more_vertIn December, 2016, the UK Government, on the advice of the Advisory Council on the Misuse of Drugs (ACMD), made two problematic changes to the UK drug control regulations of the Misuse of Drugs Act 1971. First, they put into effect new very wide-ranging bans against a whole range of synthetic cannabinoids. Second, they rejected an appeal by senior UK scientists to remove tetrahydrocannabivarin (THCV) from Schedule 1—the highest level of control—of the Act. THCV is a chemical found in the cannabis plant that UK scientists have identified as a potential therapeutic: keeping it in Schedule 1 severely impedes their research of THCV in the UK.
Preference: Statistics, epidemiology and research design
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Future Leader Receives AMA Award
A junior doctor and researcher, whose experiences as the child of refugee parents inspired her to establish a health promotion charity for migrants, refugees, and asylum seekers, has won the AMA Doctor in Training 2017 Award.
Dr Linny Phuong, a Paediatric Infectious Disease Fellow at the Royal Children’s Hospital Melbourne, was presented with the award by AMA President Dr Michael Gannon at the AMA National Conference 2017 in Melbourne.
Dr Phuong is the second winner of the Award, which was introduced in 2016 to recognise outstanding leadership, advocacy, and accomplishments of a doctor in training. The recipient is awarded a place at the AMA’s Future Leaders Program.
Dr Gannon praised Dr Phuong, the founder and director of the Water Well Project, for her contributions to teaching, medical education, research, and doctors’ wellbeing, as well as her professionalism and compassion towards children and their families.
“Dr Phuong exemplifies the characteristics of a caring doctor, an inspiring leader, and a tireless philanthropist and humanitarian,” Dr Gannon said.
Dr Phuong is highly regarded by her peers at the Royal Children’s Hospital where, as Deputy Chief Resident, she is in charge of the doctors’ wellbeing portfolio. She is also a successful medical researcher, having published several papers.
Dr Gannon also paid tribute to Dr Phuong’s awareness of the many challenges faced by refugee families in accessing health services, noting that five years ago, she founded the Water Well Project, a not-for-profit health promotion charity which improves the health and wellbeing of migrants, refugees, and asylum seekers by providing health literacy support and education.
Meredith Horne
Study questions whether older doctors are wiser
An observational study published in the BMJ has investigated whether the outcomes of patients admitted to hospital differ between those treated by younger and older doctors.
The Harvard study was undertaken because the relation between a doctor’s age and performance remains largely unknown, particularly with respect to patient outcomes. Clinical skills and knowledge accumulated by more experienced doctors can lead to improved quality of care. Doctors’ skills, however, can also become outdated as scientific knowledge, technology, and clinical guidelines change.
The conclusion to the research suggests you’re likely to live longer when treated by someone under 40.
The researchers are keen to stress that their findings should be regarded as exploratory. Nonetheless, they highlight the importance of patient outcomes as one component of an assessment of how a doctor’s practices change over a career. The purpose of continuing medical education is to ensure that doctors provide high quality care over the course of their careers.
The study, performed at acute care hospitals in the U.S between 2011 and 2014, looked at patient readmissions, the costs of care, and deaths within 30 days of being admitted to the hospital.
The difference in patients’ 30-day mortality rates were 10.8 per cent when they were treated by a doctors under the age of 40, compared to 12.1 per cent for doctors aged 60 and up.
There was an exception: for older doctors who were treating high volumes of patients, age did not translate to higher mortality in patients.
Dr Yusuke Tsugawa, the study’s author said, older doctors bring experience because they’ve been practicing a longer time, but younger doctors have more current clinical knowledge.
“A lot of patients have a perception that older doctors give better quality of care. But previous studies, multiple studies, have shown that younger doctors have more aptitude. We found those treated by younger doctors had significantly lower mortality compared with those treated by older doctors,” Dr Tsugawa said.
“Medical technologies are evolving all the time and it might be harder for older doctors to keep up with the evidence. And new guidelines are updated every five to 10 years. Newer doctors train based on the newest evidence and skills and technologies. Therefore, they may be more up-to-date when they start providing care.”
Meredith Horne
Air pollution linked with heart damage
A new report presented by the European Society of Cardiology says that there is strong evidence that particulate matter (PM) emitted mainly from diesel road vehicles is associated with increased risk of heart attack, heart failure, and death.
The lead author Dr Nay Aung, a cardiologist and Wellcome Trust research fellow at the William Harvey Research Institute, Queen Mary University of London, UK, said the cause for the heart damage “appears to be driven by an inflammatory response – inhalation of fine particulate matter (PM2.5) causes localised inflammation of the lungs followed by a more systemic inflammation affecting the whole body.”
Regarding how pollution might have these negative effects on the heart, Dr Aung said PM2.5 causes systemic inflammation, vasoconstriction and raised blood pressure. The combination of these factors can increase the pressure in the heart, which enlarges to cope with the overload. The heart chamber enlargement reduces the contractile efficiency leading to reduction in ejection fraction.
The researchers said they found evidence of harmful effects even when levels of pollution associated with diesel vehicles were less than half the safety limit set by the European Union.
Dr Aung said: “We found that the average exposure to PM2.5 in the UK is about 10 µg/m3 in our study. This is way below the European target of less than 25 µg/m3 and yet we are still seeing these harmful effects. This suggests that the current target level is not safe and should be lowered.”
In the UK, where the study was conducted, the Government recently produced its third attempt at a plan to bring air pollution to within levels considered safe under European Union legislation after judges ruled the previous versions were not effective enough to comply with the law.
Dr Penny Woods, chief executive of the British Lung Foundation, said: “Air pollution (in the UK) is a public health crisis hitting our most vulnerable the hardest – our children, people with a lung condition and the elderly.”
Dr Woods added that, while progress was being made in high-income countries to reduce deaths from cardiovascular disease and cancer, those caused by lung disease had “remained tragically constant”.
The World Health Organisation (WHO) estimates that some 3 million deaths a year are linked to exposure to outdoor air pollution. WHO also believes that indoor air pollution can be just as deadly. In 2012, an estimated 6.5 million deaths (11.6 per cent of all global deaths) were associated with indoor and outdoor air pollution together.
Only one in ten people breathe safe air according to WHO guidelines and over 80 per cent of the world’s cities have air pollution levels over what these guidelines deem safe.
The Australian Medical Association has developed a Position Statement on Climate Change and Human Health that acknowledges air pollution is the world’s single largest environmental health risk.
Meredith Horne
World leading Australian scientists developing nuclear medicine to save lives
The Australian Nuclear Science and Technology Organisation (ANSTO), has signed an MOU with the Sri Lankan Presidential Taskforce for Prevention of Chronic Kidney Disease to assist in the fight against Chronic Kidney Disease of Unknown Etiology (CKDu).
Sri Lanka’s High Commissioner to Australia, H.E. Somasundaram Skandakumar, and the CEO of ANSTO, Dr Adi Paterson, signed an MOU that will see Australia provide new insights into the disease.
“ANSTO’s expertise is in nuclear science, applied science and management of landmark infrastructure, and this new agreement is an opportunity to bring together all three, and to work on identifying the possible causes and treatments,” said Dr Paterson.
CKDu is a major health problem in Sri Lanka affecting more than 15 per cent of the population aged 15-70 years in the North Central Province, mostly poor farmers living in remote areas. According to the World Health Organization (WHO), the disease is now also prevalent in the North western, Eastern, Southern and Central provinces.
The true number of CKDu cases and the cause of the disease remain unknown. CKDu is a progressive condition marked by the gradual loss of kidney function. There is an increasingly urgent need to identify the cause of CKDu in order to prevent and treat the disease and save vulnerable lives.
Priorities for addressing CKDu include earlier diagnosis and improved working conditions in such intense heat. Initial symptoms of the disease are nondistinct, such as tiredness and appetite loss, meaning people are usually diagnosed late, when damage to the kidney is extensive and irreversible. The only option at this stage is dialysis, which is not always available or accessible.
It is also a serious public health problem in other countries, particularly in Central America, and despite more than 20 years of study in Sri Lanka and globally, it is not well understood. While CKDu appears to disproportionally affect poor, rural, male farmers in hot climates, the reasons why are not yet clear.
The World Health Organisation has identified several potential contributing factors, including heavy metals in the groundwater, agrochemicals, heat stress, malnutrition and low birth weight, and leptospirosis.
ANSTO and Australia will bring together several types of science and science infrastructure, including the ANSTO operated Synchrotron, as part of the research effort to investigate the epidemiology of CKDu.
ANSTO has capabilities to investigate a number of the possible causes, routes of distribution and treatments, particularly in relation to studying any causal links with heavy metals in water, or agrochemicals.
Meredith Horne
[Perspectives] Gerd Burmester: enduring leader in rheumatoid arthritis
Having been Professor of Medicine at Berlin’s Charité University Clinic for the past 23 years, Gerd Burmester is among the university’s longest-standing full professors. He leads a 100-strong Department of Rheumatology and Clinical Immunology, and is as committed to research in the laboratory as to work in the clinic. His team is collectively researching how to reprogramme the human immune system, with an emphasis on the molecular pathways that underpin autoimmunity across many diseases, but especially in rheumatoid arthritis (RA).
[World Report] EULAR: Countries unite to fight rheumatic diseases
Retired grammar school teacher Dieter Wiek is neither a trained scientist nor a clinician, but his perspective as a patient helps set the research and treatment agenda for rheumatic diseases in Europe and beyond.
AMA’s forward direction examined at National Conference
BY AMA SECRETARY GENERAL ANNE TRIMMER
Another AMA National Conference over with a stimulating and varied program, including appearances from the political leadership. It is rare to have a full hand of senior politicians – the Prime Minister, Health Minister, Minister for Ageing and Indigenous Health, Leader of the Opposition, Shadow Health Minister, and Leader of the Greens. It reinforces the fact that health is front and centre of national politics and will remain there as the next Federal election approaches.
Beyond national politics the Conference considered policy issues as diverse as obesity, organ and tissue donation, and the important topic of doctors’ health. It was pleasing to hear the announcement by Health Minister Greg Hunt that the Government would commit funding to assist in addressing the issue of the mental health of doctors and medical students. This will form part of a larger piece of work that the AMA is embarking on to develop a framework for doctors’ health and wellbeing.
In a year when there is no AMA election (as is the case in the odd-numbered years) delegates have more freedom to consider the policy topics, away from the politics of an election. Delegates have the opportunity to meet informally, as they did over breakfast on Sunday, when groups of members with interests in common came together to share a meal. As one psychiatry delegate commented, it provided a great opportunity to meet with other psychiatry members to realise shared interests and passions.
It was encouraging that members who had never before attended a National Conference were able to participate and see first-hand the work of the AMA. With the move in 2016 to representation from among practice groups, a more diverse representation of members is now supported to participate.
At the Annual General Meeting held during National Conference, the Chair of the Board, Dr Iain Dunlop, and I reflected on the year that was 2016. It was a strong year of medico-political advocacy and member engagement which can be seen in more detail in the Annual Report, available through the website.
I reported on the inaugural Future Leaders program, held in Canberra in early August. Calls for applications are currently open for doctors within the first five years of taking up a leadership position in a State, Territory or Federal AMA. The AMA Board is committed to investing in the development of the next generation of AMA leaders – I encourage you to apply if you qualify. Applications and selection criteria are available through the website.
At the Annual General Meeting the Chair announced to members the decision of the Board, taken after considerable research and reflection, to sell and lease back AMA House in Canberra. The Board took the view that more flexible investment of the capital tied up in the building would provide a better return on members’ funds. The building is fully capitalised following an extensive upgrade to its infrastructure over the past four years. A sale is likely later in 2017 following a marketing campaign.
For those who were not able to attend National Conference, this edition of Australian Medicine provides a good overview.
The saga of trying to put Medicare on ice
By Professor Stephen Leeder, Emeritus Professor Public Health, University of Sydney
Frozen indexation has meant effectively a cut in income for general practitioners who bulk bill their patients. Although small, it mounts up when multiplied by the number of patients they see.
If Medicare rebates on consultations lasting less than 20 minutes (the most common type of consultation) had not been frozen in 2014, instead of being $37 now they would have risen to about $40 this year if indexed to the consumer price index. That is according to a fact sheet produced by the Royal Australian College of General Practitioners.
Bulk-billing is hard to freeze
Although this may be thought to serve as a disincentive to bulk-billing, the Federal Health Minister Greg Hunt is quoted in the March 19th issue of The Australian as “highlighting the record increase in bulk billing rates, which have risen 3.5 per cent since the Coalition won Government”. So it does not seem to have reduced bulk billing?
Mr Hunt went on to say: “In the last half-yearly figures that are just out, we’ve gone from 84.7 per cent, to 85.4 per cent, so in other words, Medicare funding is up and bulk billing rates are at their highest ever on a half-yearly basis.”
Why freeze?
Associate Professor Helen Dickinson, a public service research academic at UNSW, explained the origin of the freeze a year ago in the Conversation and reported on ABC: “Although the Coalition is largely associated with this issue, Labor first introduced the Medicare rebate freeze in 2013 as a “temporary” measure, as part of a $664 million budget savings plan … A continuation of the indexation freeze, initially for four years starting in July 2014, was further extended in the 2016 budget to 2020. It has been estimated this will save $2.6 billion from the health bill over six years.”
The intention in the proposed 2014 Federal Budget was that the freeze would work alongside a co-payment and reduced reimbursement for short consultations. The continued freeze was the only measure that cleared the Senate. Although the justification for these proposed imposts on general practice included the absolute costs of primary care, these costs included a lot of activity other than general practice. According to the Australian Institute of Health and Welfare, health expenditure in Australia in 2014-2105 was $161.6 billion.
A freeze, or frost bite?
In 2013-2014 $58.8 billion was spent on hospitals and $54.7 billion on ‘primary care’ but as just said, this includes general practitioner services (about $9 billion), other health practitioners, community health care, dental services and medications. So with a total annual health budget of $161 billion, general practitioner services amounted to $9 billion or 17 per cent. The predicted savings from the freeze, each year, represent 0.25 per cent of total health expenditure. Has such a small saving been worth it?
If seeking to save money in health care, it is probably best to look first at the big expenditure items. This is why the review of the Medicare Benefits Schedule makes good sense and why, universally, there is an interest in demanding greater efficiency from our hospitals.
But as those who have had the responsibility for running a big and complex organisation know full well, it is wise to assess the likely flow-on from any cuts. Impositions on primary care are not likely to lead to the political pushback that cuts to high-powered specialty services will elicit. But if they demoralise this workforce, heaven help you in trying to integrate care for patients with complex chronic problems. And that will cost you far more in the long term than you will save by freezing general practice rebates.
Is a freeze on Medicare fair?
My final point concerns equity. How come private health insurance premiums rise each year whereas general practice fees do not? Private insurance premiums are heavily subsidised (30 per cent or $6.5 billion in the 2016 budget) by the federal government. So the Government does not worry about indexing its contribution to private health insurance but it does for Medicare. Work that one out if you can.
[Review] Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden
Type 2 diabetes in adolescence manifests as a severe progressive form of diabetes that frequently presents with complications, responds poorly to treatment, and results in rapid progression of microvascular and macrovascular complications. Although overall still a rare disease, adolescent type 2 diabetes now poses major challenges to paediatric and adult diabetes services in many countries. Therapeutic options are heavily curtailed by a dearth of knowledge about the condition, with low numbers of participants and poor trial recruitment impeding research.