Peter Thomson MB BS, FFARACS

Peter Thomson was born on 12 June 1940 in Esher, near London. His mother May was a highly trained registered nurse. His Australian-born father, George Macdonald Thomson, was a medical graduate from the University of Sydney who qualified and practised as a surgeon in England in the 1930s until he was conscripted into the British Army in World War II. Peter and the rest of the family spent the war in a heavily blitzed London. Many were the tales that May told of near misses from doodlebugs (German V-1 flying bombs). After the war, they left the United Kingdom to join George in Sydney in 1947, where he had been demobilised. George subsequently became a general practitioner and surgeon in Newtown.

Peter attended Burwood Public School and Fort Street Boys’ High School. He entered medicine at the University of Sydney in 1957, graduating in 1963. After a year’s residency at Royal Prince Alfred Hospital, he was a resident medical officer for 2 years at Royal Newcastle Hospital, developing an interest in anaesthetics, which he would maintain for the rest of his life.

While working at Lidcombe Hospital, Peter passed the first part of his Fellowship of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons in 1967 and was awarded the Renton Prize. In 1969, he passed the second part of his Fellowship.

From 1968 to 1970, Peter worked at St Vincent’s Hospital, Darlinghurst, where he was the anaesthetic registrar involved in the first heart transplant in Australia in 1968. He completed his training at Royal Alexandra Hospital for Children in Camperdown and went into private practice in 1970.

Peter was a visiting medical officer at Liverpool and Auburn Hospitals, and then Concord Repatriation General Hospital. He also worked at many private hospitals, including Strathfield, Holroyd and Ashfield. He was a very skilled and devoted anaesthetist, highly respected by his surgeons and patients. He retired from active practice in 2007.

Besides medicine, Peter had many interests. He kept extremely fit by running, walking and cycling. He was a keen birdwatcher and photographer, and greatly enjoyed his Probus club activities.

Peter retired from anaesthetics in 2007 and died on 21 June 2013. He is survived by his wife Sandra, daughters Lynda, Karen and Jenny, and stepdaughter Tammy.

Reports indicate that changes are needed to close the gap for Indigenous health

Major changes in health services are needed to redress health disparities

Two recently released reports from the Australian Institute of Health and Welfare (AIHW) make it clear that there must be major changes in the way health services for Indigenous Australians are delivered and funded if we are to improve Indigenous health and health care and ensure real returns on the substantial investments that are being made.1,2

These reports show Australia’s level of financial commitment to Indigenous health. In the 2010–11 financial year total spending on Indigenous health was $4.552 billion,1 almost double that spent in 2004–05. This was $7995 for every Indigenous Australian, compared with $5437 for every non-Indigenous Australian;1 over 90% of this funding came from governments. The surest sign that this money was not well invested in prevention, early intervention and community services is that most of it (on average $3266 per person but $4779 per person in remote areas) was spent on services for patients admitted to hospitals, while spending on Medicare services and medicines subsidised by the Pharmaceutical Benefits Scheme (PBS) on a per-person basis was less than that for non-Indigenous Australians by $198 and $137, respectively.2

The series of AIHW reports since the 1995–96 financial year highlights both where progress has been made and where programs have failed. There have been considerable increases in funding for primary care, acute care and community and public health. The 2010–11 data do not reflect the full implementation of the Indigenous Chronic Disease Health Package, but do suggest that the measure to subsidise PBS copayments for patients with chronic disease is having an effect, specifically in more remote areas where PBS spending is higher than in regional areas.

On the other hand, it is obvious that access to primary care services in remote areas remains limited, and access to referred services such as specialists and diagnostics is poor for Indigenous people everywhere, even in major cities. Per-person spending on non-hospital secondary services is about 57% of that for non-Indigenous people.2 Indigenous Australians receive nearly all their secondary care in hospitals.

The hospital data hammer the story home. In 2010–11, the overall age-standardised separation rate of 911 per 1000 for Indigenous people was 2.5 times that for non-Indigenous people; for people living in the Northern Territory the rate was 7.9 times that for non-Indigenous people.3

About 80% of the difference between these rates was accounted for by separations for Indigenous people admitted for renal dialysis, but further examination highlights how a lack of primary care and prevention services drives increased hospital costs. In 2010–11, total expenditure on potentially preventable hospitalisations for Indigenous Australians was $219 million or $385 per person, compared with $174 per non-Indigenous Australian.3 For all Australians most of this spending is for chronic conditions like complications from diabetes, but, too often, Indigenous Australians are hospitalised for vaccine-preventable conditions like influenza and pneumonia, acute conditions like cellulitis, and injury.

Avoidable hospitalisations are an important indicator of effective and timely access to primary care, and provide a summary measure of health gains from primary care interventions. The inescapable reality is that current primary care interventions are not working.

We know what the problems are. Around two-thirds of the gap in health outcomes between Indigenous Australians and other Australians comes from chronic diseases such as cardiovascular disease, diabetes, respiratory diseases and kidney disease.4 Suicide and transport accidents and other injuries are also leading causes of death.5 Half of the gap in health between Indigenous and non-Indigenous Australians is linked to risk factors such as smoking, obesity and physical inactivity.6 A number of studies have found that between a third and half of the health gap is associated with differences in socioeconomic status such as education, employment and income.7

The 2006 Census (the latest available data) found that 39% of Indigenous people were living in “low resource” households (as defined by the Australian Bureau of Statistics8), almost five times the non-Indigenous rate.9 Such disparities in income limit Indigenous people’s capacity to pay for health care and provide some context for why they are more likely to use public hospitals than privately provided services that require copayments.

There are commitments from all the major stakeholders, political parties and policymakers to close the gap. There is a new National Aboriginal and Torres Strait Islander Health Plan 2013–2023. And, arguably, there are enough funds if these are spent wisely. What is needed is a new approach to how health care is developed for and delivered to Indigenous Australians.

The approach needs to be grounded in three broad principles:

Adhering to the principle of “nothing about me without me”.10 Shared decision making must become the norm, with patients and their needs at the centre of a system they drive.
Addressing the social determinants of health, in particular, the impact of poverty.
Addressing cultural barriers in the way that Indigenous people want.

These are not new ideas and all the right words are in the new national health plan, as they were in the previous strategy document — cross-portfolio efforts, partnership, sustainability, culturally competent services, community, a rights-based approach to providing equal opportunities for health. What we must do is move beyond these fine words to meaningful action.

We have the exemplar of how to do this with Aboriginal Community Controlled Health Organisations (ACCHOs), and we need to (i) provide increased opportunities for engagement, collaboration and service delivery with ACCHOs and (ii) expand this way of working into mainstream services. This will require a different approach to policy development and implementation.11

The key barriers to health care for urban and remote populations alike relate to availability, affordability and acceptability12 and the dominance of biomedical models of health.13 ACCHOs are a practical expression of self-determination in Indigenous health and health service delivery,14 and have been very successful at reducing many of the barriers that inhibit Indigenous access to mainstream primary care.15 Importantly, ACCHOs provide both cultural safety, which allows the patient to feel safe in health care interactions and be involved in changes to health services, and cultural competence, which reflects the capacity of the system to integrate culture into the delivery of health services.16

However, the success of the design and work practices of ACCHOs have had little influence on the mainstream health system17 which remains, necessarily, the source of health care for many Indigenous people. And it can be argued that the current funding and regulatory practices of Australian governments are a heavy burden and consume too much of the scarce resources of ACCHOs in acquiring, managing, reporting and acquitting funding contracts.18

Governments and all stakeholders, including Indigenous people themselves, need to be bold enough to redesign current mainstream health policies, programs and systems to better fit Indigenous health concepts, community needs and culture. This approach should not be seen as radical — it is where we are currently headed with Medicare Locals. We should not ignore the fact that ACCHOs have led the way in developing a model of primary health care services that is able to take account of the social issues and the underlying determinants of health alongside quality care.19 Tackling these reforms will therefore benefit all Australians, but especially those Indigenous people who currently feel disenfranchised. Without real and meaningful change, we are all condemned to more government reports bearing sad, bad news and a continual yawning gap of Indigenous disadvantage.

The sources of pharmaceuticals for problematic users of benzodiazepines and prescription opioids

There are growing concerns in Australia and overseas about the increasing misuse of a range of pharmaceuticals, and associated harms.1–4 This includes the problematic use of benzodiazepines and prescription opioids in Australia.

Clients of drug treatment services are commonly reported to use a range of pharmaceuticals.5–7 For example, self-reported prevalence of benzodiazepine use among clients undergoing treatment for opioid use ranges from 66% to 100%,5,7,8 and use confirmed by urine drug testing ranges from 51% to 70%.8 Moreover, benzodiazepine use is associated with poorer treatment and health outcomes among opioid users.9,10 In North America, prescription opioid-dependent clients outnumber heroin-dependent clients among those presenting for methadone maintenance treatment.6,11 Given the considerable harms that have been linked to these pharmaceuticals, including overdose12 and mortality,13,14 understanding their use and sources is important for informing effective harm-reduction interventions.

To our knowledge, no studies examining the sources of pharmaceuticals used by problematic users in Australia have been published, but sources of prescription opioids have been described in the United States. Among recent methadone treatment entrants who reported prescription opioids as the primary problem drug, the most common sources were dealers (86%), friends and relatives (54%) and medical prescriptions (28%).6 In contrast, the US National Survey on Drug Use and Health found most non-medical users sourced analgesics from a friend or relative for free (55%) or for payment (11%).15 In both studies, the internet was rarely a cited source.6,15

The Australian Government recently announced the introduction of a real-time reporting system for prescription opioids that doctors can use to obtain an up-to-date prescription history before prescribing drugs of addiction to any patient.16 It is planned that the reporting system will monitor Schedule 8 (S8) medications, therefore it will only include benzodiazepines that are S8. One benzodiazepine, flunitrazepam, is currently S8. Alprazolam will be rescheduled to S8 in 2014. To gauge the potential usefulness of such a system, it is important to understand how often these medications are being sourced through medical practitioners.

We describe (i) the characteristics of pharmaceutical use by Australian clients of drug treatment services who reported regular and unsanctioned use of benzodiazepines and/or prescription opioids and (ii) the common sources of benzodiazepines and prescription opioids used by these clients.

Methods

Detailed methods are available elsewhere.17 In brief, we recruited a convenience sample of 305 people entering treatment at private and public withdrawal (detoxification), residential rehabilitation and opioid substitution treatment services in Victoria, Western Australia, Queensland and Tasmania. They were recruited between January and July 2008 by referral from treatment service staff and using study flyers that were distributed from drug treatment services by the staff.

Treatment entrants were eligible to participate in the study if they: reported regular (an average of ≥ 4 days per week) and unsanctioned use of benzodiazepines and/or prescription opioids over the 4 weeks before treatment entry; were 16 years or older; had entered treatment for drug or alcohol use in the previous 6 months; and had sufficient English language skills to provide informed consent and comprehend the study questions. Unsanctioned use was defined as using medication that was not prescribed to the participant or using medication that was prescribed to the participant but in a way not intended by the prescriber (eg, taking a higher dose than prescribed, or injecting a drug that was intended as oral medication).

Structured face-to-face interviews of participants were conducted. They included questions on demographics (sex, age, ethnicity, employment, education level attained, current living arrangements), substance use (primary drug of concern at treatment entry, use in the 4 weeks before treatment entry, routes of administration), trajectories of substance use, and benzodiazepine and prescription opioid sources).

We used χ2 and t tests to establish whether there were differences between participants who used benzodiazepines and those who used prescription opioids. Descriptive analyses were used to characterise benzodiazepine and prescription opioid initiation, use and sources.

The study was approved by institutional ethics committees in each jurisdiction — the Victorian Department of Human Services Human Research Ethics Committee, University of Tasmania Social Sciences Human Research Ethics Committee, Curtin University Human Research Ethics Committee and Prince Charles Hospital Human Research Ethics Committee.

Results

Characteristics of participants

A total of 204 people participated in the study; 107 had entered methadone and buprenorphine treatment programs, and the remainder had entered inpatient detoxification and residential rehabilitation programs (Box 1). One hundred and forty-two participants (70%) were seeking treatment for opioid dependence (heroin or pharmaceutical opioids), 19 (9%) were seeking treatment for benzodiazepine dependence, and 43 (21%) were seeking treatment for dependence on other substances (eg, alcohol, stimulants and cannabis). When asked about substance use in the 4 weeks before treatment entry, 144 participants reported regular and unsanctioned benzodiazepine use and 108 reported regular and unsanctioned prescription opioid use; 48 reported regular and unsanctioned use of both drug classes.

The demographic characteristics of participants who used benzodiazepines only, prescription opioids only and both benzodiazepines and prescription opioids were similar — about 60% men, mean age about 33 years, and low levels of employment and education.

Of the 144 participants who met the criteria for regular unsanctioned benzodiazepine use (with or without prescription opioids), 18 (13%) reported benzodiazepines as their primary drug of concern, and 108 (75%) reported that their benzodiazepine use had become problematic. In contrast, more than half (56%, 60) of the 108 participants who met the criteria for regular unsanctioned prescription opioid use (with or without benzodiazepines) reported prescription opioids as their primary drug of concern, and 93 (86%) reported that their prescription opioid use had become problematic.

Pharmaceutical use in the 28 days before treatment entry

On average, benzodiazepines and prescription opioids were used almost daily (27 out of 28 days for both) (Box 2). The benzodiazepines most frequently used as prescribed were diazepam (36%, 52/144), alprazolam (13%, 19/144) and oxazepam (13%, 18/144). For unsanctioned use, the benzodiazepines used most frequently were diazepam (80%, 115/144), alprazolam (58%, 84/144) and oxazepam (44%, 63/144). The prescription opioids most frequently used as prescribed were morphine preparations (10%, 11/108) and buprenorphine–naloxone tablets (8%, 9/108). For unsanctioned use, the prescription opioids used most frequently were morphine (65%, 70/108), oxycodone (50%, 54/108) and methadone liquid (29%, 31/108).

Injection of prescription opioids in the 28 days before treatment entry was reported by 81 participants (75%) in the prescription opioid group; on average, they reported injecting prescription opioids on 22 of the 28 days. In contrast, injection of benzodiazepines in the 28 days before treatment entry was reported by 12 of the participants (8%) in the benzodiazepine group; on average, they reported injecting benzodiazepines on 11 of the 28 days.

Initiation and trajectories of pharmaceutical use

On first-use occasions, both benzodiazepines and prescription opioids were most often not prescribed; 72% of participants in the benzodiazepine group and 75% of participants in the prescription opioid group reported using non-prescribed medication on the first-use occasion (Box 2). Benzodiazepine prescriptions for first-use occasions were most commonly reported to have been for anxiety (37%, 15/41) and sleep (22%, 9/41), and opioid prescriptions for first-use occasions were most commonly reported to have been for pain relief (81%, 22/27).

Mean age at initiation of pharmaceutical use was 19.1 years for benzodiazepines and 21.2 years for prescription opioids (Box 2). The mean length of time from benzodiazepine first use to monthly use was 4.1 years and to problematic use was 6.3 years. The mean length of time from prescription opioid first use to monthly use was 3.0 years, and to problematic use was 4.4 years.

Sources of pharmaceuticals

Most benzodiazepine users (78%, 113) reported a medical practitioner as a source of benzodiazepines in the 28 days before treatment entry (Box 3). Most also reported a medical practitioner as their usual benzodiazepine source (72%, 88), and most reported acquiring benzodiazepines for real symptoms. Of those reporting non-medical sources as their usual supply, access through friends or acquaintances (buying, swapping or gifts) were most common; only 7% reported buying from a dealer as their usual source.

In contrast, about half of prescription opioid users (46%, 50) reported buying from a dealer (Box 3). Most reported using non-prescribed sources (78%, 84), and most reported non-prescribed sources as their usual source (71%, 61).

Few participants reported stealing or using forged prescriptions to obtain benzodiazepines and prescription opioids (Box 3), and none reported using the internet as a source.

Discussion

Our results provide information on how benzodiazepines and prescription opioids are accessed and used by people who represent the more “severe” end of the spectrum of problematic pharmaceutical drug users — drug and alcohol treatment entrants reporting almost daily use of benzodiazepines or prescription opioids.

We found that pharmaceutical use was initiated early (at an average of about 20 years of age), and about three-quarters of participants reported that their initial use was via a non-medical source. On average, it took 3–6 years for participants to progress from first use to regular or problematic use, suggesting that there is a window of opportunity for providing interventions that could avert this progression.

There were clear differences between how the two drug classes were sourced. Prescription opioids were less commonly acquired from a doctor than benzodiazepines, and most prescription opioids were acquired from non-medical sources. This is consistent with previously reported source patterns for prescription opioids.6,15 This common finding of sharing and onselling of prescription opioids has important implications for the medical profession. It highlights that while some individuals use opioids that were prescribed for other people, there may also be patients who do not use the opioids that are prescribed for them by their doctors. Most regular prescription opioid users reported buying their opioids from others, highlighting that this prescription drug black market is an important area to better understand. Also, prescription opioids were more likely to be injected than benzodiazepines.

In contrast to prescription opioids, a medical practitioner was the main source of benzodiazepines. As such, there may be considerable opportunities for prescriber intervention to address benzodiazepine use. This finding, coupled with the serious harms associated with benzodiazepines (in terms of acute overdose, poorer health and poorer treatment outcomes9,10,12,13), is interesting in light of current plans to only monitor the prescribing of S8 benzodiazepines as part of the monitoring of all S8 class drugs in Australia — flunitrazepam and, from 2014, alprazolam.16 This means that, despite the greater opportunity for prescribers to intervene in benzodiazepine supply, most benzodiazepines will not fall under the current plans for prescription drug monitoring. This also represents a missed opportunity for monitoring the impact of the planned rescheduling of alprazolam on the extent of use of other, unmonitored, benzodiazepines.

In contrast, monitoring opioid prescribing is unlikely to have a substantial impact on the behaviour of prescription opioid users, as they mostly acquire prescription opioids from non-medical sources. Also, it might give prescribers false confidence if they relied on the information from monitoring systems for the clinical assessment of drug-seeking behaviour alone, as opioids acquired from non-medical sources would not appear in such systems.

Other strategies — such as education of consumers and health professionals, and expansion of non-pharmaceutical evidence-based treatments for chronic pain and mental health disorders — are crucial. Approaches such as “universal precautions” with opioid prescribing have been recommended internationally18 and in Australian policy,19 but are yet to be established in practice.

Education for consumers on the harms associated with sharing medications is vital. Benzodiazepines are commonly implicated in non-fatal12 and fatal13,20 opioid overdose. We found that one-third of participants were given benzodiazepines as a gift for their most recent unsanctioned use. On first-use occasions, only one-quarter of benzodiazepines and prescription opioids were from a prescriber. Education about risks associated with self-diagnosis, peer diagnosis and self-medicating may help reduce medication sharing. Also, education initiatives for consumers could be used to challenge the perception that benzodiazepines are “less risky”21 than illicit drugs.

Our study has strengths and weaknesses. Convenience sampling and collection of self-reported data are well recognised and valid methods for studying individuals who engage in unsanctioned substance use22,23 and provide reliable answers in this context.23 However, it is well recognised that these methods affect the accuracy and representativeness of the data collected, compared with prospectively collected and objectively validated data from random or more generalisable samples.

The participants of our study had similar demographic characteristics to participants in other studies of drug treatment clients in Australia conducted in Australia.7,24 Although they may not represent most long-term problematic users of pharmaceuticals in the broader community, they represent a group who are more likely to experience acute harms from their pharmaceutical use and who use larger amounts of pharmaceuticals. As such, they are a priority when targeting strategies aimed at minimising pharmaceutical misuse.

These findings show that different approaches may be required to reduce unsanctioned use of different pharmaceuticals. Prescription drug monitoring programs need to ensure that the right substances are monitored. Current proposals may represent a significant lost opportunity with regard to the most benzodiazepines. Finally, developing guidelines and resources that help health professionals respond to pharmaceutical misuse identified through monitoring systems will maximise opportunities to reduce harm.

1 Characteristics of the study participants (n = 204)

	Number (%)*

Men	126 (62%)
Mean (SD) age, years	32.6 (8.7)
Aboriginal or Torres Strait Islander	14 (7%)
Employed full time or part time	40 (20%)
Completed up to year 11 equivalent or less	126 (62%)
Living in unstable housing	59 (29%)
Current treatment
Methadone	64 (31%)
Buprenorphine (with or without naloxone)	43 (21%)
Inpatient detoxification	49 (24%)
Residential rehabilitation	48 (24%)
Regular and unsanctioned substance use
Benzodiazepines only	96 (47%)
Pharmaceutical opioids only	60 (29%)
Benzodiazepines and prescription opioids	48 (24%)

* Data are number (%) unless otherwise specified.

2 Characteristics of benzodiazepine and prescription opioid use by study participants

	Benzodiazepine users (n = 144)	Prescription opioid users (n = 108)

Use in 28 days before treatment entry
Mean (SD) period of prescribed use, days	12.5 (13.0)	7.5 (11.4)
Mean (SD) period of non-prescribed* oral use, days	20.9 (9.6)	16.3 (12.2)
Mean (SD) period of injected use, days	0.9 (4.2)	16.5 (12.0)
Mean (SD) period of use in any form, days	27.3 (2.3)	26.9 (2.8)
First-use occasion
Medication prescribed on first-use occasion, number (%)	41 (28%)	27 (25%)
Trajectory of use†
Mean (SD) age at first use, years	18.9 (6.9)	21.2 (8.1)
Mean (SD) age when first injected, years	22.7 (7.6)	22.7 (7.8)
Mean (SD) time from first use to monthly use, years	4.1 (5.9)	3.0 (5.1)
Mean (SD) time from first use to problematic use, years	6.3 (6.6)	4.4 (5.7)
Last use
Medication used was drug of choice, number (%)	50 (35%)	71 (66%)
Medication used was not drug of choice, number (%)
Seeking intoxication	29 (20%)	10 (9%)
Used to avoid or treat withdrawal symptoms	19 (13%)	1 (1%)
Used as substitute for heroin or other opioids	na	14 (13%)
Used for pain relief	na	4 (4%)

na = not applicable. * Refers to use where medication was not prescribed to the individual or where medications were used in a way other than prescribed. † Responses for questions on trajectory of use were incomplete; data presented here are based on the following numbers of responses for benzodiazepine use and prescription opioid use, respectively: 144 and 106 for age at first use, 70 and 91 for age when first injected, 134 and 105 for time from first use to monthly use, and 108 and 93 for time from first use to problematic use.

3 Self-reported sources of pharmaceuticals used by study participants in the 28 days before treatment entry*

	A source	Usual source	Source for most recent unsanctioned use

Benzodiazepines
n	144	123	139
Doctor — real symptom	104 (72%)	79 (64%)	—
Doctor — fake symptom	32 (22%)	9 (7%)	—
Any prescribed source	113 (78%)	88 (72%)	62 (45%)
Gift	63 (44%)	10 (8%)	50 (36%)
Swap	22 (15%)	1 (1%)	2 (1%)
Stolen	9 (6%)	3 (2%)	5 (4%)
Forged prescription	5 (3%)	0	2 (1%)
Bought from friend	28 (19%)	12 (10%)	11 (8%)
Buy from dealer	25 (17%)	9 (7%)	7 (5%)
Any non-prescribed source	80 (56%)	35 (28%)	77 (55%)
Both prescribed and non-prescribed	80 (56%)	—	—
Prescription opioids
n	108	86	108
Doctor — real symptom	33 (31%)	20 (23%)	—
Doctor — fake symptom	13 (12%)	5 (6%)	—
Any prescribed source	36 (33%)	25 (29%)	33 (31%)
Gift	32 (30%)	10 (12%)	22 (20%)
Swap	16 (15%)	1 (1%)	1 (1%)
Stolen	4 (4%)	0 (	0 (
Forged prescription	1 (1%)	0 (	0 (
Bought from friend	42 (39%)	19 (22%)	21 (19%)
Buy from dealer	50 (46%)	30 (35%)	29 (27%)
Any non-prescribed source	84 (78%)	61 (71%)	75 (69%)
Both prescribed and non-prescribed	20 (19%)	—	—

* Data are number (%) unless otherwise specified.

Hubert (Hugh) Roy Harris MB BS

Hubert (Hugh) Harris was a country doctor who earned the respect and affection of all who knew him.

Hugh was born in Stockton, New South Wales, in 1919 to Dr Hubert and Emily Harris. He was educated at Armidale and studied medicine at the University of Sydney.

On graduating in 1943, Hugh was appointed a resident medical officer at Grafton Base Hospital. In 1944, he enlisted in the Royal Australian Air Force, serving as a Flight Lieutenant.

After the war, Hugh returned to Grafton Base Hospital and, in 1947, he joined a large group medical practice in Grafton and pursued his interest in surgery.

In 1948, he married Shirley Holland in Christ Church Cathedral, Grafton, leading to a lifelong and wonderful partnership of 65 years.

Hugh was adept at emergency surgery and trauma work but, in later years, he turned more to obstetrics and gynaecology. Hugh’s prime focus was always the patient needing help, no matter the hour or day of the week. He unstintingly gave his time and expertise, often to his own detriment. He also served on the boards of Grafton Base Hospital and ambulance service, and lectured nurses at the hospital training school.

Hugh enjoyed fishing at Yamba. He was a skilled woodworker who loved to work with North Coast cedar and built a beautiful dining table for his home.

His later years were marred by increasing deafness and macular degeneration, which he bore without complaint. Shirley lovingly cared for him at home until he needed full-time nursing care.

Hugh passed away peacefully on 9 July 2013 and is survived by Shirley and children John, Richard and Anne.

Trust a casualty in television show stunt

When a young man professing to be tired and stressed walked into the consulting room of Dr David Chambers on 1 October and asked for a medical certificate, the Brisbane GP took his patient at his word and began trying to delve into reasons for his condition.

During the consultation, the man – who was accompanied by a woman – said he was fatigued and, according to Dr Chambers, looked anxious and avoided eye contact.

Little did Dr Chambers know that he was being secretly filmed as part of a set-up by the Channel Nine television show A Current Affair for a story intended to show the doctors readily issued medical certificates to patients who simply wanted a day off work. The patient was in fact a producer from the program, as was the woman who accompanied him.

When the story was broadcast the following night, the 16-and-a-half minute consultation – in which Dr Chambers made a thorough examination of his patient, took a full history, organised for blood tests to be taken if the professed fatigue persisted, and discussed mental health issues – was edited down to a brief grab intended to justify the story’s premise.

Dr Chambers was among five GPs caught up in the ACA sting, and although their faces were disguised in the story that went to air, he found that both colleagues and patients quickly recognised him.

Aside from the anger he feels about being “hugely misrepresented” by the program, Dr Chambers worries about the corrosive effect this and similar programs might have on the crucial doctor-patient relationship.

“Doctors are rightly held to high moral and ethical standards, treating patients with respect and trust, and protecting their privacy,” he said. “But it is also incumbent upon the patient to be truthful with the doctor.

“Most of what we do is based on good history taking, and we rely on patients being honest with us. We are not mind readers.

“If you don’t have that trust, then everything is lost.”

Dr Chambers said programs like the ACA segment had the potential to be “quite destructive, because that devalue that relationship”.

It is a concern shared by AMA Council of General Practice Chair Dr Brian Morton, who said that trust and honesty were paramount in the relationship between doctors and their patients.

“Our profession expects honesty from our patients. Communications between the patient and the doctor involve honesty from the patient and, reciprocally, from the doctor,” Dr Morton said. “We cannot mistrust what the patient is saying.”

The importance of this was underlined, he said, by the experience of a colleague who treated a patient complaining that they were hearing a cricket in their ear. Rather than dismiss the complaint as a case of tinnitus, the doctor made an examination and found that there actually was an insect inside the man’s ear.

Commenting on the premise of the ACA report, Dr Morton said medical certificates were legal documents, and doctors did not issue them lightly.

But equally, they were not simply for physical maladies, as the television show seemed to imply.

Dr Chapman said he had treated a number of young men with depression who had presented with symptoms similar to those described by the ACA producer, and was alert to the possibility his patient was suffering mental health problems.

Dr Morton said often doctors had to use judgement and care in what they wrote on medical certificates.

He said privacy considerations and stigma surrounding conditions such as mental illness or sexually transmitted infections meant it was not unreasonable for doctors to talk with their patients about what should be included when writing a certificate.

Dr Morton admitted that he did, on occasion, come under pressure from patients to issue a certificate, either claiming to be suffering a cold or even not providing any medical reason for their absence from work.

“In this situation, it behoves me to make a medical examination, take a history, and come to my own conclusion,” he said. “Doctors are expected to take a profession and legal view.”

The egregious shortcomings of the ACA report – which included file footage of Dr Morton without indicating to viewers that it was from an interview given more than two years ago – were highlighted by ABC’s Media Watch program on 14 and 21 October.

Dr Chambers provided an account of his experience to Media Watch, and has written a formal complaint to Channel Nine.

Adrian Rollins

Evaluation of the Practice Nurse Incentive Program

Call for general practices and Aboriginal health services to participate in an interview to inform the Evaluation

The Practice Nurse Incentive Program (PNIP) was introduced in January 2012 to support practice nurses and Aboriginal health workers working in general practices, Aboriginal medical services and Aboriginal community controlled health services to undertake an expanded and enhanced role in preventive health, chronic disease management and care coordination. It replaced a range of funding arrangements including Practice Incentive Program, Practice Nurse Incentive, and six of the Medicare Benefits Schedule practice nurse items.

The Department of Health and Ageing has contracted KBC Australia, in collaboration with Thinc Health, to undertake an evaluation of the PNIP.

As part of the evaluation, KBC will interview general practices and Aboriginal health services to identify the impact of the changed funding mechanism on the:

· role and function of practice nurses and GPs;

· the business model of practices; and

· the workforce mix within practices and Aboriginal health services.

Practice personnel to be interviewed

Key personnel to be interviewed could include the GP practice principal or medical director, and/or practice manager, CEO of Aboriginal health service, practice nurse manager or senior practice nurse.

Telephone interviews can be undertaken individually or in a group, dependent on the preference of the practice.

It is estimated that interviews will taken about one hour.

For inquiries, or to register your interest, please contact:

Monika Rickli at KBC Australia:

(02) 6361 4000

mrickli@kbconsult.com.au

Comprehensive primary health care and social determinants as top priorities

Make everyone more equal and good health will follow

Compared with other countries, Australia does very well in terms of health. We rank second in terms of life expectancy, reflecting our level of education, housing and living standards. We have a health system many envy — based on universal public health insurance. And yet, there is room for improvement.

Evidence suggests that more equal societies are healthier.1 An explicit goal of the next Australian federal government, therefore, should be reducing health inequities. To achieve this, vastly improved coordination of primary health care (PHC) services is needed. In addition, the new government’s agenda should prioritise action to improve the social determinants of health.2 By improving community health overall, our continually increasing and economically unsustainable health care costs that are excessively focused on hospital care will be reduced.

The World Health Organization has stated that health systems should be built on the basis of a strong, comprehensive PHC system.3,4 Such a system needs to cure disease, provide rehabilitation, prevent disease and promote health. For the past 20 years, Australian governments have been instituting reforms to achieve this. But the task is made difficult by lack of coordination between fee-for-service general practice, which provides episodic care, and parallel services offered by state and territory governments, such as community health services that provide multidisciplinary curative (eg, diabetes management), rehabilitative (diabetes self-care), preventive (exercise groups and promoting healthy eating) and promotive (lobbying to restrict the sale of high-fat and high-sugar foods) services. The origins of the latter services go back to the Whitlam government’s Community Health Program,5 and, despite uneven development, these services have offered comprehensive PHC services as recommended by the WHO.3,4 The Rudd–Gillard health reforms aimed to produce improved coordination of PHC services through Medicare Locals, created to assume responsibility for regional coordination and planning. It is too early to comment on their effectiveness. However, a new government would do well to build on these structures and to use the federal–state health care agreements to ensure that all states and territories do not abandon disease prevention and health promotion, as Queensland and South Australia appear to have done. The new government should also institute formal trials of community-managed community health centres that enrol general practice patients (rather than offering fee-for-service), offer a range of allied health services, run support groups (for people with chronic disease, mental illness and people coping with issues such as domestic violence) and promote health, including through community development. The existing network of Aboriginal community-controlled health services should be strengthened and new services established with increased funding and more supportive governance models. A well coordinated PHC sector would contribute to reducing health inequities by increasing access to health care for Indigenous people living in remote areas and people living on low incomes.

The second priority of an incoming government should be responding to the social determinants of health. The Senate Community Affairs References Committee has emphasised the importance to Australia of prioritising social determinants.6 The response should be systematic, whole-of-government and based on health in all policies (HiAP).7 An HiAP approach has been trialled in a number of countries and in South Australia.8 Its aim is to hold all government sectors accountable for their health impact and for determining how negative impacts can be minimised and positive ones maximised; for example, urban planning would be done in a way that encourages physical activity and social connectivity, and food supply would be regulated to reduce fat and sugar content in diets. An incoming government should ask the Department of the Prime Minister and Cabinet to take responsibility by ensuring that all departments are conscious of their health impact and take measures to maximise health. This will have a far greater impact on health than health care services are able to have.

Impact on diabetes management of General Practice Management Plans, Team Care Arrangements and reviews

The prevalence of diabetes is increasing worldwide, placing a major burden on individuals, communities and health services. In meeting this challenge, evidence suggests that the Chronic Care Model (CCM)1 leads to improved patient care and better health outcomes.2 The importance of the CCM delivery system — longitudinal planned care, regular follow-up and review, and multidisciplinary team care — is well established.3 Studies have shown that delivery system interventions are associated with improvements in clinical processes and outcomes,4 including glycated haemoglobin (HbA1c) and low-density lipoprotein (LDL) cholesterol levels5 and glycaemic control6 in patients with diabetes.

In Australia, Chronic Disease Management Medicare items were introduced to increase support for the management of chronic illness.7 These items provide rebates for General Practice Management Plans (GPMPs) to improve care planning, Team Care Arrangements (TCAs) to foster multidisciplinary care, and GPMP and TCA reviews to support ongoing care and regular follow-up.8 Evidence indicates that TCAs are associated with improved outcomes for patients with diabetes,9,10 but no detailed study on the impact of reviews for patients with diabetes has been done.

Web-based care management systems integrated with primary care are associated with improved glycaemic control,11 while modest improvements have been found in the absence of full integration.12–15 One such system, cdmNet (Precedence Health Care),16,17 is used by Australian practices to improve systematic management of patients with chronic disease. cdmNet supports key CCM processes: it creates best-practice, personalised GPMPs and TCAs; shares these plans with the care team and patient; continuously monitors the plans; facilitates collaboration and regular review; and supports patient self-management. Initial studies suggest that cdmNet is associated with improved team collaboration and adherence to best-practice guidelines.18

We aimed to investigate whether GPMPs, TCAs and their reviews improve the management and outcomes of patients with diabetes when supported by cdmNet.

Methods

This was a before-and-after study of prospectively collected data from cdmNet. This web-based care management system was chosen because of its relatively broad adoption in Australia.19 Patients with type 1 or 2 diabetes mellitus from across Australia (including metropolitan, rural and regional communities) who had been on a GPMP created using cdmNet for at least 14 months between June 2008 and November 2012 were selected for inclusion. cdmNet did not report comprehensive clinical data until 1 May 2011, so eligible patients had to still be actively involved in cdmNet after this date. Patients who sign up to use cdmNet agree to allow non-identifiable data collected in the system to be used for research purposes. The general practitioners in this study were those participating in the cdmNet care plans of the included patients.

The Monash University Human Research Ethics Committee approved this study (CF11/1035: 2011000519, CF11/1699: 2011000947).

Outcomes

Quality of care was measured using process and clinical outcomes.

Process outcome

Process outcomes measure adherence to best-practice care according to some standard. In this study, we used a single process outcome based on the proportion of completed clinical tests in the annual cycle of care (ACOC), as recommended in Australian diabetes guidelines.20 While the patients in the study were “available” to have multiple clinical tests done, not all patients had these done by their GPs. The process outcome was therefore defined as the percentage of ACOC clinical tests completed for the patient. The ACOC guidelines specify that seven clinical tests should be carried out within a 13-month period: one measurement each for HbA1c, total cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol, and microalbuminuria; and two measurements 5 months apart of body mass index (BMI) and blood pressure (BP).20 We calculated the process outcome by dividing the number of completed clinical tests (to a maximum of seven) by the recommended number of tests (seven). For each of BMI and BP, both tests needed to be done to count as completed. Tasks carried out by allied health personnel (eg, podiatrists, optometrists) were not included, as data on these before using cdmNet (ie, before a GPMP) were not available.

The process outcome was calculated for both the period of 1–14 months before the first cdmNet GPMP was created, and for the 13-month period after creation of the GPMP.

Clinical outcomes

In this study, clinical outcomes refer to six of the clinical measurements included in the ACOC: HbA1c level, total cholesterol level, LDL cholesterol level (derived from the HDL cholesterol test), BMI, and systolic and diastolic BP.

Clinical outcomes before the first cdmNet GPMP was created were defined as the most recent value of each clinical measurement taken between 3 months before and 1 month after the creation of the GPMP. Measurements taken in this period represent the status of the patient before the intervention, even if they were measured after creation of the GPMP. Clinical outcomes after the GPMP were defined as the most recent value of each clinical measurement taken 13–18 months after the creation of the GPMP.

Data analysis

The analysis was carried out in three parts. First, we investigated the effect of creating a GPMP on process and clinical outcomes, irrespective of whether or not a TCA was also created. Second, we investigated the effect of creating both a GPMP and TCA. Third, we analysed the effect of reviews of GPMPs or GPMPs and TCAs, for which patients were divided into three groups based on the regularity of review:

No reviews: no GPMP or TCA reviews were performed within 13 months from creation of the GPMP.
Irregular reviews: at least one GPMP or TCA review was performed within 13 months from creation of the GPMP, but the conditions for regular reviews were not met.
Regular reviews: two or more GPMP or TCA reviews were performed within 13 months from creation of the GPMP, with the first performed at least 3 months after the GPMP, and with at least two performed more than 3 months apart.

Given the importance of glycaemic management in preventing or delaying complications of diabetes,21,22 a further analysis was carried out to compare HbA1c levels before and after a GPMP for patients whose HbA1c level before the GPMP was greater than the recommended Australian target of 53 mmol/mol.

The paired-samples t test23 was used to compare process and clinical outcomes before and after the GPMP. In analysing the effect of reviews, an additional analysis was carried out using one-way between-groups analysis of variance23 to compare outcomes among the three groups. Adjustment for multiple comparisons was made using the Tukey honestly significant difference test.24 For each test, effect size was determined by calculating eta-squared and interpreted using the guidelines proposed by Cohen (0.01 is considered a small effect, 0.06 is moderate and 0.14 is large).25 We used SPSS version 20 (SPSS Inc) for statistical analysis.

Results

A total of 577 patients managed by 36 GPs satisfied the inclusion criteria. Characteristics of the patients are shown in the Appendix. There were 271 patients diagnosed with more than one chronic illness. The length of time since diagnosis of diabetes was unknown.

Effect of a GPMP on outcomes

Patients with a GPMP had significant improvements in the proportion of ACOC tests completed and in total cholesterol level, LDL cholesterol level and BMI (Box 1).

For 89 patients whose HbA1c level was > 53 mmol/mol before the GPMP, there was a significant decrease in HbA1c level after the GPMP, with a large effect (mean [SD], 68.2 [16.9] v 58.8 [11.7]; t(88) = 4.7, P < 0.001). The mean decrease in HbA1c level in this group was 9.4 mmol/mol (95% CI, 5.5–13.3 mmol/mol).

Effect of a GPMP and TCA on outcomes

For the 507 patients (87.9%) with both a GPMP and TCA, significant improvements were seen in the proportion of ACOC tests completed and in HbA1c, total cholesterol and LDL cholesterol levels and BMI (Box 2).

For 84 patients whose HbA1c level was > 53 mmol/mol before the GPMP, there was a significant decrease in HbA1c level after the GPMP, with a large effect (mean [SD], 68.7 [17.2] v 58.3 [11.5]; t(83) = 5.2, P < 0.001). The mean decrease in HbA1c level in this group was 10.4 mmol/mol (95% CI, 6.5–14.4 mmol/mol).

Effect of reviews on outcomes

Of the 577 patients, 116 (20.1%) had no reviews, 270 (46.8%) had irregular reviews and 191 (33.1%) had regular reviews. Overall, 461 patients (79.9%) had their GPMP and/or TCA reviewed.

There were no significant improvements for patients with no reviews (Box 3). Patients having irregular reviews had significant improvements in the proportion of ACOC tests completed, total cholesterol level and BMI. Patients having regular reviews had significant improvements in the proportion of ACOC tests completed, HbA1c level, total and LDL cholesterol levels, and diastolic BP. The mean increase in the process outcome was 1.4 times higher for patients having regular reviews than for those having irregular reviews.

Improvements in the process outcome showed a significant difference (P < 0.05) among the three groups (F[2, 574] = 17.2, moderate effect [0.06]). Post-hoc comparisons indicated the mean change in process outcome for no reviews was significantly different from irregular reviews and regular reviews (Box 3). Improvements in HbA1c level also showed a significant difference (P < 0.05) among the three groups (F[2, 218] = 3.5, small effect [0.03]). The mean change in HbA1c level for regular reviews was significantly different from irregular reviews.

Discussion

This study found improvements in process and clinical outcomes for patients for whom GPMPs or GPMPs and TCAs were created, particularly when these were followed up by GPMP or TCA reviews.

For managing diabetes, the proportion of ACOC tests completed gives an indication of quality of care.26 This measure increased by over 15% in magnitude for patients on a GPMP or GPMP and TCA. One explanation is that placing patients on a GPMP or TCA helps the GP implement best-practice guidelines and encourages the patient to adhere to these. cdmNet also reminds patients to make and attend appointments. As almost 90% of the patients in our study had both a GPMP and TCA, it was not possible to determine the effect of creating a TCA in addition to a GPMP.

Patients with a GPMP or GPMP and TCA also showed significant improvement in the clinical outcomes of HbA1c, total cholesterol and LDL cholesterol levels, and BMI, although the HbA1c measure was not significant for the GPMP group. This suggests that a GPMP alone may be insufficient to affect HbA1c levels. These improvements could be associated with the additional support, such as education on nutrition and weight management, that multidisciplinary teams provide.

GPMP and TCA reviews had a significant effect on the process outcome, with the proportion of ACOC tests completed increasing in magnitude by over 18% for patients receiving irregular reviews and 26% for those receiving regular reviews. In contrast, there was no improvement for patients who had no reviews. This important finding demonstrates how critical the follow-up and review process is for improving quality of care.

While both regular and irregular reviews were associated with improvements in clinical outcomes, improvements in key diabetes measures such as HbA1c and LDL cholesterol levels were only found in patients who had regular reviews. The improvement in HbA1c levels was statistically significantly different between patients who received irregular and regular reviews, and the magnitude of improvement was less for patients who received no reviews than for those with regular reviews. These findings reinforce the importance of GPMP and TCA reviews, especially when carried out regularly.

Another finding was the possible importance of the web-based management tool, cdmNet, in improving adherence to best-practice guidelines for chronic disease management. Patients using cdmNet were four times more likely to have their GPMP or TCA followed up through regular reviews than the national average (80% v 20%, respectively, within a 13-month period, based on the recommended frequency of three reviews for every GPMP or TCA).27

For patients with diabetes, demonstrating improvement in clinical measures of diabetes control, obesity, BP and lipid levels demonstrates not just a stabilisation of their diabetes but a reduction in their disease burden. For a single patient, small changes are not generally clinically meaningful, but in this study the averaged results of the group showed a significant and meaningful improvement.

Our study has some limitations. The patients were not randomly chosen but were prospectively assessed from among users of cdmNet. There was no control group, and possible bias and confounders could affect the outcomes. In addition, because the ACOC guidelines were not followed for all patients, data for each of the clinical outcomes were available for only about 20%–60% of participants. Therefore, the conclusions regarding clinical outcomes relate only to the subset of patients who had measurements available from both before and after the GPMP for analysis. The fact that data were not collected for many patients because of this divergence from the guidelines is an important finding and points to the need for future research to investigate the reasons for this.

This study provides an evidence base to support creating GPMPs and TCAs and conducting formal reviews at regular intervals. It indicates that the use of web-based tools for supporting collaborative care management for patients with diabetes has the potential for transformative change in best-practice care. Further analysis with a longer follow-up period would be beneficial in confirming these results. In the future, longitudinal data from cdmNet will allow extensive analyses that take patients’ disease and behavioural complexities into consideration, as well as analyses into health provider behaviour.

1 Process and clinical outcomes before and after creation of a General Practice Management Plan (GPMP)

		Mean (SD)
Outcome	Patients*	Before GPMP	After GPMP	Mean improvement (95% CI)	P	Effect size†

Proportion of ACOC tests completed	577	57.9% (31.9%)	74.8% (28.9%)	16.9% (13.4% to 20.3%)	< 0.001	large
HbA1c level (mmol/mol)	221	55.2 (15.5)	53.4 (10.6)	1.8 (− 0.1 to 3.8)	0.06	na
Total cholesterol level (mmol/L)	123	4.6 (1.2)	4.3 (1.0)	0.3 (0.1 to 0.4)	< 0.01	moderate
LDL cholesterol level (mmol/L)	112	2.6 (1.0)	2.3 (0.9)	0.3 (0.1 to 0.4)	< 0.001	moderate
Body mass index (kg/m2)	236	32.1 (6.3)	31.7 (6.2)	0.4 (0.2 to 0.7)	< 0.01	small
Systolic BP (mmHg)	312	137.3 (16.3)	136.6 (16.0)	0.7 (− 1.4 to 2.9)	0.50	na
Diastolic BP (mmHg)	312	75.1 (10.2)	74.0 (9.6)	1.1 (− 0.1 to 2.3)	0.08	na

ACOC = annual cycle of care. HbA1c = glycated haemoglobin. LDL = low-density lipoprotein. BP = blood pressure. na = not applicable. * Number of patients differs for clinical outcomes as not all patients had all clinical tests completed. † Determined by calculating eta-squared, where 0.01 is considered a small effect, 0.06 is moderate and 0.14 is large.25

2 Process and clinical outcomes before and after creation of a General Practice Management Plan (GPMP) for patients with a GPMP and Team Care Arrangement

Mean (SD)

Outcome

Patients*

Before GPMP

After GPMP

Mean improvement (95% CI)

Effect size†

Proportion of ACOC tests completed

507

58.9% (31.8%)

73.9% (30.0%)

15.0% (11.2% to 18.8%)

< 0.001

moderate

HbA1c level (mmol/mol)

198

55.8 (16.1)

53.4 (10.4)

2.4. (0.3 to 4.5)

< 0.05

small

Total cholesterol level (mmol/L)

110

4.6 (1.2)

4.3 (1.0)

0.3 (0.1 to 0.4)

< 0.01

moderate

LDL cholesterol level (mmol/L)

100

2.6 (1.0)

2.3 (0.9)

0.3 (0.1 to 0.4)

< 0.01

moderate

Body mass index (kg/m2)

205

32.2 (6.4)

31.8 (6.2)

0.4 (0.2 to 0.7)

< 0.01

small

Systolic BP (mmHg)

274

138.1 (16.7)

136.7 (15.8)

1.4 (− 0.9 to 3.6)

0.25

Diastolic BP (mmHg)

274

75.2 (10.3)

73.9 (9.6)

1.3 (0.0 to 2.6)

0.05

ACOC = annual cycle of care. HbA1c = glycated haemoglobin. LDL = low-density lipoprotein. BP = blood pressure. na = not applicable. * Number of patients differs for clinical outcomes as not all patients had all clinical tests completed. † Determined by calculating eta-squared, where 0.01 is considered a small effect, 0.06 is moderate and 0.14 is large.25

3 Comparison of process and clinical outcomes before and after creation of a General Practice Management Plan (GPMP), by regularity of review

		Mean (SD)
Outcome by review group	Patients*	Before GPMP	After GPMP	Mean improvement (95% CI)	P	Effect size†

Proportion of ACOC tests completed
No reviews	116	53.4% (31.7%)	51.6% (34.7%)	− 1.8% (− 10.5% to 6.8%)	0.67	na
Irregular reviews	270	59.2% (32.1%)	77.6% (24.8%)	18.4% (13.7% to 23.0%)	< 0.001	large
Regular reviews	191	58.9% (31.6%)	85.0% (22.2%)	26.1% (20.5% to 31.8%)	< 0.001	large
HbA1c level (mmol/mol)
No reviews	31	56.3 (12.9)	53.1 (10.5)	3.2 (− 0.7 to 7.1)	0.12	na
Irregular reviews	109	53.0 (12.5)	53.7 (11.4)	− 0.7 (− 3.1 to 1.7)	0.57	na
Regular reviews	81	57.7 (19.3)	53.0 (9.6)	4.8 (1.0 to 8.5)	< 0.05	moderate
Total cholesterol level (mmol/L)
No reviews	21	4.6 (1.0)	4.5 (1.1)	0.1 (− 0.3 to 0.4)	0.67	na
Irregular reviews	60	4.4 (1.1)	4.1 (0.9)	0.3 (0.0 to 0.5)	< 0.05	moderate
Regular reviews	42	4.8 (1.4)	4.5 (1.1)	0.3 (0.1 to 0.6)	< 0.05	moderate
LDL cholesterol level (mmol/L)
No reviews	20	2.7 (1.0)	2.6 (1.1)	0.1 (− 0.2 to 0.5)	0.38	na
Irregular reviews	53	2.4 (0.8)	2.2 (0.8)	0.2 (0.0 to 0.3)	0.05	na
Regular reviews	39	2.8 (1.1)	2.4 (0.9)	0.4 (0.1 to 0.7)	< 0.01	large
Body mass index (kg/m2)
No reviews	28	31.8 (5.5)	31.6 (5.6)	0.2 (− 0.8 to 1.2)	0.68	na
Irregular reviews	108	32.5 (6.7)	31.9 (6.7)	0.6 (0.2 to 0.8)	< 0.01	moderate
Regular reviews	100	31.8 (6.1)	31.4 (5.8)	0.4 (0.0 to 0.8)	0.05	small
Systolic BP (mmHg)
No reviews	42	137.4 (18.8)	138.1 (20.5)	− 0.7 (− 6.9 to 5.3)	0.80	na
Irregular reviews	149	139.3 (16.1)	137.1 (14.8)	2.2 (− 1.1 to 5.4)	0.20	na
Regular reviews	121	135.0 (15.5)	135.4 (15.6)	− 0.4 (− 3.7 to 2.7)	0.76	na
Diastolic BP (mmHg)
No reviews	42	74.6 (9.7)	74.6 (10.8)	0.0 (− 3.2 to 3.1)	0.99	na
Irregular reviews	149	74.5 (10.1)	73.9 (9.3)	0.6 (− 1.1 to 2.4)	0.48	na
Regular reviews	121	76.0 (10.4)	74.0 (9.5)	2.0 (0.0 to 4.0)	< 0.05	small

ACOC = annual cycle of care. HbA1c = glycated haemoglobin. LDL = low-density lipoprotein. BP = blood pressure. na = not applicable. * Number of patients differs for clinical outcomes as not all patients had all clinical tests completed. † Determined by calculating eta-squared, where 0.01 is considered a small effect, 0.06 is moderate and 0.14 is large.25

Contemporary themes in acute coronary syndrome management: from acute illness to secondary prevention

Acute coronary syndrome (ACS; myocardial infarction and unstable angina) is the leading cause of mortality in Australia and accounts for more than 300 000 years of life lost due to premature death (aged < 65 years) annually. The cost of repeat ACS events in 2010 exceeded $8 billion.1 About half of the cardiovascular events in Australia occur in people who have had a prior hospital episode for coronary heart disease (CHD).2 Therefore, access to evidence-based and optimal ACS management in both the acute and long-term periods is of great importance.

In recent years, advances in monitoring, revascularisation and pharmacotherapy for acute illness have contributed to a reduction in mortality. However, a quarter of these survivors will be readmitted to hospital within a year of the index event, and a significant number of readmissions will result in death.3,4 Consequently, the demand for effective secondary prevention is intensifying, and ensuring access to structured management strategies that complement standard medical care is now a priority.

The burden of CHD is disproportionately greater for certain patient groups. People living in outer regional and remote areas experience disease rates 20% higher than do those living in major cities, with higher mortality proportionate to increasing distance from major centres.5 Cardiovascular disease is also the largest contributor to the 17-year gap in life expectancy between Indigenous and non-Indigenous Australians.

Here, we provide an overview of key contemporary issues in the provision of ACS care, including the importance of early diagnosis of ischaemia; risk stratification; provision of timely, appropriate and evidence-based management; and prevention of recurrent events. We describe barriers to the equitable provision of immediate and long-term optimal care and suggested strategies to overcome them. These strategies focus on the practice and policy changes needed to implement networked systematic care across all geographical and economic strata serviced by our health care system.

Contemporary considerations for ACS management

Contemporary management of ACS should be rapid and should include reperfusion, medical therapy and ongoing secondary prevention. Management should be comprehensive, coordinated and ongoing. Ideally, patients should seek medical care as early as possible after the onset of symptoms and should be provided with: rapid access to a hospital or a defibrillator; early reperfusion therapy for ST-segment-elevation myocardial infarction (STEMI); early angiography and revascularisation where indicated; appropriate medical therapy; and ongoing secondary prevention that encompasses medication adherence and lifestyle change.6

Rapid reperfusion for STEMI

STEMI accounts for about 25% of ACS presentations and remains a cardiac emergency. As rapid restoration of epicardial blood flow is of initial importance,6 the first goal of therapy is immediate reperfusion, which is best achieved by primary percutaneous coronary intervention (PCI) when appropriately staffed facilities are available.7 If delays are likely because of the need to transfer patients long distances for primary PCI, fibrinolysis is a superior option, particularly for patients receiving medical attention early after the onset of symptoms.6,7 Fibrinolysis can be of substantial value in the rural prehospital setting, where delays to PCI are unavoidable. For patients with large infarcts receiving fibrinolysis in non-PCI-capable centres, early transfer (ideally within 24 hours) to a PCI-capable centre for coronary angiography is now recommended.8 This enables emergency treatment (rescue PCI) for patients who have not reperfused after fibrinolysis. For those who have reperfused, emergency PCI is best performed from 3 to 24 hours after lysis; this minimises both the access-site bleeding consequences of the lytic therapy and the likelihood of culprit vessel reocclusion.

An invasive management strategy for
non-ST-segment-elevation ACS

Patients with a non-ST-segment-elevation ACS and who are at high risk of inhospital and late death or myocardial infarction benefit from coronary angiography, which guides an appropriate revascularisation strategy during their hospital stay.9 The earlier this procedure is performed, the greater the benefit.10 Lower-risk patients may be risk stratified through either angiography or non-invasive testing. Intervention-related bleeding can be reduced by adopting a radial rather than femoral approach to coronary angiography. The radial approach may also be associated with reduced mortality in the STEMI population,11 and this strategy is gaining in popularity.

Medical therapy

Antithrombotic strategies using heparin or low-molecular-weight heparin remain a cornerstone of therapy to prevent propagation or embolisation of the thrombus responsible for the coronary instability. However, iatrogenic bleeding events, traditionally regarded as a tolerable complication of anti-ischaemic therapy, are themselves associated with increased mortality.12 Newer anticoagulant agents, such as fondaparinux and bivalirudin, can reduce recurrent ischaemic events with comparable efficacy and less bleeding than traditional heparins among medically managed and PCI-managed ACS patients, respectively.13,14 Where increased bleeding risk is anticipated, these newer therapies are recommended.8

In addition to anticoagulants, dual antiplatelet therapy with low-dose aspirin and the ADP receptor antagonist clopidogrel is associated with reduced ischaemia in patients after an ACS when compared with aspirin alone.15 More potent ADP receptor antagonists, such as prasugrel and ticagrelor (Box 1), prescribed as substitutes for clopidogrel, extend this benefit further, but do so at the cost of increased bleeding.16,17 Here, the risk–benefit equation is more complex because these newer agents have improved efficacy with a possible reduction in mortality,17 underscoring the need for a better understanding of the prognostic impact of different types of bleeding (eg, access-related versus gastrointestinal), together with more sophisticated tools to predict bleeding.

Emerging acute treatments

Reperfusion after coronary occlusion is associated with the release of products that are toxic to injured but perfused myocardial cells. Over the past 40 years, many therapeutic strategies have been trialled, unsuccessfully, to prevent reperfusion injury. Strategies for which there is cautious optimism include intracoronary adenosine, hypothermia, and “conditioning” the myocardium by alternating periods of brief ischaemia and reperfusion.18,19 Early studies indicate that infusing a patient’s own stem or progenitor cells in the infarct setting may promote restoration of myocardial function.20,21 Larger trials with standardised methodology are required to establish the role of this therapy.

Secondary prevention

In the transition to primary care after hospital discharge, ongoing participation in a secondary prevention program is recommended for all ACS survivors.22 Attending secondary prevention programs, adhering to risk factor modification and complying with drug regimens may reduce hospital readmissions within 1 year by 45% and increase survival.23 Advances in secondary prevention approaches include clinic-based coordinated care, individualised case management and coaching with regular monitoring and, more recently, e-health strategies that provide flexible ongoing care.4

Secondary prevention ideally requires a lifelong commitment to ongoing behaviour change. The original model for delivery of “cardiac rehabilitation” to patients with CHD focused on supervised exercise to counter deconditioning after bypass graft surgery and to improve exercise capacity after myocardial infarction. However, patients are no longer confined to long periods of bed rest after an ACS event, and their needs are different than when traditional programs were developed. Around 70% of secondary prevention programs offered in Australia continue to follow the traditional cardiac rehabilitation model of structured, group-based exercise and education delivered in a hospital setting.24 However, traditional facility-based cardiac rehabilitation is currently facing substantial challenges in terms of access, appeal and cost. Non-attendees are returning to work commitments early and are less likely to believe that rehabilitation is necessary, despite having higher baseline risk and poorer risk factor knowledge than those who do attend.25 Evidence that hospital-based secondary prevention interventions are effective26 is now supplemented by evidence that programs can be provided in various settings, by different health professionals, and in various ways.4 The development of contemporary flexible models that use existing community services (eg, government “quit smoking” programs, the Enhanced Primary Care Program, National Heart Foundation of Australia physical activity initiatives, and private health insurer programs) are examples of this.

Evidence–practice gaps in Australian ACS management

Deficits in the application of optimal ACS care occur in the prehospital, inhospital and postdischarge periods. The case studies outlined in Box 2 highlight some of these contemporary issues.

Delays in reperfusion for STEMI

In the first case study, Mr T experienced delays in presentation to hospital and in the performance and interpretation of the electrocardiogram (ECG), which significantly delayed time to reperfusion. Australian evidence suggests that patients with STEMI wait a median time of 100 minutes before seeking medical attention, and this delay has not changed since it was first described in the early 1990s. A significant proportion of patients with STEMI do not receive timely reperfusion after presentation to hospital (within 90 minutes of presentation for PCI, and 30 minutes for fibrinolysis).27 Overcrowding of emergency departments and access block can contribute to this delay.28 This means there is a median delay from symptom onset to reperfusion exceeding 190 minutes for patients receiving PCI and 130 minutes for those receiving fibrinolysis — times well beyond the threshold for the development of significant irreversible myocardial necrosis.

Of equal concern is that about 30%–40% of all patients with STEMI receive no reperfusion therapy.3 It has been estimated that increasing the numbers of patients treated with reperfusion therapy would save 270 lives per 10 000 patients with STEMI.6

Access to and appropriate application of invasive management

If Mr T had been transferred to a PCI-capable centre within 24 hours after receipt of fibrinolytic therapy, he could have had early angiography, which would likely have prevented his recurrent myocardial infarction. Similarly, had Mrs D been recognised as being at high risk of a recurrent event, she could have received earlier coronary angiography. There are well validated bedside tools29 that predict the likelihood of inhospital events and guide the application of appropriate management. However, these tools are rarely applied in Australian hospitals. There is also geographical heterogeneity in the provision of coronary angiography for ACS patients in Australia.30 Where access to coronary angiography is available, risk-averse physician behaviour is observed, whereby the highest-risk patients with the most to gain from invasive management are the least likely to receive it.31 Clinicians select therapy on the basis of acute risk factors (ECG changes and troponin level elevation), while patients accumulating chronic risk factors are less likely to receive evidence-based therapies.32

Poor access to and uptake of secondary prevention

Mr T was discharged with suboptimal secondary prevention therapies, some written information and a letter for his general practitioner. At the time of discharge, there was no strategy for ensuring he complied with these instructions.

A 2005–2007 Australian audit showed that only a minority of patients with ACS received all five guideline-recommended secondary prevention treatments at hospital discharge.33 Although there have been some improvements, gaps remain3 and there is a lack of recognition of this problem by clinicians. Australian general practice surveys show that only half of patients with established CHD take recommended treatments.34 Only about a third of patients adhere to recommendations on diet, exercise and smoking, and participation rates in cardiac rehabilitation programs are as low as 10%–30%.35

Failure to follow guidelines can result in errors of commission, as well as errors of omission. Mrs D continued taking “triple therapy” (warfarin and two antiplatelet agents) for 18 months after coronary stenting. Current recommendations minimise the duration of this combination therapy to reduce the risk of bleeding.36 The fact that this did not occur further illustrates the lack of fluidity between tertiary and primary care.

Overcoming the deficits

An integrated and multifaceted strategy that targets both the public and our systems of health care delivery is needed. Some strategies implemented in the Australian context have been shown to be effective. For example, educating the public to recognise symptoms of a heart attack has been a major focus of the National Heart Foundation of Australia’s “warning signs” campaign, which has run since 2008.37 Empowering ambulance service personnel to perform and interpret 12-lead ECGs at first patient contact allows for the immediate identification of STEMI. Reports from clinical cardiac networks in both New South Wales and Victoria have shown the benefit of prehospital diagnosis and triage.38,39 The introduction of the National Emergency Access Target to overcome issues of access block and emergency department overcrowding is an important organisational strategy that facilitates timely ACS management in busier centres. Furthermore, the creation of local hospital networks has provided a substrate for optimising interhospital transfers. If STEMI is identified in a patient self-presenting to a non-PCI-capable centre, it is possible to facilitate near-immediate transfer to a notified nearby PCI-capable hospital. Strategies to minimise transfer (door-in–door-out) time include ambulance prioritisation of these patients, and standardised protocols for STEMI reperfusion at both referring and receiving hospitals.40 Using combined geographical, road transport time and census data, researchers have estimated that implementing improved efficiencies, such as prehospital ECG diagnosis and triage and facilitated interhospital transfers, can improve access to timely reperfusion for more than five million Australians.41

One of the greatest challenges facing hospital clinicians is identifying high-risk patients and stratifying treatment accordingly. Several clinical networks are now providing systematic rural ECG reading services, with the provision of clinical advice to support rural clinicians. Additional strategies include using telemedicine to empower rural GPs to read ECGs. Beyond this, studies investigating the prognostic benefit of routine application of risk stratification tools are planned locally. Interhospital transfer for identified high-risk patients can be facilitated by real-time, web-based interhospital catheter laboratory triage systems. In Queensland, this has been associated with a dramatic improvement in timely appropriate transfer of patients from non-PCI-capable to PCI-capable hospitals.

Universal prescription of evidence-based secondary prevention therapies remains challenging and can only partly be addressed by medication reconciliation at discharge. In one Australia-wide study, the introduction of clinical tools, together with academic detailing of selected clinical staff, had a modest effect on the prescription of evidence-based therapies.42 It appears that hospital culture is the most important determinant of whether improvements in care processes are successful. An effective culture is one that values quality improvement and has clinical leadership, senior management involvement, and good communication between the various clinical groups responsible for providing care.43

Transitioning from the acute to the postdischarge phase can be facilitated by automatic referrals and availability of a range of innovative secondary prevention programs (Box 3).26 These programs frequently involve (in isolation or combination) in-person visitations, community services, and home manuals with telephone or electronic support for flexible and individualised management of CHD. They include clinic nurse-coordinated care,44 individualised case management and monitoring with periodic follow-up,45,46 and community-based groups with ongoing health practitioner support provided across a range of settings.

To achieve optimal and sustainable benefits for the majority of patients, secondary prevention strategies must be flexible; tailored to the individual’s preferences, needs and values; lifelong; and integrated with primary care.6,47 All contemporary secondary prevention programs should include individual patient assessments and structured follow-up, as well as ongoing support and monitoring. Programs should target medication adherence, coupled with biomedical and lifestyle risk factors, while also attending to psychosocial wellbeing. Further, they should recognise the role of patients in self-management and the importance of family and caregiver engagement and support.4

Future innovations

While the dominant pharmaceutical-derived research funding streams will continue to be directed towards newer therapies, the real impact of these is becoming limited as absolute event rates fall. Greater practical gains will be achieved through more widespread application of existing therapies. Improving information technology infrastructure has the potential for great impact on geographical inequities through the availability of clinical support systems (remote ECG interpretation and efficient web-based triage for interhospital transfer).

Many of the available data regarding the quality of patient care have been derived from clinician-driven clinical registries that are restricted by small patient numbers and hospital selection biases.3,30,33 Only through a national ACS registry will we be able to truly understand the patterns and gaps in treatment around the country. In the short term, these data can be acquired through manual data extraction performed at a “snapshot” in time. However, this is resource- and labour-intensive, and as the electronic medical record environment matures, there will be opportunities to collect and audit performance measures and outcomes using clinically collected data. There are ethical, governance and data quality issues that require careful attention; however, principles for the conduct of these registries have been established.48 More mature electronic medical record technology will also help bridge the divide between hospitals and primary care.

Resources need to be allocated to permit the application of a national approach to secondary prevention, encompassing the variety of services outlined here, but unified by a patient-centred focus. Ultimately, a cohesive approach that is accessible, standardised and evidence-based is needed to improve widespread effectiveness.

1 Indications and precautions for the newer orally active ADP receptor antagonist antiplatelet agents*

Agent

Indications

Precautions

Prasugrel

ST-segment-elevation myocardial infarction with planned percutaneous coronary intervention (PCI)

Non-ST-segment-elevation acute coronary syndrome undergoing PCI

Contraindicated in patients with previous stroke or transient ischaemic attack

Caution in patients aged over 75 years or weighing under 60 kg (increased bleeding; consider reduced maintenance dose)

Ticagrelor

All acute coronary syndromes

Caution in patients with second- or third-degree heart block

Caution in patients at increased risk of bleeding (although these patients are often also at high risk of recurrent ischaemic events)

* This list of precautions is not exhaustive; consult a full list before prescribing.

2 Australian case studies of acute coronary syndrome (ACS) management

Case study 1: ST-segment-elevation myocardial infarction

A 64-year-old man (Mr T) was driven by his wife to the emergency department (ED) of a rural hospital 2 hours after onset of retrosternal chest discomfort. He had a 12-month history of exertional angina, was a retired office worker and did not participate in regular exercise. His local general practitioner, whom he generally saw “as little as possible”, had recommended smoking cessation and medical treatment with aspirin, a statin and long-acting nitrates. Mr T had managed to reduce his smoking to five cigarettes/day, had not liked the statin (it gave him muscle pain), took aspirin intermittently and had stopped taking the nitrates (they gave him a headache).

Within 20 minutes of arrival at the ED, an electrocardiogram (ECG) showed ST-segment elevation in the anterior leads. The resident faxed the ECG to the coronary care unit at the nearest base hospital, where it was reviewed by a medical registrar, who discussed it with the on-call physician. The resident was instructed to administer thrombolysis with tenecteplase (TNK), which was delivered 90 minutes after Mr T’s presentation to the hospital. Within 30 minutes, his chest pain settled, and the ECG results improved. Staff at the rural hospital phoned the nearest tertiary hospital (with cardiac catheterisation facilities) to arrange a transfer. This hospital was a 4-hour drive away and had no available coronary care beds.

Forty-eight hours after initial presentation, Mr T experienced recurrent pain accompanied by further ST-segment elevation. A second dose of TNK was given, and he was transferred to the tertiary hospital. Coronary angiography showed a 90% lesion with reduced flow in the proximal left anterior descending coronary artery, a 70% lesion in the left circumflex artery and a 60% lesion in the right coronary artery. Mr T was referred for coronary artery bypass grafting, which was performed during the same admission. He was discharged 5 days later with a medication regimen of aspirin, frusemide and an angiotensin-converting enzyme (ACE) inhibitor. While in hospital, he was seen by a cardiac rehabilitation nurse, who provided some written information about heart disease and a letter for his GP. The hospital did not arrange an appointment with the GP.

Case study 2: Non-ST-segment-elevation ACS

A 75-year-old woman of Italian origin (Mrs D), who had been in Australia for 15 years but had poor command of English, called an ambulance 3 hours after developing intermittent nausea and diaphoresis. She had experienced similar symptoms before undergoing a coronary artery bypass graft 10 years earlier and had noticed recurrence of these symptoms on exertion for the past 2 weeks. Mrs D had been diagnosed with atrial fibrillation 5 years earlier when she presented with heart failure. She had been taking warfarin since then, and was also taking frusemide and an ACE inhibitor, but no statin.

The ambulance took Mrs D to the nearest hospital, which did not have percutaneous coronary intervention (PCI) facilities. Her symptoms had settled by the time of arrival. Examination showed mild left ventricular failure (crepitations in the lower third of the lung fields), an ECG showed a non-specific intraventricular conduction delay, and her troponin level was normal. Measurement of the troponin level was not repeated. Her creatinine level was elevated (165 μmol/L [reference interval, 60–115 μmol/L]). She was diagnosed with possible unstable angina and commenced taking aspirin and a nitrate, with a plan for 48 hours of observation followed by discharge for outpatient functional study. On her second day in hospital, Mrs D developed recurrent symptoms with pulmonary oedema, which responded to continuous positive airways pressure and diuretic therapy. Arrangements were made for coronary angiography at the nearest PCI-capable hospital. She was transferred 4 days later (once her international normalised ratio [INR] had fallen to < 1.5). Coronary angiography showed a stenosed vein graft to a circumflex vessel, which was treated with a 3.5 mm drug-eluting stent.

Mrs D was discharged 5 days later (once her INR had reached 2) with a medication regimen of aspirin, clopidogrel, warfarin, frusemide, an ACE inhibitor and a statin. The hospital arranged an appointment with her GP. Eighteen months later, she re-presented to the hospital with a massive gastrointestinal bleed. At this time, she was still taking aspirin, clopidogrel and warfarin.

3 Strategies aimed at increasing access to secondary prevention

Automatic referral of all eligible patients
Availability of different program types, including home, primary care, hospital and community-based strategies
Use of e-health, including communication by telephone, email, the internet or videoconferencing
Provision of programs that involve family-based strategies
Coordinated care comprising medical visits with general practitioners and specialists in combination with participation in a structured secondary prevention program

Subacute care funding in the firing line

Recent enhancements to subacute care services are threatened due to the uncertain future of federal–state funding agreements

The term “subacute” was coined for use in Australia 21 years ago to describe health care where the patient’s need for care is driven predominantly by his or her functional status rather than principal diagnosis.1 Subacute care includes rehabilitation, palliative care, geriatric evaluation and management, and psychogeriatrics. Rehabilitation represents more than 50% of all subacute hospital care in Australia.2

The past two decades have seen slow growth in subacute care. However, the public sector was given substantial momentum in recent years through two National Partnership Agreements (NPAs) between the federal government and the state and territory governments, negotiated by the Council of Australian Governments (COAG) — the Hospital and Health Workforce Reform (HHWR) NPA and the Improving Public Hospital Services (IPHS) NPA. Both NPAs aimed to “improve efficiency and capacity in public hospitals”.3

The 5-year HHWR NPA was signed in 2008 and, of the total funding of $3042 million negotiated under this agreement, $1383 million was provided by the federal government to the states and territories. This consisted of $133.41 million for activity-based funding (ABF) infrastructure, $500 million for subacute services, and $750 million for “taking the pressure off public hospitals” by addressing waiting lists and times.3 The $500 million allocated for subacute services was provided in one instalment, with its distribution to all states and territories based on age-weighted population.

The IPHS NPA was signed in 2011.4 It consisted of total funding of $3373 million, including up to $1623 million for new subacute beds. This was allocated over 4 financial years — $233.6 million in 2010–11, $317.6 million in 2011–12, $446.5 million in 2012–13, and $625.5 million in 2013–14.

Box 1 shows that activity increases in subacute services attributable to the HHWR NPA occurred in all states and territories. More than 600 000 extra bed-day equivalents (inpatient days plus ambulatory care equivalents) were provided in 2011–12 than in the baseline year of 2007–08, representing 25.9% growth across Australia.5 The target in the HHWR agreement was a 5% increase in each of the 4 years — this was exceeded by the end of Year 3 (2011–12).

The 2009 report of the National Health and Hospitals Reform Commission (NHHRC) stated that:

There is … an urgent need for substantial investment in, and expansion of, sub-acute services — the ‘missing link’ in care — including a major capital boost to build the facilities required.

It also recommended the introduction of clear targets to increase the provision of subacute services, and stated that “Incentive funding under the National Partnership Payments could be used to drive this expansion in sub-acute services”.6

The NHHRC recommended investment beyond the targeted 5% increase per year under the HHWR agreement, recognising that much of this 5% increase would only account for extra demand associated with population ageing and growth. Indeed, as shown in Box 1, most states and territories have delivered much greater than 5% growth, with South Australia and Queensland reporting increases of 50% and 43%, respectively.5

The HHWR agreement made provision for a review of progress “in respect of achieving the agreed outcomes”, to occur in July 2011.3 However, apart from the annual reports of the states and territories describing the services developed under the NPA, and the reporting of activity measures, there is no evidence that any review of the NPA on a national basis has occurred. Further, although the NPA specifically describes the role of the federal government as including provision of funding support for “research into best practice models of care” and funding and providing “national coordination of the initiative [and] monitor[ing] performance”,3 no provision was made for funding to continue beyond the term of the NPA, nor for a formal evaluation of outcomes at its conclusion. Consequently, the effectiveness of the developed services cannot be fully assessed because they have not been subjected to rigorous evaluation. Although formal outcomes cannot be reported, examples of rehabilitation programs funded by the HHWR agreement are given in Box 2.

In contrast, the IPHS agreement specifies that an evaluation framework will be developed and that a review of the agreement will be completed, with a decision by COAG by December 20134 — although no details have been released to date.

These two agreements have provided public hospitals with unprecedented opportunities to develop new inpatient and ambulatory rehabilitation services and to expand existing services. These new and expanded services have dealt with previously identified deficiencies, especially the need for early rehabilitation in the acute care setting and increasing the intensity of therapy within rehabilitation settings.8–10 Public hospitals have been able to develop better rehabilitation capital infrastructure and better meet the growing need for rehabilitation, particularly among the ageing population. Between them, these two agreements represented a turning point in the development of public sector rehabilitation services across the country.

There is growing international evidence showing improved patient outcomes from the provision of more intense therapy (ie, therapy “dose”) in the rehabilitation setting, as well as showing improved efficiency.8,9,11 In the United States, where therapy of 3 hours per day for a minimum of 5 days per week is mandated in inpatient rehabilitation,9 length of stay for patients undergoing stroke rehabilitation is shorter, and the rate of attainment of functional gain is higher, than in Australia.1 2

More intense therapy should result in more efficient use of rehabilitation beds if length of stay can be reduced as a result. This is because the cost of providing extra therapy is relatively low compared with the high fixed costs of running an inpatient bed.

With the HHWR NPA ending on 30 June 2013, many of these new and expanded rehabilitation programs will cease. Staff are already seeking alternative employment, and programs are beginning to wind down. The fact that many health services across the country will now be closing down rehabilitation and other subacute initiatives that were funded under this NPA suggests a lack of planning by the federal, state and territory governments for what would happen after the HHWR NPA ends.

Development of subacute care must continue if Australia is to keep pressure off the acute hospital system and deal effectively with population ageing. However, in our opinion, the lack of requirements for rigorous evaluation of services developed with HHWR NPA funding, which could have provided a basis for ongoing funding if the requirements were met, is not justifiable.

Even if these programs demonstrate system-wide efficiency gains, this does not free up resources; rather, it increases capacity. As such, it would be difficult for state and territory governments to continue to fund successful programs out of existing resources, unless other programs were cut. The new ABF arrangements are not sufficient to pick up where the HHWR agreement has left off, not least because federal growth funding does not begin until 2014–15.1 3

At the system level, the sudden closure of rehabilitation and other subacute services will have flow-on effects to the acute care system, as it will increasingly have to manage patients who would otherwise have been referred to rehabilitation. The net effect is likely to be that the length of stay in acute care will increase, along with bed occupancy and waiting times.

1 Reported increase in subacute care services under the National Partnership Agreement on Hospital and Health Workforce Reform, by state and territory*

Jurisdiction	Services in 2007–08 (baseline)	Services in 2011–12	Increase (%) in 2011–12 compared with baseline

New South Wales	679 048	813 283	134 235 (19.8%)
Victoria	786 648	933 930	147 282 (18.7%)
Queensland	290 368	414 531	124 163 (42.8%)
South Australia	197 583	296 604	99 021 (50.1%)
Western Australia	511 498	658 781	147 283 (28.8%)
Tasmania	46 815	56 243	9 428 (20.1%)
Australian Capital Territory	62 745	68 038	5 293 (8.4%)
Northern Territory	11 227	14 261	3 034 (27.0%)
All	2 585 932	3 255 671	669 739 (25.9%)

* Compiled from the individual state and territory government reports submitted to the Steering Committee for the Review of Government Service Provision (for Schedule C of the National Partnership Agreement on Hospital and Health Workforce Reform).5

2 Examples of rehabilitation programs funded by the National Partnership Agreement on Hospital and Health Workforce Reform

At St Vincent’s Hospital in Sydney, existing services were enhanced and two new services introduced: rehabilitation in the home, and a mobile rehabilitation team. The latter provides rehabilitation within 3 days of acute admission in parallel with acute care. The program targets young disabled patients for whom there are few community services. Hospital length of stay was reduced and patients avoided inpatient rehabilitation, instead accessing ambulatory programs after discharge.
In South Australia, large investments were made in home and day rehabilitation services, including substantial investments in Whyalla, Mt Gambier and Berri. The Women’s and Children’s Hospital in Adelaide is now able to provide multidisciplinary community services, allowing access to community-based rehabilitation for 50 children who have had complex surgery, as well as the establishment of a state-wide hip surveillance program for children with cerebral palsy.
The South Eastern Sydney Local Health District (SESLHD), one of the largest health districts in New South Wales, focused on increasing intensity of therapy in inpatient rehabilitation and developed acute rehabilitation teams in acute hospitals. The SESLHD has evaluated the outcomes of its enhanced rehabilitation services and reports a 13% reduction in the average length of stay, improved speed of functional gain, and more than 130 avoided rehabilitation admissions annually.7