost savings result from increasing access to primary care and thereby decreasing potentially preventable hospitalisation.4,11,12 So we need to strengthen primary care, avoid introducing barriers to it, and strengthen preventive care across remote and rural Australia through appropriate investment to create effective, integrated regional models of care that are fit for context. We know how to do this, but need to get better at generalising what we know works well.

Proton pump inhibitors: too much of a good thing?

Proton pump inhibitors (PPIs) are a mainstay in the management of acid peptic disorders; they are highly effective at relieving symptoms and are generally well tolerated. However, there is growing international concern about their increasing use. Long-term use is only recommended in specific clinical situations, yet data indicate that this accounts for the majority of total use and large numbers of PPI users do not actually have a clear indication for therapy (http://www.nps.org.au/publications/health-professional/medicinewise-news/2015/proton-pump-inhibitors).

A big problem is that once people are on a PPI, therapy is often not stepped down appropriately. Up to 30% of patients may be able to stop PPI therapy after the initial course of therapy without experiencing symptoms, but a step-down approach is not necessarily part of their ongoing management. Overuse of PPIs may increase risks of adverse effects and incur unnecessary costs for both taxpayers and individuals.

While PPIs are generally considered safe, there are reports (mostly from observational studies) about more serious, albeit rare, adverse events associated with their use, including enteric infections, pneumonia, fractures and acute interstitial nephritis. While reports are insufficient to establish a causal relationship, they may warrant consideration, especially against a backdrop of significant overprescribing of PPIs.

In the past decade, at least two PPIs have featured annually in the top 10 most prescribed Pharmaceutical Benefits Scheme (PBS)-subsidised medicines and, in the 2013–14 financial year, over 19 million prescriptions were issued, most of these for managing gastro-oesophageal reflux disease. The most commonly prescribed PPI in 2013–14 incurred a cost of over $200 million to the PBS.

NPS MedicineWise has recently published a suite of free resources (http://www.nps.org.au/heartburn-and-reflux) to support quality use of PPIs, including a symptomatic management pad for use with patients, and a clinical e-audit and interactive online case study (Continuing Professional Development points available).

Changes to the GP training environment

 By Dr Sally Banfield, an Australian College of Rural and Remote Medicine (ACRRM) trainee with Northern Territory General Practice Education in Central Australia, and is likely to complete vocational training in 2016 with an AST in remote medicine.

Like any changes, those made to the GP training environment in last year’s Federal Budget pose obvious threats but significant opportunities.

The medical community needs to remain united to sustain high-quality training and meet the diverse health needs of our country. To improve the training system, the experience, feedback and input of trainees is essential.

GP registrars often encounter undifferentiated patients and are required to make decisions on their own early on in their careers. We rely heavily on a broad prevocational training experience, followed by a well-structured and supportive vocational training program.

Currently, the delineation of training responsibilities between Government, colleges, regional training providers and the individual is often difficult to navigate.

Large variations in the delivery of vocational training programs mean confusion and often frustration for the registrar trying to meet the requirements for Fellowship.

As trainee numbers increase, both supervision and education capacity is being stretched, and new training methods need to be explored and shared between providers. This can all be improved in this time of change.

Current issues include defining the training and education roles of the Royal Australian College of General Practitioners, the Australian College of Rural and Remote Medicine and the regional training providers.

The potential for greater college involvement could provide a more seamless general practice training pipeline, with a stronger link to our profession and our colleagues.

Ultimately, we need a system that challenges, supports and mentors registrars to meet the requirements for safe independent practice.

The sustainability of the ‘apprenticeship model’ of training relies on a system that supports the large investment supervisors, educators and registrars put into excellence.

The newly formed GP Training Advisory Committee must continue to foster medical education, supervision and research opportunities for trainees.

The profession must work closely with Government to ensure the ultimate goal of meeting health equality for our community.

This change to the GP training environment can place further focus on drivers for servicing the most disadvantaged. We should use our increasing evidence base to influence selection and training delivery to drive change in workplace shortages.

This will need support from all sectors of the health care system across the training pipeline.

The transition will create points of tension and hurdles to overcome; but we should use this as an opportunity for development.

The Government and the medical profession need to continue to involve future general practitioners in this conversation. Collectively, we have the vision and the passion to meet the future needs of our community.

 

 

 

Into the great unknown

Dr Danielle McMullen

As 2015 rolls rapidly on, current and future GP registrars grow ever more nervous about the uncertainties in GP training from 2016.

We’ve all heard about the GP co-payment, frozen Medicare rebates and planned changes to level B consultations.

But there is another, at least equally important, issue lurking quietly in the corner. In its 2014 Budget, the Commonwealth announced radical changes to GP training across Australia. General Practice Education and Training, which had coordinated and overseen the GP training provided by regional training providers (RTPs) since 2001, closed its doors last December and its functions were transferred to the Department of Health. In December this year, the RTPs will also be wound up, and their replacements are yet to be announced.

The boundaries for the new training organisations have recently been released. But, for current registrars in particular, these raise more questions than are answered given we still don’t know who will form these new organisations and what the transition process will look like.

The tender process for new training organisations has not yet begun, much less been completed. As the days and weeks and months tick by we grow ever more nervous as to when these doctors will have any certainty about their training location and governance.

In addition to the significant changes to vocational training, the 2014 Budget also scrapped the Prevocational General Practice Placements Program, which was the only avenue for prevocational doctors in their intern or PGY2 year to experience the general practice environment. This gaping hole in the general practice workforce pipeline will result in fewer interested GP trainees, and throw general practice back to being an option of last resort.

Excellent GP clinical supervisors will forever form the cornerstone of quality general practice training. But they need to be supported by high quality training organisations. And registrars deserve a well-organised, well-supported training environment.

Change is coming – that is for certain. And time is running short but it’s not out yet. We need urgent clarity and real consultation to plan and shape the future of general practice training in Australia.

In the short term, registrars need certainty around the transition to new training organisations. In the longer term, we need to ensure these organisations continue to provide the high quality, flexible general practice training we’ve become accustomed to.

General practice is an incredible career offering variety, flexibility and fantastic medicine. We need to sing its praises, protect its future, and safeguard its quality. The time for that is now!