Ley tries to stymie opposition with hep C link

Health Minister Sussan Ley has attempted to stifle opposition to controversial pathology and diagnostic imaging bulk billing incentive cuts by linking the changes to plans to eradicate hepatitis C within a generation.

The Health Minister said a $1 billion initiative to publicly subsidise access to breakthrough hepatitis C drugs had been “fully accounted for” in the mid-year Budget update unveiled on 15 December, but had not been announced at the time to enable confidential price negotiations with the drug companies to be finalised.

Ms Ley confirmed to the Adelaide Advertiser that axing and winding back bulk billing incentive payments for pathology and diagnostic imaging tests – collectively expected to save $650 million over four years – would help fund the subsidy for hepatitis C drugs.

“This demonstrates that the Government is prepared to make the tough decisions to prioritise where we should put our health dollar in Australia,” the Minister said.

By linking the two measures, Ms Ley will make it harder for political opponents of the bulk billing incentive cuts to block the measures in the Senate, where many previous health measures have foundered – most recently proposed changes to the Medicare safety net.

But, while he was “really pleased” hepatitis C patients would get access to potentially life-saving drugs, AMA President Professor Brian Owler warned the Minister she would be “on dangerous ground” if she sought to trade the interests of one group of patients against those of another.

Shadow Health Minister Catherine King told the Adelaide Advertiser that, while she welcomed the decision to list hepatitis C treatments on the PBS, it was “an absurd proposition” to make patients with cancer, diabetes and other serious health conditions pay for the treatment of other seriously ill people.

Professor Owler has criticised the bulk billing cuts, warning that they amounted to a “co-payment by stealth” because they would force pathology companies to begin charging patients a fee.

One of the nation’s largest providers, Sonic Healthcare, has already warned that patients could be charged $20 for a blood test.

Professor Owler said such a co-payment would hit chronically ill patients in need of frequent pathology tests particularly hard, and would discourage many from having diagnostic tests, increasing the risk of more serious health problems later in life.

But Ms Ley has vowed to confront providers over any plans to introduce a co-payment, claiming such a move was “not appropriate”.

She has argued that competitive pressures in the pathology industry meant that companies should absorb the cut, rather than passing it on to patients.

But the pathology market is dominated by two major providers, and the fact that they are contemplating introducing a co-payment suggests the Government’s analysis of the dynamics of the market is flawed.

But the Minister appears confident that she has the upper hand in the politics of the debate, particularly given her move to link the bulk billing incentive cuts to the hepatitis C announcement.

“I have every expectation that Labor will pass these savings, as they make perfect sense – and, particularly, in the context of an announcement like [the hepatitis C initiative],” she told the Australian Financial Review.

Under the measure, the Government will list four new frontline drugs for the treatment and cure of hepatitis C, including sofosbuvir with ledipasvir (Harvoni), sofosbuvir (Sovaldi), daclatasvir (Daklinza), and ribavirin (Ibavyr), on the Pharmaceutical Benefits Scheme from March next year.

The move is expected to benefit around 233,000 people currently infected with the blood-borne virus that attacks the liver causing serious illness, including cirrhosis and cancer. Around 10,000 people are diagnosed with the disease each year, and it responsible for about 700 deaths annually.

The Government’s decision came eight months after the Pharmaceutical Benefits Advisory Committee recommended that sofosbuvir be listed on the PBS because of “high clinical need”.

This overturned advice from the PBAC a year earlier, in which it recommended against listing the drug because it was likely to have “a high financial impact on the health budget”.

In recommending the drug’s listing, the PBAC warned it was likely to cost taxpayers $3 billion over five years to put 62,000 chronic hepatitis C patients through a course of treatment – three times the Government’s current budgeting.

Though sofosbuvir has been hailed as a “game-changing” medicine that can cure hepatitis C in as little as 12 weeks, its prohibitive price – a course of treatment can cost more than $110,000 – has meant that until now it has been out of the financial reach of most sufferers.

Listing on the PBS means a prescription will cost as little as $37.70 for general patients and $6.10 for concession card holders.

Ms Ley said the combination therapies listed on the PBS had a 90 per cent success rate, and caused fewer side effects than current treatments. She said in most cases patients will only need to take the drug as a pill.

The fact that the Government has budgeted just $1 billion for the measure suggests either that it has managed to negotiate a significant discount with the drug companies, or will eventually need to allocate more money to the effort.

Adrian Rollins

‘Why does this Government have it in for sick people?’

AMA President Professor Brian Owler has accused the Federal Government of ‘having it in’ for the ill over its plan to scrap bulk billing incentives for pathology services and downgrade them for diagnostic imaging.

As Health Minister Sussan Ley admitted some patients “may be worse off” as a result of the changes announced in the Mid Year Economic and Fiscal Outlook, Professor Owler warned they would increase expenses for patients and amounted to a “co-payment by stealth”.

“I really don’t understand why this Government has it in for sick people,” he told Channel Nine.

The AMA President said the Government’s decision to save around $300 million by axing bulk billing incentives for pathology services would force many providers, who haven’t had their Medicare rebate indexed for 17 years, to introduce a charge for patients.

“That is why it is a co-payment by stealth,” Professor Owler told ABC radio. “It’s about forcing providers to actually pass on those costs to their patients.

“So, while Tony Abbott might have said that the co-payments plans was dead, buried and cremated, it seems to have made a miraculous recovery and it’s reaching out from beyond the grave – or, at least, components of it are.”

Treasurer Scott Morrison has denied the claim, and Health Minister Sussan Ley said competition in the pathology industry would ensure increased costs were absorbed by providers rather than being passed on to patients.

In an interview on ABC radio she initially claimed there were 5000 providers operating in a “highly corporatised and highly competitive” environment.

She later clarified her comments, admitting that there were 5000 collection centres rather than individual operators, and most were owned by “two very large corporate entities and they’re doing very nicely.”

Ms Ley said the charging practices of providers was a commercial decision and “we can’t dictate what they charge patients”.

But Professor Owler said it was “completely ridiculous” for the Government to pretend its cuts would not result in charges for patients.

“You can’t take out what is essentially over $300 million from pathology and not expect that there’s going to be some sort of effect on patients,” he said. “Without that money being supplied to those providers, of course they’re going to have to charge the patients and so you’re going to see more patients with more out of pocket expenditure.

“And that is the plan of this Government – to pass more expense on to the pockets of the patients, and that is going to affect the sick and the most vulnerable in our community.”

In addition to axing and downgrading bulk billing for pathology and diagnostic imaging services, the Government expects a further $595 million will be saved by “streamlining” health workforce funding, including dumping several programs including the Clinical Training Fund (which was originally intended to fund up to 12,000 clinical training places across a range of disciplines), the Rural Health Continuing Education Program, the Aged Care Education and Training Initiative and the Aged Care Vocational Education and Training professional development program.

The Federal Government is also tapping the aged care sector for significant savings. It plans to cut more than $480 million by improving the compliance of aged care providers and making revisions to the Aged Care Funding Instrument Complex Health Care Domain.

The Government also expects to realise $146 million in savings from improving the efficiency of health programs, and plans to extract $78 million from the Independent Hospital Pricing Authority and $104 million from the National Health Performance Authority.

A further $31 million will be withdrawn from public hospital funding over the next four years.

Professor Owler said the health sector needed more detail and explanation from the Government regarding the MYEFO cuts.

“All up, MYEFO has delivered another significant hit to the health budget with services and programs cut, and more costs being shifted on to patients,” he said.

The health savings have been announced as part of measures to help improve the Budget, which has been rocked by a plunge in revenues caused by soft economic activity and falling commodity prices.

Since May, the Budget deficit has swelled by more than $2 billion to $37.4 billion, and is expected to be $26 billion bigger than anticipated over the next four years. Mr Morrison has targeted social services and health to deliver the bulk of spending cuts needed to put the Budget on the path to a surplus, which has been pushed back to 2020-21.

But the tenuous nature of this goal has been underlined by the fact that the Government is relying on savings measures that have little prospect of being implemented to help achieve the surplus.

In particular, proposed changes to the Medicare Safety Net worth $267 million were withdrawn by Ms Ley earlier this month after failing to garner sufficient support in the Senate, but still included in the Budget.

While the Government targeted health for major cuts, it did announce some initiatives welcomed by the AMA, including $131 million to expand the Rural Health Multidisciplinary Training Program and establish grants for private healthcare providers to support undergraduate medical places, and a further $93.8 million to develop an integrated prevocational medical training pathway in rural and regional areas – a measure the AMA has long been advocating for.

The Government has also introduced new MBS items for sexual health and addiction medicine services.

Adrian Rollins

News briefs

Loneliness can be a killer

A new study from the United States’ National Institutes of Health shows that loneliness can increase the risk of premature death in older adults by as much as 14%, Forbes reports. “The research team found that perceived social isolation—the ‘feeling of loneliness’—was strongly linked to two critical physiological responses in a group of 141 older adults: compromised immune systems and increased cellular inflammation. Both outcomes are thought to hinge on how loneliness affects the expression of genes through a phenomenon the researchers call conserved transcriptional response to adversity, or CTRA. The longer someone experiences loneliness, the greater the influence of CTRA on the expression of genes related to white blood cells (aka, leukocytes, the cells involved in protecting us against infections) and inflammation. A lessened ability to fight infections along with a slow erosion of cellular health leaves the body open to a host of external and internal problems, some of which worsen over time with few distinct symptoms.” The researchers said the results were specific to “perceived social isolation” and were unrelated to stress and depression.

Fifth retraction for former Baker IDI heart researcher

Retraction Watch reports that JAMA has issued a second retraction for former Baker IDI Heart and Diabetes Institute researcher Anna Ahimastos. In September, JAMA announced that Ahimastos had “fabricated [records] for trial participants that did not exist” in a trial for a blood pressure drug. That trial was retracted, along with a subanalysis. The second paper — Effect of perindopril on large artery stiffness and aortic root diameter in patients with Marfan syndrome: a randomized controlled trial — has been retracted at the request of Ahimastos’ coauthors because it included data from the first discredited paper. The retraction is the fifth for Ahimastos, who has admitted to fabricating data for studies published in the Journal of Hypertension and Annals of Internal Medicine. Three more are expected.

WHO partly to blame for Ebola deaths

An independent group of public health researchers, published in The Lancet, has called for big changes to the World Health Organization in the wake of the 11 000 deaths from Ebola, Wired reports. Suerie Moon from Harvard, a co-author of the report, said: “Ebola was really a wake-up call. If we don’t get together to make reforms after something as devastating as Ebola, you really have to wonder when we will.” According to Wired “in the early days of the Ebola outbreak, WHO’s response was so lackadaisical it [messed] up even the chlorine — the disinfectant doctors got was expired”. The researchers called for a new WHO centre “dedicated to emergency outbreak response, and an independent commission that will hold the agency accountable for its actions”. WHO has since convened another group of independent experts to assess its response to the Ebola outbreak.

Naegleria warning in WA

In the wake of an episode of the ABC’s Australian Story program, the Western Australian Health Department has issued an official warning about the lethal amoeba, Naegleria fowleri, and the subsequent risk of Amoebic meningitis, Outbreak News Today reports. Australian Story told of the Keough family whose son Lincoln who died of the illness after playing in infested water from a garden hose. N. fowleri can be found in any fresh water body or poorly treated water. It thrives in warm water temperatures, between 28oC and 40oC. Amoebic meningitis only occurs if water containing active amoeba goes up the nose and then to the brain. The warning recommended swimming only in saltwater or chlorinated pools.

New president for RCPA

Dr Michael Harrison has been confirmed as the new president of the Royal College of Pathologists of Australia. Dr Harrison, who has been vice-president for the past 4 years, replaces Associate Professor Peter Stewart in the role. He has been a consultant pathologist with Sullivan Nicolaides Pathology for 30 years, first in their clinical chemistry and microbiology division and then as CEO and Managing Partner for the past 12 years.

Don’t order vitamin B12 and Folate tests for tiredness: pathologists

Vitamin B12 and Folate don’t have overlapping risk factors and shouldn’t be tested together, particularly for non-specific symptoms such as tiredness, the Royal College of Pathologists has announced.

These new position statements provide context to recent changes to the Australian Medical Benefits Schedule.

“Testing for Vitamin B12 or Folate deficiencies in patients with non-specific symptoms, such as weakness and tiredness is not recommended,” Vice President Dr Michael Harrison said.

They say Vitamin B12 and Folate deficiencies should only be suspected in patients with:

neuropsychiatric symptoms
haematological disorders
malabsorption
Type 1 diabetes
malnourished and undernourished
patients taking proton pump inhibitors long term.”

Dr Harrison also reminds doctors that although rare, severe untreated Vitamin B12 deficiency can lead to permanent neurological damage and maternal folate deficiency is linked to fetal neural tube defects.

The RCPA testing recommendations are:

Vitamin B12 Testing Protocol – Measure serum Total B12, and if this result is less than a laboratory determined sufficiency threshold, perform a holotranscobalamin level. Depending on the outcome of this test, a metabolite of a Vitamin B12-dependant metabolic pathway, for example, homocysteine or methyl malonic acid (MMA) may then be measured.

New Folate testing Protocol – Serum Folate level is the first line test with red blood cell (RBC) Folate estimation only to be performed when the serum value is low.

Read the full Vitamin B12 and Folate position statement.

New faecal pathogen screening recommendations

The College also announced new recommendations for faecal pathogen screening to try to lower over treatment and diagnosis of patients.

It recommended using a multiplex PCR without Dientamoeba fragilis and Blastocystis species when testing for faecal pathogens.

Dr Harsha Sheorey, spokesperson on faecal pathogens for the RCPA, said recent DNA-based diagnostic methods have determined that these organisms are much more common than first thought.

“The PCR techniques have led to unnecessary diagnoses and the over treatment of these two organisms. This results in needless anxiety amongst patients and parents and can even cause possible harm due to the disruption of the normal flora from the use of antibiotics as treatment.”

If a PCR is requested and a positive result is found, the report should highlight the questionable pathogenicity of these two organisms.

Read the full faecal pathogen position statement.

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Cost-effective GPs a health saving

A major study has found that the nation’s GPs are playing a vital role in holding health costs down, calling into question the Federal Government’s push to gouge money out of primary care to boost the Budget bottom line.

Sydney University health researchers have found that GPs are playing a crucial role in caring for aging patients with multiple and complex health problems, helping them lead longer and healthier lives at a fraction of the cost of other health systems, particularly the United States.

The conclusion is politically awkward for the Federal Government, which has targeted the health budget for cuts, claiming that Medicare expenditure is out of control.

The Government has imposed a four-year freeze on Medicare rebates, and Health Minister Sussan Ley has directed a review of the Medicare Benefits Schedule to achieve savings that can be ploughed back into general revenue.

The Minister has sought to justify the cuts by accusing doctors of manipulating and exploiting the Medicare system for personal financial gain – a line of attack that AMA President Professor Brian Owler has condemned as deeply offensive.

The latest report from the long-running Bettering the Evaluation and Care of Health (BEACH) study being undertaken by the Family Medicine Research Centre backs AMA warnings that the Government’s attack on primary health care funding is misguided and will cost both patients and the country dearly.

The BEACH report found that the aging of the population is imposing an increasing burden on the health system.

While less than 15 per cent of all Australians are aged 65 years or older, they are twice as likely to see a GP, have a pathology test, see a specialist and be on medication as the rest of the population.

This is due, to a large extent, to the fact that they tend to have multiple chronic health complaints – the study found 60 per cent of them had three or more health problems, and a quarter had five or more.

And the health demands of older Australians are growing quickly – their use of GP time, diagnostic tests, medicines and referrals is expanding much more rapidly than their numbers would imply.

But, despite this, Australia’s total health spending as a proportion of GDP is on a par with countries such as Britain, Canada and New Zealand while achieving among the longest life expectancies in the world – and is far better than the United States, which spends double the amount but whose life expectancy is four years shorter.

The BEACH researchers attributed this world-class result to the work of the nation’s GPs and central role they play in the health system.

“One of the biggest differences between the health care systems in Australia and the United States is that primary care is the core of Australia’s system, with GPs acting as ‘gatekeepers’ to more expensive care,” they said. “If general practice wasn’t at the core of our health care system, it is likely the overall cost of health care would be far higher.”

The BEACH researchers said that the early diagnosis of health complaints and increasing life spans meant people were living longer with complex conditions, adding greatly to health costs: “This is the price Australia pays for good health, but we would argue this price is very reasonable”.

GPs are central to holding costs down, in large part because of the work they do in co-ordinating the care provided by hospitals, specialists, allied health professionals and community and aged care services.

The BEACH researchers said this coordinating role was crucial because it cut down on duplication of tests and helped ensure continuity of care – both considered vital in sustaining health and holding down costs.

They found that 98.6 of older patients had a general practice they usually attended – a de facto ‘medical home’.

“If our Government wants to make our health care system sustainable, it should invest in primary care to improve the integration of, and communication between, these different parts of the health system,” the researchers said.

“Further strengthening the role of general practitioners will reduce unnecessary interventions in the secondary and tertiary health sectors.”

Adrian Rollins

More patients, more complex problems, more often: the lot of GPs

Patients are seeing their GP more often, and taking up more of their doctor’s time seeking help with an increased array of health problems, adding weight to medical practitioner complaints about the inadequacy of the Medicare rebate.

A long-running study of general practice has found that the proportion of older patients being seen by GPs has increased as the nation’s population has aged, bringing with them multiple health problems that require more time-consuming and complex care.

The Bettering the Evaluation and Care of Health (BEACH) study, which involves a random sample of 1000 GPs each year, found that between 2005 and 2014 the proportion of patients 65 years or older seen by GPs increased from 27 to 31 per cent.

At the same time, the number of consultations claimed through Medicare climbed 36 per cent to more than 137 million and the number of problems managed per 100 encounters rose from 146 to 155.

Together, these results mean that 65 million more problems were managed by GPs in 2014-15 compared with 2005-06 – underlining concerns that doctor remuneration through Medicare has failed to keep pace with the volume and complexity of the work GPs undertake.

The AMA has condemned the Federal Government’s decision to freeze the Medicare rebate until mid-2018, warning the measure is likely to drive some GPs out of practice and cause many more to cease bulk-billing, potentially deterring the sickest and most vulnerable from seeking care.

While the rebate is stuck, the complexity and multiplicity of problems that GPs are treating has meant a blow-out in the time they spend with each patient. Consultation time has increased from a mean of less than 14 minutes a decade ago to 14.7 minutes last financial year – and the increase in time taken could be accelerating. The BEACH study found that in the last two years alone, the median consultation has increased from 12 to 13 minutes.

While hypertension, check-ups, coughs and colds remain the common reason to see a GP, in the past decade there has been a sharp increase in other types of complaints – particularly those chronic in nature.

Last financial year, GPs has 23 million more consultations for chronic complaints than in the mid-2000s, including many more for depressive disorders, oesophageal disease, heart problems, chronic back pain and other, unspecified, chronic pain.

Not only has the type of patients and the problems they have changed in the past decade, but so has the way GPs operate.

The BEACH study found that GPs now were less likely to prescribe medicine, particularly antibiotics and anti-inflammatories, than they were 10 years ago.

Instead, they were likely to order more pathology and imaging tests, and more readily referred their patients to a specialist.

Adrian Rollins

Latest news:

The dangers of diagnosing cystic neck masses as benign in the era of HPV-associated oropharyngeal cancer

Clinical record

A 59-year-old woman presented to her general practitioner with a lump in the left neck. She was a non-smoker, non-daily drinker and had no significant past medical history. Fine needle aspiration biopsy (FNAB) was performed and led to the diagnosis of a branchial cleft cyst. The mass collapsed after aspiration and the patient was managed conservatively by observation. In the year after diagnosis, re-emergence of the mass was noted by the GP at follow-up. Further investigations were declined on the patient’s presumption that the lesion was a benign branchial cleft cyst.

Two years after her initial diagnosis, the patient re-presented with a 1- to 2-month history of a sore throat and further increase in the size of the neck mass. On examination, a 7 cm mass was palpable, there was no overlying skin invasion and the mass was mobile to deep structures. Repeat FNAB of the neck mass was performed and revealed squamous cell carcinoma (SCC) with p16 positivity.

A staging computed tomography (CT) scan detected a lobulated tumour centred on the left tonsil invading the vallecula, base of tongue and parapharyngeal space. Further, a 27 mm cystic mass consistent with her initial lump was identified in the left level II group of lymph nodes, with additional necrotic nodes present at levels III and IV. A subsequent positron emission tomography scan confirmed increased uptake in these regions.

The patient was diagnosed with a T3 N2b M0 oropharyngeal SCC and was referred for radical chemoradiation. Expression of the surrogate marker p16 on cytological testing was highly suggestive that this was a human papilloma virus (HPV)-positive oropharyngeal SCC.

This case illustrates the diagnostic challenges faced in differentiating cystic nodal metastases from branchial cleft cysts, in the context of the increasing prevalence of HPV-related oropharyngeal SCC in Australia over the past two decades.1

HPV-related oropharyngeal SCC differs from traditional head and neck cancer in both its aetiology and clinical features; and because it is a relatively new clinical condition, GPs, radiologists and pathologists often do not recognise it as a potential diagnosis. Unlike traditional head and neck cancer, it occurs in a younger population who are frequently non-smokers and not heavy drinkers. Clinically, it most frequently presents with a neck mass, and often primary lesions are not easily discernible, as they are commonly small and in clinically difficult areas to examine, such as the base of the tongue or tonsil.

The natural disease pattern of oropharyngeal SCC is to metastasise to the cervical lymph nodes. In the setting of HPV-related cancer, these nodal metastases are frequently cystic in morphology and, as previously indicated, are frequently the first mode of presentation.2 Given the differing clinical features of HPV-related oropharyngeal cancer compared with non-HPV-associated oropharyngeal cancer, it is not uncommon for these nodal metastases to be misdiagnosed as branchial cleft cysts, as described in this case report. The proportion of metastatic SCCs in cysts initially presumed to be of branchial cleft origin has been reported to range from 11% to 21%.3,4

Misdiagnosis can negatively affect patient prognosis as it delays treatment, allows for further disease progression and increases the potential for metastatic spread. Alternatively, proceeding to excisional biopsy of a cystic mass suspected to be a branchial cleft cyst without adequate investigation for an occult primary can lead to tumour spillage into the surrounding tissues.

Differences in the demographics between branchial cleft cysts and cystic nodal metastases may aid clinicians in accurate diagnosis. While branchial cleft cysts may occur at any age, they most commonly present in early adulthood in the second and third decade of life.5 The reported mean age for cervical cystic masses histologically confirmed as branchial cleft cysts ranges from 32 to 37 years.6,7 In contrast, cystic nodal metastases present later, with a reported mean age ranging from 53 to 57.8 years.6,7 Particular attention must be paid to cervical cysts in patients over 40 years of age, as 44% of cystic masses in this patient population are reported to be malignant in origin.8 The most commonly represented lesions associated with cystic metastases are HPV-related head and neck cancer and thyroid papillary carcinoma.9

CT is a mainstay in the diagnosis and staging of head and neck cancer and plays an important role in differentiating benign lesions of the neck from malignant cystic lymphadenopathy. On contrast-enhanced CT, there is homogeneous attenuation throughout the substance of branchial cleft cysts.6 Features suggestive of malignancy include the presence of septations, heterogeneous attenuation and extracapsular spread.6,7 Significant overlap between the radiological features of benign and malignant cysts is, however, present. Repeated local infection involving a branchial cleft cyst may confer a radiological appearance similar to that of nodal metastasis of an SCC.7 In one study, 31% of cystic nodal metastases were reported as benign in appearance, while 38% of branchial cleft cysts had aggressive features mimicking nodal metastases.6 Evidently, isolated use of CT in evaluating a cystic neck mass confers a high degree of misdiagnosis.

FNAB cytology is the current standard of care in diagnostic workup of solid masses of the neck and is reported to have an overall sensitivity of 92% and a positive predictive value of 100% for head and neck carcinomas.10 Unfortunately, this has not been the common experience with cystic lesions, for which its role remains controversial. Reported sensitivities range from 33% to 55%,11 with a false-negative rate of up to 50%.2 The aspirate of cystic metastatic nodes may be difficult to interpret as a result of hypocellularity from the dilutional effect of the cyst fluid.2 There is commonly an associated inflammatory reaction within the cystic nodes, resulting in large quantities of degenerating epithelial cells, inflammatory cells and cellular debris within the aspirate. These cytological features overlap considerably with those of branchial cleft cysts12 and can lead to misdiagnosis.

Despite these limitations, FNAB still retains some relevance in the diagnosis of cystic lesions. Further, with the emergence of molecular analysis techniques, the detection of HPV DNA and thyroglobulin within fine needle aspirates may facilitate the pathological diagnosis of malignant cystic lymphadenopathy and detection of occult primary tumours. The presence of HPV DNA or thyroglobulin in aspirates is strongly correlated with HPV-related oropharyngeal SCC and thyroid cancer, respectively.13,14 Although these tests are primarily used for research purposes at present, their utility may expand to the clinical setting in future to help to differentiate benign and malignant cystic neck lesions.

Differentiating cystic nodal metastases from branchial cleft cysts is an important, albeit sometimes difficult, diagnostic challenge. With the growing prevalence of HPV-related oropharyngeal SCC in Australia, we conclude that metastatic lymphadenopathy should be considered as the primary provisional diagnosis in the adult population with cystic neck masses until proven otherwise. We encourage caution in the interpretation of neck masses as benign by isolated use of either CT or FNAB. Clinicians should use these modalities in conjunction with each other and, if necessary, include referral for an ear, nose and throat specialist opinion to increase diagnostic accuracy.

Lessons from practice

HPV-related oropharyngeal cancer is an increasingly common and relatively new entity that differs from traditional head and neck cancer in its aetiology, epidemiology, clinical features and prognosis.
Lateral cystic neck masses in adults are often misdiagnosed as branchial cleft cysts and should be considered as metastatic lymphadenopathy until proven otherwise.
Isolated use of computed tomography or fine needle aspiration biopsy in evaluating a neck mass can lead to misdiagnosis. Instead, these modalities should be used in conjunction with each other and, if necessary, include referral for an ear, nose and throat specialist opinion to increase diagnostic accuracy.
The emergence of molecular analysis techniques for detecting HPV DNA and thyroglobulin in fine needle aspirates may assist clinicians in the diagnosis of occult primary tumours with cystic nodal metastasis.

Signs workforce planning getting back on track

It’s been a chequered time for medical workforce planning in recent years.

Health Workforce Australia (HWA) was a Commonwealth statutory authority established in 2009 to deliver a national and co-ordinated approach to health workforce planning, and had started to make substantial progress toward improving medical workforce planning and coordination. It had delivered two national medical workforce reports and formed the National Medical Training Advisory Network (NMTAN) to enable a nationally coordinated medical training system.

Regrettably, before it could realise its full potential, the Government axed HWA in the 2014-15 Budget, and its functions were moved to the Health Department. This was a short-sighted decision, and it is taking time to rebuild the workforce planning capacity that was lost.

NMTAN is now the Commonwealth’s main medical workforce training advisory body, and is focusing on planning and coordination.

It includes representatives from the main stakeholder groups in medical education, training and employment. Dr Danika Thiemt, Chair of the AMA Council of Doctors in Training, sits with me as the AMA representatives on the network.

Our most recent meeting was late last month, and the discussions there make us hopeful that NMTAN is finally in a position where it can significantly lift its output, contribution and value to medical workforce planning.

In its final report, Australia’s Future Health Workforce, HWA confirmed that Australia has enough medical school places.

Instead, it recommended the focus turn to improving the capacity and distribution of the medical workforce − and encouraging future medical graduates to train in the specialties and locations where they will be needed to meet future community demands for health care.

The AMA supports this approach, but it will require robust modelling.

NMTAN is currently updating HWA modelling on the psychiatry, anaesthetic and general practice workforces. We understand that the psychiatry workforce report will be released soon. This will be an important milestone given what has gone before.

Nonetheless, it will be important to lift the number of specialties modelled significantly now that we have the basic approach in place, so that we will have timely data on imbalances across the full spectrum of specialties.

The AMA Medical Workforce Committee recently considered what NMTAN’s modelling priorities should be for 2016.

Based on its first-hand knowledge of the specialities at risk of workforce shortage and oversupply, the committee identified the following specialty areas as priorities: emergency medicine; intensive care medicine; general medicine; obstetrics and gynaecology; paediatrics; pathology and general surgery.

NMTAN is also developing some factsheets on supply and demand in each of the specialities – some of which now available from the Department of Health’s website (http://www.health.gov.au/internet/main/publishing.nsf/Content/nmtan_subc…). I encourage you to take a look.

These have the potential to give future medical graduates some of the career information they will need to choose a specialty with some assurance that there will be positions for them when they finish their training.

Australia needs to get its medical workforce planning back on track.

Let’s hope that NMTAN and the Department of Health are up to the task.

Forcing GPs to adopt half-baked e-health record a dud idea: AMA

The Federal Government has hit a major snag in its overhaul of the troubled e-health record system after the AMA rejected plans to link GP incentive payments to the adoption of the scheme.

The Government has proposed that Practice Incentive Program e-health payments be tied to doctor use of the MyHealth Record (MyHR) system being developed to replace the $1 billion Personally Controlled Electronic Health Record scheme. The PCEHR has been dumped amid dismal take-up rates among patients, doctors and medical practices.

But AMA President Professor Brian Owler said the MyHR system was far from fully developed, so using PIP incentives to get doctors to sign up was ill-considered and premature.

“The MyHealth Record is not at a stage where it can be adopted by practices, so it should not be linked to the PIP scheme,” Professor Owler said. “There are fundamental issues with the design of the MyHR that are yet to be fully addressed.”

The AMA has detailed a long list of problems with the current version of the system in a submission to the Health Department, including:

the ability of patients to remove information from view, making the record potentially incomplete and of no clinical value;
no flags to indicate if information has been removed from view;
radiology or pathology results are not yet included;
the shared health summaries are not automatically updated, rendering them quickly out-of-date; and
inaccuracies occur in the upload of data.

In addition MyHR, in its current iteration, remains an ‘opt-in’ system.

The reliance on patients to sign up for an e-health record was seen as a fatal weakness of the PCEHR, and a three-person review of the system recommended that MyHR be an opt-out scheme.

But Health Minister Sussan Ley has indicated that the opt-out approach will first be trialled next year before being adopted.

“It’s important that all Australians are signed up to ensure we have a functioning system, and trialling an opt-out model means we can do it carefully, methodically and ensure the appropriate protections are in place to give patients peace of mind,” Ms Ley said.

“If automatic registration for a digital health record in the opt-out trials leads to higher participation in the My Health Record system, the Government will consider adopting opt-out on a national scale.”

Professor Owler said this lengthy catalogue of unresolved problems with MyHR meant it was unfair to expect GPs to adopt it.

“Until the problems with the MyHR have been rectified, so that it is easy to use and offers real clinical benefits for patients, it is unreasonable to expect GPs to actively use it,” the AMA President said.“The AMA has been a strong advocate for a well-designed and governed e-health record which can deliver real benefits for patients, but the current MyHR model has well-known flaws that must be fixed.”

The AMA has recommended the Government focus on rectifying problems with MyHR rather than trying to force GPs to use a system that is cumbersome and incomplete.

Even when the system is complete and fit for use, the AMA has argued that, instead of using the existing e-PIP incentive, the Government instead create a Medicare Benefits Schedule item and a Service Incentive Payment scheme to promote its use.

To help establish MyHR, Ms Ley has announced the appointment of former National Mental Health Commission Chief Executive Robyn Kruk to head an 11-member eHealth Implementation Taskforce Steering Committee.

The Committee, which includes Dr Hambleton, will design, implement and oversee the establishment of the Australian Commission for eHealth.

For its part, the Commission will oversee the operation and development of e-health systems, including operating the My Health Record System.

Revised eligibility requirements for the e-Health Incentive are due to be announced in November 2015, and to commence from 1 February 2016.

The AMA submission can be viewed at: at submission/ama-submission-proposed-changes-pip-ehealth-incentive

Adrian Rollins

News briefs

Trailblazing former MJA editor dies

Professor Priscilla Kincaid-Smith, former acting editor of the Medical Journal of Australia, and a trailblazer for Australian female scientists, has died at her Melbourne home from complications following a stroke, the ABC reports. She was 88. Professor Kincaid-Smith was a world-renowned nephrologist, discovering the link between overuse of headache powders and kidney disease. She was the first female professor at the University of Melbourne in 1975, first female chair of the Royal Australian College of Physicians, first female chair of the Australian Medical Association and the first female — and first Australian — chair of the World Medical Association. She was acting editor of the MJA in 1995. A full obituary will be published in a forthcoming issue of the MJA.

Social media use linked to teens’ mental health

A new Canadian study has found that teenagers who use social media sites for two hours or more each day are significantly more likely to suffer from poor mental health, psychological distress and suicidal thoughts, the Huffington Post reports. “It could be that teens with mental health problems are seeking out interactions as they are feeling isolated and alone,” Dr Hugues Sampasa-Kanyinga, the lead author of the Ottawa Public Health study, wrote. “Or they would like to satisfy unmet needs for face-to-face mental health support.” The solution, he suggested, was not to get teens off social media. “Since teens are on the sites, it is the perfect place for public health and service providers to reach out and connect with this vulnerable population and provide health promotion systems and supports.”

Nominations open for 2015 ACHS Medal

Nominations for the Australian Council on Healthcare Standards 2015 ACHS Medal are now open. The award recognises outstanding achievement in the advancement of quality and safety in health care in Australia. “The ACHS Medal provides an opportunity to further promote the work of an individual who has made a strong contribution in their particular field in health, by highlighting the improvements being made in safety and quality,” ACHS Chief Executive Officer, Dr Christine Dennis, said. Recent recipients of the medal include Kae Martin (2014); Adjunct Professor Christopher Brook PSM (2013); and Professor Robert “Bob” Gibberd (2012). The closing date for nominations is 5pm, Friday 25 September, and the nomination form can be found at www.achs.org.au/ACHSMedal

Top Canadian pathologist steps down

Retraction Watch reports that prominent pathologist Dr Sylvia Asa has resigned from running the largest hospital diagnostic laboratory in Canada because of an investigation that uncovered evidence of falsified data in two papers. Dr Asa was the program medical director of the Laboratory Medicine Program at the University Health Network, affiliated with the University of Toronto. Two papers coauthored by Dr Asa have been retracted by the American Journal of Pathology. “Following correspondence in September 2012 from a concerned reader … [an investigative committee] informed the Editors in April 2015 that the articles in question contain falsified data”, the AJP editors said. Problems included “manipulated and/or fabricated data”.

Transgender women show “shocking” HIV rates

A World Health Organisation report shows that a transgender woman was 49 times more likely to be living with HIV [than the general population] in 15 countries in which data was analysed, NPR reports. Transgender people are not receiving adequate health care, and widespread discrimination is largely to blame, according to the WHO paper. Among sex workers, transgender women are nine times more likely to have HIV than their non-transgender counterparts. “What is driving the epidemic is really the refusal of governments to pass legislation that allows [transgendered people] to function in society, and allows them to participate in the workplace”, JoAnne Keatley, a coauthor of the WHO report, said. “Trans people struggle in order to obtain identity documents that allow them to participate in the workforce. Many trans people are not able to obtain health coverage.”