Tobacco smoking – enough of the puff

BY ROB THOMAS, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

It is no surprise that the smoking of tobacco has decreased significantly from a generation ago, amid targeted and widespread programs to deter its use. Indeed, in Australia we seem to view our stringent tobacco legislation and divestment movements as huge wins for public health. However, what may come as a surprise is that our smoking rates are still roughly one in seven people, and it continues to cause more deaths than alcohol and illicit drugs combined.

As a young person, I’m astounded when I see friends and other young people lighting up. On the one hand, it’s probably good that myself and others have such a cultural distaste for this deadly habit, but on the other it’s tragic to see people beginning something that they will inevitably struggle with for years.

Like many medical students, I’ve spent time in respiratory medicine and seen patients dying of cancer, infection and chronic obstructive pulmonary disease, where people describe their existence as “slowly drowning”. There is simply no safe level of tobacco consumption. It shocks me that this harsh reality, not just the threat of cancer, causes more than 15,000 Australian deaths per year and yet young people continue to pretend they’re invincible.

Interestingly, in the US and UK, smoking rates are now dropping to comparable or even lower levels than in Australia, where our plain packaging and advertising laws are very strong. On a pure price disincentive, we still have some of the most expensive cigs in the world, yet perhaps we are starting to see diminishing returns on smoking rates. Clearly, more needs to be done.

Earlier in the year, AMA President Dr Michael Gannon gave out the “Dirty Ashtray Award” to the State most behind on their smoking crackdown. The Northern Territory, 11-time recipient of that award, has a rate of smoking of more than one in five, with comparatively lax laws regarding smoking in pubs, clubs and even schools. We cannot sit by while children and young people are indoctrinated into a culture where smoking is tacitly accepted.

Some advocates for smoking reduction have looked at the possibility of e-cigarettes as a tool for cessation or alternative. We must be wary of these products, none of which have yet proved to be useful as cessation tools, and may in their use and marketing make smoking more socially acceptable.

Many universities have some form of a tobacco-free policy available on their websites. However, many of these are not enforced or incomplete, meaning that smoking and particularly passive smoking continue. As medical students, we call for more stringent tobacco-free policies to reduce prevalence and change attitudes.

While universities are a great target, we need also to ensure that smoking-related disease does not become a disease of the poor. There is a significant gap in smoking rates between the highest and lowest economic quintiles (8.0 per cent and 21.4 per cent respectively). Although this gap is slowly closing, we need to pursue methods of education and intervention that promote equity and work for the people most at risk.

At the patient level, it’s important for doctors to remain vigilant, to work with smokers to quit. We acknowledge this is not easy, it is often a long and relapsing process, but ultimately it cannot just be ignored. Thankfully in medical school we are taught some of the tools of motivational interviewing, but we can’t afford complacency.

Complacency cannot be afforded at the Government level, too. The Council of Australian Governments several years ago made the target of 10 per cent daily smokers by 2018, a rate we may just fall short of. Continued efforts, including banning in public places, availability of support to quit programs and widespread public education need to continue. This is not a fight we can say we’ve won just yet.

Twitter: robmtom
Email: rob.thomas@amsa.org.au

Commitment to safety and quality or new cuts to Commonwealth hospital funding?

BY ASSOCIATE PROFESSOR SUSAN NEUHAUS, CHAIR, HEALTH FINANCING AND ECONOMICS COMMITTEE

A key focus of the Health Financing and Economics Committee (HFE) is the pricing and funding of public hospitals.

Public hospitals are a critical part of our health system but remain historically and chronically underfunded. They struggle to manage the demands of aging populations, the burden of chronic disease and new technologies and treatments.

At the April 2016 COAG meeting, the Commonwealth committed an extra $2.9 billion to hospital funding. At the same time they secured State and Territories agreement to:

“Incorporate safety and quality into the pricing and funding of public hospitals services with the aim of improving health outcomes, avoid funding unnecessary or unsafe care and decrease avoidable demand for public hospital services.” (IHPA, Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19 p4)

In February 2017, the Commonwealth Minister for Health directed the Independent Hospital Pricing Authority (IHPA) to reduce the level of Commonwealth contribution to activity based hospital pricing for:

i. Sentinel events;

ii. Hospital acquired complications (HACs); and

iii. Avoidable readmissions.

The events listed in each category are developed by the Australian Commission on Safety and Quality in Healthcare. See Sentinel Events List of Hospital Acquired Complications (HACs). The list of avoidable readmissions is due for release later in 2017.

The Independent Hospital Pricing Authority Consultation Paper on the Pricing Framework for Australian Public Hospital Services 2018-19 detailed implementation timeframes and pricing adjustment methodology for the three categories of safety and quality events.

1 July 2017 Sentinel events will not be funded.

1 July 2018 HACs funding will be reduced by a patient “risk adjusted” factor.

1 July 2018 Avoidable hospital readmissions funding will be reduced.

The AMA supports sensible and well-considered initiatives to improve safety and quality in our public hospitals. The AMA wants to see a reduction in HACs and avoidable readmissions but does not endorse the use of Commonwealth financial penalties as an effective way to achieve this. Adverse outcomes result from a complexity of patient and institution factors. If hospitals are overstretched and under-resourced, errors are more likely to occur and less likely to be recognised or remediated.

Safety and quality funding penalties will not assist these hospitals to lift performance. It will instead entrench a spiralling decline in the hospital’s capacity to undertake the internal changes needed to focus on safety and avoid future penalties.

The HAC list

The HFE Committee also questioned the validity of some of the HACs that will incur a financial penalty. Examples include:

i. Malnutrition – Patients admitted to hospital with pre-existing skin eruptions that have, with exclusion of other causes, been diagnosed in hospital as nutrition related. The hospital should not be financially penalised for diagnostic accuracy;

ii. Respiratory complications – aspiration pneumonia. Superficially this seems a reasonable HAC inclusion except it may occur through no negligence, for example as a non-preventable consequence of “grand mal” fit;

iii. Gastrointestinal bleeding – A patient with gastric bleeding secondary to biopsy of melanoma metastasis. While bleeding in this setting is an identifiable risk, it was not avoidable; and

iv. Delirium is another poorly defined HAC that should be excluded.

Patients are unique and respond to treatment differently. Unless a root cause analysis is undertaken it will not be possible to justifiably attribute the event or apportion all of the adverse consequence to “poor or mismanaged public hospital care”.

The timeframe before HAC penalties take effect from 1 July 2018 is too rushed. A three to four month HAC shadow data collection (July–Sept 2017) will not permit reliable indications of financial impact on jurisdictions or identify unintended negative outcomes for patients as hospitals adapt to the financial penalty risks.

We raised similar concerns about the rush to penalise public hospitals for avoidable readmissions from 1 July 2018. The AMA wonders how genuine the planned stakeholder consultation will be given the avoidable admissions list will not be known until late 2017 and IHPA must report to COAG before they meet on 30 November 2017.

The AMA wants to see significantly less HACs and genuinely avoidable readmissions in public hospitals but does not endorse the rushed, bizarre notion that financial penalties will lead to a positive culture of hospital improvement in a severely underfunded and chronically overloaded system. Safety and quality improvement is more likely in “no blame” hospital reporting cultures such as those adopted in Norway and Denmark and recommended in 2014 by the European Commission. I have grave concerns that much of the progress public hospitals have made to date in areas of open reporting and transparency will be lost in the move to a defensive, financially penalised performance system.

New treatment for resistant hypertension with ultrasound

Researchers at The University of Western Australia (UWA) have taken a step forward in the fight against high blood pressure, after the first human trials of a ground-breaking treatment produced successful results at Royal Perth Hospital.

The cutting-edge procedure targets carotid bodies, the tiny organs found on either side of the neck, which regulate the cardiovascular and respiratory systems.

The procedure guides a catheter through the femoral vein in the groin up to the neck and ends adjacent to the carotid body. The device then specifically targets the organ with short ultrasound energy pulses, rendering it ineffective.

Exposing a carotid body to ultrasound could permanently lower blood pressure in patients who failed to respond to medication or lifestyle changes, the research has shown.

“We know that patients with uncontrollable high blood pressure will often have an overactive carotid body, so we’re looking to silence it or at least reduce its activity,” said Professor Markus Schlaich, a team leader in the research at UWA.

Professor Schlaich said the therapeutic ultrasound can emit waves of energy that travel through tissue and target the organ of interest.

Cardiovascular disease is an enormous burden on health and society, with more than 30 per cent of Australians affected by high blood pressure and more than 8.5 million deaths each year worldwide, directly attributable to uncontrolled blood pressure.

One of the participants in the study was 78-year-old patient Agnes Johnson, who suffered from high blood pressure for 30 years and was the first person in Australia to undergo the procedure in 2016.

After the treatment, Mrs Johnson said her blood pressure dropped from 220 over 90 to a more manageable 140 over 80 mmHg.

“The medications I tried kept making me sick so having this done was of huge benefit to me. The procedure was fine, I had no side effects and now I feel much better,” she said.

Professor Schlaich said the world-first catheter based approach had been performed on 29 patients in Australia and Europe and he hopes to have the procedure readily available around the world in three to four years.

“There is clear evidence to demonstrate that if you manage to reduce blood pressure you can dramatically reduce the risk of heart attack and stroke,” he said.

The researchers point out that this approach won’t be used for everyone with hypertension but it could be a great approach for those patients whose blood pressure cannot be controlled with medication or lifestyle changes.

The Australian Stroke Foundation warns that high blood pressure can have many harmful effects which can eventually lead to a stroke; can speed up common forms of heart disease that can lead to stroke; and can cause blood clots or plaque (cholesterol and other fat-like substances) to break off artery walls and block a brain artery causing a stroke.

MEREDITH HORNE

[Perspectives] Alvar Agusti: bringing systems biology to COPD

“Some people think he’s a bit too wild, a bit too radical”, says Jørgen Vestbo. “He’s an unconventional thinker. When most of us start discussing things from a particular starting point he’ll often question the starting point as well.” Peter Sterk takes a similar view. “He thinks out of the box and ahead of the crowd. He’s a clinician who’s open to fundamental innovative developments that will change clinical practice dramatically in 5 or 10 years. He’s one of the frontrunners shaping that future.” Professors Vestbo and Sterk are both respiratory physicians, the former at the UK’s University of Manchester, the latter at the Academic Medical Centre of the University of Amsterdam in the Netherlands.

[Comment] Determining the burden of respiratory syncytial virus disease: the known and the unknown

60 years ago, respiratory syncytial virus (RSV) was identified in children admitted to hospital in Baltimore, MD, USA, with bronchiolitis or pneumonia.1 Since that time, RSV has been established as a leading cause of acute lower respiratory illness (ALRI) in infants and children living in all regions of the world.2–5 As the widespread use of Haemophilus influenzae type b and pneumococcal conjugate vaccines decreases the burden of bacterial pneumonia in children, the proportional contribution of RSV to childhood ALRI will continue to increase.

[Editorial] Palliative care in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is increasing in prevalence, and is associated with a high mortality rate. The latest data from the Global Burden of Disease Study 2015, published on Aug 16 in The Lancet Respiratory Medicine, show that 3·2 million people died from COPD worldwide in 2015, an increase of 11·6% com-pared with 1990. From 1990 to 2015, the prevalence of COPD increased by 44·2%, although age-standardised death and prevalence rates have fallen overall.

Somalis Americans rush to vax their children, despite campaign against

Despite an emboldened anti-vaccination movement in Minnesota, the State’s Somali American community has turned out in droves to have their children immunised against measles.

The Midwestern US State has recorded its worst measles outbreak in decades, with most cases involving unvaccinated Somali American pre-schoolers.

Since March this year, Minnesota public health officials have confirmed 79 local measles cases, resulting in 22 people being hospitalised with dehydration, high fever and respiratory difficulties.

Officials also report that more than 8,200 people were exposed to the virus in day-care centres, schools, clinics and hospitals.

In a bizarre twist, the outbreak has energised the anti-vaxxers in their campaign to thwart health authorities’ effort to prevent the spread of the disease.

The movement opposed to immunisation has ramped up its use of social media to denounce the need for childhood vaccinations.

Activists are openly talking about exposing unvaccinated children to those with measles so that they can be infected and build up immunities.

But while the ferocity of the sudden anti-vax push has surprised health officials in Minnesota, they have also noted that the Somali community is largely ignoring the activists.

Describing it as an “unprecedented collaboration” between doctors and health officials, and community leaders, Somali American imams are urging families to have their children vaccinated.

The imams are telling their followers to protect their children against disease and have them vaccinated against measles, mumps and rubella (MMR).

Doctors are reporting they are seeing parents who had previously repeatedly refused to have their children immunised, now accepting the need for the vaccinations.

Health authorities are describing it as a “major shift in the uptake” of Somali families seeking immunisations.

The biggest jump was noticed between April and July.

The anti-vax activists appear to be motivated by the tour of the film Vaxxed: From Cover-up to Catastrophe, which has been widely ridiculed elsewhere.

The film was directed by Andrew Wakefield, a former doctor who promotes the debunked claim that MMR vaccinations are linked to autism.

Australian Medical Association President Dr Michael Gannon has described the film as ludicrous and dangerous.

“Andrew Wakefield was found to have fraudulently produced evidence around the original MMR scare in Britain, which led to him being deregistered as a doctor,” Dr Gannon said.

“The next phase of his career is as an amateur filmmaker. That’s not where I’d be getting my advice from.”

The Minnesota Vaccine Freedom Coalition posted on its Facebook page that it had not been involved in the sudden surge of targeted anti-vax campaigns that health authorities in the State are reporting.

CHRIS JOHNSON

[Comment] Procalcitonin-guided antibiotic stewardship from newborns to centennials

In 1993, Assicot and colleagues1 reported in The Lancet that procalcitonin was a marker of systemic infections in neonates and paediatric patients. In 2004, Christ-Crain and colleagues2 reported that procalcitonin guidance substantially reduced antibiotic use in adult patients presenting to the emergency room with lower respiratory tract infections, and in 2010, Bouadma and colleagues3 reported that a procalcitonin-guided strategy to treat suspected bacterial infections in non-surgical adult patients in intensive care units reduced antibiotic exposure and selective pressure with no apparent adverse outcome.

[Seminar] Influenza

Influenza is an acute respiratory illness, caused by influenza A, B, and C viruses, that occurs in local outbreaks or seasonal epidemics. Clinical illness follows a short incubation period and presentation ranges from asymptomatic to fulminant, depending on the characteristics of both the virus and the individual host. Influenza A viruses can also cause sporadic infections or spread worldwide in a pandemic when novel strains emerge in the human population from an animal host. New approaches to influenza prevention and treatment for management of both seasonal influenza epidemics and pandemics are desirable.

[Comment] Azithromycin in uncontrolled asthma

Asthma is a highly prevalent chronic airway disease affecting more than 300 million people worldwide. Despite treatment with inhaled corticosteroids and long-acting bronchodilators, asthma is uncontrolled in a substantial number of patients who remain symptomatic and are at risk of asthma exacerbations. These asthma attacks are often triggered by viral respiratory infections and might lead to emergency room visits, hospitalisations, and rarely, death; they result in a huge personal and societal burden.