This is where the health system fails

The effect of where you live on your health is nowhere more apparent than on Palm Island.

Inhabitants of the small island just north of Townsville are being hospitalised for chronic obstructive pulmonary disease at almost 21 times the rate of other Queenslanders, are being admitted for epilepsy and the bacterial skin infection cellulitis at 12 times the state-wide rate, are in hospital for diabetes complications at almost nine times the state-wide rate, and are six times more likely to be admitted for a urinary tract infection.

Leading health economist Professor Stephen Duckett says these figures show a community that is being failed by the health system.

“When people end up in hospital for diabetes, tooth decay or other conditions that should be treatable or manageable out of hospital, it’s a warning sign of system failure. Australia’s health system is consistently failing some communities,” he says.

Palm Island is among 63 locations in two states – Queensland and Victoria – identified by Professor Duckett and his colleagues at the Grattan Institute in their report Perils of place: identifying hotspots of health inequalitywhere rates of preventable hospitalisation are at least 50 per cent above the state-wide average for a decade or more. These include conditions such as asthma, diabetes, high blood pressure and malnutrition.

“Persistently high rates of potentially preventable hospitalisations are not normal,” the health economist says. “They are a signal that the existing health policies are not working or are insufficient.”

What causes these areas to have such high rates of health disadvantage are as individual as the places themselves, and influences include air and water quality, housing standards, employment, services like schools, clinics, roads and public transport, crime and community cohesion.

Professor Duckett says that while these areas tend to be more disadvantaged, “we found that potentially preventable hospitalisations are actually generally widely spread, and the places where hospitalisations are most concentrated are quite different for different diseases”.

The complex picture means that policy prescriptions have to be tailored to the individual characteristics of each location: “There is no single solution. The driving forces will be different in each place”.

But just because they defy generalisation and a one-size-fits-all solution, that is no reason not to address the issue, and the rewards in improved health and lower expenditure are considerable – Professor Duckett calculates that reducing preventable hospitalisation rates in the 63 areas identified in the Grattan Institute report to the state-wide average would, conservatively, save between $10 and $15 million a year in direct health costs alone, without taking into account indirect savings from fewer sick days and improved workforce participation.

Professor Duckett says the Commonwealth should fund trials, led by local Primary Health Networks, to test solutions and, crucially, commission rigorous and independent evaluations to identify what works and what does not.

PHNs should also develop tools to more precisely identify and target preventable hospitalisation hotspots. As data from trials is accumulated and lessons drawn, PHNs should use this information and experience to strengthen and expand their efforts.

Professor Duckett admits the priority areas identified in his report represent only a fraction of the problem, and “prevention efforts in these areas alone will not substantially reduce the overall burden of potentially preventable hospitalisations”.

“But,” he added, “they will help to efficiently reduce the worst health inequalities and will build the evidence base for how to address health inequalities more broadly.”

The bottom 10

The nation’s worst preventable hospitalisation hotspots

Palm Island

Yarrabah

Mount Isa

Mount Morgan

Northern Peninsula

Donald

Langwarrin South and Baxter

Broadmeadows

Frankston North

Kingaroy

Source: Grattan Institute

Adrian Rollins

Contaminated mouth wash recalled

A common mouth wash and denture cleaner has been recalled after being blamed for a rash of infections among intensive care patients at a hospital.

Batches of Chlorofluor Gel, which is taken to help treat mouth infections and is often used as a post-operative treatment following teeth extraction and other oral surgery, have been found to be heavily contaminated with a bacteria that can cause serious infections in patients with chronic lung diseases such as cystic fibrosis.

The Therapeutic Goods Administration has called on all those with Chlorofluor Gel from with a batch number BK 119 to immediately stop using the preparation, and distributor Professional Dentist Supplies has undertaken a nationwide recall of the product.

The TGA said the contamination was discovered after a group of intensive care patients at an unnamed hospital were found to be colonised or infected with the bacterium Burkholderia cepacia.

Investigations found that Chlorofluor Gel used to treat the patients, as well as from unopened containers in the same batch, were contaminated with high levels of B. cepacia. The contamination was found in all bottle sizes of the formula from the same batch.

The medicines watchdog said that although the bacterium posed little threat to healthy people, those with weakened immune systems, such as intensive care patients, might be more susceptible to infection and “at increased risk of associated health problems”.

“The effects of B. cepacia infection vary widely, ranging from no symptoms at all to serious respiratory infections, especially in patients with chronic lung diseases, such as cystic fibrosis,” the regulator said.

Chlorofluor Gel can be purchased over-the-counter, and those with products from the contaminated batch have been advised to return it to the place of purchase to get a refund, or to call Professional Dentist Supplies on 03 9761 6615 to arrange for the affected product to be collected and receive a refund.

Doctors treating patients who have used Chlorofluor Gel and who are showing signs of infection are being advised to include potential exposure to B. cepacia in clinical notes accompanying a pathology referral. The TGA said a test was unnecessary if patients were showing no signs of infection.

Adrian Rollins

[Viewpoint] Who’s been left behind? Why sustainable development goals fail the Arab world

A set of Sustainable Development Goals (SDGs) was adopted by the UN General Assembly in September, 2015. The Arab world, alongside other regions, has problems of poverty, poor health, and substantial environmental degradation—ie, the kind of problems that the SDGs aim to address.1–5 Evidence of persistent infectious disease in low-income and middle-income Arab countries exists, alongside increased prevalence of non-communicable diseases in all Arab countries,6,7 high out-of-pocket health expenditure,8 poor access to safe water, as well as violent conflict, persistent foreign interventions, and high levels of social and political fragmentation that result in weak health systems and diminished rights to health.

Aged care sector calls for cuts to be deferred

The aged care sector has called for a taskforce to review the sector’s funding process, as new analysis shows the 2016-17 Budget would strip funding to older people in care by 11 per cent per resident each year.

The Turnbull Government announced $1.2 billion in cuts to aged care funding in the May Budget, largely through reductions in the complex care component of the Aged Care Funding Instrument.

The Government argued that providers were overclaiming by wrongly classifying residents as high complex care patients.

“There’s no hiding away from the fact that the residential aged care budget will blow out by a further $3.8 billion over the next four years without action to address inconsistencies in the way claims are made, with as many as one in five ruled to be too high,” Minister for Health Sussan Ley said in June.

Ms Ley’s comments were borne out by a Health Department response to a Freedom of Information request by the Australian Financial Review.

The Department rejected the request, saying that there were more than 26,000 pages detailing non-compliance in relation to claims for Government funding from aged care providers.

Making public such a significant volume of related information would be too time-consuming, the Department said.

“A preliminary search has identified that there are approximately 1100 emails, 430 documents and 800 page reports, comprising over 26,000 pages that may fall within the scope of the request,” it told the newspaper in July.

The Labor Opposition has also refused to reverse the cuts.

But a coalition of service providers said, while the sector understood the need to manage growth in health care spending, the cuts went too far.

UnitingCare Australia (UCA), Aged and Community Services Australia (ACSA), and Catholic Health Australia (CHA) commissioned Ansell Strategic to undertake a review of 501 aged care homes and almost 39,000 residents around the country.

The modelling indicated that the actual impact of the cuts would be more than $2.5 billion over the next four years alone, nearly $840 million more than the Government’s forward estimates.

“The 2016-17 Budget was particularly harsh as it targeted people with complex health care needs and those receiving treatment for severe pain and chronic diseases like heart disease, diabetes, and dementia,” UCA Chair Steve Teulan said.

“We wanted to fully assess the impact of the funding reductions so we commissioned modelling that looked at the potential impact on nearly 39,000 people in aged care homes.

“The results are stark. The cuts far exceed the amounts stated by Government and will reduce funding to support older people in care by $6,655 – or 11 per cent – per resident each year.”

Under these arrangements, the funding would not cover the costs of services currently provided to residents with complex needs, meaning many older people in care might miss out on vital treatments including physiotherapy, pain management, and skin care, Mr Teulan said.

“If these cuts are implemented as stated, by 2017 service providers will be forced to seriously consider both turning away sick old people who are seeking admission from hospital and reducing services, particularly allied health,” Mr Teulan said.

The providers called on the Government to defer the proposed cuts until it undertook proper analysis of their impact, and an evaluation of the relative costs of providing care to frail aged people in nursing homes.

They also called for a taskforce to review the funding process for aged care, with a view to establishing a more sustainable model which provides certainty to providers, residents, their families and carers, and long-term affordability for taxpayers.

Maria Hawthorne

Baggoley steps down

The former Deputy Chair of Health Workforce Australia has been appointed to replace Professor Chris Baggoley, who has retired as the nation’s Chief Medical Officer.

Professor Brendan Murphy, who served on the now-defunct HWA and has been Chief Executive Officer of Austin Health in Victoria since 2005, has been selected by Health Department Secretary Martin Bowles to succeed Professor Baggoley in the frontline role.

Mr Bowles announced Professor Baggoley’s departure last week, and praised the leadership he had shown in the CMO role in the past five years, particularly in advancing the nation’s response to mounting global antibiotic resistance, the threat of communicable diseases, and improved detection of non-communicable illnesses such as cancer.

The Health Department head singled out Professor Baggoley’s significant contribution to the international response to epidemics including Ebola, Middle East Respiratory Syndrome (MERS) and, most recently, the Zika virus.

In addition to his work on the World Health Organisation’s International Health Regulations Emergency Committee – which played a central advisory role during the Ebola, MERS and Zika outbreaks – Mr Bowles said Professor Baggoley had also been instrumental in work to improve the nation’s defences against, and response to, international health emergencies.

Professor Murphy will take up the CMO position on 4 October. In the interim, the position will be filled by Dr Tony Hobbs, who has been appointed Deputy CMO.

Adrian Rollins

Focus on rheumatic heart disease

As the new President of the AMA I will, like my predecessors, chair the AMA’s Taskforce on Indigenous health. This recognises and emphasises the importance of the AMA’s efforts to improve the health and wellbeing of Aboriginal and Torres Strait Islander people, and our desire to keep ‘Closing the Gap’ initiatives at the top of our agenda.

The Taskforce, which was established in 2000, is comprised of representatives of the AMA Federal Council, AMA members and Indigenous health groups, including the National Aboriginal Community Controlled Health Organisation (NACCHO) and the Australian Indigenous Doctors’ Association (AIDA).

The Taskforce is a robust and dedicated entity which identifies, develops and recommends Indigenous health policy and strategies for the AMA and oversees the AMA’s annual Report Card on Indigenous Health.

This year, the 2016 Report Card on Indigenous Health will focus on rheumatic heart disease (RHD) – a major preventive health issue that significantly affects Indigenous people, particularly those in remote areas. As AMA WA President, I supported legislative change to improve reporting and reduce the burden of disease in Aboriginal communities in Western Australia.

RHD is a classic example of the many preventable chronic diseases that are largely responsible for the health gap between Indigenous and non-Indigenous people, with its burden largely extinguished in other parts of the Australian community. We can no longer allow the prevalence of chronic diseases like RHD to remain unaddressed.

The 2016 Federal election provided an opportunity for the AMA to present all political parties and candidates with the issues that the AMA sees as vital in meeting the challenge of closing the health gap.

While we have seen some recent improvements in Indigenous health, particularly in reducing infant mortality and smoking rates, the AMA wants to see the Commonwealth commit to improving resourcing for culturally appropriate primary health care for Aboriginal and Torres Strait Islander people.

The AMA has repeatedly said that it is not credible that Australia, one of the world’s wealthiest nations, cannot address the health and social justice issues that affect 3 per cent of its citizens. We say this again. The fact that it is our nation’s first people makes it an even greater moral imperative.

With the re-election of the Turnbull Government, the AMA will continue its call for long-term funding and commitments to Indigenous health. We will work closely with key ministers, government departments and other key stakeholders to ensure that appropriate action is taken.

As outlined in its Key Election Issues statement, the AMA urges the Federal Government to:

correct the under-funding of Aboriginal and Torres Strait Islander health services;
establish new, or strengthen existing, programs to address preventable health conditions that are known to have a significant impact on the health of Aboriginal and Torres Strait Islander people, such as cardiovascular disease (including rheumatic fever and rheumatic heart disease), diabetes, kidney disease, and blindness;
increase investment in Aboriginal and Torres Strait Islander community-controlled health organisations. Such investment must support services to build their capacity and be sustainable over the long term;
develop systemic linkages between Aboriginal and Torres Strait Islander community-controlled health organisations and mainstream health services to ensure high quality and culturally safe continuity of care;
identify areas of poor health and inadequate services for Aboriginal and Torres Strait Islander people and direct funding according to need;
institute funded, national training programs to support more Aboriginal and Torres Strait Islander people become health professionals to address the shortfall of Indigenous people in the health workforce;
implement measures to increase Aboriginal and Torres Strait Islander people’s access to primary health care and medical specialist services;
adopt a justice reinvestment approach to health by funding services to divert Aboriginal and Torres Strait Islander people from prison, given the strong link between health and incarceration;
increase funding for family violence and frontline legal services for Aboriginal and Torres Strait Islander people;
appropriately resource the National Aboriginal and Torres Strait Islander Health Plan to ensure that actions are met within specified timeframes; and
support the establishment of a Central Australia Advanced Health Research and Translation Centre. Central Australia faces many unique and complex health issues that require specific research, training and clinical practice to properly manage and treat and this type of collaborative medical and academic research, along with project delivery and working in remote communities, is desperately needed.

Closing the gap in health and life expectancy between Indigenous and non-Indigenous people is an achievable task – it is also an agreed national priority.

The Federal Government must build on existing platforms and ramp up its ambitions to achieve health equality for Aboriginal and Torres Strait Islander people. Without commitment and action from our national leaders, the gap will remain wide and intractable. The Taskforce will inform the AMA’s advocacy in ensuring that this does not remain the case.

Stroke in a young man with untreated HIV infection and neurosyphilis

Clinical record

A 33-year-old man presented to an emergency department with acute dysphasia and a dense right hemiparesis. His National Institute Health Stroke Scale score was 12, indicating a moderate severity stroke (score range 0–42, with increasing values indicating increasing severity). His computed tomography (CT) brain scan was normal. A CT angiogram showed a filling defect in the left intracranial internal carotid artery. Intravenous thrombolysis was commenced 2.5 hours after stroke onset and completed during urgent transit to our hospital for endovascular thrombectomy. Combined stent retrieval and suction thrombectomy of the left internal carotid occlusion restored flow 4.5 hours after stroke onset. A small dissection in the left intracranial internal carotid artery was the source of the thrombotic occlusion (Figure). A magnetic resonance imaging scan of the brain showed small scattered infarctions in the left middle cerebral arterial territory.

The patient was later found to have a human immunodeficiency virus (HIV) infection that had been diagnosed 5 years earlier but for which he had not sought or received treatment. There was no history of screening for syphilis. He had a remote and brief history of recreational use of methamphetamines and cocaine (more than 12 months previously). He had no other vascular risk factors (non-smoker, normal fasting lipid and blood glucose levels, negative autoimmune serology). His CD4 cell count was 220 × 10⁶ cells/L (reference interval [RI], ≥ 360 × 10⁶ cells/L) and serum quantitative HIV RNA testing revealed 77 400 copies/mL. Hepatitis serology results were negative. Syphilis serology results were positive: reactive rapid plasmin reagin (RPR) with a titre of 1:256; reactive Treponema pallidum particle agglutination (TPPA) assay; and positive syphilis antibody enzyme immunoassay. His cerebrospinal fluid (CSF) protein level was 1.17 g (RI, < 0.45 g/L) and his white cell count was elevated at 62 μ/L (RI, < 5 μ/L), predominantly due to monocytosis (84%). CSF syphilis serology was positive, with reactive results from the venereal disease research laboratory, TPPA and fluorescent treponemal absorption antibody tests, confirming neurosyphilis. There were no other clinical or radiological features of tertiary syphilis. CSF polymerase chain reaction test results were negative for other pathogens including varicella-zoster virus, John Cunningham virus and tuberculosis. Cryptococcal antigen test results were negative. Other stroke investigations, including transoesophageal echocardiogram, returned negative results.

A 15-day course of intravenous benzylpenicillin (1.8 g, 4-hourly) with prednisone cover (three doses of 20 mg twice daily to prevent Jarisch–Herxheimer reaction) was completed as treatment for neurosyphilis. He received counselling and was commenced on antiretroviral therapy including abacavir–dolutegravir–lamivudine. Contact tracing was performed. The 3-month outcome was excellent, with only minor persistent dysphasic speech errors and a modified Rankin scale score of 1 (range 0–6, with increasing values indicating worse deficit and 6 for death). Progress serum RPR titres were significantly reduced (1:64), indicating a serological treatment response. A recent progress CD4 cell count was 630 × 10⁶/L and quantitative HIV RNA testing revealed < 20 copies/mL.

Studies indicate that HIV infection increases the risk of ischaemic stroke, particularly in young patients (≤ 45 years) with low CD4 cell counts (< 350 × 10⁶ cells/L).1,2 It is important for clinicians to recognise the various mechanisms by which HIV infection predisposes to stroke. These include a direct HIV-induced vasculopathy, and an indirect opportunistic co-infection-related arteritis with organisms such as tuberculosis, syphilis and varicella-zoster virus.2 HIV vasculopathy has been reported in the extracranial and intracranial cerebral circulations and may cause aneurysmal fusiform or saccular dilatation of vessels or a non-aneurysmal vasculopathy manifest by stenosis, occlusion or vasculitis.2–4 Additional factors contributing to stroke risk in HIV include a more frequent smoking history, coagulopathy, increased homocysteine levels and metabolic syndromes associated with antiretroviral therapies, which may result in accelerated atherosclerosis.1,3 Descriptions of intracranial arterial dissection in patients with HIV infection are limited to rare case reports.5 We postulate that HIV and syphilis co-infection in our patient may have caused a vasculopathy-associated intracranial arterial dissection.

The role and safety of intravenous thrombolysis in patients with HIV infection is not established.2,4 Thrombolysis could be theoretically harmful in patients with HIV vasculopathy or co-infection-related arteritis owing to a potential increased bleeding risk from abnormal vessel wall integrity.4 Despite this, intravenous thrombolysis has been used successfully in patients with untreated HIV infection to treat myocardial infarction and, in our patient, to treat acute ischaemic stroke without adverse outcomes.2,4 Clinicians should be aware that endovascular thrombectomy of proximal anterior cerebral circulation clots after intravenous thrombolysis is now evidence-based treatment for acute ischaemic stroke.6 Our case illustrates the “drip, ship and retrieve” concept of acute stroke management; with intravenous thrombolysis (“drip”) commenced at an initial hospital and completed while the patient was transferred (“shipped”) to another hospital for endovascular thrombectomy (clot “retrieval”). At present, only a limited number of stroke centres provide an endovascular thrombectomy service. Reorganisation of existing systems is required to allow rapid access to endovascular thrombectomy for all appropriate patients in Australia.6

This case presents an important reminder that HIV infection is a risk factor for stroke and that HIV testing should be performed in all young stroke patients. A lumbar puncture is recommended for diagnosis or exclusion of co-existing infections including tuberculosis, syphilis and varicella-zoster, which are all associated with vasculopathy in patients with HIV infection.

Lessons from practice

HIV infection is an important risk factor for stroke and HIV testing should be performed in all young stroke patients.
Patients with HIV infection and stroke should have a lumbar puncture to examine for co-existing opportunistic infections.
A diagnosis of neurosyphilis requires a cerebrospinal fluid (CSF) cell count and protein measurement and serological testing on serum and CSF.
There is evidence that the “drip, ship and retrieve” management approach to managing acute ischaemic stroke is effective. However, in patients with known HIV infection, acute stroke should be managed on a case-by-case basis.

Figure

Digital subtraction angiography: A: Pre-clot retrieval showing left internal carotid occlusion (arrow). B: Post-clot retrieval showing dissection (arrow) and restoration of flow.

[Correspondence] Blood pressure lowering for cardiovascular disease

Dena Ettehad and colleagues1 show that the lowering of blood pressure significantly reduces vascular risk across various baseline blood pressures and comorbidities. However, this result will only be applicable to populations in whom the trials were done because the mechanisms of hypertension—and hence the responses—could be dissimilar in different cardiovascular diseases in diverse populations.

[Perspectives] Pharmacy jar

Tastes in food change. We like our lettuce crunchy nowadays. Emma Darwin (1808–96) cooked hers for 2 hours to make a lettuce and pea soup for Charles’s delicate stomach. Such caution has long antecedents. In fact, lettuce was probably originally cultivated for its medicinal properties, although culinary use followed. It featured in the kitchens of ancient Middle-Eastern cultures and of the Greeks and Romans, but also with the knowledge that its cool, wet properties made it a natural for calming hot, dry diseases.

[Correspondence] The Hajj health requirements: changing a mindset

In response to our Correspondence on the Hajj health requirements,1 the statement by Ziad Memish and colleagues (April 23, p 1719)2 that we called to “restrict the Hajj pilgrimage based on non-communicable diseases (NCDs)” is extremely misleading. We would like to clarify that we called for a global discussion, to include all Hajj stakeholders nationally and internationally, on whether seriously ill pilgrims should be allowed to attend Hajj and not for a unilateral action from the Saudi authorities to prevent pilgrims with any form of NCD or chronic illness from doing the pilgrimage.