more_vertEven the most colourless clinical description of schistosomiasis comes across like a pitch for an early David Lynch body horror. Waterborne flatworm larvae penetrate the skin, and move in the bloodstream through the heart and lungs to the liver. Here they mature and mate in the portal circulation, before laying eggs that lodge in the liver—occasionally the spinal cord or genitals—or leave the body via the bladder or intestinal walls. The framing of schistosomiasis as a parasitic tropical disease emerged from a series of global encounters—between medicine and science, between industrial nations competing for dominance, and between imperial governments and their indigenous subjects.
Preference: Government and politics
Latest healthcare variations atlas released
The Third Australian Atlas of Healthcare Variation has been released and identifies high-level variation in health care use by region.
But AMA President Dr Tony Bartone said the Atlas does not satisfactorily explain the causes or offer solutions, so it should only be considered as a statistical guide.
Dr Bartone said the Atlas provides a statistical, wider-population overview of the health system that, when considered along with the many other variables at a local level, has the potential to lead to improvements in clinical decision-making and the allocation of medical services.
“The reasons for any observed variation in health service utilisation reflect regional differences in people’s health care needs, variation in the patient’s treatment preferences, or other factors that require further examination,” he said.
“Some variation in patterns of health care utilisation should be expected. Once any variation is identified, the next step is identifying good variation from bad variation, and investigating the cause.
“It is very important for policymakers to be clear what the Atlas data is and isn’t. It is good at highlighting variation in health utilisation at the regional level, but it is not good at explaining why.
“The Atlas must be considered a statistical guide only, and is definitely no substitute for clinical experience and expertise.
“For example, it is important for health care providers to be aware of the latest evidence guiding the optimal gestation period for newborns. But it is also important to remain measured when interpreting the hospital data.
“In reporting variations in caesarean sections, the Atlas claims that up to 60 per cent are being performed before full term without a medical reason.
“There is an implication that these are ‘sinful’ caesareans done before 37 weeks for no good reason.
“In fact, the most recent available data from the Australian Institute of Health and Welfare (AIHW) estimates that only about 1.6 per cent of births in Australia are truly maternal-request caesareans.
“The same data shows that less than 9 per cent of caesarean sections are performed before 37 weeks, and these are almost always because of problems such as hypertension, breech labour, or bleeding.
“About one third of caesareans performed before 37 weeks are emergency cases.
“The real-life, real-time patient experience is a better clinical indicator than statistics in many areas of medical practice.”
Dr Bartone said the AMA fully supports efforts to continually improve the level of safety and quality, and the delivery of evidence-based, high-value care.
“Clinical stewardship is a core tenet of the AMA Code of Ethics,” Dr Bartone said.
“But clinicians must always retain the autonomy to exercise professional judgement in the care and treatment of their patients.
“The analysis in the Atlas typically analyses the utilisation levels of a single health care service in isolation.
“Patients are more complex than this, and rarely have a single condition or health care need. Patients frequently present with multiple conditions with multiple causes.
“A treatment that is high value for some patients might be low value for others. Clinician-led care takes the whole patient into account before advising treatment options.
“This does not mean there is no room for improvement. Governments must acknowledge, however, that the greatest successes in boosting evidence-based care and reducing low-value care are clinician-led, based on reliable patient data.”
NPS MedicineWise CEO Steve Morris said reinforces the value of the work done by key healthcare bodies across the country to improve healthcare outcomes for Australians.
The Atlas can be viewed at: https://www.safetyandquality.gov.au/Atlas
[Health Policy] Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UK
This report presents further evidence on the escalating alcohol consumption in the UK and the burden of liver disease associated with this major risk factor, as well as the effects on hospital and primary care. We reiterate the need for fiscal regulation by the UK Government if overall alcohol consumption is to be reduced sufficiently to improve health outcomes. We also draw attention to the effects of drastic cuts in public services for alcohol treatment, the repeated failures of voluntary agreements with the drinks industry, and the influence of the industry through its lobbying activities.
[Comment] A global accountability mechanism for access to essential medicines
Access to affordable, quality-assured essential medicines is a prerequisite for effective universal health coverage.1,2 Efforts to ensure comprehensive access to essential medicines have been hindered by a dearth of information. Most monitoring efforts have focused on measurement of a prespecified list of essential medicines in health facilities. Measures of affordability in private and public health facilities have relied on periodic surveys, usually by non-governmental organisations (NGOs) or academia.
Steadfast support
BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE
As 2018 rushes to a close I want to reflect on some of the AMA’s activities this year in supporting GPs in their role as the primary provider of medical care. The primacy of the role that the usual GP and their general practice plays in a patient’s health care is something that the AMA steadfastly defends. Throughout this year we have strongly advocated for an improvement to GP funding to sustain and nourish general practice in effectively delivering patient-centred quality care and in meeting the health care needs of the community.
GP services are in high demand as the population ages, complex and chronic disease become more prevalent, and poor lifestyle choices add to the risk for and burden of disease. Yet, general practice is the most efficient and cost-effective part of Australia’s health system. Given the increasing cost pressures general practices have experienced over the years, this is a true testament to the general practice profession.
While the Federal Budget this year made some down-payments towards improving GP funding, much more is required to support our vision for general practice into the future. A vision that involves general practice being supported as its patients’ medical home and that strengthens and supports team-based care. A vision that involves GPs being rewarded for the non-face-to-face work involved in caring for patients, that enables better access to quality GP care to patients in aged care facilities and at home, that supports greater use of technology to enhance access to care and its continuity and delivery. A vision that ensures quality improvement is supported and rewarded.
The Government must invest, and invest significantly, to make this vision a reality.
This is a message that AMA leadership and advocacy has continually impressed upon key politicians and around Commonwealth departmental meeting tables throughout the year.
Our proposal and advocacy for the integration of non-dispensing pharmacists into general practice to enhance medication management resulted in incentive reforms that will see practices further supported to build their practice-based health care teams. From July 1 2019, the Workforce Incentive Program will see the provisions of the Practice Nurse Incentive Program expanded to include non-dispensing pharmacists and allied health providers for all eligible general practices regardless of location.
While the MBS Review process has had its issues, when it comes to general practice and primary care the AMA is optimistic that our message around improved rebates, the centrality of the GP to the health system and to patient care has resonated. The AMA is keen to see the recommendations of the MBS Review Taskforce in this space support longitudinal care, patient centred and multi-disciplinary care, and provide for enhanced access via telehealth services.
Finally, the AMA, through a number of submissions, in our discussions and representations, has worked hard to convey the risks to patient care and health system expenditure of moves that would fragment primary care. Proposals for inappropriate expansions of scopes of practice, prescribing rights, and models of care that would see skilled GPs excluded from elements of the cradle to grave care they provide have been and will continue to be stridently argued against.
The coming year, I’m sure, will provide many more opportunities for the AMA to advocate for and support general practice.
In the meantime I wish you all safe and happy holidays.
Preventing heart disease – a continuing story
BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR PUBLIC HEALTH, UNIVERSITY OF SYDNEY
Public Health England (PHE) is the organisation responsible for the oversight of all preventive activity in England. This ranges from vigilance for infectious disease outbreaks and epidemics, through immunisation programs, to advice and support for prevention in general practice – including that relating to non-communicable diseases, especially circulatory disorders.
With the increased prevalence of cardiovascular disease in an ageing population, PHE has been reviewing investment in its prevention strategy. (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/749866/CVD_ROI_tool_final_report.pdf)
As in Australia, since the mid-1960s, deaths in middle age from heart attack have decreased in England by well over 50 per cent. This is attributable, almost equally as best we can tell, to improvements due to primary prevention, most notably dramatic downturns in smoking, and to improved treatment.
Falls in the rate of ‘sudden death’, which are substantial, are an obvious place where primary prevention is working. But the evidence is difficult to collect and assess. As Earl Ford, an American epidemiologist, and Simon Capewell, a clinical epidemiologist from Liverpool University in the UK, wrote in 2011 (www.annualreviews.org/doi/full/10.1146/annurev-publhealth-031210-101211), “Changes in risk factors may explain approximately from 44 per cent to 76 per cent of declining CHD mortality and treatments may explain approximately from 23 per cent to 47 per cent. Thus, both prevention and treatments have contributed immensely to the decline in CHD mortality.”
Nevertheless, despite these advances, cardiovascular disease remains a major problem. This year, according to calculations from the Australian Heart Foundation, based on data from the Bureau of Statistics, about 8,000 Australians will die from a heart attack.
Heart attack death was previously restricted to economically advanced societies, but it now spread widely through economically developing, and even the poorest, nations. Here, death from heart disease follows the pattern we saw in Australia before the decline in mortality began in the 1960s, namely, middle-aged men and women, rather than the elderly, being at serious risk. Our effectiveness in managing infectious disease in those less affluent countries means that those people are now more prone to the degenerative diseases familiar to us.
What is the scope for prevention in clinical practice? A survey this year by the Heart Foundation found: “One in two Australians who have had a heart attack [and there are about 40,000 of them under 55] continue to smoke. Of these, close to 40 per cent did not even attempt to quit … almost one in four have failed to regularly monitor their blood pressure levels. More than a quarter are not having regular cholesterol checks. Around one in three tried to increase their physical activity levels or lose weight, however failed to maintain the changes.”
In clinical practice, prevention of death – and disability – from cardiovascular disease is a deep concern –a frequent reason for consultation and prescription and a major consumer of time in general practice.
Despite the lack of information about outcomes, Public Health England, with help from the University of Sheffield, examined the available evidence for what works and how much it costs (including general practitioners’ time). PHE settled on five interventions – detection and treatment which had merit both in terms of medical outcome and cost for:
- Hypertension
- Atrial fibrillation (anticoagulation)
- Hypercholesterolaemia
- Diabetes
- Non-diabetic hyperglycaemia (‘pre-diabetes’)
- Chronic kidney disease.
Based on a 2014 health survey in England, the prevalence of individuals aged 16+ with one or more of these high risk conditions was 49 per cent.
The best evidence concerning effective interventions for each condition was then assembled, along with data on the cost of the most effective interventions and the duration of likely effect following the interventions. This information was combined into a package which allows individual practitioners to calculate the local costs and benefits of these interventions in their practice.
“The single intervention with the highest net total savings in the short term (years 2-5) is to optimise the proportion of people taking statins… a saving of £700 million in England [total population: 45 million] by year five. However, in the long term (20 years), optimising antihypertensive treatment is the single intervention predicted to save the most money (over £2 billion)… but most of the lifestyle interventions are not cost-saving over 20 years.”
What may we conclude for Australia? Among the preventive interventions for managing cardiovascular disease in general, and heart disease in particular, we are committed to long-term care for optimal effect. This may not become obvious for 20 years, but this is not to gainsay it.
Preventive treatment requires a philosophy of long-term care and support to be effective.
AMA advocacy on medicine shortages
BY A SSOCIATE PROFESSOR ANDREW C MILLER, CHAIR, AMA MEDICAL PRACTICE COMMITTEE
AMA members increasingly report that shortages of PBS medicines are impacting on the care of their patients.
We are all familiar with the scenario; patients turn up at their local pharmacy to be told that their current prescription for a long-standing condition cannot be filled. Usually alternative medicines can be prescribed, but these may not be subsidised under the PBS, or easily accessible themselves.
This situation is stressful, and sometimes expensive, for patients. It challenges the concept of stable chronic disease management, increases the risk of patient confusion resulting in medication errors and wastes the valuable time of patients and doctors.
Medicine supply shortage is not a new phenomenon, but it is becoming more frequent. Shortages are attributable to several factors, including the consolidation of suppliers in the US following changes in regulations; emerging markets in China and India that have also reduced the number of suppliers due to greater competition; and requirements to upgrade plants and processes following stricter quality controls and standards. With fewer suppliers worldwide, this means that a problem in production from one source may result in magnified impact across the globe, often impacting several brands.
For Australia, the impact is exacerbated: as the TGA points out, Australia has only two per cent of the world’s medicine usage and more than 90 per cent of prescription medicines are imported. Australia enjoys a relatively lowly place in ‘the queue’ for medicines in short supply. In addition our long supply lines complicate delivery of medicines requiring critical transport conditions, increasing the risk of in-transit spoilage, and reduce the capability of rapid resupply in any circumstance.
While medicine shortages are outside the direct control of governments, there is still considerable scope for regulatory bodies to take action to minimise the impact of shortages.
The AMA first started advocating for more proactive government interventions and regulatory solutions in 2012. The then AMA Vice-President, Professor Geoff Dobb, led the charge, meeting with and writing to Health Ministers, pharmaceutical industry representatives and the TGA. Subsequently, the TGA began working with industry stakeholders, the AMA and others to work out better ways of anticipating and managing shortages.
This ultimately led to the development in 2014 of a Medicine Shortages Protocol, an agreement signed by the TGA, Medicines Australia and the Generic and Biosimilar Medicines Association. The protocol established a voluntary regime for suppliers to notify the TGA of shortages in a timely manner as well as a public database of shortages activity.
Unfortunately, industry compliance has been patchy and as a consequence the TGA often becomes aware of shortages after they are impacting patients; and so before remedial action can be taken. This has rendered the shortages database next to useless.
COAG intervention led to a TGA review early last year. The AMA again contributed to the search for more effective solutions by participating in a stakeholder committee and providing feedback based on Medical Practice Committee advice.
It has become clear that, despite pharmaceutical industry opposition, a mandatory rather than voluntary reporting scheme is needed. The AMA fully supported the proposal that pharmaceutical companies must report all medicine shortages to the TGA within specific timeframes and that the TGA must also publish information about all shortages that have a critical patient impact.
The ‘mandatory notifications’ law was passed in Parliament last month and will come into effect on January 1 2019. Drafting of a new guide for pharmaceutical companies on their responsibilities is underway.
Will this fix the problem? It will certainly improve the ability of the TGA, health organisations and health practitioners to proactively manage shortages and to source alternatives.
However, a critical player in the continuum of medicine supply is not covered in the new legislation nor mentioned in the accompanying guide. In subsidising the supply of nearly all medicines prescribed in Australia, the PBS has a significant role to play in minimising the financial impact on patients of medicine shortages.
Where an alternative medicine may be available to patients, but not subsidised under the PBS, or subsidised but with restrictions which do not encompass the specific patient use a simple, a temporary change to the PBS authority restriction may provide needed relief. For example when there was a shortage earlier this year of norfloxacin, subsidised under the PBS to treat complicated urinary tract infection, ciprofloxacin – a good alternative – could not be prescribed under the PBS because its use does not extend to any form of UTI not due to pseudomonas (prostatitis only).
The voluntary notifications scheme may not have allowed the Department of Health to act in a timely way to effect temporary amendments, but there should be no excuse from next year.
The AMA has now raised this concern with the Department several times and been assured that timely shortages information would lead to a timely PBS response. The AMA will be watching closely.
You can find out more about accessing alternative medicines during a shortage on the TGA’s website.
Taking a gamble on TheLott
BY DR CLIVE FRASER
After protesting recently about MHR (My Health Record) and all of the possibilities of my privacy being breached, I thought that I would let my colleagues know that I have just celebrated a sentinel birthday which for the purposes of this column I’ll call my 40th.
There was a week-long celebration with all manner of food and beverages, culminating in the ritual of gift giving.
After a lifetime of consumerism I think that I can reliably claim to have at least one of everything, so what birthday gift would you buy a man who has it all?
With $100 million dollars on offer in a mid-week Gold Lotto draw I’d say that you’d probably buy a ticket in that, just for fun.
After all, if I won I could help myself to another LCD screen or gadget of my choosing to fill a house that is already bulging with ‘stuff’.
But with only a one in seven million chance of winning I regret to say that I usually never check my numbers with any of these gifts.
After an anxious phone call from the generous donor I thought that I had better check to see whether I had won the grand prize.
Too inconvenienced to go to a shrinking number of news agencies I thought that I’d check my numbers on-line.
I downloaded TheLott app and as per the instructions I took a photo of the ticket.
But the response was: “Sorry, your request cannot be serviced at present #1008.”
No luck there.
My next step was to create a log-in at www.thelott.com.
The site required my full name, title, date of birth, phone number and full residential address.
Greedily, I willingly provided all of this information.
After all I had a one in seven million chance of taking out the jackpot, retiring, philanthropy and all that stuff.
But then I was hit with the startling reality that at those odds I was more likely to be killed by my Takata airbag and that I had just given all of my identifying information to the Tatts Group.
There weren’t even any frequent flyer points on offer for handing over my personal data.
Tatts Group is after all a benevolent company which has a monopoly on lotteries and a big stake in wagering and gaming solutions (aka pokies) in Australia.
Surely they didn’t employ any stalkers or terrorists and I’d be safe in my abode.
In terms of data security I thought that Tatts Group would have to be safer than giving my personal information to a Commonwealth Government whose Ministers regularly guarantee that they support their leader.
So what does this story have to do with motoring?
I’d say nothing at all.
That is, apart from when you are driving in your car I’d recommend keeping your windows wound up and your doors locked while abstaining from handing out your personal identifying data.
Oh, and don’t forget to get your faulty Takata airbag replaced.
After all. Life is a gamble.
Safe motoring,
Doctor Clive Fraser
Gamblers Help 1800 858 858
AMA supports asylum seeker medical treatment bill
The AMA supports the asylum seeker Urgent Medical Treatment Bill being promoted by Independent MP and former AMA President, Professor Kerryn Phelps.
The AMA has gained assurances on key amendments to the legislation in recent days.
The Phelps bill will allow the temporary removal of children from offshore detention, create a workable system providing proper health care for refugees and asylum seekers under the protection of the Australian Government, and keeps in place deterrents that prevent asylum seekers risking their lives at sea and endangering themselves and others.
AMA President Dr Tony Bartone said that it was vital that all asylum seekers and refugees in the care of the Australian Government have access to quality care.
“There is compelling evidence that the asylum seekers on Nauru, especially the children, are suffering from serious physical and mental health conditions, and they should be brought to Australia for appropriate quality care,” Dr Bartone said.
“This week’s alarming Médecins Sans Frontières report on the health of detainees on Nauru was another signal that urgent action is needed.
“This is a health and human rights issue of the highest order. We must do the right thing.
“The amended Phelps bill is an important measure that will allow the temporary transfer to Australia from Nauru and Manus sooner for those in need of urgent care.
“The AMA has been advocating strongly for better health care for asylum seekers for many years.
“Our 2015 Position Statement, Health Care of Asylum Seekers and Refugees, called for the removal of all children from offshore detention, among other measures.
“We want a new national statutory body of clinical experts, independent of government, with the power to investigate and advise on the health and welfare of asylum seekers and refugees.”
The AMA is pushing for further legislation that incorporates the following reforms:
- asylum seekers and refugees should have access to the same level of health care as all Australian citizens;
- asylum seekers and refugees living in the community should have continued access to culturally appropriate health care, including specialist care, to meet their ongoing physical and mental health needs, including rehabilitation;
- all asylum seekers and refugees, independent of their citizenship or visa status, should have universal access to basic health care, counselling, and educational and training opportunities; and
- asylum seekers and refugees living in the community should have access to Medicare and the Pharmaceutical Benefits Scheme (PBS), state welfare and employment support, and appropriate settlement services.
Dr Bartone wrote to Prime Minister Morrison in September calling for the children on Nauru to be brought to Australia for appropriate medical care, with similar letters going to all MPs and Senators.
“We have worked closely with the Chief Medical Officer of the Home Affairs Department, and we acknowledge that the Government has since removed some of the children from Nauru,” Dr Bartone said.
“But we need a compassionate and enduring long-term solution that ensures quality appropriate health care for all asylum seekers and refugees in the care of the Australian Government.”
[Perspectives] How much should we be worried?
Global health is in the midst of an uncertain, confusing, and uncomfortable passage. Donor financing for infectious disease control has plateaued and is in decline, while low-income national governments are loath to pick up the slack and state leaders, especially in Africa, have largely exited the stage. Expensive and competing priorities spotlighted in the Sustainable Development Goals—non-communicable diseases, universal health coverage—are capturing the headlines at glossy global summits and stand at the centre of the WHO Director-General’s vision for revitalising WHO, at a suggested price tag exceeding US$10 billion in new funds.