Risk of fragility fracture among patients with gout and the effect of urate-lowering therapy [Research]

BACKGROUND:

Previous studies that quantified the risk of fracture among patients with gout and assessed the potential effect of urate-lowering therapy have provided conflicting results. Our study aims to provide better estimates of risk by minimizing the effect of selection bias and confounding on the observed association.

METHODS:

We used data from the Clinical Practice Research Datalink, which records primary care consultations of patients from across the United Kingdom. We identified patients with incident gout from 1990 to 2004 and followed them up until 2015. Each patient with gout was individually matched to 4 controls on age, sex and general practice. We calculated absolute rate of fracture and hazard ratios (HRs) using Cox regression models. Among patients with gout, we assessed the impact of urate-lowering therapy on fracture, and used landmark analysis and propensity score matching to account for immortal time bias and confounding by indication.

RESULTS:

We identified 31 781 patients with incident gout matched to 122 961 controls. The absolute rate of fracture was similar in both cases and controls (absolute rate = 53 and 55 per 10 000 person-years, respectively) corresponding to an HR of 0.97 (95% confidence interval 0.92–1.02). Our finding remained unchanged when we stratified our analysis by age and sex. We did not observe statistically significant differences in the risk of fracture among those prescribed urate-lowering therapy within 1 and 3 years after gout diagnosis.

INTERPRETATION:

Overall, gout was not associated with an increased risk of fracture. Urate-lowering drugs prescribed early during the course of disease had neither adverse nor beneficial effect on the long-term risk of fracture.

Candidate profile – Dr Tony Bartone MBBS FRACGP MBA FAMA

Nominating for the position of AMA President

The opportunity to serve as Federal AMA President at a crucial time for our association, our health system and the community we serve, is indeed one that is not taken lightly. Nor should it.

As a proud member of our AMA, I humbly but emphatically seek your support to do so.

Most of you will know that I am a GP. My family GP was a strong role model from a young age and crucial in that calling. I have spent my professional life in many different general practices of varying size and structures. An MBA and a national management role with 450 GPs adds to a long-term intricate understanding of primary care and ultimately led to my initial AMA committee 12 years ago, the last six years involving leadership positions including the last two years as Vice President.

The decision to run has many layers, including a desire to give back, given the expertise and networks amassed over the past. Furthermore, a deep desire to listen, engage and assist, combined with an underpinning need for strategic leadership add to the aspiration. Mounting concerns confronting us in our world class health system augment the call. Concerns such as:

Eroding access, equity and affordability, especially rurally and regionally;
The relentlessly squeezing of practice viability;
Extremely low value yet increasingly unaffordable private health insurance policies and the resultant patient exodus;
A training pipeline bottleneck with a frustrating lack of post graduate training places; and
The continual long-term disinvestment in general practice tearing at its heart.

Solutions of course must be advocated, including the appropriate funding, especially for public hospitals, for a significant ramping up of post graduate training places; investing in rural end-to-end training and restoring value and affordability to private health insurance just to name a few. Long-term strategies and investment in mental health and aged care policy framework are also an imperative and part of the quest.

My passion for general practice is often associated with rhetoric about its importance as the corner stone of primary care. This will not ensure quality outcomes. Measly rebate increases are not the solution. Off-the-cuff comments by the Minister will not progress its cause. A section of our membership is at risk in the current climate. Investment in general practice, which rewards quality longitudinal patient-centred care, is sorely needed.

Let me be very clear, there are many other important reasons as to why I am seeking to lead our association.

I am very passionate about mental health and well-being of our colleagues. Of course it’s complex. More needs to be done to ensure the future security of our overworked poorly supported workforce. There is no place for bullying, harassment and discrimination in our work place culture; my time as Victorian President will attest to my commitment.

It is time for the Minister’s words to become concrete actions; to articulate a long-term vision, and a robust preventive health strategy.

We know that a Federal election is due within 12 months or so.

The imperative of membership penetration continues to remain a concern. The importance of an equal member value proposition for all our members is critically paramount, as is the importance of strong, vibrant State and Territory AMAs; serving members locally. This is unfinished business – a challenge which will require bilateral understanding, the mutual desire and will to progress it.

With your continued support, I will continue to listen and engage with all our members; leading your AMA as it continues to champion our world class health system, defending patient outcomes and professional satisfaction in serving them.

Thank you.

* See other candidate profiles on this site.

Candidate profile – Dr Jill Tomlinson MBBS(Hons), PG Dip Surg Anat, FRACS(Plast), GAICD

Nominating for the position of AMA Vice President

We are at a critical period of change in health. We are asked by Government and the community to do more with less. Healthcare costs are rising. Technology is changing how we practise, offering opportunities but also challenges. Our profession faces significant cultural change.

The AMA must remain relevant and engaged in this time of change. It needs a strong leadership team who will deliver advocacy, political representation and passion to do better for our patients and for the profession.

If elected, I will make digital strategy a key priority. Within the AMA, this means improving communication and engagement with members by expanding digital services and addressing barriers at State and Federal levels. The AMA must be where doctors are, and must support a strong AMA in every State.

Within the health system, a focus on digital strategy means strong advocacy for systems and programs that work for doctors, not create work for doctors. This is not just about My Health Record, it’s about real time prescription monitoring, secure messaging, data use and security, accessibility, interoperability, care co-ordination, the digital determinants of health and the regulatory and administrative burden on doctors. We must get digital systems right, or else – as we’ve seen with hospital constructions across the country – billions are spent but the final product doesn’t address the needs of patients or doctors.

Preventable illnesses associated with obesity are literally killing our patients. We need a radical, whole of community approach to the problem – one that drives meaningful change. We must advocate for public health improvements and make real investment in general practice, which is the most efficient part of the health system and has been neglected for too long. We must improve mental health care, aged care and veterans’ services. We must reduce inequality, and Close the Gap. We must be inclusive, and support equity and diversity. It’s the fair thing to do but it’s also in the best interests of our patients and the profession.

We must address workforce issues, including doctor and training position maldistribution. We must support medical students and doctors-in-training who are increasingly struggling to manage the overwhelming demands of training and service delivery. We must improve access to flexible training and end discrimination on the grounds of pregnancy, mental illness, disability, parental leave and return to work. We must advocate for marginalised individuals and groups that cannot speak for themselves.

We must fight for an independent profession. Patient care suffers when health funds control access to care or make decisions for patients; corporatisation increasingly affects general practice, radiology and pathology.

I seek your support and your vote at National Conference. I seek your advice and insights into how we can improve health in Australia as, while I have a vision for the AMA, I do not claim to have all the answers. And most importantly, I seek your enthusiasm, passion and engagement – only by working together will we achieve the best outcomes for our patients and the profession.

* See other candidate profiles on thios site.

Candidate profile – Dr Chris Zappala MBBS (Hons), AMusA, GCAE, MHM, MD, FRACP

Nominating for the position of AMA Vice President

The AMA represents an extremely diverse group of professionals and as such our focus and efforts evolve and change to reflect contemporary need.

The enervating effects of bulk-billing and enforced five-minute consultations puts high-quality medicine in jeopardy. General practice has been progressively disinvested despite all the talk about augmenting community based care and preventing hospital re-admission. The Federal Government must understand that many of their objectives for the health of Australians will be realised if they invest properly in general practice. I accept we must also convince GPs that the AMA understands this and holds it as a priority.

The maldistribution of the workforce has not been solved by an exponential increase in medical graduates. Despite clear AMA policy regarding rural training hubs, appropriate industrial/MBS schedule recognition and bespoke rural/regional training models, we still have a problem. Until this is solved we will continue to endure nefarious role substitution models which pander to other tribal groups and damaging medical over-supply in some areas.

Oversupply forces public hospital doctors into a vulnerable enterprise bargaining position and poses a threat to private medicine and our professional credibility from possible over-charging/over-servicing, fee splitting and selling fringe medical services. This data is being released by those who wish to subjugate or cheapen doctors, so the AMA needs to be leading the discussion in order to shape perception and potential solutions.

Exorbitant graduating workforce numbers compound upon the burgeoning group of vulnerable junior doctors. They should be assured of transparent and fair selection and examination processes with open knowledge of workforce trends. The AMA has a clear need to strengthen relationships with Colleges and move us collectively in this direction.

It is not protectionism to want to preserve the freedom of decision-making for doctors and the ability to charge a fee commensurate with training/expertise and the service provided. This preserves high-quality medicine. Pharmacists, non-medical endoscopists, optometrists all encroach on the medical domain with no decisive rebuttal. We are not being enlightened ‘team players’ if we allow medical practice in the future to be harder, less rewarding or diminished in any way.

The public hospital system struggles under perpetual funding shortfalls and a blinkered rigidity that focuses predominantly on targets of dubious relevance to clinical outcomes. This partly relates to operational inefficiency but also politically expedient emphasis on spurious initiatives. Any evolution that simplifies hospital funding and reduces the cost-shifting game would be welcome.

Our Association’s membership worryingly continues to decline, which jeopardises our collective ability to influence. Only the AMA can bring the profession together and has the expertise to achieve medicopolitical outcomes that improve the daily working lives of doctors. Membership must be cheaper and we can engage better through cohesive action amongst the entire AMA family and an expansion of our digital/online capability.

As always, there is much to do. We need the entire AMA family to be effective and united in promoting thoughtful initiatives at every level. There are too many external threats for us not to be at our most potent, but the AMA will need to do things a little different to achieve this. Hopefully, as AMA Vice President, I can contribute to this.

* See other candidate profiles on this site.

Candidate profile – Xavier Yu MBBS/BA FRANZCR GAICD

Nominating for the position of AMA Vice President

Yes, I am a radiologist. But one who actually enjoys engaging with patients and fellow clinician referrers….

I began my medical career 18 years ago, but only recently gained my FRANZCR two years ago. My 16-year doctor-in-training career included stints in general surgical and orthopaedics training programs, while working in hospitals across New South Wales, Victoria and Tasmania, before joining the world of radiology. My current public and private practices include inner city, outer suburban and regional Victoria, as well as interstate through teleradiology.

My credentials include graduate qualifications and advanced training though the Australian Institute of Company Directors, and being involved in AMA committees forever, including as Council of Doctors In Training Victorian representative, and AMA Victoria Board member for six years (including the past two as Vice President). A transition from one VP role to another seems natural enough!

We must unite and rebuild, with collaborative and respectful engagement of the most important asset – you as the member. Our organisation faces increasing challenges with membership recruitment and retention, provision of membership services and assessing our vision: what and where is the future in advocacy for the AMA?

The role of the next AMA Vice President is threefold:

* support act to the President;

* bring good modern governance credentials to the Board, Councils, Committees; and

* listen to the voice of the membership.

My five ‘passions’ include:

* General Practice.

You might find this strange coming from me, but my frequent professional discussions with GPs has highlighted the powerlessness they feel about being able to effect genuine change – and continuing to fight the escalating war on punitive over-regulation and intrusions by threats from task substitution like ‘superpharmacies’. I also hear loud and clear the anxiety from GPs about talk of changes in regards to Health Care Homes, outcome based practice incentives and e-PIP.

* Membership engagement.

To say we have a lack of engagement ‘on the ground’ is an understatement. I want to ‘close the gap’ between President and the ‘normal’ doctor, fostering better member engagement and networking opportunities, and being the person behind the scenes to whom you can freely talk to and get stuff changed. The State and Territory AMAs must be at the forefront of advocacy activity, and therefore be suitably better resourced.

* Culture and systems change.

We have to end the ‘blame game’ in hospitals and workplaces, by lobbying for better mechanisms to improve work-life balance and doctor well-being, assist colleagues in distress without vilification or victimisation, and promoting equity to give opportunities to all our colleagues, regardless of gender, ethnicity, religion or orientation.

* The ‘maldistribution mess’.

Medical school, prevocational and vocational training settings all need to work together better.

* Regional, rural and remote recruitment.

To whom are the doctors going to hand the keys of their practice when they retire?

Follow me on LinkedIn (search “Xavier Yu”) and Twitter (@docxy75) leading up to National Conference for more: I’m more than ‘just a radiologist’….

* See other candidate profiles on this site.

Health Budget steady as she goes

The AMA has labelled the 2018-19 Health Budget as “safe and steady”, but adds that it is notable as much for what is not to be found in it as it is for what is included.

Treasurer Scott Morrison has delivered a Federal Budget with an eye on the next federal election, promising tax relief for middle Australia, significant infrastructure investment and more funding for aged care.

On the health front, the establishment of a new 21^st century medical industry plan to create more jobs and support more medical research projects is a major commitment.

This Budget includes an extra $1.4 billion for listings on the PBS, including medicines to treat spinal muscular atrophy, breast cancer, refractory multiple myeloma, and relapsing-remitting multiple sclerosis, as well as a new medicine to prevent HIV.

The Government will also provide $154 million to promote active and healthy living, including $83 million to improve existing community sport facilities, and to expand support for the Sporting Schools and Local Sporting Champions programs.

It has dismissed a proposal for a single and separate Murray Darling Medical School, in favour of a network, in what AMA President Dr Michael Gannon has described as a better approach.

Mr Morrison said the plan was to get more doctors to where they are needed through a new workforce incentive program.

“This plan includes the establishment of a new network of five regional medical schools within the broader Murray Darling Region,” Mr Morrison said when delivering his Budget Address to Parliament on May 8.

Dr Gannon said many of the rural health initiatives outlined in the Budget are a direct response to AMA rural health policies and the AMA Budget Submission.

“We welcome the Government’s strong focus in this Budget on improving access to doctors in underserviced communities, particularly rural Australia,” Dr Gannon said.

“The decision to reject the proposal for a stand-alone Murray Darling Medical School, in favour of a network, is a better approach with the Government instead pursuing a policy that builds on existing infrastructure to create end-to-end medical school programs.

“However, while the Government has made a welcome commitment not to increase Commonwealth-supported medical school places, it has taken the unnecessary step of compensating medical schools with additional overseas full-fee paying places.

“This will not address community need, and instead simply waste precious resources.”

Dr Gannon said overall, the Government had delivered a safe and steady Health Budget, which outlines a broad range of initiatives across the health portfolio.

Necessary funding to aged care, mental health, rural health, the PBS, and medical research, were all welcome commitments.

“But some of the bigger reforms and the biggest challenges are yet to come,” he said.

“Due to a number of ongoing major reviews, this Budget is notable as much for what is not in it as for what is in it.

“The major reviews of the Medicare Benefits Schedule (MBS) and private health are not yet finalised, and the ensuing policies will be significant.

“We are pleased that indexation has been restored to general practice and other specialty consultations, but new and considerable investment in general practice is missing.

“Also, the signature primary care reform – Health Care Homes – did not rate a mention.”

Health Minister Greg Hunt described the Budget as a “record investment in health” and pointed to a previously announced commitment from the Federal Government to public hospitals.

“The Government will deliver more than $30 billion in additional public hospital funding under a five-year National Health Agreement, with funding increasing for every State and Territory, every year,” Mr Hunt said.

But Shadow Health Minister Catherine King said the Budget failed the health test.

The Government was persisting with a plan to cut $715 million from hospitals over the next two years, she said.

“Their hospital cuts are putting doctors, nurses and hospital staff under increasing pressure; forcing delays in surgeries; and making emergency department waiting times even worse,” Ms King said.

CHRIS JOHNSON

Rural health focus welcomed

The AMA welcomes the Budget announcement of a range of initiatives to improve access to health services for rural and regional Australians.

AMA President Dr Michael Gannon said many of the initiatives outlined in the Stronger Rural Health Strategy as part of the Health Budget – are a direct response to AMA rural health policies and the AMA Budget Submission.

“The evidence shows that selecting medical students with a rural background and providing high quality training in rural areas are the most effective policy measures to address workforce maldistribution,” Dr Gannon said.

“With medical graduate numbers in Australia at record numbers, well above the OECD average, there is a strong emphasis in this Budget on building a rural training pipeline so that it will be possible for doctors to complete their medical degree in a rural area – and then continue to be able to work and train in these areas.

“We welcome the decision to create a pool of medical school places that can be reallocated over time, a nimble way of better responding to community need.

“The AMA has championed a Community Residency Program, focusing on rural areas, and the significant expansion of prevocational training places in general practice announced delivers on that policy proposal.

“The decision to set aside funding for an extra 100 GP training places from 2021, earmarked for the proposed National Rural Generalist Pathway (NRGP), is a good first step in supporting its rollout.

“This will build on the work of the Rural Health Commissioner, who is currently consulting on the design of the NRGP.

“It is also good to see that the Government is funding support for non-vocationally registered doctors to progress to College Fellowship. Rural areas are very reliant on International Medical Graduates (IMGs) to deliver care, and this decision will help them in continuing to deliver high quality care for patients.

“The AMA is also pleased to see the Government take the decision to completely overhaul the bonded medical graduate programs, which have so far largely failed to deliver extra doctors to needy communities.

“The new arrangements will be more flexible, and provide greater career certainty for doctors who have signed up for these programs.”

JOHN FLANNERY

Budget’s rural health initiatives from medical students’ viewpoint

AMSA Rural Health (Australian Medical Students’ Association rural health division) welcomes the rural health workforce measures outlined in the 2018-19 Federal Budget, but meets the announcement of a new medical school network with cautious optimism.

The $83.3 million Stronger Rural Health Strategy to address access to medical care by rural and regional Australians is an important step towards health equity in rural and regional Australia.

Murray Darling Medical School Network

The announcement of the Murray Darling Medical School Network, accompanied by $95.4M in funding, represents a welcome focus on rural medical education. However, AMSA Rural questions what the network means for overall medical student numbers, and the impact it will have on rural health workforce shortages.

“While there will be no new Commonwealth Supported Places (CSPs), the inclusion of two more universities within the network – Charles Sturt and La Trobe – means the existing universities will replace redistributed places with full fee-paying places. We are concerned the introduction of a new school in Orange that has been allocated 30 of the existing CSP will open the door to future increases in student numbers,” said AMSA Rural Co-Chair Nic Batten.

“The overall number of medical students will increase as these universities will replace lost income by recruiting more international students, which will only worsen the oversupply of medical graduates and bottlenecks in further training,” said AMSA Rural Co-Chair, Gaby Bolton.

“In Victoria alone there will be 100 more graduating doctors than internship places for 2019, and most of those missing out will be Australian trained international students. It is unethical to continue to encourage international students to study in Australia if they will be unable to work here as doctors after graduation – this loophole must be closed,” said Ms Bolton.

All sites in the network – Bendigo, Albury-Wodonga, Shepparton, Wagga Wagga, Orange, and Dubbo – already teach medical students within Rural Clinical Schools. However, the funds for the network will allow expansion of existing infrastructure to enable end-to-end rural medical school training.

“We hope that the network model translates into more doctors committed to rural practice, and that the university partnerships involved will enable greater recruitment of and support for students of rural background to study medicine,” said Ms Batten.

“While we welcome the network model over a large new stand-alone medical school, these funds could be better spent in addressing the issue of too few vocational training spots for doctors who want to work, train and live in rural and regional areas, and are currently forced to return to metro areas to complete specialty training.”

Junior Doctor Training Program

The Junior Doctor Training Program, which includes an increase of 300 rural places for junior doctors, represents the beginning of a clear pathway for rural practice. Details, including a possible expansion of internship rotations in rural general practice, are yet to be outlined.

“For medical students wanting to practice in rural areas, and particularly those who aim for careers in rural generalism, this is an invaluable program,” Ms Bolton said.

Ms Batten said: “PGY1-3 is where many doctors who have trained in Rural Clinical Schools are lost to metro hospitals. This initiative will help stem this barrier to rural practice.”

Rural Generalism

AMSA Rural is pleased to see commitment to the National Rural Generalist Pathway with 100 additional vocational training places to be administered by Australian GP Training (AGPT), beginning in 2021. This comes off the back of a historical agreement between RACGP and ACRRM earlier in the year, facilitated by the Rural Health Commissioner Professor Paul Worley.

“We are excited to see this measure devoted to addressing rural training pathways. Many of our members are keen to work in this area, so this is will be a great step to increase the number of rural doctors,” said Ms Bolton.

“While we would have liked to see more funding towards the National Rural Generalist Pathway, this is an important move towards increasing the number of rural GPs, and recognises the special skill-set required of doctors working in rural and remote areas,” said Ms Batten.

Rural Specialty Training

In comparison to funding for rural generalism training places, no announcement was made of an expansion of the Specialty Training Program. AMSA Rural hopes the release of further information after the Budget will include support for specialty training within the Regional Training Hubs.

“Access to further rural opportunities for specialty training is key to retention of these doctors in rural and regional areas. This will help to address the maldistribution of certain specialities as well as provide necessary additional specialty training places,” Ms Batten said.

Bonding

AMSA Rural Health welcomes the changes relating to rural bonding contracts.

“The return of service obligations have not been fulfilled by many rural bonding contract holders, and have only damaged perceptions of living and working within rural communities,” said Ms Batten.

“Bonding contracts have not been administered in a way which encourages doctors to fulfil their obligations to work in a rural location,” Ms Bolton said.

“The changes announced in the Budget will provide a flexibility around training that will encourage more doctors to complete their return of service and work in a rural location.”

Summary

AMSA Rural enthusiastically supports the changes to rural bonding and the opportunities presented by the Junior Doctor Training Program and the National Rural Generalist Pathway. Whilst the MDMS network may represent an expensive mis-step in addressing rural health workforce shortages, with funds better spent on rural Specialty Training Places, the announcement of better targeting, monitoring and planning for future rural workforce needs is encouraging. Overall, AMSA Rural welcomes the government’s renewed focus on health equity for rural and regional communities, and looks forward to hearing more details of the Stronger Rural Health Strategy.

CANDICE DAY
VICE CHAIR AMSA RURAL HEALTH

PIC: AMSA’s Candice Day, Joel Selby, Alex Farrell (Pres) and Victoria Cook (Vice Pres) with Dr Bill Glasson (former AMA Pres), Dr Michael Gannon (AMA Pres) and Dr Tony Bartone (AMA Vice Pres) on Budget night.

Health Budget safe and steady

The AMA has labelled the 2018-19 Health Budget as “safe and steady”, but adds that it is notable as much for what is not to be found in it as it is for what is included.

On the health front, the establishment of a new 21^st century medical industry plan to create more jobs and support more medical research projects is a major commitment.

It has dismissed a proposal for a single and separate Murray Darling Medical School, in favour of a network, in what Dr Gannon has described as a better approach

Mr Morrison said the plan was to get more doctors to where they are needed through a new workforce incentive program.

Dr Gannon said many of the rural health initiatives outlined Budget are a direct response to AMA rural health policies and the AMA Budget Submission.